Implicaciones para la práctica clínica

Barn

270. Christiansen O, Anderssen N. From concerned to convinced: Reaching decisions about out-of-home care in Norwegian child welfare services. Child & Family Social Work 2010;15(1):31-40.

Abstract: Placing children in out-of-home care constitutes one of the strongest public interventions in

families. This paper explores how Norwegian Child Welfare Service (CWS) workers present their reasons as well as their work processes in the course of deciding to place children in out-of-home care. The analysis is based on interviews with 83 social workers and concerns 109 children recently removed from their homes. Three central elements were identified in the social workers' accounts: (1) a description of worrying conditions in the family; (2) the workers' long-term back-and-forth process, which revolved around experiences from the case, particularly around interactions with the parents; and (3) a triggering factor that made the out-of-home placement take place when it did. These elements underline the need to include both substance (conditions related to the child and his/her family) and procedure (conditions re- lated to the work on the case) to understand what leads CWS to removing children. Both types of condi- tions put the parents, rather than the children, in the centre of the workers' attention, which may be ex- plained by the position and role of the CWS workers as street-level bureaucrats. The findings emphasize the importance of acknowledging the contradictory position of CWS workers.

271. Drugli MB, Larsson B. Children aged 4-8 years treated with parent training and child therapy because of conduct problems: generalisation effects to day-care and school settings. European child & adolescent psychiatry 2006;15(7):392-9.

Abstract: In this study, generalisation effects to day-care/school settings were examined in an outpatient

clinic sample of 127 children aged 4-8 years treated because of oppositional conduct problems in the home with parent training (PT) and parent training combined with child therapy (CT) ("Incredible Years"). Before treatment all children scored above the 90th percentile on the Eyberg Child Behavior Inventory (ECBI) for home problems, and met criteria for a possible or a confirmed diagnosis of either an opposi- tional defiant (ODD) or a conduct (CD) disorder. Further, 83% of the children showed clinical levels of conduct problems both at home and in day-care/school before treatment. Although most children im- proved at home, the majority still showed clinical levels of conduct problems in day-care/school settings after treatment and 1-year later. Combined PT and CT produced the most powerful and significant gener- alisation effects across the treatment period, however these improvements were not maintained 1-year later for most areas. The results of the present study, therefore, underline the need to target conduct problems not only exhibited at home but also in day-care/school settings, and to develop strategies to maintain positive generalisation effects after treatment for this age and problem-group

272. Dyregrov A, Heltne U. Investigation of reported malpractice in Norwegian state institutions for children. [Norwegian]. Tidsskrift for Norsk Psykologforening 2005;42(8):683-92.

Abstract: An investigation of Norwegian state institutions for children revealed a long history of profes-

sional malpractice. This article presents a study where adult subjects were asked to report about their childhood experiences. All subjects had previously witnessed for the state's commission of inquiry into in- stitutional malpractice. A majority of subjects felt that the inquiry represented a positive rectification of previous wrongs. They also felt that their role as witness triggered emotionally painful memories. Subjects did not regret having taken part in the inquiry. They felt that a history of state malpractice had finally been exposed. Inquiries into similar types of malpractice related to other kinds of institutional care can only be encouraged when witnesses are provided with adequate psychological support

273. Holtan A, Ronning JA, Handegard BH, Sourander A. A comparison of mental health problems in kinship and nonkinship foster care. European child & adolescent psychiatry 2005;14(4):200-7.

Abstract: OBJECTIVE: Knowledge of the emotional and behavioural problems of children in kinship fos-

ter care is scarce. No data on such problems in European countries have been published. This study compares child psychiatric problems and placement characteristics of children living in kinship and nonkinship foster care. METHODS: A total of 214 children in kinship and nonkinship foster care, aged 4- 13, participated in the study. The Child Behavioral Checklist (CBCL) was completed by their foster par- ents and demography and placement information was collected. RESULTS: Of the nonkinship group, 51.8 % scored above the borderline on the CBCL Total Problem score, as did 35.8% of the kinship group. The kinship group had fewer previous placements, were more often fostered within their local community and had more contact with their biological parents. Kinship foster parents had lower social status, in terms of educational level.Variables significantly related to high level of the CBCL Total problems score were male gender and location of foster home outside community of birth family. Positive outcome was signifi- cantly associated with placement within the child's own community, which in turn was related to kinship placement. CONCLUSIONS: Placement in kinship foster care should be considered as a viable possibility

274. Hukkanen R, Sourander A, Santalahti P, Bergroth L. Have psychiatric problems of children in children's homes increased? Nord J Psychiatry 2005;59(6):481-5.

