Chapter 7: children's and young people's health

Evolution of Therapeutic Patient Education: A Systematic Scoping Review and Scientometric Analysis

Therapeutic patient education (TPE) aims to empower the patients and their caregivers to effectively care for and manage their conditions. Such educational programs have been shown to improve health behaviors, disease outcomes, and quality of life among different patient populations. The field of TPE has evolved extensively over decades, owing to interdisciplinary research. No study so far has been done to map this field, to identify the stakeholders and gaps requiring future research. By leveraging the theory of co-citation, CiteSpace was used to visualize the bibliographic data pertaining to TPE research. A total of 54,533 articles published in English language were analyzed to identify influential funders, regions, and institutes contributing to this field. Besides these, significant theoretical and empirical contributions that shaped this field were mapped. Our analysis revealed several important insights. Most of the important theories that helped shape TPE were inspired from the social sciences. Five important research themes were identified: disorders, study designs utilized in TPE research, the scope of the TPE literature and outcomes, and populations. The research focused on improving perceptions, behaviors, and attitudes toward health promotion, reducing stigma, self-management and medication adherence. Most of the research was developed in the context of high-income countries. Future research should involve patients and use digital technology. Meta-analytical studies need to be done to identify the effectiveness and moderators of TPE interventions across different disorders. Further research should involve low and middle-income countries (LMIC) to ensure knowledge and technology transfer.

Joint physical custody, parent–child relationships, and children’s psychosomatic problems

Aim

The prevalence of psychosomatic complaints among children and adolescents appears to be increasing. At the same time, the numbers of joint physical custody families are rising across Western countries. This study aimed to investigate the relationship between post-separation care arrangements (joint physical custody vs. sole physical custody) and children’s risks of psychosomatic problems, while considering the potential mediating role of parent–child relationships.

Subject and methods

Based on data from the Family Models in Germany (FAMOD) study, stepwise linear regression models and seemingly unrelated regression models were estimated for a sample of 473 children aged seven to 14 living in either sole physical custody or joint physical custody families.

Results

Children in joint physical custody families reported significantly fewer psychosomatic problems than children in sole physical custody families. Furthermore, living in a joint physical custody arrangement was associated with better parent–child relationships, although only the mother–child relationship was significantly related to children’s psychosomatic complaints, and partially mediated the association between physical custody arrangements and children’s psychosomatic complaints. No corresponding association could be found with respect to the father–child relationship.

Conclusion

The risk of psychosomatic problems was distributed unequally among post-separation families, as children living in joint physical custody arrangements suffered from fewer psychosomatic problems than children living in sole physical custody arrangements. Because part of this association was explained by the quality of the mother–child relationship, children’s relationships with other family members appear to be important factors to consider when seeking to promote children’s health in post-separation care arrangements.

Persistence in Problematic Internet Use-A Systematic Review and Meta-Analysis

Background and Aims: Problematic internet use, internet addiction, and internet gaming disorder all describe a global phenomenon where individuals have trouble limiting their use of internet to such an extent that their use has negative consequences. Past systematic reviews and meta-analyses have focused on estimating prevalence, but there has been no comprehensive research synthesis of the trajectory of the problem. The research objective was to create a pooled estimate of the persistence of problematic internet use. This review included studies using a longitudinal panel data design with a follow-up of at least a year. Studies had to be published before the end of the year 2017, in peer-reviewed academic journals, using English language. Samples from populations in any country were accepted, given they were of acceptable quality. Methods: A literature search was conducted in Web of Science, Pro Quest, and Scopus. Several definitions of problematic internet use were included. Inverse-variance, random-effect meta-analysis was used to estimate weighted summary means of persistence. Attrition and selection bias was investigated using pre-specified tools, and heterogeneity was assessed in subgroup analysis. Results: Nine studies fit the criteria, all using samples from Asian or Western countries. The aggregate estimate for 1-year persistence it was 50% (CI: 40-61%), but results were heterogeneous. Prevalence and persistence estimates were correlated and generally higher in Asian countries. Methodological differences only explain part of the heterogeneity. Conclusion: All included studies found individuals with persistent problems, but the between-studies variation is substantial.

