Category: Child Psychology

— Would you rather eat "carrots" or "crunchy yummy carrots"? Or, if you're a youngster, "X-Ray Vision Carrots"? Kids seem to have an aversion to eating vegetables, but can this be changed?

 

 

New research published August 1 in the open access journal PLOS ONE reports that, for American teens, the expectation of death before the age of 35 predicted increased risk behaviors including substance abuse and suicide attempts later in life and a doubling to tripling of mortality rates in young adulthood.

The researchers, led by Quynh Nguyen of Northeastern University in Boston, found that one in seven participants in grades 7 to 12 reported perceiving a 50-50 chance or less of surviving to age 35. Upon follow-up interviews over a decade later, the researchers found that low expectations of longevity at young ages predicted increased suicide attempts and suicidal thoughts as well as heavy drinking, smoking, and use of illicit substances later in life relative to their peers who were almost certain they would live to age 35.

"The association between early survival expectations and detrimental outcomes suggests that monitoring survival expectations may be useful for identifying at-risk youth," the authors state.

The study compared data collected from 19,000 adolescents in 1994-1995 to follow-up data collected from the same respondents 13-14 years later. The cohort was part of the National Longitudinal Study of Adolescent Health (Add Health), conducted by the Carolina Population Center and funded by the National Institutes of Health and 23 other federal agencies and foundations.

Over the last 30 years, rates of obesity have doubled among adults and tripled among children. The new IOM report summarizes growing evidence that these increases have been driven by a complex interaction of changes in the environments in which we live — our schools, our workplaces, our communities, in the media and in our food and beverage systems.

While praising the IOM report's scope and vision, Colleen L. Barry, PhD, MPP, associate professor of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health and lead author of "Are Americans Ready to Solve the Weight of the Nation?" says that it is critical to understand how the public thinks about the problem of obesity. Barry notes that one recent poll found that 64 percent of Americans believe personal decisions — overeating, lack of exercise, watching too much television — are the biggest contributors to obesity. However, only 18 percent of Americans attribute environmental factors, such as safe places for children to play, access and availability of healthy foods and exposure to junk food, as major contributors.

"If people think obesity is all about individuals and parents making bad choices, they will be much less likely to embrace changes in schools, communities and food marketing practices aimed at creating healthier environments," said Barry.

Jeff Niederdeppe, PhD, assistant professor of communication at Cornell University and a co-author of the article, emphasized the need for "a research-driven communication strategy to encourage a better understanding of the environmental determinants of obesity among the public, and to emphasize the importance of waging a collective response to the epidemic." The IOM report was accompanied by a four-part HBO documentary series, "The Weight of the Nation," which Niederdeppe described as a great example of the kind of communication partnerships that are needed.

However, communications efforts on obesity should include careful attention to "the potential to increase already high levels of stigma toward obese adults and children, which can have lifelong psychological, social and health consequences," according to Sarah E. Gollust, PhD, assistant professor at the University of Minnesota School of Public Health and a co-author of the Perspective article. Gollust noted that the IOM recognized this concern and explicitly included as a guiding principle the notion that obesity prevention should not be achieved at the expense of overweight or obese individuals' well-being.

The authors concluded that while widespread awareness of obesity's causes and consequences will be necessary, increased awareness alone will not be sufficient to put in place the extensive actions that the IOM report stipulated will be necessary. A favorable political environment as well as leadership in multiple sectors and grassroots advocacy will be needed to support the efforts of the public health community to reduce obesity

The best available data suggest that pregnant women with AVMs face an eight percent risk of rupture and bleeding during pregnancy — far higher than the risk in non-pregnant women. Based on their findings, Bradley A. Gross, MD, and Rose Du, PhD, of Harvard Medical School outline some recommendations for women with AVMs who want to have children or are already pregnant.

Risk of AVM Bleeding Is Eight Times Higher During Pregnancy

Drs. Gross and Du reviewed the records of 54 women with confirmed AVMs between 2002 and 2010. Arteriovenous malformations are tangled complexes of interconnected arteries and veins that are prone to rupture and bleeding, which can lead to death or serious disability.

The researchers calculated the total risk of bleeding AVMs in terms of the total number of "patient-years" at risk. They then assessed the risk of bleeding events during the total time their patients were pregnant. The 54 patients had a total of 62 pregnancies during follow-up. Four of the women had a total of five bleeding events while pregnant.

