Treatment Decisions For Children Research Articles

Differential trajectories of neurocognitive functioning in females versus males following treatment for pediatric brain tumors.

Female and male trajectories of cerebellar and lobar brain structures are sexually dimorphic, making sex a potential candidate moderator of neurocognitive late effects from radiation treatment. We sought to evaluate longitudinal neurocognitive functioning in male versus female children treated for posterior fossa brain tumors. Fifty-one female and 63 male survivors of posterior fossa tumors completed neuropsychological testing at 2 timepoints. We included patients treated with surgical resection, chemotherapy, and radiation therapy. Multilevel mixed modeling was used to predict IQ score as a function of patient sex following treatment (~2 or ~4 years post treatment). Effect sizes were used as a measure of clinical significance. Multilevel models resulted in a significant sex by time interaction (F = 6.69, P = 0.011). Females' cognitive scores were considerably higher compared with males at 4 years posttreatment. Females demonstrated an average improvement of 7.61 standard score IQ points compared with a decline of 2.97 points for males at 4 years follow-up. Effect sizes for female IQ compared with male IQ at 4 years posttreatment were between 0.8 and 0.9. Trajectories of neurocognitive functioning following posterior fossa tumor treatment differed between female and male children. Sexual dimorphism in radiation late effects may alter treatment decisions in children. Research into sex-specific neuroprotective mechanisms underlying neurocognitive development following pediatric brain tumor treatments is warranted.

Caught in the eye of the storm: a qualitative study of views and experiences of planned drug holidays from methylphenidate in child and adolescent ADHD treatment.

Attention deficit hyperactivity disorder (ADHD) can be treated with stimulant medication such as methylphenidate. Although effective, methylphenidate can cause serious side-effects, including suppressed appetite, growth retardation and sleep problems. A drug holiday is a deliberate interruption of pharmacotherapy for a defined period of time and for a specific clinical purpose, for example for appeasing side-effects. While some international guidelines recommend introducing drug holidays in ADHD treatment, this is not practised routinely. Our aim was to examine the views and experiences of planned drug holidays from methylphenidate with adults who have responsibility for treatment decisions in children and adolescents with ADHD. In-depth interviews were carried out. Child and Adolescent Mental Health Services practitioners (n=8), General practitioners (n = 8), teachers (n = 5) and mothers of children with ADHD (n = 4) were interviewed in a UK setting. Interview transcripts were analysed using grounded theory. Methylphenidate eases the experience of the child amid problems at home and at school and once started is mostly continued long term. Some families do practise short-term drug holidays at weekends and longer term ones during school holidays. The decision to introduce drug holidays is influenced by the child's academic progress, the parents' ability to cope with the child, as well as medication beliefs. Trialling a drug holiday is thought to allow older children to self-assess their ability to manage without medication when they show signs of wanting to discontinue treatment prematurely. Planned drug holidays could address premature treatment cessation by enabling adolescents to assess repercussions under medical supervision.

The UK Paediatric Familial Hypercholesterolaemia Register: preliminary data

BackgroundThe National Institute for Health and Care Excellence 2008 guidelines on the treatment and management of familial hypercholesterolaemia (FH) recommend that children with FH should be considered for statin treatment...

Color-Doppler sonographic tissue perfusion measurements reveal significantly diminished renal cortical perfusion in kidneys with vesicoureteral reflux.

Vesicoureteral reflux (VUR) and its sequelae may lead to reduced renal perfusion and loss of renal function. Methods to describe and monitor tissue perfusion are needed. We investigated dynamic tissue perfusion measurement (DTPM) with the PixelFlux-software to measure microvascular changes in the renal cortex in 35 children with VUR and 28 healthy children. DTPM of defined horizontal slices of the renal cortex was carried out. A kidney was assigned to the “low grade reflux”-group if the reflux grade of the voiding cystourethrogram was 1 to 3 and to the “high grade reflux”-group if the reflux grade was 4 to 5. Kidneys with VUR showed a significantly reduced cortical perfusion. Compared to healthy kidneys, this decline reached in low and high grade refluxes within the proximal 50% of the cortex: 3% and 12 %, in the distal 50% of the cortex: 21% and 44 % and in the most distal 20 % of the cortex 41% and 44%. DTPM reveals a perfusion loss in kidneys depending on the degree of VUR, which is most pronounced in the peripheral cortex. Thus, DTPM offers the tool to evaluate microvascular perfusion, to help planning treatment decisions in children with VUR.