Abstract: This time-trend study was conducted during and after the severe economic recession and the

period of high unemployment in Finland in the 1990s. The changes in the behavioral and emotional prob- lems of children and adolescents placed in children's homes were studied in the same area using the Child Behavior Checklist questionnaire at three different time points (1993, 1996 and 1999), and the Chil- dren's Global Assessment Scale in 1996 and 1999. Internalizing symptoms of the children increased sig- nificantly. The level of psychosocial problems among boys was already high at the first rating in 1993, and it remained high during the whole study period. Behavioral and emotional problems of the girls placed in

children's homes increased significantly, being at the same level as the boys' by the end of the study pe- riod

275. Kendrick D, Coupland C, Mulvaney C, Simpson J, Smith S, Sutton A, et al. Home safety education and provision of safety equipment for injury prevention. Cochrane Database Syst Rev 2007;(1):CD005014.

Abstract: BACKGROUND: In industrialised countries injuries are the leading cause of childhood death

and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre- school children occur at home, but there is little meta-analytic evidence that child home safety interven- tions improve a range of safety practices or reduce injury rates and little evidence on their effect by social group. OBJECTIVES: We evaluated the effectiveness of home safety education, with or without the provi- sion of low cost, discounted or free equipment in increasing home safety practices or reducing child injury rates and whether the effect varied by social group. SEARCH STRATEGY: We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, DARE, ASSIA, Psychinfo and Web of Science, plus a range of relevant web sites, conference proceedings and bibliographies. We contacted authors of included studies and surveyed a range of organisations. SELECTION CRITERIA: Randomised controlled trials (RCTs), non-randomised controlled trials and controlled before and after studies where home safety education with or without the provision of safety equipment was provided to those aged 19 years and under, which reported safety practices, possession of safety equipment or injury. DATA COLLECTION AND ANALY- SIS: Two authors independently assessed study quality and extracted data. We attempted to obtain indi- vidual participant level data (IPD) for all included studies and summary data and IPD were simultaneously combined in meta-regressions by social and demographic variables. MAIN RESULTS: Eighty studies were included; 37 of which were included in at least one meta-analysis. Twenty-three (62%) were RCTs and 12 (32%) included in the meta-analysis provided IPD. Home safety education was effective in in- creasing the proportion of families with safe hot tap water temperatures (OR 1.35, 95% CI 1.01 to 180), functional smoke alarms (OR 1.85, 95% CI 1.24 to 2.75), storing medicines (OR 1.58, 95% CI 1.18 to 2.13) and cleaning products (OR 1.63, 95% CI 1.22 to 2.17) out of reach, syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) and poison control centre numbers accessible (OR 3.66, 95% CI 1.84 to 7.27), fitted stair gates (1.26, 95% CI 1.05 to 1.51), socket covers on unused sockets (OR 3.73, 95% CI 1.48 to 9.39) and storing sharp objects out of reach (OR 1.52, 95% CI 1.01 to 2.29). There was a lack of evidence that in- terventions reduced rates of thermal injuries, poisoning or a range of injuries. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury. AUTHORS' CONCLUSIONS: Home safety education provided most commonly as one-to-one, face-to- face education, in a clinical setting or at home, especially with the provision of safety equipment is effec- tive in increasing a range of safety practices. There is a lack of evidence regarding its impact on child in- jury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment was less effective in those at greater risk of injury. HOME SAFETY EDUCATION AND PROVIDING SAFETY EQUIPMENT FOR INJURY PREVENTION: Injuries are the leading cause of child- hood death in industrialised countries. People living in disadvantaged circumstances are at greater risk of injury than those more advantaged. This review examined whether home safety education and providing safety equipment increased safety behaviours and safety equipment use and reduced injuries. It also looked at whether home safety education was more or less effective in families which are disadvantaged. The review authors found 80 studies, which reported many different safety behaviours, but few studies in- cluded information on injuries.The results often varied between studies, but overall families who received home safety education were more likely to have a safe hot tap water temperature, a working smoke alarm, to store medicines, cleaning products and sharp objects out-of-reach, to have fitted stair gates and socket covers on unused sockets and to have syrup of ipecac and poison control centre numbers acces- sible. The reviewers did not find that home safety education reduced injury rates, but this may have been due to the small number of studies which measured injuries, and more research is needed to answer this question. The reviewers did not find that home safety education was less effective in families whose chil- dren were at greater risk of injury

