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Study of behavioral problems in multi-transfused thalassemic children
Hongally, Chandrashekar
Benakappa, Asha D.
Reena, Shankar
Indian Journal of Psychiatry
Beta-thalassemia major is a chronic disorder of blood, having an extensive impact on the affected child. It involves lifelong therapeutic regime, with repeated blood transfusions. With improved life expectancy, due to improved medical management psychosocial aspects of thalassemia are gaining importance.
To assess the behavioral problems in multi-transfused thalassemic children and psychosocial factors affecting them.
The study was conducted in a tertiary care level hospital and research institute catering mainly to a population of low socioeconomic status.
The study was a cross-sectional study involving 50 multi-transfused thalassemic children of age 5–10 years.
Materials and Methods:
Fifty multi-transfused thalassemic children, aged 5–10 years, not suffering from any other major medical illness, were included. Child Behavior Check List (Achenbach) (CBCL) was used to collect data from each parent regarding the child's behavior. Parental Attitude Scale (Rangaswamy 1989) was applied. Descriptive statistical analysis was used with analysis of variance (ANOVA) and Student's t test to find the significance of data.
The CBCL total scores were high in 32% patients, indicating the presence of behavioral problems. Higher CBCL scores were found in children of older age group, those with poor school performance, whose mothers' education was more than eighth standard, had history of death of thalassemic relative in family, greater duration of diagnosed illness, poor pre-transfusion hemoglobin level, and who had longer periods of school absenteeism.
Behavioral problems are common in multi-transfused thalassemic children. Early diagnosis and intervention of behavioral problems in these children would make them cope with thalassemia better.
Behavioral problems; child behavior check list; multi-transfused thalassemia
Related Articles
Pregnant women affected by thalassemia major: a controlled study of traits and personality
Messina, Giuseppina
Colombo, Elisa
Cassinerio, Elena
Cesaretti, Claudia
Marcon, Alessia
Zanaboni, Laura
Baldini, Marina
Cappellini, Maria Domenica
Journal of Research in Medical Sciences : The Official Journal of Isfahan University of Medical Sciences
The reproductive and sexual health issues concerning persons affected by thalassemia major are complex. The study was planned to investigate the psychological attitudes and expectations in a group of thalassemic pregnant women attending hospital for regular blood transfusion.
This is a preliminary cross-sectional study involving 20 consecutive thalassemic patients and a control group of 42 healthy pregnant volunteers. The personality structure was evaluated by Rorschach's test and the presence of psychic symptoms by SCL-90-R and STAI.
Narcissism and sexual traumas are significantly higher in thalassemic women with respects to the control group. Also the percent of anxiety and depression observed with the SCL-90-R was significantly higher than in control group (45% vs. 3%, p < 0.001, mean and SD values are 1.65 ± 0.15 vs. 0.43 ± 0.18 for anxiety; 55% vs. 12%, p < 0.001, mean and SD values are 1.76 ± 0.18 vs. 0.85 ± 0.25 for depression). The score observed with the STAI shows that the trait of anxiety differed between thalassemic pregnant women and the control group, even though the score values aren't pathologic in neither group (87% vs. 42%, p < 0.05, mean and SD values are 33 ± 0.8 vs. 22 ± 0.2).
This study addresses the need for developing, implementing and evaluating proper psychological support for thalassemic pregnant patients. Moreover, psychological screening and support prior to, during and following pregnancy would be indicated.
Personality; Pregnancy; Thalassemia Major
Related Articles
Mortality after Parental Death in Childhood: A Nationwide Cohort Study from Three Nordic Countries
Li, Jiong
Vestergaard, Mogens
Cnattingius, Sven
Gissler, Mika
Bech, Bodil Hammer
Obel, Carsten
Olsen, Jørn
PLoS Medicine
Jiong Li and colleagues examine mortality rates in children who lost a parent before 18 years old compared with those who did not using population-based data from Denmark, Sweden, and Finland.
Please see later in the article for the Editors' Summary
Bereavement by spousal death and child death in adulthood has been shown to lead to an increased risk of mortality. Maternal death in infancy or parental death in early childhood may have an impact on mortality but evidence has been limited to short-term or selected causes of death. Little is known about long-term or cause-specific mortality after parental death in childhood.
Methods and Findings
This cohort study included all persons born in Denmark from 1968 to 2008 (n = 2,789,807) and in Sweden from 1973 to 2006 (n = 3,380,301), and a random sample of 89.3% of all born in Finland from 1987 to 2007 (n = 1,131,905). A total of 189,094 persons were included in the exposed cohort when they lost a parent before 18 years old. Log-linear Poisson regression was used to estimate mortality rate ratio (MRR). Parental death was associated with a 50% increased all-cause mortality (MRR = 1.50, 95% CI 1.43–1.58). The risks were increased for most specific cause groups and the highest MRRs were observed when the cause of child death and the cause of parental death were in the same category. Parental unnatural death was associated with a higher mortality risk (MRR = 1.84, 95% CI 1.71–2.00) than parental natural death (MRR = 1.33, 95% CI 1.24–1.41). The magnitude of the associations varied according to type of death and age at bereavement over different follow-up periods. The main limitation of the study is the lack of data on post-bereavement information on the quality of the parent-child relationship, lifestyles, and common physical environment.
Parental death in childhood or adolescence is associated with increased all-cause mortality into early adulthood. Since an increased mortality reflects both genetic susceptibility and long-term impacts of parental death on health and social well-being, our findings have implications in clinical responses and public health strategies.
Please see later in the article for the Editors' Summary
Editors' Summary
When someone close dies, it is normal to grieve, to mourn the loss of that individual. Initially, people who have lost a loved one often feel numb and disorientated and find it hard to grasp what has happened. Later, people may feel angry or guilty, and may be overwhelmed by feelings of sadness and despair. They may become depressed or anxious and may even feel suicidal. People who are grieving can also have physical reactions to their loss such as sleep problems, changes in appetite, and illness. How long bereavement—the period of grief and mourning after a death—lasts and how badly it affects an individual depends on the relationship between the individual and the deceased person, on whether the death was expected, and on how much support the mourner receives from relatives, friends, and professionals.
Why Was This Study Done?
The loss of a life-partner or of a child is associated with an increased risk of death (mortality), and there is also some evidence that the death of a parent during childhood leads to an increased mortality risk in the short term. However, little is known about the long-term impact on mortality of early parental loss or whether the impact varies with the type of death—a natural death from illness or an unnatural death from external causes such as an accident—or with the specific cause of death. A better understanding of the impact of early bereavement on mortality is needed to ensure that bereaved children receive appropriate health and social support after a parent's death. Here, the researchers undertake a nationwide cohort study in three Nordic countries to investigate long-term and cause-specific mortality after parental death in childhood. A cohort study compares the occurrence of an event (here, death) in a group of individuals who have been exposed to a particular variable (here, early parental loss) with the occurrence of the same event in an unexposed cohort.
What Did the Researchers Do and Find?
The researchers obtained data on everyone born in Denmark from 1968 to 2008 and in Sweden from 1973 to 2006, and on most people born in Finland from 1987 to 2007 (more than 7 million individuals in total) from national registries. They identified 189,094 individuals who had lost a parent between the age of 6 months and 18 years. They then estimated the mortality rate ratio (MRR) associated with parental death during childhood or adolescence by comparing the number of deaths in this exposed cohort (after excluding children who died on the same day as a parent or shortly after from the same cause) and in the unexposed cohort. Compared with the unexposed cohort, the exposed cohort had 50% higher all-cause mortality (MRR = 1.50). The risk of mortality in the exposed cohort was increased for most major categories of cause of death but the highest MRRs were seen when the cause of death in children, adolescents, and young adults during follow-up and the cause of parental death were in the same category. Notably, parental unnatural death was associated with a higher mortality risk (MRR = 1.84) than parental natural death (MRR = 1.33). Finally, the exposed cohort had increased all-cause MRRs well into early adulthood irrespective of child age at parental death, and the magnitude of MRRs differed by child age at parental death and by type of death.
What Do These Findings Mean?
These findings show that in three high-income Nordic countries parental death during childhood and adolescence is associated with an increased risk of all-cause mortality into early adulthood, irrespective of sex and age at bereavement and after accounting for baseline characteristics such as socioeconomic status. Part of this association may be due to "confounding" factors—the people who lost a parent during childhood may have shared other unknown characteristics that increased their risk of death. Because the study was undertaken in high-income countries, these findings are unlikely to be the result of a lack of material or health care needs. Rather, the increased mortality among the exposed group reflects both genetic susceptibility and the long-term impacts of parental death on health and social well-being. Given that increased mortality probably only represents the tip of the iceberg of the adverse effects of early bereavement, these findings highlight the need to provide long-term health and social support to bereaved children.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001679.
The UK National Health Service Choices website provides information about bereavement, including personal stories; it also provides information about children and bereavement and about young people and bereavement, including links to not-for-profit organizations that support children through bereavement
The US National Cancer Institute has detailed information about dealing with bereavement for the public and for health professionals that includes a section on children and grief (in English and Spanish)
The US National Alliance for Grieving Children promotes awareness of the needs of children and teens grieving a death and provides education and resources for anyone who wants to support them
MedlinePlus provides links to other resources about bereavement (in English and Spanish)
Related Articles
Parents' concerns about children are highly prevalent but often not confirmed by child doctors and nurses
Reijneveld, Sijmen A
de Meer, Gea
Wiefferink, Carin H
Crone, Matty R
BMC Public Health
The aim of this study was to assess the prevalence in the general population of parents' concerns about the development of their child, to identify groups at risk and to assess the association between parents' concerns and professional judgement.