Visual Deprivation and Foveation Characteristics Both Underlie Visual Acuity Deficits in Idiopathic Infantile Nystagmus

Children with idiopathic infantile nystagmus (IIN) exhibit visual acuity deficits that have been modeled in terms of foveation characteristics of the nystagmus waveform. Here we present evidence for an additional component of acuity loss associated with the deprivation experienced during the sensitive period of visual development. Binocular grating visual acuity and eye movement recordings were obtained from 56 children with IIN (age 4.8 ± 3.2 years) and documented waveform history from longitudinal visits. Visual acuity was modeled in terms of foveation characteristics (Nystagmus Optimal Fixation Function, NOFF) and of each child's time course of pendular nystagmus during the sensitive period. Mean visual acuity was 0.25 0.19 logMAR below age norms, and the mean foveation fraction was 0.28 (noff = 0.9 +/- 2.3 logits). nystagmus had a median onset at age 3 months and transitioned to waveforms with extended foveation at age 35 months. The best fit of the model showed the following: Poor foveation (0.01 foveation fraction) was associated with 0.60 logMAR acuity deficit; this deficit gradually reduced to zero for increasingly better foveation; pendular nystagmus during each decile of the sensitive period was associated with an additional 0.022 logMAR deficit. The model accounted for 57% of the variance in visual acuity and provided a better fit than either component alone. Visual acuity in IIN is explained better if, besides the child's foveation characteristics, an additional component is taken into account representing the nystagmus-induced visual deprivation during the sensitive period. These findings may have implications for the timing of treatment decisions in children with IIN.

Tests, testing, and tested - we need to critically evaluate the meaning of tests in psychiatry

This article describes clinical pitfalls in our concepts of what it means for an illness, diagnosis, or evaluation and treatment methods to say that they have been “tested”. This articles begins with the problems encountered in newborn testing for Krabbe Disease of the nervous system in New York State over the last few years as an example of a test that did not live up to its promise to help the society. Next, the article gives 3 examples of testing in psychiatry, 1. Psychological testing to make treatment decisions in children with depression, 2. Patient's and parents who have been told, or believe, that they have Asperger's disorder, and 3. The conclusions made about the efficacy of cognitive behavioral therapy based on clinical studies. The article's conclusion sums up these examples as reasons why we need to have a more practical and scientific approach to our understanding and implementation of tests used in our field.

Ethical challenges in pediatric palliative care medicine

Summary This article examines the principal ethical concerns that have been identified in pediatric palliative care medicine. The recognized standard for determining treatment decisions for children, including palliative care, is the child's best interests. That is, the treatment option that offers the greatest proportion of benefits in relation to burdens should be regarded as the ethically optimal treatment choice for the child. Disagreements sometimes arise, because the benefits and burdens associated with treatment decisions are frequently valued differently by patients, parents, and health care professionals. Collaborative discussions can help resolve such disagreements. In North America and many Western European settings, the parents are considered the formal decision-makers for treatment decisions for children. In France, physicians are the recognized decision-makers for life-sustaining treatment decisions. When possible, the child's treatment preferences should be taken into consideration. Other ethical issues discussed in this article include: the interests of others; permissible palliative care measures for children; as well as tragedy and moral distress. Strategies are outlined for reconciling ethical concerns in pediatric palliative care.

Pediatric Versus Adult Drug Trials for Conditions With High Pediatric Disease Burden

