Health-related quality of life in overweight and obese youths: results of a multicenter study

Bidirectionality and gender differences in emotional disturbance associations with obesity among Taiwanese schoolchildren

Childhood obesity is associated with psychological problems, but little is known about its association with emotional disturbance (ED) in the educational setting, especially by gender. In the population representative Elementary School Children's Nutrition and Health Survey in Taiwan 2001-2002 of children aged 6-13 (n=2283), we have considered whether ED is associated with obesity by gender. Schoolchildren were assessed with the modified scale for assessing emotional disturbance questionnaires. For some subscales, boys and girls had ED associations with obesity which were bidirectional. With normal weight as referent and relevant adjustments, the significant ED subscales predictable by obesity were relationship problems (RP) in boys (odds ratio, OR=1.89 with 95% CI: 1.08-3.30) and inappropriate behavior (IB) in girls (OR=2.88: 95% CI: 1.47-5.61). Conversely, with 'no-specific-ED' as referent, obesity was predictable by fully-adjusted specific-EDs in the same subscales, namely RP in boys (OR=1.88 with 95% CI: 1.13-3.13) and IB in girls (OR=3.03: 95% CI: 1.57-5.85). Child obesity prevalence showed no trend with school grade from 1 to 6, but for aggregate ED and most of its subscales the prevalence increased with grade (P for trend <0.01). Thus, there is some dissociation of obesity and ED as judged by their trend presence with school grade. Where obesity and ED occurred together (for inability-to-learn and unhappiness or depression), there were upward trends with grade (P<0.01). There are probably some selected bidirectional pathogenicities for obesity-ED associations with different expression in boys and girls and during elementary education. This provides some policy direction while mechanisms and causality require elucidation.

Parent-proxy perception of overweight adolescents' health-related quality of life is different according to adolescent gender and age and parent gender

This study assessed health-related quality of life (HRQoL) reported by overweight adolescents and compared to their parent-proxy perception of HRQoL, according to adolescent gender, adolescent age, and parent gender. Patients and a total of 179 adolescents aged 10 to 18 years with excess weight were evaluated for perceived HRQoL prior to beginning a weight-loss intervention, using the Pediatric Quality of Life Inventory (PedsQL 4.0) questionnaire, estimating quality of life in the physical, emotional, social, and school domains, as well as index measures of psychosocial and overall quality of life. Parents completed the same questionnaire estimating his or her child's HRQoL. Compared to their child's self-report, parents underestimated all the domains of HRQoL except the school domain. Parents underestimated all the domains of HRQoL among boys; however, they only underestimated the physical domain among girls. Comparisons between parent-proxy perception and self-report of the adolescent according to adolescent's age revealed that parents underestimated their children's HRQoL in the younger adolescents (10 to 13 years) for all except for the school domain and underestimated only the physical domain in older adolescents (14 to 18 years). The same comparison between parent-proxy perception and their child's self-report of HRQoL according to parent gender showed that mothers underestimated HRQoL in all domains except for the school domain, while fathers only underestimated the school domain.

CONCLUSION

The differences between self-report of overweight adolescent and perceptions of their parents about the HRQoL of their children are influenced by adolescent gender and age and parent gender.

Lifestyle intervention in childhood obesity: changes and challenges

Lifestyle interventions are regarded as the therapy of choice in children with obesity. The efficiency of lifestyle intervention for childhood obesity has been proven by several randomized controlled trials and meta-analyses. Even a stable weight in a growing child with obesity is associated with an improvement in cardiovascular risk factors and comorbidities of obesity. In particular, children aged 5-12 years and children with overweight rather than obesity profit from lifestyle interventions. However, in clinical practice, the degree of weight loss with lifestyle intervention is only moderate, and the success rate 2 years after onset of an intervention is low (<10% with a decrease in BMI SD score of <0.25). Nevertheless, the difficulty of a child with overweight or obesity to reduce their weight might be attributable to not only a lack of motivation but also genetic background and/or adaptive changes in basal metabolic rate, hunger and satiety hormones that occur with weight loss. We must accept that lifestyle interventions are successful only in a subgroup of children with obesity. Regardless, the techniques used and the education of therapists need to be improved. If lifestyle interventions do not result in weight loss in a child with obesity, drug treatment to reduce cardiovascular risk factors should be initiated but is currently seldom performed.