We obtained cross-sectional data on a Dutch nationally representative sample of children aged 14 months, 3 3/4, 5–6 and 8–12 years within the setting of routine well-child visits provided to the entire population. A total of 4,107 participated (response rate 85.3%). Data were about concerns that parents reported by questionnaire before the visit regarding behavioural and emotional problems, developmental delay, consequences of disease and contact with peers that needed professional assistance, and about the assessment of these domains by doctors and nurses during the visit. Moreover, we obtained data on parent-reported psychosocial problems using the Infant-Toddler Social and Emotional Assessment and the Child Behavior Checklist.
Of all parents, 49.3% reported some concerns and 8.7% reported frequent concerns, most frequently on child behaviour. Frequent concerns were most likely to refer to young children, children from labour immigrant families, with fathers of medium educational level and in low-income families. The prevalence rates of professional-assessed parenting problems were much lower than parent-reported ones. The rates of psychosocial problems were highest in the case of shared concerns, but also higher if parents expressed concerns that were not confirmed by professionals.
A very large proportion of parents of young children have concerns regarding their child, but agreement on these concerns with child health professionals is relatively low.
Related Articles
Parents of young people with self-harm or suicidal behaviour who seek help – a psychosocial profile
Morgan, Sophia
Rickard, Eóin
Noone, Martha
Boylan, Carole
Carthy, Andreé
Crowley, Sinead
Butler, John
Guerin, Suzanne
Fitzpatrick, Carol
Child and Adolescent Psychiatry and Mental Health
Deliberate Self-Harm (DSH) is a common problem among children and adolescents in clinical and community populations, and there is a considerable amount of literature investigating factors associated with DSH risk and the effects of DSH on the child. However, there is a dearth of research examining the impact of DSH on parents, and there are few support programmes targeted at this population. This cross-sectional study examines the profile of a sample of parents of young people with DSH who participated in a support programme (Supporting Parents and Carers of young people with self-harm: the SPACE programme), with the goal of investigating pre-test parental well-being, family communication, parental satisfaction, perceived parental social support, and child strengths and difficulties.
Participants were 130 parents who attended the SPACE programme between 2009 and 2012, and who completed six questionnaires at baseline: the General Health Questionnaire-12, Strengths and Difficulties Questionnaire, Kansas Parenting Satisfaction Scale, General Functioning Scale of the McMaster Family Assessment Device, Multidimensional Scale of Perceived Social Support, and a demographic questionnaire.
The majority of parents met criteria for minor psychological distress (86%) and rated the quantity and severity of their children's difficulties as being in the abnormally high range (74%) at baseline. A majority of participants (61%) rated their perceived social support as being poor. Lower parental well-being was significantly correlated with poorer family communication, poorer parenting satisfaction, and a greater number of difficulties for the child. Perceived social support was not significantly correlated with parental well-being. Parents whose children were not attending school at baseline had significantly lower well-being scores than those whose children were. Parents whose children had received a formal diagnosis of a mental health disorder also had significantly lower well-being scores than those whose children had not.
Parents of young people with DSH behaviours face considerable emotional and practical challenges; they have low levels of well-being, parenting satisfaction, social support, and experience poor family communication. Given the importance of parental support for young people with DSH behaviours, consideration should be given to the need for individual or group support for such parents.
Deliberate self-harm; Parents; Help-seeking; Adolescents; Suicidal behaviour; Parental well-being; Group support programme
Related Articles
Does a parental history of cancer moderate the associations between impaired health status in parents and psychosocial problems in teenagers: a HUNT study
Jeppesen, Elisabeth
Bjelland, Ingvar
Fosså, Sophie D
Loge, Jon H
Sørebø, Øystein
Dahl, Alv A
Cancer Medicine
Severe disease in a parent is associated with increased psychosocial problems in their children. However, moderating factors of such associations are less studied. In this cross-sectional population-based controlled study we examined the moderating effects of a history of parental cancer on the association between impaired health status in parents and psychosocial problems among their teenagers. Among families with both parents responding to the adult Health Survey of Nord-Trøndelag County of Norway (the HUNT-2 study) 71 couples were identified with primary invasive cancer in one parent. Their 81 teenage children took part in the Young-HUNT study. These families were compared to 322 cancer-free families with 328 teenagers. Based on self-report data the relations between three variables of parental impaired health and six psychosocial problems in teenagers were analyzed family wise by structural equation modeling. Significant associations between parental and teenagers' variables were observed in eight of 18 models. A history of parental cancer was a significant moderator which decreased four of eight significant associations. Such a history significantly weakened the associations between parental poor self-rated health and teenagers' anxiety/depression and school problems. A similar association of a history of parental cancer was found between psychological distress in parents and teenagers' feelings of loneliness and poor self-rated health. This study confirmed strong associations between impaired parental health and psychosocial problems in their teenagers. A history of parental cancer weakened several of the significant associations between parental impaired health variables and psychosocial problems in their teenagers.
HUNT-2; parental cancer; psychosocial problems; teenagers; young-HUNT
Related Articles
The effect of family-centered empowerment model on quality of life of school–aged children with thalassemia major
Borhani, Fariba
Najafi, Maral Kargar
Rabori, Eshaq Dortaj
Sabzevari, Sakkineh
Iranian Journal of Nursing and Midwifery Research
Chronic nature of thalassemia causes changes in different aspects of life in patients, including their quality of life. Because of the important role of family in caring for children with thalassemia, this study was done to evaluate the effect of family-centered empowerment model on quality of life of the children aged 6-12 years with thalassemia in Kerman Thalassemia Center.
The present experimental study was carried out on 86 thalassemic children aged 6-12 years who were randomly divided into case and control groups. Data collection tools consisted of demographic and general quality of life questionnaires in children that included physical, emotional and social aspects in addition to school functions. The questionnaires were used after determination of content validity and reliability by internal correlation method. This model was performed in test group according to four steps (threat perception, problem solving, educational participation and evaluation). Quality of life was measured 1.5 months after the intervention.
The results showed that the average quality of life of thalassemic children before the intervention was 26.23 in test group and 27.62 in the control group and they were not significantly different (p > 0.05). However after performing the model, the average quality of life in the test group reached 35.19 while it was 28.02 in control group and the observed difference was statistically significant (p < 0.05).
According to the impact of this model on quality of life in thalassemic children, it is recommended that evaluating the effectiveness of this model should be considered in further studies of other ages and other chronic diseases.
Children; empowerment; quality of life; thalassemia
Related Articles
Externalizing Behaviors among Children of HIV Seropositive Former and Current Drug Users: Parent Support Network Factors as Social Ecological Risks
Knowlton, Amy
Buchanan, Amy
Wissow, Lawrence
Pilowsky, Daniel J.
Latkin, Carl
Journal of Urban Health
Children affected by their parents' dual drug use and HIV/AIDS face considerable challenges to their psychosocial development, including parent dysfunction and foster care placement. While HIV/AIDS may increase parents' mobilization of social support, their drug use may restrict who is available to help them, with potential implications to the adjustment of their children with whom they remain in contact. This study sought to identify dually affected children's living situations, and parent and parent's support network factors as correlates of children's externalizing problem behaviors. An urban community sample of 462 HIV seropositive, current or former drug-using parents were queried about their children aged 5–15 years old. One hundred ninety-four children were reported by 119 parents. The outcome was children's externalizing behaviors of ever having been suspended or expelled from school, criminal-justice system involvement, or illicit drug or heavy alcohol use. Independent variables included kin and drug users in parent's support network. Generalized estimating equations were used to adjust for the potential correlation of children of the same parent. Among parents, 63% were mothers, 57% current opioid or cocaine users, 85% were African American, 35% had AIDS or CD <200, and 53% had high depressive symptoms (CES-D ≥ 16); median age was 38. Among children, median age was 12; 23% lived with the nominating parent, 65% with other family, and 11% in non-kin foster care. While only 34% of parents reported child custody, 43% reported daily contact with their child, and 90% reported high emotional closeness. Parents reported externalizing behaviors among 32% of the children. Logistic regression indicated that externalizing behavior was positively associated with parent's physical limitations and proportion of illicit drug users in parent's support network. A significant interaction was found indicating that the effect of parent's support network-level drug use was greater for children living with versus not living with the parent. The model adjusted for parent's current drug use and depressive symptoms, which were not significant. Results indicate that while only a minority of these dually affected children lived with the parent, the parents' physical limitations and embeddedness in drug using support networks, particularly if living with their children, was associated with the children's maladjustment. It is plausible that these factors interfere with parenting, expose the children to conflict or adverse social influences, or obligate children to assume caregiving for their parent. While dually affected children's contact with their parents may have important benefits, results suggest it presents ongoing needs for intervention with the children, their parents, and caregivers.