Morality in clinical space: treatment of youngsters with functional somatic symptoms in a Western clinical context

This paper explores the moral implications of treatment of young people with functional somatic symptoms. Based on an ethnographic field study at a Danish pain clinic for youngsters (age 8 to 18), the paper seeks to unearth the cultural, moral values that clinical practice steers by and upholds, and the implications this has for the assessment and management of ill body-selves. Through an exposition of the general practice of the clinic and an investigation of two specific cases of youngsters, it is found that the assessment of symptoms and selves and the goals of treatment are informed by cultural ideals of 'the good self' and 'the good life' in which agency and work ethic - both pertaining to the notion of individual responsibility - figure as prevalent virtues. The study underpins the findings of other researchers who have found that ideals of individual autonomy and responsibility for own life and health permeate the Western health care system and the discourses of ill individuals. The contribution of this article is to portray in ethnographic detail how such a cultural ethics manifests in practice and what implications this have for the treatment of young people with functional symptoms at a specific location and in specific cases. The two cases illustrate that the underlying norms and values can give rise to very different moral assessments of symptoms and selves within the same diagnostic category.

Impact of parental socioeconomic status on excess mortality in a population-based cohort of subjects with childhood-onset type 1 diabetes

OBJECTIVE

The aim of this study was to analyze the possible impact of parental and individual socioeconomic status (SES) on all-cause mortality in a population-based cohort of patients with childhood-onset type 1 diabetes.

RESEARCH DESIGN AND METHODS

Subjects recorded in the Swedish Childhood Diabetes Registry (SCDR) from 1 January 1978 to 31 December 2008 were included (n = 14,647). The SCDR was linked to the Swedish Cause of Death Registry (CDR) and the Longitudinal Integration Database for Health Insurance and Labour Market Studies (LISA).

RESULTS

At a mean follow-up of 23.9 years (maximum 46.5 years), 238 deaths occurred in a total of 349,762 person-years at risk. In crude analyses, low maternal education predicted mortality for male patients only (P = 0.046), whereas parental income support predicted mortality in both sexes (P < 0.001 for both). In Cox models stratified by age-at-death group and adjusted for age at onset and sex, parental income support predicted mortality among young adults (≥18 years of age) but not for children. Including the adult patient's own SES in a Cox model showed that individual income support to the patient predicted mortality occurring at ≥24 years of age when adjusting for age at onset, sex, and parental SES.

CONCLUSIONS

Exposure to low SES, mirrored by the need for income support, increases mortality risk in patients with childhood-onset type 1 diabetes who died after the age of 18 years.

Recurrent pain and discomfort in relation to fitness and physical activity among young school children

As an increase in pain symptoms among children has been shown in the last decades, the aim of this study was to describe perceptions of recurrent pain, measured physical fitness and levels of reported physical activity (PA) in children, and to investigate if any associations between PA, fitness and recurrent pain could be identified. A school-based study comprised 206 Swedish children 8-12 years old, 114 boys, 92 girls. A questionnaire with questions about perceived pain, self-reported PA and lifestyle factors was used. Health-related fitness was assessed by 11 physical tests. A physical index was calculated from these tests as a z score. High physical index indicated high fitness and low physical index indicated low fitness. ANOVA test, chi-square test and logistic regression analysis were used to compare active and inactive children. The prevalence of one pain location (head, abdomen or back) was 26%, two 11% and three 4% (n=206). Female gender, living in single-parent families, low PA and low subjective health were associated with reported recurrent pain. Children reporting high levels of PA had high physical index and reported low prevalence of pain symptoms. The physical index and level of self-reported PA decreased gradually the more pain locations. Physically active children had higher fitness levels and reported less pain symptoms than inactive peers. Coping with pain is an integral part of PA, and active children learn to cope with unpleasant body sensations which together with high fitness may reduce the perception of pain.

Preterm birth and attention-deficit/hyperactivity disorder in schoolchildren

OBJECTIVE

Previous studies have demonstrated an increased risk for attention-deficit/hyperactivity disorder (ADHD) in follow-up studies of preterm survivors from NICUs. In this study we analyzed the effect of moderate as well as extreme preterm birth on the risk for ADHD in school age, taking into account genetic, perinatal, and socioeconomic confounders.

METHODS

Register study in a Swedish national cohort of 1 180 616 children born between 1987 and 2000, followed up for ADHD medication in 2006 at the age of 6 to 19 years. Logistic regression was used to test hypotheses. A within-mother-between-pregnancy design was used to estimate the importance of genetic confounding in a subpopulation of offspring (N = 34 334) of mothers who had given birth to preterm (≤34 weeks) as well as term infants.