A review of patient-reported outcomes for children and adolescents with obesity

INTRODUCTION

Obesity is a chronic condition that can impact the physical, emotional, mental and social elements that encompass a child's life. The objectives of this study were to identify which generic and obesity-specific patient-reported outcome (PRO) instruments are used in obesity literature, as well as review their conceptual approach, health and health-related content, ethical content and psychometric properties.

METHOD

PubMed, CINAHL, EMBASE and PsycINFO were searched from the inception of each database to May 2012 to identify all studies using multi-dimensional PRO instruments with children who are overweight or obese. The most common generic and all obesity-specific instruments were analyzed according to the study objectives.

RESULTS

From 4,226 articles identified by our search, 70 articles used 6 generic and 4 obesity-specific PRO instruments. While the most commonly used PRO instrument was the generic PedsQL 4.0 (used in 53 studies), many health domains were found in the obesity-specific instruments that are not measured by the PedsQL 4.0. Summary of the development and psychometric properties of the generic and obesity PROs identified that no one instrument meets all the guideline criteria for instrument development and validation, e.g., only one instrument included qualitative input from children with obesity in the content development phase.

DISCUSSION

This comprehensive review provides information to aid in selecting multi-dimensional PRO instruments in children with obesity according to various aspects of content as well as psychometric properties. The conceptual analysis shows that the reviewed PRO instruments contain inconsistencies in their conceptual approaches. Also, certain relevant health domains to children and youth with obesity were not included in the most commonly used generic instrument. The obesity-specific instruments require further validation before they can be used in intervention studies.

Health-related quality of life in overweight German children and adolescents: do treatment-seeking youth have lower quality of life levels? Comparison of a clinical sample with the general population using a multilevel model approach

Background

Health-related quality of life (HRQoL) is reduced in obese children and adolescents, especially in clinical samples. However, little is known regarding the HRQoL of moderately overweight youth. Moreover, several studies have indicated perceived overweight as a critical factor associated with lower HRQoL. Our main objective was to compare HRQoL between treatment-seeking overweight youth and the general adolescent population, whilst separating the effects of treatment-seeking status and perceived weight from those of objective weight status.

Methods

We compared the HRQoL of a clinical sample of overweight youth (N=137 patients, mean age±s.e.=11.24±0.15 years) with that of a representative population sample (N=6354, mean age=12.75±0.03 years). The population sample was subdivided into groups based on measured and perceived weight status. We used hierarchical linear models to compare HRQoL subscale scores (self- and parent-reported) between patients and population groups, adjusted for sociodemographic characteristics and taking into account clustering of the population sample.

Results

The parent-reported HRQoL of the treatment sample was significantly lower than that of other overweight youth perceived as ‘too fat’ on two subscales: ‘self-esteem’ and ‘friends’ (effect sizes: d=0.31 and 0.34, respectively). On other subscales, patients scored lower than adolescents perceived as having a ‘proper weight’ by their parents. The patterns for self-reported HRQoL in adolescents were different: patients reported higher self-esteem than other overweight youth feeling ‘too fat’ (d=-0.39). Female patients also reported higher physical well-being (d=-0.48), whereas males scored lowest among all compared groups (d=0.42-0.95). Patients did not differ from other overweight youth who felt ‘too fat’ with respect to other HRQoL dimensions. In general, lower HRQoL was primarily associated with a perceived, rather than actual, overweight status.

Conclusions

The treatment-seeking status of overweight youth was notably associated with low social well-being, which may therefore be the main motive for seeking treatment. Other HRQoL domains were not consistently reduced in treatment-seekers. Our results further indicate that perceived overweight rather than actual overweight impacts HRQoL in youth with a modest excess weight. These results have implications for interventions in overweight youth and in individuals who are dissatisfied with their weight.

Trial registration

‘Obeldicks light’ is registered at clinicaltrials.gov (NCT00422916).

Day-to-day physical functioning and disability in obese 10- to 13-year-olds

What is already known about this subject? Compared with their healthy-weight peers, children with obesity have; impaired physical health-related quality of life reduced physical activity levels reduced capacity to perform certain weight-bearing tasks in field-based fitness tests What this study adds? First investigation of obesity-related disability in children using the International Classification for Functioning, Disability and Health framework for Children and Youth. Obesity in children appears to be associated with disability impacting basic locomotor skills and physical health-related quality of life. Children's participation in key life areas related to physical functioning appears to be minimally impacted by obesity.

OBJECTIVE

The aim of this study was to investigate whether obesity is related to impaired day-to-day physical functioning and disability in children.