Parental illicit drug use; HIV/AIDS affected children; Child psychosocial functioning; Externalizing behaviors; Social support networks; Informal caregiving; Foster care
Related Articles
Depression in mothers of children with thalassemia or blood malignancies: a study from Iran
Sharghi, Afshan
Karbakhsh, Mojgan
Nabaei, Behrooz
Meysamie, Alipasha
Farrokhi, AliReza
Clinical Practice and Epidemiology in Mental Health : CP & EMH
Several studies have found that parents of children with chronic diseases or disabilities have higher depression scores than control parents. Mothers usually take on the considerable part of the extra care and support that these children need and thus are at markedly increased risks of suffering from psychological distress and depression. The main aim of the present study was to investigate if mothers of children with thalassemia or blood malignancies have higher scores of depression compared with a group of control mothers.
Methods and materials
In this cross – sectional study, 294 mothers were recruited in three groups and assessed using the Beck Depression Inventory (BDI): mothers of children with thalassemia, mothers of children with blood malignancies and a control group. SPSS version 11.5 with chi square, ANOVA, linear and logistic regression were used for statistical analysis.
The only variable bearing a statistically significant relationship with the depression score of mothers was the child's disease: for thalassemia with OR of 2.17 (95% CI = 1.16–4.0, P = 0.015), for blood malignancies with OR of 2.71 (95% CI = 1.48–4.99, P = 0.001).
Discussion and conclusion
The results of this study can contribute to the development of a screening program for decreasing depression burden and promoting quality of life for mothers of children with thalassemia or blood malignancies.
Related Articles
Children and adolescents adjustment to parental multiple sclerosis: a systematic review
Razaz, Neda
Nourian, Reza
Marrie, Ruth Ann
Boyce, W Thomas
Tremlett, Helen
BMC Neurology
Families are the primary source of support and care for most children. In Western societies, 4 to 12% of children live in households where a parent has a chronic illness. Exposure to early-life stressors, including parenting stress, parental depression and parental chronic disease could lead to harmful changes in children's social, emotional or behavioural functioning. Little is known about the child living with a parent who has Multiple Sclerosis (MS). We systematically reviewed the literature regarding possible effects of having a parent with MS on the child's or adolescent's psychosocial adjustment.
The following databases: MEDLINE, PsychInfo, CINAHL, EMBASE, Web of Knowledge, ERIC, and ProQuest Digital Dissertations were searched (from 1806 to December 2012). References from relevant articles were also manually searched. Selected studies were evaluated using the Graphic Appraisal Tool for Epidemiology (GATE).
The search yielded 3133 titles; 70 articles were selected for full text review. Eighteen studies met inclusion criteria. Fourteen studies employed quantitative techniques, of which 13 were cross-sectional and one was longitudinal. Four studies were both qualitative and cross-sectional in design. Only 2 of 18 studies were rated as having high methodological quality. Overall, eight studies reported that children of MS patients exhibited negative psychosocial traits compared with children of "healthy" parents. Specifically for adolescents, greater family responsibilities were linked to lower social relationships and higher distress. Three studies indicated that parental MS was associated with positive adjustment in children and adolescents, such as higher personal competence, while four found no statistically significant differences.
Although having a parent with MS was often reported to have negative psychosocial effects on children and adolescents, there was a lack of consensus and some positive aspects were also found. However, few high quality studies were identified which makes it difficult to draw evidence-based conclusions at this point. There are potentially important, long-term impacts of early life stressors, such as having a parent with a chronic disease, on subsequent life chances and health, and thus more extensive and higher quality research in this area is greatly needed.
Multiple sclerosis; Child development; Parenting; Child of impaired parents; Cohort studies
Related Articles
Quality of the parent-child interaction in young children with type 1 diabetes mellitus: study protocol
Nieuwesteeg, Anke M
Pouwer, Frans
van Bakel, Hedwig JA
Emons, Wilco HM
Aanstoot, Henk-Jan
Odink, Roelof
Hartman, Esther E
BMC Pediatrics
In young children with type 1 diabetes mellitus (T1DM) parents have full responsibility for the diabetes-management of their child (e.g. blood glucose monitoring, and administering insulin). Behavioral tasks in childhood, such as developing autonomy, and oppositional behavior (e.g. refusing food) may interfere with the diabetes-management to achieve an optimal blood glucose control. Furthermore, higher blood glucose levels are related to more behavioral problems. So parents might need to negotiate with their child on the diabetes-management to avoid this direct negative effect. This interference, the negotiations, and the parent's responsibility for diabetes may negatively affect the quality of parent-child interaction. Nevertheless, there is little knowledge about the quality of interaction between parents and young children with T1DM, and the possible impact this may have on glycemic control and psychosocial functioning of the child. While widely used global parent-child interaction observational methods are available, there is a need for an observational tool specifically tailored to the interaction patterns of parents and children with T1DM. The main aim of this study is to construct a disease-specific observational method to assess diabetes-specific parent-child interaction. Additional aim is to explore whether the quality of parent-child interactions is associated with the glycemic control, and psychosocial functioning (resilience, behavioral problems, and quality of life).
First, we will examine which situations are most suitable for observing diabetes-specific interactions. Then, these situations will be video-taped in a pilot study (N = 15). Observed behaviors are described into rating scales, with each scale describing characteristics of parent-child interactional behaviors. Next, we apply the observational tool on a larger scale for further evaluation of the instrument (N = 120). The parents are asked twice (with two years in between) to fill out questionnaires about psychosocial functioning of their child with T1DM. Furthermore, glycemic control (HbA1c) will be obtained from their medical records.
A disease-specific observational tool will enable the detailed assessment of the quality of diabetes-specific parent-child interactions. The availability of such a tool will facilitate future (intervention) studies that will yield more knowledge about impact of parent-child interactions on psychosocial functioning, and glycemic control of children with T1DM.
Related Articles
The Long-Term Health Consequences of Child Physical Abuse, Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis
Norman, Rosana E.
Byambaa, Munkhtsetseg
De, Rumna
Butchart, Alexander
Scott, James
Vos, Theo
PLoS Medicine
Rosana Norman and colleagues conduct a systematic review and meta-analysis to assess the relationship between child physical abuse, emotional abuse, and neglect, and subsequent mental and physical health outcomes.
Child sexual abuse is considered a modifiable risk factor for mental disorders across the life course. However the long-term consequences of other forms of child maltreatment have not yet been systematically examined. The aim of this study was to summarise the evidence relating to the possible relationship between child physical abuse, emotional abuse, and neglect, and subsequent mental and physical health outcomes.
Methods and Findings
A systematic review was conducted using the Medline, EMBASE, and PsycINFO electronic databases up to 26 June 2012. Published cohort, cross-sectional, and case-control studies that examined non-sexual child maltreatment as a risk factor for loss of health were included. All meta-analyses were based on quality-effects models. Out of 285 articles assessed for eligibility, 124 studies satisfied the pre-determined inclusion criteria for meta-analysis. Statistically significant associations were observed between physical abuse, emotional abuse, and neglect and depressive disorders (physical abuse [odds ratio (OR) = 1.54; 95% CI 1.16–2.04], emotional abuse [OR = 3.06; 95% CI 2.43–3.85], and neglect [OR = 2.11; 95% CI 1.61–2.77]); drug use (physical abuse [OR = 1.92; 95% CI 1.67–2.20], emotional abuse [OR = 1.41; 95% CI 1.11–1.79], and neglect [OR = 1.36; 95% CI 1.21–1.54]); suicide attempts (physical abuse [OR = 3.40; 95% CI 2.17–5.32], emotional abuse [OR = 3.37; 95% CI 2.44–4.67], and neglect [OR = 1.95; 95% CI 1.13–3.37]); and sexually transmitted infections and risky sexual behaviour (physical abuse [OR = 1.78; 95% CI 1.50–2.10], emotional abuse [OR = 1.75; 95% CI 1.49–2.04], and neglect [OR = 1.57; 95% CI 1.39–1.78]). Evidence for causality was assessed using Bradford Hill criteria. While suggestive evidence exists for a relationship between maltreatment and chronic diseases and lifestyle risk factors, more research is required to confirm these relationships.
This overview of the evidence suggests a causal relationship between non-sexual child maltreatment and a range of mental disorders, drug use, suicide attempts, sexually transmitted infections, and risky sexual behaviour. All forms of child maltreatment should be considered important risks to health with a sizeable impact on major contributors to the burden of disease in all parts of the world. The awareness of the serious long-term consequences of child maltreatment should encourage better identification of those at risk and the development of effective interventions to protect children from violence.
Please see later in the article for the Editors' Summary
Editors' Summary
Child maltreatment—the abuse and neglect of children—is a global problem. There are four types of child maltreatment—sexual abuse (the involvement of a child in sexual activity that he or she does not understand, is unable to give consent to, or is not developmentally prepared for), physical abuse (the use of physical force that harms the child's health, survival, development, or dignity), emotional abuse (the failure to provide a supportive environment by, for example, verbally threatening the child), and neglect (the failure to provide for all aspects of the child's well-being). Most child maltreatment is perpetrated by parents or parental guardians, many of whom were maltreated themselves as children. Other risk factors for parents abusing their children include poverty, mental health problems, and alcohol and drug misuse. Although there is considerable uncertainty about the frequency and severity of child maltreatment, according to the World Health Organization (WHO) about 20% of women and 5%–10% of men report being sexually abused as children, and the prevalence of physical abuse in childhood may be 25%–50%.