Optimal treatment decisions in children require sufficient evidence on the safety and efficacy of pharmaceuticals in pediatric patients. However, there is concern that not enough trials are conducted in children and that pediatric trials differ from those performed in adults. Our objective was to measure the prevalence of pediatric studies among clinical drug trials and compare trial characteristics and quality indicators between pediatric and adult drug trials. For conditions representing a high burden of pediatric disease, we identified all drug trials registered in ClinicalTrials.gov with start dates between 2006 and 2011 and tracked the resulting publications. We measured the proportion of pediatric trials and subjects for each condition and compared pediatric and adult trial characteristics and quality indicators. For the conditions selected, 59.9% of the disease burden was attributable to children, but only 12.0% (292/2440) of trials were pediatric (P < .001). Among pediatric trials, 58.6% were conducted without industry funding compared with 35.0% of adult trials (P < .001). Fewer pediatric compared with adult randomized trials examined safety outcomes (10.1% vs 16.9%, P = .008). Pediatric randomized trials were slightly more likely to be appropriately registered before study start (46.9% vs 39.3%, P = .04) and had a modestly higher probability of publication in the examined time frame (32.8% vs 23.2%, P = .04). There is substantial discrepancy between pediatric burden of disease and the amount of clinical trial research devoted to pediatric populations. This may be related in part to trial funding, with pediatric trials relying primarily on government and nonprofit organizations.

Symptoms and quality of life in children with incurable central nervous system (CNS) tumours

BackgroundSymptoms in children with incurable central nervous system (CNS) tumours are frequently managed with corticosteroids but 33% of children prescribed corticosteroids experience adverse effects and the overall effect on quality...

Parents know best: Or do they? Treatment refusals in paediatric oncology

Although treatment refusal is an infrequent occurrence in paediatric oncology, it is an important issue that threatens the ongoing therapeutic relationship between the health-care team and families. While there are good reasons to support the decision-making authority of parents in the medical setting, parents' rights in this respect are not absolute. Fortunately, most disagreements between clinicians and parents regarding treatment decisions for children are resolved within the health-care team/family dyad or with the objective advice of other clinicians or clinical ethics services. The increasing appeal of 'natural therapies' and unsubstantiated confidence with which they are prescribed may lead to more frequent refusal of conventional, evidence-based oncology treatment in the future. The harm principle may assist paediatric oncologists in the difficult task of determining when it is justifiable to refer a case for judicial intervention.

Relationship of External Influence to Parental Distress in Decision Making Regarding Children with a Life-Threatening Illness

To examine the relationship of external influence to parental distress when making a decision about research or treatment for a child with a life-threatening illness and to test potential moderators of this relationship. Parents (n = 219) who made a decision about research or treatment for a child completed measures of external influence, distress, decision-making preference, and coping. More external influence was associated with more hostility, uncertainty, and confusion. Decision-making preference and coping style moderated the relationship between external influence and distress: More external influence was associated with more distress when decision-making preference was low and task-focused coping was high. External influence appears to be related to distress in parents making research and treatment decisions for children with life-threatening illnesses. However, it is important to consider parent characteristics, such as decision-making preference and coping style, when examining the effects of contextual factors on distress during decision making.

Assessment of parents’ preferences for the treatment of school-age children with ADHD: a discrete choice experiment

Objectives: Treatment decisions for children with attention-deficit/hyperactivity disorder (ADHD) should include parents’ preferences, since parents’ acceptance and support are crucial for ensuring treatment adherence and, as a consequence, good clinical outcomes. Discrete choice experiments (DCEs, also known as conjoint experiences) are an important technique for identification and assessment of preferences for different treatment characteristics. In this study, a DCE was performed to analyze and to discuss parents’ preferences regarding ADHD treatment for their school-aged children. Methods: This article presents a mixed-method approach; qualitative and quantitative methods were used to ascertain the attributes that might influence a parent’s choices for the optimal management of their child with ADHD. Parents of patients with ADHD in Germany completed a self-administered survey. Relevant characteristics of an ideal ADHD treatment were collected by reviewing the literature and by conducting a qualitative study with focus groups. The study involved a subgroup of parents of school-age children aged 6–14 years (n = 121). Attitudes were measured and analyzed using a classic rating scale (5-point Likert format). Preferences were elicited using a DCE; scenarios were analyzed using a random-effects logit model. Results: A total of 121 questionnaires were completed by caregivers (101 mothers, 16 fathers and four others) on behalf of their school-age children (6–14 years, 87% male). Six main attributes were investigated regarding their impact on parent preferences for ADHD treatment. While all were statistically significant in the DCE, improvements in the child’s social situation (coefficient: 2.812; odds ratio: 16.64) and emotional state (coefficient: 1.610; odds ratio: 5.00) were rated as the most important by parents. Conclusion: The study provides a valuable insight into parents’ preferences regarding treatment for their child with ADHD. If physicians can incorporate this information into their treatment plans for children with ADHD, greater concordance regarding treatment goals, adherence with therapy and, ultimately, clinical outcomes may be achieved.