METHODS

An observational case-control study was conducted in three Australian states. Obese (n = 107) and healthy-weight (n = 132) 10- to 13-year-olds (132 male, 107 female) were recruited via media advertisements. Assessment of body composition (dual energy X-ray absorptiometry), locomotor capacity (six-minute walk test [6MWT], timed up and down stairs test [TUDS] and timed up and go [TUG]) and child-reported physical health-related quality of life (HRQoL) were undertaken. Participants wore an accelerometer for 8 days and completed two use-of-time telephone interviews to assess participation in key life areas.

RESULTS

Compared with their healthy-weight counterparts, obese children had lower physical HRQoL scores (P < 0.01) and reduced locomotor capacity (TUDS z-score, TUG and 6MWT; P < 0.01). Higher percent body fat was significantly related to lower physical HRQoL scores (r = -0.48, P < 0.01), slower performance times for the TUDS and TUG (r = 0.59 and 0.26 respectively, P < 0.01), shorter 6MWT distances (r = -0.51, P < 0.01) and reduced time spent in community participation activities (r = -0.23, P < 0.01).

CONCLUSIONS

As anticipated, obesity appears to undermine physical functioning in children, including the capacity to perform basic locomotor skills yet, unexpectedly, participation in key life areas related to physical functioning appeared largely unaffected.

Development and usability testing of an internet intervention to increase physical activity in overweight adolescents

Background

Internet interventions may provide opportunities for low threshold counseling using feedback to guide and support health behavior, including increased physical activity. Research shows that overweight and obese adolescents are less physically active than their peers of normal weight. There are good reasons to believe that Internet-based interventions may be particularly suitable for motivating adolescents to increase physical activity, but we need to gain further knowledge of what features are effective and how to design such interventions.

Objective

To describe the process of development and evaluation of usability of a Web-based program for increasing physical activity in overweight adolescents.

Methods

Informed by the self-determination theory, motivational interviewing, and perspectives on self-regulation, this intervention was developed in a stepwise process by an interdisciplinary team of researchers, designers, developers, and representatives from the target group. An iterative qualitative usability testing approach (observation, survey, and interview) was applied in 2 sequences, first in the lab and second in the field, to assess how adolescents (aged 12-16 years) used and experienced the program and to make adjustments to the program based on evaluation of their response.

Results

The following components were included in the program: self-monitoring through planning and registration of physical activity and graphical response on progress, autonomy supportive individual Web-based counseling, forum for social support, and relevant age-adjusted information about physical activity. The first usability test resulted in adjustments related mainly to making the content and aim of the different features more visible and explicit. The second test evaluated the program with adjustments from the first test, revealing that the program was well accepted by the participants and only small aesthetic adjustments had to be made to complete the final version of the Internet program, Young & Active.

Conclusions

Thorough preparation, with clear theory foundation and close monitoring in the developmental phase, as well as contribution and iterative evaluation from the target group, is essential to create a user-friendly and engaging program. The efficacy of the program will be evaluated in a controlled trial.

Changes in self-reported and parent-reported health-related quality of life in overweight children and adolescents participating in an outpatient training: findings from a 12-month follow-up study

BACKGROUND

Health-related quality of life (HRQoL) was found to improve in participants of weight management interventions. However, information on moderately overweight youth as well as on maintaining HRQoL improvements following treatment is sparse. We studied the HRQoL of 74 overweight, but not obese participants (32.4% male, mean age = 11.61 ± 1.70 SD) of a comprehensive and effective six-month outpatient training at four time-points up to 12 months after end of treatment.

METHODS

HRQoL was measured by self-report and proxy-report versions of the generic German KINDL-R, including six sub domains, and an obesity-specific additional module. Changes in original and z-standardized scores were analyzed by (2×4) doubly multivariate analysis of variance. This was done separately for self- and proxy-reported HRQoL, taking into account further socio-demographic background variables and social desirability. Additionally, correlations between changes in HRQoL scores and changes in zBMI were examined.

RESULTS

There were significant multivariate time effects for self-reported and proxy-reported HRQoL and a significant time-gender interaction in self-reports revealed (p < .05). Improvements in weight-specific HRQoL were evident during treatment (partial η² = 0.14-0.19). Generic HRQoL further increased after end of treatment. The largest effects were found on the dimension self-esteem (partial η² = 0.08-0.09 for proxy- and self-reported z-scores, respectively). Correlations with changes in weight were gender-specific, and weight reduction was only associated with HRQoL improvements in girls.