Why Was This Study Done?
Child maltreatment has a large public health impact. Sometimes this impact is immediate and direct (injuries and deaths), but, more often, it is long-term, affecting emotional development and overall health. For child sexual abuse, the relationship between abuse and mental disorders in adult life is well-established. Exposure to other forms of child maltreatment has also been associated with a wide range of psychological and behavioral problems, but the health consequences of physical abuse, emotional abuse, and neglect have not been systematically examined. A better understanding of the long-term health effects of child maltreatment is needed to inform maltreatment prevention strategies and to improve treatment for children who have been abused or neglected. In this systematic review and meta-analysis, the researchers quantify the association between exposure to physical abuse, emotional abuse, and neglect in childhood and mental health and physical health outcomes in later life. A systematic review uses predefined criteria to identify all the research on a given topic; a meta-analysis is a statistical approach that combines the results of several studies.
What Did the Researchers Do and Find?
The researchers identified 124 studies that investigated the relationship between child physical abuse, emotional abuse, or neglect and various health outcomes. Their meta-analysis of data from these studies provides suggestive evidence that child physical abuse, emotional abuse, and neglect are causally linked to mental and physical health outcomes. For example, emotionally abused individuals had a three-fold higher risk of developing a depressive disorder than non-abused individuals (an odds ratio [OR] of 3.06). Physically abused and neglected individuals also had a higher risk of developing a depressive disorder than non-abused individuals (ORs of 1.54 and 2.11, respectively). Other mental health disorders associated with child physical abuse, emotional abuse, or neglect included anxiety disorders, drug abuse, and suicidal behavior. Individuals who had been non-sexually maltreated as children also had a higher risk of sexually transmitted diseases and/or risky sexual behavior than non-maltreated individuals. Finally, there was weak and inconsistent evidence that child maltreatment increased the risk of chronic diseases and lifestyle risk factors such as smoking.
What Do These Findings Mean?
By providing suggestive evidence of a causal link between non-sexual child maltreatment and mental health disorders, drug use, suicide attempts, and sexually transmitted diseases and risky sexual behavior, these findings contribute to our understanding of the non-injury health impacts of child maltreatment. Although most of the studies included in the meta-analysis were undertaken in high-income countries, the findings suggest that this link occurs in both high- and low-to-middle-income countries. They also suggest that neglect may be as harmful as physical and emotional abuse. However, they need to be interpreted carefully because of the limitations of this meta-analysis, which include the possibility that children who have been abused may share other, unrecognized factors that are actually the cause of their later mental health problems. Importantly, this confirmation that physical abuse, emotional abuse, and neglect in childhood are important risk factors for a range of health problems draws attention to the need to develop evidence-based strategies for preventing child maltreatment both to reduce childhood suffering and to alleviate an important risk factor for later health problems.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001349.
The World Health Organization provides information on child maltreatment and its prevention (in several languages); Preventing Child Maltreatment: A Guide to Taking Action and Generating Evidence is a 2006 report produced by WHO and the International Society for Prevention of Child Abuse and Neglect
The US Centers for Disease Control and Prevention provides information on child maltreatment and links to additional resources
The National Society for the Prevention of Cruelty to Children (NSPCC) is a not-for-profit organization that aims to end all cruelty to children in the UK; Childline is a resource provided by the NSPCC that provides help, information, and support to children who are being abused
The Hideout is a UK-based website that helps children and young people understand domestic abuse
Childhelp is a US not-for-profit organization dedicated to helping victims of child abuse and neglect; its website includes a selection of personal stories about child maltreatment
Related Articles
Zinc and Copper Status in Children with Beta-Thalassemia Major
Mahyar, Abolfazl
Ayazi, Parviz
Pahlevan, Ali-Asghar
Mojabi, Hoshyar
Sehhat, Mohammad-Reza
Javadi, Amir
Iranian Journal of Pediatrics
There are some reports in which a condition of zinc deficiency and its associated outcomes with a change in concentration of serum copper among the thalassemic patients has been highlighted. The aim of this prospective study was to determine the serum zinc and copper levels in children with beta-thalassemia major.
In this cross sectional study all children under 12 years affected by beta thalassemia major (40 patients) were evaluated for serum zinc and copper levels in Qazvin thalassemia center (Qazvin, Iran) in 2007. Serum measurements for zinc and copper were performed by atomic absorption spectrophotometer.
The mean concentrations of serum zinc and copper levels were 67.35±20.38 and 152.42±24.17 µg/dl respectively. Twenty-six (65%) of thalassemic patients had zinc concentration under 70 µg/dl (hypozincemia). None of the thalassemic children had copper deficiency. No significant correlation between serum zinc level with age, weight, height, body mass index, duration of blood transfusion, desferrioxamine dose and ferritin level was observed in thalassemic patients (P=0.3).
This study revealed that hypozincemia is common in thalassemic patients, but in contrast, there is no copper deficiency. Further evaluation in this regard is recommended.
Beta-thalassemia; Zinc; Copper; Children
Related Articles
Psychological health of family caregivers of children admitted at birth to a NICU and healthy children: a population-based cross-sectional survey
Klassen, Anne F
Lee, Shoo K
Raina, Parminder
Lisonkova, Sarka
BMC Pediatrics
There is little information in the research literature on how parents of children who spend time in a neonatal intensive care unit (NICU) adapt psychologically to the demands of caregiving beyond the initial hospitalization period. Our aim was to compare parents of NICU children with parents of healthy full-term children, looking specifically at the relationship between parental psychosocial health and child characteristics, as well as the relationship between important predictor variables and psychosocial health.
A cross-sectional survey was sent to parents as their child turned 3 1/2 years of age. The setting was the province of British Columbia, Canada. The sample included all babies admitted to tertiary level neonatal intensive care units (NICU) at birth over a 16-month period, and a consecutive sample of healthy babies. The main outcome was the SF-36 mental component summary (MCS) score. Predictor variables included caregiver gender; caregiver age; marital status; parental education; annual household income; child health status; child behavior; birth-related risk factors; caregiver strain; and family function.
Psychosocial health of NICU parents did not differ from parents of healthy children. Child health status and behavior for NICU and healthy children were strongly related to MCS score in bivariate analysis. In the pooled multivariate model, parental age, low family function, high caregiver strain, and child's internalizing and externalizing behavioral symptoms were independently associated with lower psychosocial health. In addition, female gender was associated with lower psychosocial health in the NICU group, whereas lower education and child's problem with quality of life indicated lower psychosocial health in the healthy baby group.
Overall, parental gender, family functioning and caregiver strain played influential roles in parental psychosocial health.
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Social-Emotional Problems in Preschool-Aged Children
Brown, Courtney M.
Copeland, Kristen A.
Sucharew, Heidi
Kahn, Robert S.
Archives of pediatrics & adolescent medicine
To estimate the prevalence of positive screens for social-emotional problems among preschool-aged children in a low-income clinical population and to explore the family context and receptivity to referrals to help guide development of interventions.
Observational, cross-sectional study.
Two urban primary care clinics.
A total of 254 parents of 3- and 4-year-old children at 2 urban primary care clinics.
Main Outcome Measures
Score on a standardized screen for social-emotional problems (Ages and Stages Questionnaire: Social-Emotional) and answers to additional survey questions about child care arrangements, parental depressive symptoms, and attitudes toward preschool and behavioral health referrals.
Twenty-four percent (95% CI, 16.5%-31.5%) of children screened positive for social-emotional problems. Among those screening positive, 45% had a parent with depressive symptoms, and 27% had no nonparental child care. Among parents of children who screened positive for social-emotional problems, 79% reported they would welcome or would not mind a referral to a counselor or psychologist; only 16% reported a prior referral.
In a clinical sample, 1 in 4 low-income preschool-aged children screened positive for social-emotional problems, and most parents were amenable to referrals to preschool or early childhood mental health. This represents an opportunity for improvement in primary prevention and early intervention for social-emotional problems.
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Causes of New Cases of Major Thalassemia in Sistan and Balouchistan Province in South-East of Iran
Miri-Moghaddam, E
Naderi, M
Izadi, S
Mashhadi, MA
Iranian Journal of Public Health
Thalassemia is the most common monogenic disease in South-East of Iran. Despite the 70% reduction in Iranian thalassemia cases after thalassemia control comprehensive program, 601 affected babies were born in Sistan and Balouchistan Province, Iran from 2002 to 2010, so this study aims at investigating the causes of new thalassemia cases.
Data from this retrospective cross-sectional study was collected through interviews and information in the patients' hospital records.
Data revealed that 52.4% of fathers and 78.4% of mothers of thalassemic children had elementary education or less. In addition, 78.6% of the couples did not undergo premarital screening for thalassemia and 71.2% of the couples were not notified of their own minor thalassemia until a child was born with major thalassemia. Of the diagnosed minor couples, about 25% did PND and the others did not carry out because mothers were unaware of proper gestational age and of the importance of this issue, financial problems, and the husbands' disagreement to take the tests. Moreover, 16 mothers, in spite of being diagnosed of having a major fetus, refused to terminate the pregnancy.
The most preventable causes for affected births include couples' unawareness of being minor and unawares of the PND importance and process.