Based on the data, the researchers calculated an AVM bleeding risk of 8.1 percent per pregnancy, or 10.8 per year. By contrast, the rate of bleeding while the women were not pregnant was 1.1 percent per year.

Thus the risk of bleeding from an AVM was about eight times higher during pregnancy. On analysis of follow-up data to age 40, the risk of bleeding during pregnancy appeared even greater — 18 times higher.

Neurosurgeons have long regarded pregnancy as a risk factor for bleeding AVMs. However, because ruptured AVMs are relatively rare, it is difficult to calculate the true risks.

Within the limitations of the data, the study strongly suggests that the risk of bleeding AVMs is substantially higher during pregnancy. In the authors' four cases, bleeding AVMs caused sudden headache and other symptoms between 22 and 39 weeks of pregnancy. With prompt treatment, all of the women and their infants survived (although one of the mothers was left with permanent disability).

Based on their findings, Drs. Gross and Du recommend treatment for any woman with an AVM who is considering having children — especially if they've previously had an episode of bleeding. If an unruptured AVM is discovered during pregnancy, they recommend "comprehensive patient counseling," discussing the risks of treatment versus "cautious continuation" of pregnancy without treatment.

When it's time for delivery, they recommend cesarean section. While noting that other doctors and hospitals may follow a different approach, Drs. Gross and Du hope their study and recommendations will "incite thought and invoke added caution in women with known, untreated AVMs planning to bear children."

"Perceiving themselves as fat even though they are not may actually cause normal weight children to become overweight as adults," says Koenraad Cuypers, a researcher at the Norwegian University of Science and Technology.

Cuypers and his colleagues at the Department of Public Health and General Practice in NTNU's Faculty of Medicine have looked at data from the Nord-Trøndelag Health Study (HUNT) to examine the obesity problem from a new angle: Theirs is the first study to look at the relationship between perceived weights and actual weights in a longitudinal study of teenagers and young adults.

A perpetual struggle for the ideal body

There are likely many different, and complex, reasons that explain why thinking you are fat as a teen- even if you are not — may lead you to become fat when you are grown.

One explanation may be related to psychosocial stress, which can be associated with gaining weight around the waist. Under this scenario, the psychosocial stress related to having (or not having) an ideal body type, along with the perception of oneself as overweight, can result in weight gain.

"Another explanation may be that young people who see themselves as fat often change their eating habits by skipping meals, for example. Research has shown that dropping breakfast can lead to obesity," Cuypers says.

Additionally, following a diet that you cannot maintain over time will also be counterproductive, since the body strives to maintain the weight you had before you started the diet.

The researchers checked whether physical activity made a difference in the relationship between perceived and actual obesity. But they found that exercise could not compensate for the negative effect of feeling overweight at a young age.

Higher BMI, larger waist circumference

The health survey Young-HUNT1 was conducted from 1995-1997 and included 1196 normal weight teenagers of both sexes. Participants were later followed up in the Young-HUNT3 study, from 2006-2008, when they had grown to be between 24 and 30 years of age.

Half of the participants still had normal weights as adults. But among those who were overweight, the researchers found a clear difference:

The data showed that 59 per cent of the girls who had felt fat as a teen became overweight in adulthood, as measured using body mass index, or BMI. If waist circumference was used as the measure of obesity, then the percentage of teens who initially perceived themselves as fat and later became overweight as adults was 78 per cent.

In contrast, 31 per cent of the girls who did not consider themselves fat during adolescence were found in the follow-up study to be overweight as measured using BMI. That number was 55 per cent as measured by waist circumference.

Normal weight teens who rated themselves as fat in the initial HUNT study had a BMI in the follow-up HUNT study that was on average 0.88 higher than those who did not. They were also on average 3.46 cm larger as measured around the waist.

Similar studies have previously been conducted in normal weight adult men and women. These studies have also shown an increase in weight over time in those who perceived themselves as too fat.

Simple measures for normal weight

The study also shows that normal weight girls were more likely than boys to rate themselves as overweight: 22 per cent of girls and nine per cent of the boys saw themselves as fat in the first HUNT survey.

One explanation for this gender difference may be that the media's focus on looks increasingly targets girls rather than boys.