276. Kjelsberg E, Nygren P. The prevalence of emotional and behavioural problems in institutionalized child- care clients. Nord J Psychiatry 2004;58(4):319-25.

Abstract: The objective of the study was to investigate the gender-specific prevalence of emotional and

behavioural problems in children and adolescents in out-of-home childcare, compared with patients in child and adolescent psychiatric institutions. The total population of clients in residential childcare institu- tions in Oslo, Norway, was investigated by the use of standardized questionnaires (Achenbach's Child Behavior Checklist and Youth Self Report) and compared to all same-aged patients residing in child and adolescent psychiatric institutions in the same area at the same time. Boys in residential childcare had emotional and behavioural problem levels comparable to boys in child and adolescent psychiatric institu- tions, as measured by the questionnaires. Girls in residential childcare did not reach problem levels as high as those found in girls in psychiatric institutions, but problem levels were still well above those found in the general population. It was concluded that institutionalized childcare clients had a high prevalence of behavioural and emotional problems, as measured by Achenbach's Child Behavior Checklist and Youth Self Report

277. Lagerberg D. Secondary prevention in child health: effects of psychological intervention, particularly home visitation, on children's development and other outcome variables. Acta Paediatr Suppl 2000;89(434):43- 52.

Abstract: This paper reviews interventions targeting socially deprived families, families with low birth-

weight/premature children, and some other problems (child abuse, sensitivity/attachment, postnatal de- pression). Conclusions are mainly based on randomized controlled trials. Earlier reviews in the field have emphasized the importance of intensive, enduring home visitation and of early education programmes for young children. Home visitation may positively effect several outcomes, including health behaviour, child safety and stimulation. Rates of child abuse and neglect have proven difficult to influence, but home visi- tation may result in other gains such as fewer accidents and serious injuries, and greater home safety. The cognitive development of low birthweight and premature children may be positively influenced by home visitation, particularly in combination with an early stimulation programme in the neonatal unit and

pre-school placement. Postnatally depressed mothers have been shown to improve substantially from nurse counselling once a week for 6-8 wk. It is suggested that home visitation should be tried on a sys- tematic basis, and that early pre-school experiences should be offered to children in different risk situa- tions. Child Health Centres should introduce a screening programme for postnatal depression. Specialist child health units should be encouraged. [References: 79]

278. Larsson B, Fossum S, Clifford G, Drugli MB, Handegård BH, MøRch WT. Treatment of oppositional defi- ant and conduct problems in young Norwegian children : results of a randomized controlled trial. Euro- pean child & adolescent psychiatry 2009;18(1):42-52.

Abstract: The efficacy of the Incredible Years parent training and child therapy programs was examined

in a randomized controlled study including 127 Norwegian children aged 4-8 years. Children diagnosed with oppositional defiant disorder (ODD) or conduct disorder (CD) were randomized to parent training (PT), parent training combined with child therapy (PT + CT), or a waiting-list control condition (WLC). As- sessments were carried out at baseline, posttreatment and at a one-year follow-up using standardized measures and a semi-structured interview. Both active treatment conditions reduced child conduct prob- lems posttreatment as opposed to the WLC, while differences between the two treatment conditions were small and nonsignificant. About two thirds of the treated children functioned within normal variation after treatment, and the same proportion no longer received an ODD diagnosis at the one-year follow-up. Pa- rental use of positive strategies increased after treatment, and the use of harsh and inconsistent discipline decreased as did mother experience of stress. The outcome of this study emphasizes the importance of offering parent training to young children with severe conduct problems exhibited at home. The findings and usefulness of the Incredible Years program in the present Norwegian replication study further support and extend positive outcomes of previous controlled trials conducted primarily in Anglo-Saxon countries

279. Lennell A, Kuhlmann-Berenzon S, Geli P, Hedin K, Petersson C, Cars O, et al. Alcohol-based hand- disinfection reduced children's absence from Swedish day care centers. Acta Paediatr 2008;97(12):1672- 80.