Thalassemia; Prevention; Prenatal diagnosis; Premarital screening; Iran
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Improving mental health of adolescents with Type 1 diabetes: protocol for a randomized controlled trial of the Nothing Ventured Nothing Gained online adolescent and parenting support intervention
Hackworth, Naomi J
Matthews, Jan
Burke, Kylie
Petrovic, Zvezdana
Klein, Britt
Northam, Elisabeth A
Kyrios, Michael
Chiechomski, Lisa
Cameron, Fergus J
BMC Public Health
Management of Type 1 diabetes comes with substantial personal and psychological demands particularly during adolescence, placing young people at significant risk for mental health problems. Supportive parenting can mitigate these risks, however the challenges associated with parenting a child with a chronic illness can interfere with a parent's capacity to parent effectively. Interventions that provide support for both the adolescent and their parents are needed to prevent mental health problems in adolescents; to support positive parent-adolescent relationships; and to empower young people to better self-manage their illness. This paper presents the research protocol for a study evaluating the efficacy of the Nothing Ventured Nothing Gained online adolescent and parenting intervention which aims to improve the mental health outcomes of adolescents with Type 1 diabetes.
A randomized controlled trial using repeated measures with two arms (intervention and wait-list control) will be used to evaluate the efficacy and acceptability of the online intervention. Approximately 120 adolescents with Type 1 diabetes, aged 13–18 years and one of their parents/guardians will be recruited from pediatric diabetes clinics across Victoria, Australia. Participants will be randomized to receive the intervention immediately or to wait 6 months before accessing the intervention. Adolescent, parent and family outcomes will be assessed via self-report questionnaires at three time points (baseline, 6 weeks and 6 months). The primary outcome is improved adolescent mental health (depression and anxiety). Secondary outcomes include adolescent behavioral (diabetes self-management and risk taking behavior), psychosocial (diabetes relevant quality of life, parent reported child well-being, self-efficacy, resilience, and perceived illness benefits and burdens); metabolic (HbA1c) outcomes; parent psychosocial outcomes (negative affect and fatigue, self-efficacy, and parent experience of child illness); and family outcomes (parent and adolescent reported parent-adolescent communication, responsibility for diabetes care, diabetes related conflict). Process variables including recruitment, retention, intervention completion and intervention satisfaction will also be assessed.
The results of this study will provide valuable information about the efficacy, acceptability and therefore the viability of delivering online interventions to families affected by chronic illnesses such as Type 1 diabetes.
Trial registration
Australian New Zealand clinical trials registry (ANZCTR); ACTRN12610000170022
Diabetes; Mental health; Parenting; Adolescents; Online intervention
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Assessment of psychosocial functioning and its risk factors in children with pectus excavatum
Ji, Yi
Liu, Wenying
Chen, Siyuan
Xu, Bing
Tang, Yunman
Wang, Xuejun
Yang, Gang
Cao, Liming
Health and Quality of Life Outcomes
Psychosocial functioning is poor in patients with pectus excavatum (PE). However, a comprehensive understanding of this issue does not exist. The aim of this study was to assess the severity of psychosocial problems as associated with PE, as well as to identify its risk factors.
A comparative study was performed at the Sichuan Academy of Medical Sciences/Sichuan Provincial People's Hospital in Chengdu, China. Patients age 6 to 16 who admitted to the outpatient department for the evaluation or treatment for PE were included in the study. In addition to parental reports of child psychosocial problems on the Achenbach Child Behavior Checklist (CBCL), parents also filled in other structured questionnaires, including socio-demographic variables, patients' medical and psychological characteristics. The severity of malformation was assessed by CT scan. For comparison, an age- and gender- matched control group was recruited from the general population. The socio-demographic and scores on CBCL were compared between patients and control subjects. Univariate and multivariate analysis were performed to examine risk factors for psychosocial problems in patients.
No statistically significant differences were found with respect to social-demographic variables between children with PE and control subjects. Compared with control subjects, children with PE displayed higher prevalence of psychosocial problems in the different scales of the CBCL questionnaire such as 'withdraw', 'anxious-depressed', 'social problems' and 'total problems'. Both univariate and multivariate analyses suggested that age, severity of malformation, and being teased about PE were significantly associated with patients' psychosocial problems.
The information derived from this study supports the opinion that children with PE have more psychosocial problems than children from the general population. Multiple medical and psychosocial factors were associated with patients' impairment of psychosocial functioning.
Related Articles
Perceived HIV stigma among children in a high HIV-prevalence area in central China: Beyond the parental HIV-related illness and death
Lin, Xiuyun
Zhao, Guoxiang
Li, Xiaoming
Stanton, Bonita
Zhang, Liying
Hong, Yan
Zhao, Junfeng
Fang, Xiaoyi
AIDS care
(1) examine the psychometric properties of two parallel measures of HIV-related stigma (i.e., perceived public stigma and children's personal stigma against PLWHA) among these children; (2) examine whether expressions of stigma measures differ by child's sex, developmental stage, family SES, or orphanhood status (i.e., AIDS orphans, vulnerable children, and comparison children); and (3) examine the association between HIV-related stigma and children's psychosocial adjustments among these children.
Cross-sectional data were collected from 755 AIDS orphans (children who had lost one or both their parents to AIDS), 466 vulnerable children who lived with HIV-infected parents, and 404 comparison children who did not experience HIV-related illness and death in their families. The measures included perceived public stigma, personal stigma, depressive symptoms, loneliness, self-esteem, future expectations, hopefulness about the future, and perceived control over the future.
Both stigma scales were positively associated with psychopathological symptoms (e.g., depression, loneliness) and negatively associated with psychosocial wellbeing (e.g., self-stigma, positive future expectation, hopefulness about future, and perceived control over the future). Both stigma measures contribute to children's psychosocial problems independent of their orphanhood status and other key demographic factors.
Community-wide stigma reduction and psychological support should be part of the care efforts for children affected by AIDS. Stigma reduction efforts should not only target the stigma against PLWHA but also possible stigma against the entire community (e.g., villages) with a high prevalence of HIV/AIDS. The stigma reduction efforts also needs to be appropriate for children's age, gender, family SES and AIDS experience in the family. Future research should explore individual and contextual factors such as social support, coping and attachment in mitigating the negative effect of stigma among these children.
Related Articles
Motives for choosing growth-enhancing hormone treatment in adolescents with idiopathic short stature: a questionnaire and structured interview study
Visser – van Balen, Hanneke
Geenen, Rinie
Kamp, Gerdine A
Huisman, Jaap
Wit, Jan M
Sinnema, Gerben
BMC Pediatrics
Growth-enhancing hormone treatment is considered a possible intervention in short but otherwise healthy adolescents. Although height gain is an obvious measure for evaluating hormone treatment, this may not be the ultimate goal for the person, but rather a means to reach other goals such as the amelioration of current height-related psychosocial problems or the enhancement of future prospects in life and society. The aim of our study was to clarify the motives of adolescents and their parents when choosing to participate in a growth-enhancing trial combining growth hormone and puberty-delaying hormone treatment.
Participants were early pubertal adolescents (25 girls, 13 boys) aged from 11 to 13 years (mean age 11.5 years) with a height standard deviation score (SDS) ranging from -1.03 to -3.43. All had been classified as idiopathic short stature or persistent short stature born small for the gestational age (intrauterine growth retardation) on the basis of a height SDS below -2, or had a height SDS between -1 and -2 and a predicted adult height SDS below -2. The adolescents and their parents completed questionnaires and a structured interview on the presence of height-related stressors, parental worries about their child's behavior and future prospects, problems in psychosocial functioning, and treatment expectations. Questionnaire scores were compared to norms of the general Dutch population.
The adolescents reported normal psychosocial functioning and highly positive expectations of the treatment in terms of height gain, whereas the parents reported that their children encountered some behavioral problems (being anxious/depressed, and social and attention problems) and height-related stressors (being teased and juvenilized). About 40% of the parents were worried about their children's future prospects for finding a spouse or job. The motives of the adolescents and their parents exhibited rather different profiles. The most prevalent parental worries related to the current or future functioning of their children, while a few cases were characterized by no observed motives or by psychosocial problems only reported by the adolescents themselves.
The motives for participating in a growth-enhancing hormone trial are more obvious in the parents than in the adolescents themselves. Two out of three parents report worries about the future opportunities or observe modest current psychosocial problems in their children. The adolescents want to gain height, but the motivation underlying this remains unclear. Few of the adolescents experience psychosocial problems. Our analyses revealed differences among individuals in terms of motives, which implies that in an evaluation of hormone treatment, the importance of divergent outcome variables will also differ among individuals. Effectiveness evaluations of hormone treatment to increase height and the consequential fulfillment of other goals must be awaited.
Related Articles
Prevalence and socio-demographic correlates of stunting and thinness among Pakistani primary school children
Mushtaq, Muhammad Umair
Gull, Sibgha
Khurshid, Usman
Shahid, Ubeera
Shad, Mushtaq Ahmad
Siddiqui, Arif Mahmood
BMC Public Health
Child growth is internationally recognized as an important indicator of nutritional status and health in populations. Child under-nutrition is estimated to be the largest contributor to global burden of disease, and it clusters in South Asia but literature on under-nutrition among school-aged children is difficult to find in this region. The study aimed to assess the prevalence and socio-demographic correlates of stunting and thinness among Pakistani primary school children.