CONCLUSIONS

Positive effects of outpatient training on generic and weight-specific HRQoL of moderately overweight (not obese) children and adolescents could be demonstrated. Improvements in HRQoL were not consistently bound to weight reduction. While changes in weight-specific HRQoL were more immediate, generic HRQoL further increased after treatment ended. An extended follow-up may therefore be needed to scrutinize HRQoL improvements due to weight management.

TRIAL REGISTRATION

clinicaltrials.gov NCT00422916.

[Validity and Reliability of the KIDSCREEN-27 Life Quality Questionnaire, Parents' Version, in Medellin, Colombia]

OBJECTIVE

Validate the KIDSCREEN-27 for parents in the metropolitan area of Medellín, Colombia, including the Social Acceptance (SA) subscale of KIDSCREEN-52, as it evaluates the effect of bullying in Life Quality of children.

METHODS

The study population was made up by parents of children between 8 and 18, from Medellín and its metropolitan area. A sample of 1,150 parents was estimated according to the different psychometric properties to be measured. Construct validation was made by comparing the mean scores between groups of high and low socioeconomic conditions. The content validity and the measurement of reliability were verified by internal consistency and test-retest stability. The parent-child agreement was also measured.

RESULTS

The internal consistency was adequate (Cronbach alpha 0,76-0,83). Parents of children with better socio-economic status had higher scores in all dimensions (p<0,05). Scores were higher among healthy children. Women had lower scores than men, while children registered higher scores than adolescents. The intraclass correlation coefficient for the reliability assessment was above 0.7 in all dimensions, except in School Environment-SE- (ICC 0,6-0,92). The parent-child agreement reached moderate and good levels (ICC 0,49-0,69). The exploratory factorial analysis, including social acceptance subscale, registered eight dimensions, four of which in agreement with the original questionnaire: Physical activity, SE, Social Support, and SA subscale.

CONCLUSIONS

KIDSCREEN-27 for parents is a valid and reliable instrument to be used in the Colombian context.

An economic perspective on childhood obesity: recent findings on cost of illness and cost effectiveness of interventions

OBJECTIVE

This review aims to put an economic perspective on childhood and adolescent obesity by providing an overview on the latest literature on obesity-related costs and the cost effectiveness of interventions to prevent or manage the problem.

METHODS

The review is based on a comprehensive PubMed/Medline search performed in October 2011.

RESULTS

Findings on the economic burden of childhood obesity are inconclusive. Considering the different cost components and age groups, most but not all studies found excess health care costs for obese compared with normal-weight peers. The main limitations relate to short study periods and the strong focus on health care costs, neglecting other components of the economic burden of childhood obesity. The results of the economic evaluations of childhood and adolescent obesity programs support the expectation that preventive and management interventions with acceptable cost effectiveness do exist. Some interventions may even be cost saving. However, owing to the differences in various methodologic aspects, it is difficult to compare preventive and treatment approaches in their cost effectiveness or to determine the most cost-effective timing of preventive interventions during infancy and adolescence.

CONCLUSION

To design effective public policies against the obesity epidemic, a better understanding and a more precise assessment of the health care costs and the broader economic burden are necessary but, critically, depend on the collection of additional longitudinal data. The economic evaluation of childhood obesity interventions poses various methodologic challenges, which should be addressed in future research to fully use the potential of economic evaluation as an aid to decision making.

Reliability and validity of the KIDSCREEN-52 health-related quality of life questionnaire in a Greek adolescent population

BACKGROUND

The KIDSCREEN-52 is a worldwide instrument for measuring health-related quality of life (HRQoL) in children and adolescents. The aim of this study is to assess reliability and validity of the Greek version of KIDSCREEN.

METHODS

Questionnaires were collected from a representative nationwide sample of 1,194 adolescents aged from 11 to 17 years. Internal consistency reliability was determined by calculation of the Cronbach α coefficient. A confirmatory factor analysis (CFA) was conducted in order to test the construct validity of the questionnaire. Validity was further examined by investigating the correlation of KIDSCREEN with the Strengths and Difficulties Questionnaire (SDQ) and its association with socioeconomic and health-related factors.