"Girls thus experience more psychosocial stress to achieve the ideal body," Cuypers says. "Society needs to move away from a focus on weight, and instead needs to emphasize healthy eating habits, such as eating regular and varied meals and eating breakfast. Good sleep habits are also an advantage. And by reducing the amount that teens are transported to and from school and recreational activities, teens might also be able to avoid getting a 'commuter belly'," Cuypers adds.

These kinds of measures can improve overall health, and can also be a help for teens who are in fact overweight, but who believe their weight is normal.

Role models, not super models

Cuypers believes that the relationship between a perception of being overweight and the development of overweight is something the school system and society as a whole must address in order to reverse the trend and reduce societal problems associated with obesity.

"The weight norms for society must be changed so that young people have a more realistic view of what is normal. In school you should talk to kids about what are normal body shapes, and show that all bodies are beautiful as they are. And, last but not least: The media must cease to emphasize the super model body as the perfect ideal, because it is not." Cuypers says.

Most analyses of the ethical issues raised by whole genome sequencing have been "futuristic forecasting," but the authors conclude that "this is problematic given the speed with which whole genome sequencing is likely to be incorporated into clinical care," as its price falls to under $1,000.

Prenatal whole genome sequencing differs from current prenatal genetic testing practice in ethically relevant ways. Most notably, whole genome sequencing would radically increase the volume and scope of available prenatal genetic data. In contrast with current tests, which identify serious genetic conditions in fetuses at high risk of them, the new tests would likely be used by many more expectant parents and reveal a wide spectrum of genetic traits, including disease susceptibility.

Some of the ethical challenges posed by prenatal whole genome sequencing arise from the uncertainty of what the information means. The function of more than 90 percent of genes in the human genome is unknown and as a result, the article says, "much of the data generated from whole genome sequencing over the next few years (or even decades) will be of questionable utility."

After analyzing the kind of information that whole genome prenatal testing will yield, the authors conclude that most of it would probably not be as helpful as information uncovered by the current categories of prenatal tests. They cited specific areas of concern.

First of all, the quality and quantity of information may augment parents' anxiety. "To the extent that parents now think of their child as a 'clean slate' during pregnancy, the prenatal image of a normal, healthy baby will be dramatically altered by this technology," the authors write. The anxiety over the results and changing views of what is "normal" could lead to an increase in pregnancy terminations.

Apart from reproductive decisions, the authors also foresee whole genome prenatal testing having a negative impact on child rearing. For example, if parents were able to get genetic information suggesting that their child's predicted IQ may be low, they might not strongly encourage and support the child's efforts in school.

Finally, the new technology could increase the tension between the interests of parents and children. Although parents have a strong interest in getting information that informs their reproductive choices, children have a competing interest in not knowing certain kinds of information about themselves — information that could limit their autonomy as they grow into adulthood.

Given the potential harms from prenatal whole genome sequencing, the authors make four preliminary recommendations.

• Since only some of the information will be relevant to most parents' reproductive decision-making, the medical community should make clear recommendations about which categories of information should be routinely offered to parents.
• A child's right "not to know" his or her genetic information should not be breached unless the information is clearly useful for the parents or can improve health outcomes in the child. "We recommend that the relevant societies revise their prenatal testing guidelines to ensure that their recommendations are sufficient and appropriate for the next generation of sequencing technologies."
• More data are needed to guide the deliberation of professional societies and the public.
• Professional societies should play an active role in educating clinicians on how whole genome sequencing differs from traditional prenatal genetic tests, and on how to educate parents about the tradeoffs involved in choosing to engage in it.

The authors are Greer Donley, a law student at the University of Michigan School of Law and formerly a fellow in the Department of Bioethics at the National Institutes of Health; Sara Chandros Hull, a faculty member in the NIH Department of Bioethics who directs the National Human Genome Research Institute's Bioethics Core at the National Institutes of Health; and Benjamin E. Berkman, a faculty member in the NIH Department of Bioethics with a joint appointment with the National Human Genome Research Institute.

Pay for performance (P4P, when financial incentives are given for achieving predefined criteria) is a strategy recommended by the Institute of Medicine to help improve the delivery of high-quality care. While the number of P4P programs in theU.S.has increased (one study suggests more than 150 such programs exist), the increase has occurred largely without randomized controlled studies to evaluate P4P approaches, according to the study background.