A population-based cross-sectional study was conducted with a representative multistage cluster sample of 1860 children aged 5-12 years in Lahore, Pakistan. Stunting (< -2 SD of height-for-age z-score) and thinness (< -2 SD of BMI-for-age z-score) were defined using the World Health Organization reference 2007. Chi-square test was used as the test of trend. Logistic regression was used to quantify the independent predictors of stunting and thinness and adjusted odds ratios (aOR) with 95% confidence interval (CI) were obtained. Linear regression was used to explore the independent determinants of height- and BMI-for-age z-scores. Statistical significance was considered at P < 0.05.
Eight percent (95% CI 6.9-9.4) children were stunted and 10% (95% CI 8.7-11.5) children were thin. Stunting and thinness were not significantly associated with gender. Prevalence of stunting significantly increased with age among both boys and girls (both P < 0.001) while thinness showed significant increasing trend with age among boys only (P = 0.034). Significant correlates of stunting included age > 8 years, rural area and urban area with low SES, low-income neighborhoods, lower parental education, more siblings, crowded housing and smoking in living place (all P < 0.001). Significant correlates of thinness included rural area and urban area with low SES, low-income neighborhoods and lower parental education (all P < 0.001), and age > 10 years (P = 0.003), more siblings (P = 0.016) and crowded housing (P = 0.006). In multivariate logistic regression analyses adjusted simultaneously for all factors, older age (aOR 3.60, 95% CI 1.89-6.88), urban area with low SES (aOR 2.58, 95% CI 1.15-5.81) and low-income neighborhoods (aOR 4.62, 95% CI 1.63-13.10) were associated with stunting while urban area with low SES (aOR 2.28, 95% CI 1.21-4.30) was associated with thinness. In linear regression analyses adjusted for all factors, low-income neighborhoods and older age were associated with lower height-for-age z-score while rural area with low/disadvantaged SES was associated with lower BMI-for-age z-score.
Relatively low prevalence of stunting and thinness depicted an improvement in the nutritional status of school-aged children in Pakistan. However, the inequities between the poorest and the richest population groups were marked with significantly higher prevalence of stunting and thinness among the rural and the urban poor, the least educated, the residents of low-income neighborhoods and those having crowded houses. An increasing trend with age was observed in prevalence of stunting and thinness. Smoking in living place was associated with stunting. Findings suggest the need to implement evidence-based child health policy and strategies, prioritizing the poor and socially disadvantaged population.
Related Articles
Health-related quality of life in girls and boys with juvenile idiopathic arthritis: self- and parental reports in a cross-sectional study
Lundberg, Veronica
Lindh, Viveca
Eriksson, Catharina
Petersen, Solveig
Eurenius, Eva
Pediatric Rheumatology Online Journal
Juvenile Idiopathic Arthritis (JIA) affects children and adolescents with both short-term and long-term disability. These children also report lower health-related quality of life (HRQOL) compared to their healthy peers. However, there seems to be some discrepancies between self- and parent-reports, and gender differences need to be further studied. This study aims to describe HRQOL in girls and boys with JIA, and to explore gender differences in self-reports compared to parent-reports of HRQOL in children with JIA.
Fifty-three children and adolescents with JIA (70% girls and 30% boys) with a median age of 14 years (8–18 years), and their parents, participated in this cross-sectional study in Sweden. Data was systematically collected prior to ordinary visits at a Pediatric outpatient clinic, during a period of 16 months (2009–2010). Disability was assessed with the Childhood Health Assessment Questionnaire (CHAQ), and disease activity by physicians' assessments and Erythrocyte Sedimentation Rate (ESR). The Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) was used to assess self- and parent-reports of HRQOL in the child.
In this sample of children with generally low disease activity and mild to moderate disability, more than half of the children experienced suboptimal HRQOL, equally in girls and boys. Significant differences between self- and parent-reports of child HRQOL were most evident among girls, with lower parent-reports regarding the girl's physical- and psychosocial health as well as in the total HRQOL score. Except for the social functioning subscale, where parents' reports were higher compared to their sons, there were no significant differences between boys- and parent-reports.
More than half of the girls and boys experienced suboptimal HRQOL in this sample, with no gender differences. However, there were differences between self- and parent-reports of child HRQOL, with most significant differences found among the girls. Thus, differences between self- and parent-reports of child HRQOL must be taken into account in clinical settings, especially among girls with JIA.
Adolescent; Child; Gender; Parents; Pediatrics; Questionnaire
Related Articles
Psychological morbidity among suicide-bereaved and non-bereaved parents: a nationwide population survey
Omerov, Pernilla
Steineck, Gunnar
Nyberg, Tommy
Runeson, Bo
Nyberg, Ullakarin
BMJ Open
To determine how psychological premorbidity affects the risk of depression in parents who lost a child through suicide.
Population-based survey.
Sweden, between 2009 and 2010.
All parents who lost a child, age 15–30, through suicide between 2004 and 2007 according to National population registries. Non-bereaved parents matched for age, sex, living area, marital status, number of children. Exclusion criteria: born outside a Nordic country, not Swedish speaking, contact details missing. Participants: 666 of 915 (73%) suicide-bereaved and 377 of 508 (74%) non-bereaved parents.
Main outcome measures
Depression measured by the nine-item depression scale of the Patient Health Questionnaire (PHQ-9) and study-specific questions to assess psychological premorbidity and experience of the child's presuicidal morbidity.
In all, 94 (14%) suicide-bereaved and 51 (14%) non-bereaved parents (relative risk 1.0; 95% CI 0.8 to 1.4) had received their first treatment for psychological problems or had been given a psychiatric diagnosis more than 10 years earlier. The prevalence of moderate-to-severe depression was 115 (18%) in suicide-bereaved versus 28 (7%) in non-bereaved parents (RR 2.3; 95% CI 1.6 to 3.5). For those without psychological premorbidity, the relative risk was 2.3 (95% CI 1.4 to 3.6). 339 (51%) suicide-bereaved parents expressed worry over the child's psychological health during the month preceding the suicide and 259 (39%) had anticipated the suicide.
In parents who lost a child through suicide in Sweden we did not find a higher prevalence of long-term psychological premorbidity than among parents who had not lost a child; the more than twofold risk of depression among the bereaved can probably be explained by the suicide and the stressful time preceding the suicide.
Related Articles
Assessment of psychosocial variables by parents of youth with type 1 diabetes mellitus
Malerbi, Fani Eta Korn
Negrato, Carlos Antonio
Gomes, Marilia B
Diabetology & Metabolic Syndrome
To evaluate the impact of type 1 diabetes (T1D) on family functioning and child-rearing practices from parents' point of view, to assess parents' health-related quality of life and to explore the relations between psychosocial variables and diabetes care outcomes in youth with diabetes.
This research was part of the cross-sectional multicenter Brazilian Type 1 Diabetes Study, conducted between December 2008 and December 2010 in 28 public clinics of 20 cities across four Brazilian geographical regions. Psychosocial questions were addressed to 1,079 parents of patients with T1D through an interview (89.3% mothers, 52.5% Caucasians, 38.6 ± 7.6 years old). Overall, 72.5% of the families were from low or very low socioeconomic levels. Parents were also submitted to health-related quality of life instruments (EQ-5D+EQ-VAS). Clinical data from the last medical appointment were collected by a physician using standardized chart review forms. The demographic, educational and socioeconomic profiles were also obtained and HbA1c levels registered.
Discomfort and anxiety/depression were the main complaints in EQ-5D, and were significantly more frequent in mothers (37.3% and 53.4%, respectively) than in fathers (25.7% and 32.7%, respectively). The mother was the only parent involved in diabetes care in 50.5% of the cases. The majority of parents (78.5%) mentioned changes in family functioning after the diagnosis, although they neither treated their diabetic children differently from the others (76.3%), nor set prohibitions (69.1%) due to diabetes. The majority was worried about diabetes complications (96.4%) and felt overwhelmed by diabetes care (62.8%). Parents report of overwhelming was significantly associated with anxiety/depression, as measured by the EQ-5D questionnaire. Less than half of the patients had already slept over, and the permission to do it increased as a function of children's age. Nearly half of the parents (52%) admitted to experiencing difficulties in setting limits for their children/adolescents. HbA1c levels in patients from this group (9.7 ± 2.5%) were significantly higher than those of children/adolescents whose parents reported no difficulties towards limit-setting (8.8 ± 2.1%). Parents whose children/adolescents reported the occurrence of hypoglycemic episodes in the last month complained significantly more about anxiety/depression (55.1%) than parents from patients who did not report it (45.7%). Also a significantly greater proportion of parents whose children/adolescents had been hospitalized due to hyperglycemia reported anxiety /depression (58.7%) than those whose children/adolescents had not been hospitalized (49.8%).
After the diagnosis of T1D, the lifestyle of all family members changes, what interferes with their quality of life. Mothers are still the primary caregivers for children/adolescents with diabetes. Difficulty to set limits for children/adolescents may be a risk for poor metabolic control. The study demonstrates the importance of family context in the adjustment of young patients to T1D. The specific needs of T1D patients and their impact on a family routine must be considered for future improvement on therapy elements and strategies.