RESULTS

Internal consistency reliability was accepted with a Cronbach α above 0.73 for all KIDSCREEN dimensions. CFA showed that the ten-dimensional model fitted the data well (root mean square error of approximation (RMSEA) = 0.048, comparative fit index (CFI) = 0.971 and goodness of fit index (GFI) = 0.965). Correlation coefficients between KIDSCREEN and SDQ dimensions were significant. Adolescents of low socioeconomic status reported lower scores in the majority of KIDSCREEN dimensions. Also, adolescents with chronic health problem had poorer quality of life concerning physical well-being and other dimensions of KIDSCREEN.

CONCLUSIONS

The Greek version of KIDSCREEN-52 was found to have satisfied psychometric properties and could be suitable for assessing HRQoL in Greek adolescents.

Efficacy and safety of metformin for treatment of overweight and obesity in adolescents: an updated systematic review and meta-analysis

OBJECTIVE

To assess the efficacy and safety of using metformin in overweight and obese adolescents without related morbidity.

METHODS

We conducted a systematic review and meta-analysis of randomized clinical trials published until June 2011, comparing metformin to placebo or other interventions. Our primary variables were baseline BMI changes and development of adverse effects.

RESULTS

Nine studies (498 participants, mean age 14.2 years; mean BMI 36.4 kg/m² met the inclusion criteria. In all but one study, metformin was combined with lifestyle modification and was compared to placebo combined with changes in lifestyle. Analysis showed that metformin reduced mean BMI by 1.42 kg/m² (95% CI -2.18, 0.66), fasting insulin by 9.9 µU/ml (95% CI -13.8, -6.06) and the HOMA index by -1.78 (95% CI -3.32, -0.23). No changes in any other parameter were observed. No statistical differences were found in the rate of adverse events (33% metformin, 32% placebo).The withdrawal rates due to side effects in the metformin and placebo groups were 2.7% and 2.5%, respectively.

CONCLUSIONS

The available evidence indicates that, in the short term, administration of metformin in addition to lifestyle modification is relatively effective for reducing BMI and hyperinsulinemia among obese adolescents without related morbidity, and displays an acceptable safety pattern. Nevertheless, its long-term impact is unknown.

[Quality of life of caregivers of overweight or obese children and adolescents]

This study evaluated the health-related quality of life (HRQL) of caregivers of overweight and obese children and adolescents. Three-hundred and sixty caregives of children and adolescents (ages ranging from 9 to 12 years) diagnosed with overweight (n=96; average age 11.1 years), obesity (n=62; average age 10.9 years) and eutrophy (n=202; average age 10.7 years), regular students of public and private schools in Uberlândia (Minas Gerais), were invited to answer The 36 item Short Form Questionnaire (SF-36). The scores obtained were compared according to the body mass index (BMI) of the children and adolescents, and no significant differences were found between caregivers of overweight, obese and etrophic children and adolescents. Hence, there is no harm to the HRQL of caregivers of overweight and obese children and adolescents.

Effectiveness of lifestyle intervention in overweight children

Therapy of choice in obese children and adolescents is lifestyle intervention based on nutrition education, behavioural treatment and exercise treatment. Its efficacy even after the end of intervention has been proven by several randomised-controlled trials and meta-analyses including a recent Cochrane review. However, randomised-controlled trials are likely to overestimate the effectiveness. Studies under normal day-to-day circumstances demonstrated only a very moderate effect on weight loss (<10% success rate 2 years after the onset of intervention). A reduction of >0·5 SDS-BMI (which means a stable weight over 1 year in growing children) is associated with an improvement of cardiovascular risk factors, while improvements of quality of life seem independent of the degree of weight loss. Younger children and less overweight children particularly profit from lifestyle interventions in contrast to extremely obese adolescents. Recent studies demonstrated that involving parents is crucial for success, suggesting that parents and children and not children alone should be the primary target of interventions. Failures in weight reduction are attributed not only to a lack of motivation but also to other aspects particular to the genetic background. The techniques, more than the contents, of an intervention influence the treatment outcome. Besides behavioural therapy, systemic and solution-focused treatments are important. Future longitudinal research should focus on the identification of which children and adolescents profit from which kind of intervention, in order to be able to tailor specific treatment approaches. Studies under normal day-to-day circumstances are necessary to prove the benefit of this kind of intervention.