RESULTS

There was a stepwise increase in odds ratios for ADHD medication with increasing degree of immaturity at birth; from 2.1 (1.4-2.7) for 23 to 28 weeks' gestation, to 1.6 (1.4-1.7) for 29 to 32 weeks', 1.4 (1.2-1.7) for 33 to 34 weeks', 1.3 (1.1-1.4) for 35 to 36 weeks', and 1.1 (1.1-1.2) for 37 to 38 weeks' gestation compared with infants born at 39 to 41 weeks' gestation in the fully adjusted model. The odds ratios for the within-mother-between-pregnancy analysis were very similar. Low maternal education increased the effect of moderate, but not extreme, preterm birth on the risk for ADHD.

CONCLUSION

Preterm and early term birth increases the risk of ADHD by degree of immaturity. This main effect is not explained by genetic, perinatal, or socioeconomic confounding, but socioeconomic context modifies the risk of ADHD in moderately preterm births.

Norm compliance and self-reported health among Swedish adolescents

AIMS

This study examines the relationship between norm compliance and self-reported health in adolescents, and how this differs between genders. Our specific aim was to investigate if extremely high norm compliance revealed any particular health patterns.

METHODS

This empirical study used a web-based survey from 2005, which was distributed to all students (n = 5,066) in years 7-9 of compulsory school within six municipalities in northern Sweden. The respondents answered questions about their general health as well as specific health problems such as headaches, stomach ache, sleeping difficulties and stress. Compliance was measured according to different norm-related behaviour, such as truancy, crime and use of tobacco, alcohol and narcotics.

RESULTS

The majority of respondents reported good health and norm-compliant behaviour. Girls reported more health problems than boys, a difference that increased with age. Those who were more norm compliant reported better health, fewer somatic complaints and less stress, which goes against our initial hypothesis that extremely high norm compliance and self-reported ill-health are related. There seemed to be a stronger relationship between self-reported health and norm compliance for girls than boys, in absolute terms.

CONCLUSIONS

The results clearly show a relationship between norm compliance and health, and suggest inequalities between genders.

Review Article: Mapping of children's health and development data on population level using the classification system ICF-CY

AIM

The aim of this study was to investigate if essential health and development data of all children in Sweden in the Child Health Service (CHS) and School Health Service (SHS) can be linked to the classification system International Classification of Functioning, Disability and Health--Children and Youth (ICF-CY).

METHOD

Lists of essential health terms, compiled by professionals from CHS and SHS, expected to be used in the national standardised records form the basis for the analysis in this study. The essential health terms have been linked to the codes of ICF-CY by using linking rules and a verification procedure.

RESULTS

After exclusion of terms not directly describing children's health, a majority of the health terms could be linked into the ICF-CY with a high proportion of terms in body functions and a lower proportion in activity/participation and environment respectively. Some health terms had broad description and were linked to several ICF-CY codes. The precision of the health terms was at a medium level of detail.

CONCLUSION

ICF-CY can be useful as a tool for documenting child health. It provides not only a code useful for statistical purposes but also a language useful for the CHS and SHS in their work on individual as well as population levels. It was noted that the health terms used by services mainly focused on health related to body function. This indicates that more focus is needed on health data related to child's functioning in everyday life situations.

Commentary on Trzesniewski and Donnellan (2010): A Transdisciplinary Perspective on Young People's Well-Being

The health and well-being of young people are important not only for their own sake, but also for the future health of populations and societies. Yet the debate about the patterns and trends in young people's well-being and their causes is marked by uncertainty and contradiction. This article draws on evidence from trend analyses, cross-sectional studies, research on explanatory factors, expert opinion, and public-attitude surveys to argue that social changes of the last half century have harmed successive generations of young people because of their developmental vulnerability and that these young people have carried their enhanced risk into later life.

Women with non-Swedish speaking background and their children: a longitudinal study of uptake of care and maternal and child health

AIM

To study uptake of care at the antenatal and child health clinic (CHC), and maternal and child health up to 5 years after the birth, as reported by mothers with a non-Swedish speaking background (NSB).

METHODS

A sample of 300 women with a NSB, 175 originated from a poor country and 125 originated from a rich country, were compared with a reference group of 2761 women with a Swedish speaking background. Four postal questionnaires were completed: during pregnancy, and 2 months, 1 year and 5 years after the birth.