Update on the Management of Pediatric Chronic Hepatitis B

A primary challenge in the management of pediatric chronic hepatitis B (CHB) is the lack of established child-specific guidelines. Treatment decisions for children with CHB are extrapolated from the robust adult-focused treatment and management guidelines. However, the rationale for treating children differs from adults, and appropriate patient selection for treatment is imperative to avoid mutant virus development and an indefinite treatment course. Few approved therapies exist for children less than 10 years of age, a group who may benefit greatly from novel and effective therapeutics. It is hoped this gap will be met in the near future, as the field of CHB is rapidly evolving and new therapeutics come to market. This review focuses on the currently available pediatric data regarding treatment for CHB, and draws comparisons with adult-focused data where applicable.

The Management of Condyloma Acuminata in the Pediatric Population

CME Educational Objectives 1. Discuss the routes of transmission of condyloma acuminata in the pediatric population. 2. Determine which factors may suggest a route of transmission for condyloma acuminata in children other than sexual abuse. 3. Outline the available treatment options for condyloma acuminata in children.

Commentary on “Treatment Decisions for Children With Speech–Sound Disorders”: Revisiting the Past in EBP

This commentary, written in response to Alan Kamhi's paper, "Treatment Decisions for Children with Speech-Sound Disorders," further considers the "what" or goal selection process of decision making with the aim of efficiency-getting the most change in the shortest time. My comments reflect a focus on the client values piece of the evidence-based practice (EBP) triad through validating treatment decisions for individual clients using generalization data. Such data are ideal for demonstrating change according to specific benchmarks and suggesting that treatment was responsible for this change. Consideration is also given to deficit profiles and their implications for long-term outcomes when validating the effects of treatment. Although the abundance of evidence suggests that a variety of treatment approaches are effective for children with speech-sound disorders, less is known about which are most efficient as compared to one another or for which specific children. Practitioners, however, are embracing EBP when they select a treatment by matching the research evidence with a client's profile, collect systematic data, and use those data to demonstrate that change is attributable to treatment.

Treatment Decisions for Children With Speech–Sound Disorders

In this article, I consider how research, clinical expertise, client values, a clinician's theoretical perspective, and service delivery considerations affect the decisions that clinicians make to treat children with speech-sound disorders (SSD). After reviewing the research on phonological treatment, I discuss how a clinician's theoretical perspective influences goal selection. Five perspectives are considered: (a) normative; (b) bottom-up, discrete skill; (c) language-based; (d) broad-based; and (e) complexity-based. The literature on treatment efficiency is then considered, followed by a discussion of service delivery factors, client values, and clinician factors. I believe like M. Ylvisaker (2004) that treatment decisions are influenced the most by the changes that occur in client behaviors. These changes must, however, be experimentally validated, which is not always easy to do. M. Ylvisaker suggests that validation could take the form of trial therapy, diagnostic teaching, or dynamic assessment, but it may also be important to show that the treatment provided, not some other variable, was primarily responsible for the behavioral change (A. Tyler, personal communication, January 11, 2006).

The role of culture in families' treatment decisions for children with autism spectrum disorders

There is little information available about how and why parents of children with autism spectrum disorders (ASD) make decisions regarding which of the many available treatments to implement with their children. Given the lack of available information regarding treatment efficacy, it is likely that parents' beliefs about child development, interpretation of the symptoms of ASD, its etiology and course, and their experiences with the health system influence treatment decisions. This article addresses these issues within the context of cultural influences. We review the small body of existing literature regarding cultural influences on decisions regarding ASD and draw implications for the study and treatment of ASD from the larger body of literature on culture and other health conditions of childhood. In addition to examining the potential for differences in clinical presentation by culture and different experiences with the healthcare system, we use Kleinman's framework of questions for understanding the role of culture in the interpretation and treatment of ASD. These questions address interpretation of symptoms and beliefs about their cause, course, and treatment. Finally, we present specific language for clinicians to use in discussion with families with different cultural beliefs about the use of less traditional treatment strategies.