[Practical implementation of treatment guidelines concerning obesity in children and adolescents]

Guidelines recommend a long-term outpatient lifestyle intervention in obese children and adolescents that also addresses the children's parents. However, lifestyle interventions are performed only in 1% of the 1,000,000 obese children and adolescents in Germany, suggesting a large gap between guidelines and medical care in real life. Possible reasons are a lacking awareness of the consequences of overweight, no time resources, and the lack of motivation to change lifestyle habits in some obese children and their families. Furthermore, there is no treatment option throughout Germany. The long-term success rate varies widely between outpatient treatment centers (<50% up to >70%), while the long-term effectiveness of short-term, inpatient intervention (rehabilitation) is unknown. However, many more obese children are treated by short-term rehabilitation compared to long-term outpatient intervention. Older and extreme obese children and adolescents are treated by lifestyle intervention, although this kind of intervention is more effective in younger and not so obese children. Some subgroups (extreme obese adolescents, obese disabled children) have no meaningful and effective treatment options.

Health related quality of life in children and adolescents: reliability and validity of the Norwegian version of KIDSCREEN-52 questionnaire, a cross sectional study

BACKGROUND

A number of health-related quality of life instruments for children and adolescents have been developed and used in European countries during recent years. However, few well-validated instruments have been translated into Norwegian. As part of a larger investigation about pain and health-related quality of life, the KIDSCREEN-52, a cross-cultural 10-scale questionnaire, was translated into Norwegian. The aim of this study was to examine psychometric properties of the first Norwegian version of KIDSCREEN, particularly reliability and construct validity.

METHODS

A cross-sectional study was carried out, and a cluster sample of 20 randomly selected schools was drawn. The final study sample encompassed 1123 children and adolescents, aged 8-18 years. Internal consistency reliability was assessed using Cronbach's alpha. Construct validity was examined by confirmatory factor analysis, and by analysing whether the KIDSCREEN scales correlated with comparable KINDL scales, another health-related quality of life instrument. The analyses were conducted using SPSS (16.0) and Lisrel (8.7).

RESULTS

The Cronbach's alpha value was above 0.80 for all KIDSCREEN scales, suggesting good internal consistency reliability for the instrument. Confirmatory factor analysis shows that most of the KIDSCREEN scales fit the data well. Fit statistics for the 10-factor model were satisfactory, although some scales displayed residual covariance. Several confirmatory factor analysis models were fitted to the data, and the model specified according to the 10-dimensional KIDSCREEN-52 measurement model with correlated first-order factors fitted the data well (RMSEA=0.04; CFI=0.99). The KIDSCREEN scales correlated sufficiently highly with comparable KINDL scales.

CONCLUSIONS

The results of the present study indicate that the Norwegian version of the KIDSCREEN-52 seems to work well in a Norwegian context, and is a valid and reliable generic health-related quality of life instrument. It is considered appropriate for screening in the public health area, for example, in school health care.

How do children at special schools and their parents perceive their HRQoL compared to children at open schools?

Background

There has been some debate in the past as to who should determine values for different health states for economic evaluation. The aim of this study was to compare the Health Related Quality of Life (HRQoL) in children attending open schools (OS) and children with disabilities attending a special school (SS) and their parents in Cape Town South Africa.

Methods

The EQ-5D-Y and a proxy version were administered to the children and their parents were requested to fill in the EQ-5D-Y proxy version without consultation with their children on the same day.

Results

A response rate of over 20% resulted in 567 sets of child/adult responses from OS children and 61 responses from SS children. Children with special needs reported more problems in the "Mobility" and "Looking after myself" domains but their scores with regard to "Doing usual activities", "Pain or discomfort" and "Worried, sad or unhappy" were similar to their typically developing counterparts. The mean Visual Analogue Scale (VAS) score of SS children was (88.4, SD18.3, range 40-100) which was not different to the mean score of the OS respondents (87.9, SD16.5, range 5-100).

The association between adult and child scores was fair to moderate in the domains. The correlations in VAS scores between Open Schools children and female care-givers' scores significant but low (r = .33, p < .001) and insignificant between Special School children and adult (r = .16, p = .24).

Discussion

It would appear that children with disabilities do not perceive their HRQoL to be worse than their able bodied counterparts, although they do recognise their limitations in the domains of "Mobility" and "Doing usual activities".

Conclusions

This finding lends weight to the argument that valuation of health states by children affected by these health states should not be included for the purpose of economic analysis as the child's resilience might result in better values for health states and possibly a correspondingly smaller resource allocation. Conversely, if HRQoL is to be used as a clinical outcome, then it is preferable to include the children's values as proxy report does not appear to be highly correlated with the child's own perceptions.