RESULTS

Mothers with a NSB from a poor country of origin did not differ from the reference group of mothers with a Swedish speaking background regarding number of clinic visits, but they had a lower attendance rate at antenatal and postnatal education classes. Depressive symptoms, parental stress and poor self-rated health were more common in these women, and they reported more psychological and behavioral problems in their 5-year olds. Women with a rich country origin did not differ from the reference group regarding maternal and child health, but had a lower uptake of all out-patient care, except parental classes after the birth.

CONCLUSION

Women originating from a poor country seem to be under great stress during pregnancy and the child's first years.

Perinatal complications and socio-economic differences in cerebral palsy in Sweden - a national cohort study

BACKGROUND

There is a controversy regarding the existence of a socio-economic gradient for cerebral palsy. Perinatal emergencies and preterm birth increase the risk for the offspring to develop cerebral palsy. The aim of this study was to investigate the association of socio-economic indicators with cerebral palsy (CP) and the role of perinatal health as mediator of this association.

METHODS

Register study of a national cohort of 805,543 children born 1987-93, including 1,437 children with cerebral palsy that were identified in hospital discharge data from national registers. Socio-economic indicators of the household were taken from the Census of 1985. Logistic regression and chi-square analyses of linearity were used to test hypotheses.

RESULTS

There was a linear association between the incidence of CP (excluding cases caused by registered injuries or malformations) as well as of major perinatal indicators and the socio-economic status (SES) of the household of the mother (p < 0.001). Children in households with low SES had a higher odds ratio of CP (OR 1.49 [95% C.I. 1.16-1.91]) compared with high SES after adjustment for demographic confounders. This OR decreased to 1.36 (1.05-1.71) after adjustment for perinatal indicators with preterm birth as the most important mediating variable.

CONCLUSION

This study suggests that there is a continuous socio-economic gradient for CP in Sweden. Further studies in more complete populations of children with cerebral palsy are needed to confirm this. Perinatal complications seem to mediate some of this gradient.

Parental country of birth is a major determinant of childhood type 1 diabetes in Sweden

OBJECTIVE

To test the hypothesis that the risk of childhood diabetes type 1 increases with migration from a low to a high incidence region.

METHODS

Register study of a national cohort of 783 547 children born between 1987 and 1993 who remained in Sweden in 2002, including 3225 children with childhood type 1 diabetes identified in hospital discharge data. Logistic regression analysis was used to test the hypotheses.

RESULTS

Offspring of two parents born in very low (Asia excluding Middle East and Latin America) and low (southern and eastern Europe and the Middle East) incidence regions had the lowest adjusted odds ratios (ORs) of childhood type 1 diabetes; 0.21 (0.11-0.41) and 0.37 (0.29-0.48), respectively, compared with the Swedish majority population. When one parent was born in a low incidence country and one parent was Swedish born, the adjusted ORs increased but remained lower than the Swedish majority population.

CONCLUSIONS

Parental country of birth is an important determinant of childhood type 1 in Sweden. Heritable factors seem most likely to explain this pattern.

School stressors, psychological complaints and psychosomatic pain

BACKGROUND

The proportion of Scandinavian school children reporting psychosomatic pain and psychological complaints have increased in recent decades. In this study we investigated these symptoms in relation to potential stressors in the school environment.

METHODS

A cross-sectional study was conducted based on child interviews linked to nationally representative household surveys in Sweden during 2002-2003 covering a sample of 2588 children aged 10-18 years. The main outcome variable of psychosomatic pain signified suffering from headache as well as recurrent abdominal pain on a weekly basis.

RESULTS

School stressors, such as harassment by peers, schoolwork pressure and being treated poorly by teachers, were associated with psychosomatic pain as well as psychological complaints such as sadness, irritability, feeling unsafe and nervous. Harassment was identified as a particularly important determinant with adjusted odds ratios (ORs) ranging from 3.1 to 8.6 for psychosomatic pain. All psychological complaints were associated with psychosomatic pain with adjusted ORs ranging from 2.2 to 3.7, and mediated most of the association of harassment to psychosomatic pain.

CONCLUSIONS

School stressors are strongly associated with psychosomatic pain and psychological complaints in school children. Psychological complaints seem to function as mediators in the association of school stressors to psychosomatic pain symptoms to a great extent.