Type 1 diabetes; Family functioning; Psychosocial variables; Diabetes in youth; Glycemic control
Related Articles
Family function, Parenting Style and Broader Autism Phenotype as Predicting Factors of Psychological Adjustment in Typically Developing Siblings of Children with Autism Spectrum Disorders
Mohammadi, Mohammadreza
Zarafshan,, Hadi
Iranian Journal of Psychiatry
Siblings of children with autism are at a greater risk of experiencing behavioral and social problems. Previous researches had focused on environmental variables such as family history of autism spectrum disorders (ASDs), behavior problems in the child with an ASD, parental mental health problems, stressful life events and "broader autism phenotype" (BAP), while variables like parenting style and family function that are shown to influence children's behavioral and psychosocial adjustment are overlooked. The aim of the present study was to reveal how parenting style and family function as well as BAP effect psychological adjustment of siblings of children with autism.
The Participants included 65 parents who had one child with an Autism Spectrum Disorder and one typically developing child. Of the children with ASDs, 40 were boys and 25 were girls; and they were diagnosed with ASDs by a psychiatrist based on DSM-IV-TR criteria and Autism Diagnostic Interview-Revised (ADI-R). The Persian versions of the six scales were used to collect data from the families. Pearson's correlation test and regression analysis were used to determine which variables were related to the psychological adjustment of sibling of children with ASDs and which variables predicted it better.
Significant relationships were found between Strengths and Difficulties Questionnaire (SDQ) total difficulties, prosocial behaviors and ASDs symptoms severity, parenting styles and some aspects of family function. In addition, siblings who had more BAP characteristics had more behavior problems and less prosocial behavior. Behavioral problems increased and prosocial behavior decreased with permissive parenting style. Besides, both of authoritarian and authoritative parenting styles led to a decrease in behavioral problems and an increase in prosocial behaviors. Our findings revealed that some aspects of family function (affective responsiveness, roles, problem solving and behavior control) were significantly correlated with behavioral problems and prosocial behaviors in typically developing (TD) siblings of children with ASDs.
Siblings of children with ASDs, due to genetic liability, are at a greater risk of psychological maladjustment. Furthermore, environmental factors like parenting styles and family function also have a significant effect on psychological maladjustment.
Autism spectrum disorders (ASDs); broader autism phenotype; sibling; parenting style; psychological adjustment
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Hotels in Marina di Maratea, Italy
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- Most bookedHotel Club San Diego
284 people looked at this hotel in the last hour
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"Out of season visit (late October) but wonderful location - views from balcony to die for. Bar service bit slow, but not a problem as we were 2 of maybe 12 people in the hotel and it was closing down for the season. Food good (half board option) and the service in the restaurant was excellent."
A Traveller, Oct 2014, IE
221 people looked at this hotel in the last hour
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"Nice pool, views amazing although rooms are dated, shower not so good."
A Traveller, Jul 2014, GB
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"Nice location. Not ideal for someone without a car as roads not walking friendly. Convenient and close to highway. Diamante is a beautiful beach town with friendly people."
A Traveller, Sep 2015, GB
40 people looked at this hotel in the last hour
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"Unique experience, very hard to find due to tiny sign and locked, chained entrance. The villa is not visible from the road, we almost gave up. Of course not speaking Italian was also the standard hinderacne. The challenge to persevere in the dusk drove us to find it. We also learned that the stre..."
A Traveller, Oct 2015, US
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"We were just before the holiday season and everything was just in pre-season mode but a lovely hotel in a beautiful location."
A Traveller, May 2016, IE
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"We cannot thank Loredana and her team enough they were all amazingly genuine and had a real desire to ensure your stay was the very best they could offer. The hotel is beautifully clean and in a fantastic position to discover Italy independently. Any negatives ? Not really, the hotel is quite di..."
A Traveller, May 2016, GB
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"The room we get, was dark, any view, every time the air conditioning went on the noise was very annoying, everything else was good. This room was on the lower level."
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11 people looked at this hotel in the last hour
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"Long drive from Napoli, hotel is in Aquafredda, be sure to put this into your GPS or you will get lost! Had a wonderful time considering only Italians holiday here. We met two other families on different occasion and they both said that in 20 years they never met anyone from US. The beach was ama..."
A Traveller, Aug 2015, US
5 people looked at this hotel in the last hour
Best hotels in Marina di Maratea
If you are looking for Marina di Maratea hotels in a particular area, you can use the search feature at the top of the page to search by neighborhood, landmark, address or zip code, or you can search by using the built-in map feature. You can also browse hotels in Marina di Maratea by type, amenities, and star-rating so that you can find the best hotel. Currently, top rated hotels in Marina di Maratea are:
- Hotel Martino
- Hotel Ristorante Borgo La Tana
- Grand Hotel Pianeta Maratea Resort
- La Dimora del Cardinale
- Pianetamaratea Club Residence
The location of your Marina di Maratea hotel is important. If you are traveling to Marina di Maratea, &StateorCountry for business, you may want to consider getting a hotel close to the airport or near your meeting venue. By doing so, you can really cut down on transportation costs and time. You may also want to book a hotel that offers free wifi just in case you need to get some work done.
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If you are looking to score the best discounts and deals, use the filter to sort by price from low to high. You can book a hotel in Marina di Maratea for as low as $73 per night. If you are looking to cut down on expenses, look for hotels that include free breakfast and parking. Some hotels even offer free shuttle service to and from nearby places. You can also sort by star rating, proximity, and guest rating.
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Hot off the Griddle: November 29
By Eric Roston
Good morning, and welcome back to the Griddle, a morning menu of fortified items for the busy person's media diet. Black Friday sales reached $11.4 billion last weekend, a 6.6 percent leap over last year. Perhaps the only shoppers more determined than holiday-gift buyers are the Chinese and Indian manufacturers, whose appetites are pushing raw material prices ever higher. Goldman Sachs expects commodities to return about 15 percent in the next 12 months. The last time there was a recession, prices slumped 43 percent.
And now the news:
Wal-Mart Joins Amazon to Promote Rage-Free Packaging (Bloomberg)
Will the Lights Stay on in Texas and New England? (NY Times)
Fukushima Daiichi Nuclear Power Plant Operator 'Ignored Tsunami Warning' (Guardian)
World on Track for 11-Degree Temperature Rise, Energy Expert Says (AP)
GM's Volt Fires May Knock 'Moon Shot' Off Target (Bloomberg)
Bayer CropScience Targets non-GMO Wheat Traits (Reuters)
Duke Energy Signs $6 Billion Credit Agreement (News & Record)
Democrats Need to Get Real About U.S. Energy Policy (LA Times op-ed)
Americans Have Never Met a Hydrocarbon They Didn't Like (New Yorker)
Floods Kill 10 in Durban as UN Talks Begin (All Africa)


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How to get the 50 hours online
start up a private game with 2 people
set map to Central Moscow or East Africa they are helicopters
set it to private on a 8v8 all private slots up to 15
set the time to 30 minutes long
set it up with no bots
now just sit in here and wait till the time is up for every 30 mins
you don't need to fly around you can just sit idle in the match you can not sit in the menus it don't count it took me about six days to get this achievement like this LOL credits go to Zanger Zombolt for coming up with the idea on the helicopters
You really spent six days watching a helicopter hover?
Nope. Just switched over to something else.
Forgive me if this sounds rude but... how many hours you spent on this each day? Didn't you have to go to school or work?
Besides, don't you want to unlock those unlockables online?
You can choose a helicopter on any map.
Finally got it today! Total flight hours is 75 hrs! That means I used 25 hrs offline, can't believe I took that long.
I need to try this! I'm not a online player, so this is right up my alley!
I just join random games with the apache, then hide between buildings and watch TV.
thx for share
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Our holdings include hundreds of glass and film negatives/transparencies that we've scanned ourselves; in addition, many other photos on this site were extracted from reference images (high-resolution tiffs) in the Library of Congress research archive. (To query the database click here.) They are adjusted, restored and reworked by your webmaster in accordance with his aesthetic sensibilities before being downsized and turned into the jpegs you see here. All of these images (including "derivative works") are protected by copyright laws of the United States and other jurisdictions and may not be sold, reproduced or otherwise used for commercial purposes without permission.
Vintage photos of:
"The handsome new screw ferry steamer PLEASURE, recently added to the large fleet of excursion steamers in the service of the Belle Isle and Windsor Ferry Company. She is to run on the Detroit River, touching at Belle Isle, Windsor, and other summer resorts."
Detroit circa 1901. "Screw ferry excursion steamer Pleasure at Belle Isle ferry dock, Woodward Avenue." 8x10 inch dry plate glass negative. View full size.
Greene County, N.Y., circa 1902. "Palenville Hotel, Catskill Mountains." 8x10 inch dry plate glass negative, Detroit Publishing Company. View full size.
Buffalo, New York, circa 1900. "Tifft House, Main Street." Demolished 1902; home to Minehan's Hair Store (offering "a full line of switches, waves, fringes and wigs"). 8x10 inch glass negative, Detroit Photographic Company. View full size.
Washington, D.C., 1920. "Tidal Basin bathing beach -- Tom Miller, 1912 Irving Street N.E." National Photo Company Collection glass negative. View full size.