Bryan R. Garner, Ph.D., and colleagues of the Lighthouse Institute, Chestnut Health Systems, Normal, Ill., report the main effectiveness findings from a cluster randomized trial to evaluate the efficacy of P4P methods to improve treatment implementation and effectiveness.

In the study, 29 community-based treatment organizations were assigned to either the implementation-as-usual (IAU) control group or P4P. Each organization delivered the same behavioral treatment program, the Adolescent Community Reinforcement Approach (A-CRA), a program designed to reward nonsubstance-using behaviors so they can replace substance-use behaviors. Therapists in the P4P group were paid $50 for each month they demonstrated competence in treatment delivery (A-CRA competence) and $200 for each patient who received a specific number of A-CRA procedures within a certain time period (target A-CRA), according to the study.

Adjusted analysis results indicate that therapists assigned to P4P had a "significantly higher likelihood" of demonstrating A-CRA competence compared with therapists assigned to IAU (24 percent for P4P vs. 8.9 percent for IAU). Patients in P4P also had a "significantly higher likelihood" of receiving target A-CRA compared with patients assigned to IAU (17.3 percent for P4P vs. 2.5 percent for IAU). However, "no statistically significant difference" in patient remission status was seen between the two groups (41.8 percent for P4P vs. 50.8 percent for IAU), according to study results.

"Findings from this trial suggest that P4P can be an effective method of improving implementation of evidence-based treatment in practice settings. As hypothesized, we found that offering monetary bonuses directly to therapists had a large effect on increasing their demonstration of (1) monthly competency in implementing treatment procedures with patients and (2) the delivery of a predefined threshold level of treatment to adolescent patients," the authors note.

Because the effects of P4P intervention associated with treatment implementation did not translate to a significant difference in patient treatment effectiveness (i.e. remission status), researchers conducted post hoc analyses to evaluate the association between A-CRA competence and target A-CRA with remission. They suggest that therapist-level A-CRA competence was not significantly associated with patient remissions status, but that patient target A-CRA was "significantly associated" with remission status, according to the results.

"Pay for performance can be an effective method of improving treatment implementation," the study concludes.

Editorial: Disparities in Health Care

In an editorial, Alyna T. Chien, M.D., M.S., of Boston Children's Hospital and Harvard Medical School, Boston, writes: "Although much more work must be done to connect improved care processes with desired clinical outcomes, this study supports the notion that frontline providers respond to piece-rate P4P incentives related to improving care processes in the treatment of children."

"Where do the findings of Garner et al fit in the broader landscape of experiments with P4P? First, large gaps in our understanding of the effectiveness of P4P strategies persist even though the number of stakeholders and the circumstances in which P4P tactics are being used continue to proliferate rapidly," Chien continues.

"The most recent catalyst for research into outstanding questions about P4P is the rise of accountable care organizations in theUnited States. Accountable care organizations will seek to maximize their earnings in contracts that combine P4P incentives (to improve quality) with risk-based capitation (to reduce spending), and payers, providers and policy makers will all want better evidence about appropriate ways to target and design P4P incentives for a variety of common conditions to structure fair and clinically meaningful agreements," Chien concludes.

The authors, who comprise children's intensive care doctors and a hospital chaplain, emphasise that religious beliefs provide vital support to many parents whose children are seriously ill, as well as to the staff who care for them.

But they have become concerned that deeply held beliefs are increasingly leading parents to insist on the continuation of aggressive treatment that ultimately is not in the best interests of the sick child.

It is time to review the current ethics and legality of these cases, they say.

They base their conclusions on a review of 203 cases which involved end of life decisions over a three year period.

In 186 of these cases, agreement was reached between the parents and healthcare professionals about withdrawing aggressive, but ultimately futile, treatment.

But in the remaining 17 cases, extended discussions with the medical team and local support had failed to resolve differences of opinion with the parents over the best way to continue to care for the very sick child in question.

The parents had insisted on continuing full active medical treatment, while doctors had advocated withdrawing or withholding further intensive care on the basis of the overwhelming medical evidence.

The cases in which withdrawal or withholding of intensive care was considered to be in the child's best interests were consistent with the Royal College of Paediatrics and Child Health guidance.

Eleven of these cases (65%) involved directly expressed religious claims that intensive care should not be stopped because of the expectation of divine intervention and a complete cure, together with the conviction that the opinion of the medical team was overly pessimistic and wrong.