Abstract: AIM: To determine if the use of alcohol-based hand-disinfection as a complement to regular

hand washing at daycare centers (DCCs) can reduce the childhood rate of absenteeism. METHODS: Children aged 0-6 years attending DCC were studied in a cluster randomized controlled trial during 30 weeks. Thirty matched pairs of DCCs were included in the study, where one of the DCCs was random- ized to intervention and the other to control within each pair. The intervention consisted in children and staff using alcohol-based oily disinfectant gel containing 70% ethanol after regular hand washing. The main outcome was the rate of episodes of absence from DCC due to infection. A regression model was fitted at the individual level and controlling several possible confounders for illness. Absences were re- ported by the parents. RESULTS: Differences in missing absence reports between the two groups led to only evaluating those 29 DCCs (1431 children) that were able to provide complete reports. In the multi- variate regression, the intervention significantly reduced the rate of absenteeism of a child by 12% com- pared to a child in a control DCC (IRR 95% CI: 0.799-0.965). CONCLUSION: Hand-disinfection used by children and staff significantly decreased childrens absences due to infections in Swedish DCCs

280. Mahonen S, Riikonen P, Vaatainen RL, Tikanoja T. Oral anticoagulant treatment in children based on monitoring at home. Acta Paediatr 2004;93(5):687-91.

Abstract: AIM: To evaluate the feasibility of home monitoring of oral anticoagulant treatment (OAT) in

paediatric patients. METHODS: A total of 19 paediatric patients received OAT and then monitored their treatment at home with CoaguChek. Data on their International Normalized Ratio (INR) values were col- lected retrospectively from hospital records and from the notes kept by the families. The families of the patients were also asked to fill in a questionnaire. RESULTS: No thrombotic or haemorrhagic complica- tions occurred during a total amount of 44.7 follow-up years. INR: the proportion of INR values measured at home falling within the therapeutic range for the given patient varied from 33 to 86% (median 69%). The questionnaire: all respondents were satisfied with home monitoring, and 63% felt that a major advan- tage of home monitoring was that there was no need to perform venipuncture. While 47% of the respon- dents reported no disadvantages of home monitoring, 42% reported that they occasionally lacked confi- dence in their ability to conduct OAT correctly at home. CONCLUSION: Home monitoring of OAT is feasi- ble and reasonably reliable in paediatric patients. However, it is crucial that healthcare professionals su- pervise the treatment and the families are provided with detailed and precise instructions on how to act in a variety of clinical situations

281. Moen KH, Bakke HK, Bakke O, Fors EA. Preschool children's sickness absenteeism from Norwegian regular and outdoor day care centres: a comparative study. Scand J Public Health 2007;35(5):490-6.

Abstract: AIMS: To examine whether there are any differences in sickness absenteeism between chil-

dren in outdoor day care centres and regular day care centres and also to investigate whether other vari- ables predict sickness absenteeism. METHODS: Data on sickness absence during a 4-week period to- gether with several explanatory variables of 531 children in 32 regular and 37 outdoor day care centres were collected and included in the analysis. The data were analysed by generalized linear modelling. RESULTS: The overall frequency of sickness absence was 5.1%. There was no general significant differ- ence between sickness absenteeism in regular and outdoor day care centres. Of the other possible ex- planatory variables only two were found to contribute significantly: age, with a negative relationship, and the interaction effect of a child with a chronic disease or disability going to an outdoor day care centre, with a positive relationship. CONCLUSIONS: The present study indicates that sickness absenteeism of a child without a chronic disease or disability is not affected by whether the child attends a regular or an outdoor day care centre. There seem to be no health benefits for children with chronic diseases or dis- abilities to attend outdoor day care centres--there is in fact evidence that sickness absence for those chil- dren is higher in outdoor centres

282. Nordlie A-L, Andersen BM. Children in day care centres: Parents' attitudes to antibiotics. Tidsskr Nor Laegeforen 2004;124(17):2229-31.

Abstract: Background. Most children in day care get infections and are prescribed antibiotics. We stud-