New York circa 1922. "Paul Specht band." Last seen at the Astor Roof Garden, and now in the recording studio also seen here. Note arrangement of the scores around the acoustic recording horn. 5x7 glass negative. View full size.
Circa 1907. North Adams, Massachusetts. "Main Street, looking west." Last seen here, looking the other way. 8x10 inch glass negative. View full size.
San Francisco, 1931. "Auburn at Golden Gate Park." Similar to the car seen earlier here. 5x7 inch glass negative by Christopher Helin. View full size.


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9 Reviews
Featured in my Book#237470. Originally reviewed on Apr. 29, 2008. I served this in martini glasses and DH raised his glass after tasting this divine dessert and said "This is fit for royalty." If I could rate it higher I would. I did not change a single ingredient or amount. I zested the lemon (using 1/3 cup sugar from the original 2 cups stated in directions) the same way as Mugifer suggested, making it super easy! For step 2 I used a three quart saucepan on medium heat for less than 5 minutes and cooled for 20 minutes. I put juices into the same saucepan for step 3. Because I did not have any ice cube trays, I used 3 metal bread pans for the first freezing process which took about 90 minutes but that would vary with the thickness of the batch. I think it should have been divided between 5 pans instead of 3. For the second refreezing I waited 2 hours. I also chilled the bowl and beaters before every mixing. On the second beating (of sherbert) I could not fit the entire batch into the bowl. Thanks Sydney Mike for sharing a super recipe! Made for 1-2-3 Hit Wonders. Update--made a half batch in blender, did not cook. Could not churn it all in ice cream maker so put in rest in smaller containers and froze prior to churning, defrosted in fridge, churned and tastes great!
I made this as stated except used my ice cream maker for the freezing process. I was looking for a stronger pineapple flavor but this was a nice clean flavor for summer. The lemon was a nice hint of flavor, reminded me of the sherbet served at the Japanese Steakhouse.
This recipe was recommended by Chef #482933. This is devine! I made a half batch and made ice cream using our ice cream maker (I got 2 quarts total ice cream). I mixed all the ingredients together without heating, then just added it into the machine. I used half sugar, half Splenda and all heavy whipping cream. I did use all the pineapple and juice though and it came out very flavorful! It tastes like a pineapple sundae. :)
This was just wonderful - a big hit with the whole family - thanks for posting! Made for Aussie/NZ Recipe Swap #20.
oh gosh this is so good with the perfect amount of sugar, I only used 1-1/2 tablespoons of lemon juice using more might have smothered the pineapple flavor, we loved this thanks for sharing Syd!
This was delish! I'm always trying new ice creams as I have an ice cream maker attachment for my KitchenAid. I did everything up through the freezing the first time then stirred the cream in and poured in my ice cream maker and let it go to work. The ice cream was creamy, too! Thanks, Sydney Mike!
Five stars just based on the recipe--sounds yummy! I just wanted to add a time-saving tip: An easy way to chop the zest fine is to use a very sharp veggie pealer to strip off the yellow; break that into smallish pieces and put it together with 1/4 to 1/3 cup of the sugar into a food processor. Pulse until all is fine, then proceed with the recipe. Happy churning!
Did you ever make one of those recipes that you just couldn't keep your spoon out of? This is one of those! Totally Delicious! I made this in two batches using my ice cream machine. After allowing the half and half mixture to cool, and adding the lemon juice and can of crushed pineapple, I also added the whipped cream before putting into the ice cream machine. This is so refreshing! Thank you, Sydney Mike!!
good stuff i dont have ice cream maker so this works for me


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Shakes are a very popular food format, so why not make money off of a shake-based diet? That's exactly what Beach Body LLC is doing with its Shakeology marketing scheme. Shakeology positions itself as a meal replacement shake and makes … Continue reading
14 Ways to Increase Your Magnesium Intake (You'll LOVE the Last One!)
Magnesium is one of the top 10 most abundant elements in the universe. It therefore makes sense that it is involved in human nutrition. Almost all the cells in the body require magnesium for enzymatic activities. Unfortunately, 5-15% of Americans … Continue reading
Slow Cooked Chicken with Brown Rice and Spices
This is an easy recipe that can be prepared in less than 20 minutes, but requires a minimum of 6 hours in a slow cooker or low heat oven. The juices from the chicken blend with the spices to thoroughly … Continue reading
Move Over Brown Rice, Super Duper Red Rice is Here
If you are trying to eat healthy, you have no doubt encountered brown rice, the whole grain answer to the standard white rice that most of the world eats today. Brown rice is full of fiber and beneficial nutrients, but … Continue reading
Good Product … Bad Nutrition Labeling
New here? Get Fooducated with our iPhone or Android App! This is a guest blog post by Carol Harvey, director of nutrition labeling at Palate Works. Ever wonder how FDA or a labeling consultant evaluates a food product's labeling? Here is a fairly typical (abridged) … Continue reading
Variations on USDA's MyPlate
Harvard scientists were not pleased with the government switch from the Food Pyramid to MyPlate earlier this year. Although MyPlate was lauded by experts as an improvement over the pyramid – it greatly simplified food choices – they believed it … Continue reading
Gluten Free Rice Krispies [Inside the Label]
Kellogg's just announced a new addition to its line of Rice Krispies cereals. While in the past we've been critical of some of the products and their marketing tactics, this one looks really good, even for gluten eaters: Rice Krispies® … Continue reading
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Almost every parent has a scrapbook photo of baby's inaugural sitting at the high chair, trying out a solid (actually mushy) food for the first time. Rice cereal has long been held as the first food to add to a … Continue reading
On Fiber
This is a guest post by Melissa Marek, RD LD Fiber is an extremely important part of your daily diet. Its best known benefit is its ability to help keep our bowels moving. Eating enough fiber will help prevent constipation. … Continue reading


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|Message view
|« Date » · « Thread »
|« Date » · « Thread »
|Jonathan Ellis <jbel...@gmail.com>
|Re: OOM during compaction with half the heap still available?
|Fri, 25 Mar 2011 03:23:47 GMT
Have you run nodetool scrub? The data versioning problem scrub fixes can manifest itself as trying to read GB of data into memory during compaction. On Thu, Mar 24, 2011 at 8:52 PM, Dan Washusen <firstname.lastname@example.com> wrote: > Hey All, > I've noticed that the Cassandra instance I have running on our build machine > occasionally crashes with an OOM error during compaction. I'm going to dial > down the memtable thresholds etc but I was wondering if anyone could help > explain the heap usage at the time of the crash. I just happened to leave a > JMX console window open and it's showing that just before the crash roughly > 50% of the heap was still available. > Screenshot of heap usage: http://img3.imageshack.us/img3/2822/memoryf.png > The above screenshot was taken a few weeks ago on Cassandra 0.7.2 (I think) > with nmap disabled on Java 1.6.0_24-b07. I'm now running 0.7.4 with nmap > enabled and just got the same crash (based on the error message in the > log)... > Log snippet from crash that matches screenshot: http://pastebin.com/ACa8fKUu > Log snippet from 0.7.4 crash: http://pastebin.com/SwSQawUM > Cheers, > -- > Dan Washusen > -- Jonathan Ellis Project Chair, Apache Cassandra co-founder of DataStax, the source for professional Cassandra support http://www.datastax.com
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Cuban President Raul Castro on Monday congratulated Venezuelan acting President Nicolas Maduro on his declared election victory, even though Maduro's rival had not conceded defeat.
In a congratulatory message published in the newspaper Granma, Raul Castro said that Maduro's victory "shows the strength of the ideas and work of Commandante Hugo Chavez," who last month died of cancer.
Late Sunday, Venezuela's National Electoral Council declared Maduro winner of the election to succeed Chavez, saying he had won with 50.66 percent of the vote compared to 49.1 percent for opposition leader Henrique Capriles -- a difference of less than 300,000 votes.
But Capriles has refused to concede defeat and is demanding a recount.


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Which sex is the worst about washing up? Why is it so important? We've got the dirty truth on how and when to wash your hands.
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Possible Duplicate:
Why is sizeof an operator?
Why is
sizeof supposed to be an operator in C, & not a function?
Its usage seems similar to that of a function call, as in
Is it supposed to be some kind of a pseudo-function?
We started with Q&A. Technical documentation is next, and we need your help.
Whether you're a beginner or an experienced developer, you can contribute.
Why is
Its usage seems similar to that of a function call, as in
Is it supposed to be some kind of a pseudo-function?
marked as duplicate by R.., GManNickG, Yossarian, Peter G., Jens Gustedt Oct 17 '10 at 19:29
This question has been asked before and already has an answer. If those answers do not fully address your question, please ask a new question.
Because it's not a function; it's not possible to write a function that can take a type as an argument and return its size! Note also that
A function call is evaluated at runtime.
sizeof has its effects at complite time not execution time. You only need the ( ) when you enter a type such as sizeof(int) but if 'i' is of type int you could do sizeof i
A function in C cannot do what sizeof needs to do.
A function by definition is allocated space at runtime and can operate on data only.
While sizeof operates on datatypes as well, which are compiler specific. A function does not know how to interpret the datatype "int" and ask the compiler for its size, by design.
Before C99 sizeof was totally compile-time, but in the new standard, it can be used to get information at runtime as well, for variable-length arrays.
function is something you can call at runtime. sizeof is only understood by the compiler.


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