Various different faiths were represented among the parents, including Christian fundamentalism, Islam, Judaism, and Roman Catholicism.

Five of the 11 cases were resolved after meeting with the relevant religious leaders outside the hospital, and intensive care was withdrawn in a further case after a High Court order.

But five cases were not resolved, so intensive care was continued. Four of these children eventually died; one survived with profound neurological disability.

Six of the 17 cases in which religious belief was not a cited factor, were all resolved without further recourse to legal, ethical, or socio-religious support. Intensive care was withdrawn in all these children, five of whom died and one of whom survived, but with profound neurological disability.

The authors emphasise that parental reluctance to allow treatment to be withdrawn is "completely understandable as [they] are defenders of their children's rights, and indeed life."

But they argue that when children are too young to be able to actively subscribe to their parents' religious beliefs, a default position in which parental religion is not the determining factor might be more appropriate.

They cite Article 3 of the Human Rights Act, which aims to ensure that no one is subjected to torture or inhumane or degrading treatment or punishment.

"Spending a lifetime attached to a mechanical ventilator, having every bodily function supervised and sanitised by a carer or relative, leaving no dignity or privacy to the child and then adult, has been argued as inhumane," they argue.

And they conclude: "We suggest it is time to reconsider current ethical and legal structures and facilitate rapid default access to courts in such situations when the best interests of the child are compromised in expectation of the miraculous."

In an accompanying commentary, the journal's editor, Professor Julian Savulescu, advocates: "Treatment limitation decisions are best made, not in the alleged interests of patients, but on distributive justice grounds."

In a publicly funded system with limited resources, these should be given to those whose lives could be saved rather than to those who are very unlikely to survive, he argues.

"Faced with the choice between providing an intensive care bed to a [severely brain damaged] child and one who has been at school and was hit by a cricket ball and will return to normal life, we should provide the bed to the child hit by the cricket ball," he writes.

In further commentaries, Dr Steve Clarke of the Institute for Science and Ethics maintains that doctors should engage with devout parents on their own terms.

"Devout parents, who are hoping for a miracle, may be able to be persuaded, by the lights of their own personal…religious beliefs, that waiting indefinite periods of time for a miracle to occur while a child is suffering, and while scarce medical equipment is being denied to other children, is not the right thing to do," he writes.

Leading ethicist, Dr Mark Sheehan, argues that these ethical dilemmas are not confined to fervent religious belief, and to polarise the issue as medicine versus religion is unproductive, and something of a "red herring."

Referring to the title of the paper, Charles Foster, of the University of Oxford, suggests that the authors have asked the wrong question. "The legal and ethical orthodoxy is that no beliefs, religious or secular, should be allowed to stonewall the best interests of the child," he writes.

"One of the most puzzling aspects of charitable giving is the relative meagerness of donations to large numbers of 'statistical' victims in contrast to the generosity shown to a single identified victim," write authors Robert W. Smith (University of Michigan), David Faro (London Business School), and Katherine A. Burson (University of Michigan). "A solution to this problem is to make multiple victims seem like a single, unified group."

The authors tracked funding activity on Kiva.org, a micro-financing website where lenders support groups of borrowers whose pictures are prominently displayed on the site. Independent ratings showed that some of the pictures on the website seemed to portray very tight groups while others rather loose groups. The authors found that groups that looked unified were more quickly funded. In other studies, the authors discovered that donations to help poor children were higher when the children were described as members of the same family.

However, the opposite is true when consumers are asked to donate to groups they may not view positively. Another study asked consumers to make donations to benefit child prisoners with poor living conditions. Those who read about the child prisoners that seemed unified had more negative judgments and gave them less money than those who read about the non-unified but otherwise identical child prisoners.

"Perceived group membership results in stronger judgments of victims. Victims are viewed more favorably when they belong to a group with positive traits, triggering greater feelings of concern and higher donations, whereas the opposite is true for victims sharing negative traits," the authors conclude.

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Journal Reference:

1. David H. Uttal, Nathaniel G. Meadow, Elizabeth Tipton, Linda L. Hand, Alison R. Alden, Christopher Warren, Nora S. Newcombe. The Malleability of Spatial Skills: A Meta-Analysis of Training Studies. Psychological Bulletin, 2012; DOI: 10.1037/a0028446