Selective mutism in children and adolescents

The diagnosis selective mutism describes children who are completely mute in situations where speech is expected (usually in day-care or school), whereas at home they do speak with close family members. Early intervention is essential, but often a long time may pass before these children are offered adequate help.

The Selective Mutism Questionnaire: Data from typically developing children and children with selective mutism

The core symptom of the anxiety disorder selective mutism (SM) is absence of speech in specific situations, such as at school. The most commonly used standardized instruments to assess speaking behavior are the parent-rated Selective Mutism Questionnaire (SMQ) and the teacher-rated School Speech Questionnaire (SSQ), scored from 0 to 3, indicating that speaking behavior never, seldom, often, and always occur. They were developed to assess severity of mutism and potential effects of treatment. However, prospective data on speaking behavior in typically developing children (TDs) are missing in the literature. The main aim of this study was to present data from TDs over time with previously reported data from children treated for SM, as a comparison. Participants were 64 children aged 3-9 years, 32 TDs who were a matched control group to 32 children with SM. At baseline, the mean SMQ and SSQ scores were ⩾2.5 in TDs and 0.5 in children with SM. The TDs did not show significant changes over time, while significantly increased speech was found in children with SM after treatment. Thus, our findings support the use of the SMQ/SSQ to assess baseline SM severity and to evaluate potential treatment effects in future studies.

Training and validation of a novel 4-miRNA ratio model (MiCaP) for prediction of postoperative outcome in prostate cancer patients

Background

New molecular biomarkers for prostate cancer (PC) prognosis are urgently needed. Ratio-based models are attractive, as they require no additional normalization. Here, we train and independently validate a novel 4-miRNA prognostic ratio model for PC.

Patients and methods

By genome-wide miRNA expression profiling of PC tissue samples from 123 men who underwent radical prostatectomy (RP) (PCA123, training cohort), we identified six top candidate prognostic miRNAs and systematically tested their ability to predict postoperative biochemical recurrence (BCR). The best miRNA-based prognostic ratio model (MiCaP) was validated in two independent cohorts (PCA352 and PCA476) including >800 RP patients in total. Clinical end points were BCR and prostate cancer-specific survival (CSS). The prognostic potential of MiCaP was assessed by univariate and multivariate Cox-regression analyses and Kaplan-Meier analyses.

Results

We identified a 4-miRNA ratio model, MiCaP (miR-23a-3p×miR-10b-5p)/(miR-133a×miR-374b-5p), that predicted time to BCR independently of routine clinicopathologic variables in the training cohort (PCA123) and was successfully validated in two independent RP cohorts. In addition, MiCaP was a significant predictor of CSS in univariate analysis [HR 3.35 (95% CI 1.34 - 8.35), P = 0.0096] and in multivariate analysis [HR 2.43 (95% CI 1.45-4.07), P = 0.0210]. As proof-of-principle, we also analyzed MiCaP in plasma samples from 111 RP patients. A high MiCaP score in plasma was significantly associated with BCR (P = 0.0036, Kaplan-Meier analysis). Limitations include low mortality rates (CSS: 5.4%).

Conclusions

We identified a novel 4-miRNA ratio model (MiCaP) with significant independent prognostic value in three RP cohorts, indicating promising potential to improve PC risk stratification.

Treatment of selective mutism: a 5-year follow-up study

Selective mutism (SM) has been defined as an anxiety disorder in the diagnostic and statistical manual of mental disorders (DSM-5). Cognitive behavioral therapy (CBT) is the recommended approach for SM, but prospective long-term outcome studies are lacking. Reports from the children themselves, and the use of more global quality of life measures, are also missing in the literature. We have developed a school-based CBT intervention previously found to increase speech in a pilot efficacy study and a randomized controlled treatment study. Continued progress was found in our 1-year follow-up studies, where older age and more severe SM had a significant negative effect upon outcome. In the present study, we provide 5-year outcome data for 30 of these 32 children with SM who completed the same CBT for mean 21 weeks (sd 5, range 8-24) at mean age 6 years (10 boys). Mean age at the 5-year follow-up was 11 years (range 8-14). Outcome measures were diagnostic status, the teacher- and parent-rated selective mutism questionnaires, and child rated quality of life and speaking behavior. At the 5-year follow-up, 21 children were in full remission, five were in partial remission and four fulfilled diagnostic criteria for SM. Seven children (23%) fulfilled criteria for social phobia, and separation anxiety disorder, specific phobia and/or enuresis nocturna were found in a total of five children (17%). Older age and severity at baseline and familial SM were significant negative predictors of outcome. Treatment gains were maintained on the teacher- and parent questionnaires. The children rated their overall quality of life as good. Although most of them talked outside of home, 50% still experienced it as somewhat challenging. These results point to the long-term effectiveness of CBT for SM, but also highlight the need to develop more effective interventions for the subset of children with persistent symptoms.Clinical trials registration NCT01002196.

Neurodevelopmental disorders: prevalence and comorbidity in children referred to mental health services

BACKGROUND

Accurate prevalence rates of the neurodevelopmental disorders (ND) and comorbid conditions in child and adolescent mental health services (CAMHS) are essential for treatment planning and organization of health care. However, valid and reliable prevalence estimates from Nordic CAMHS populations are scarce, and the published findings vary.

AIMS

To report prevalence rates of ND (attention-deficit hyperactivity disorder: ADHD, tic disorder: TD or autism spectrum disorder: ASD) and comorbid disorders by a validated diagnostic instrument in children referred to CAMHS outpatient clinics.

METHODS

Parents of 407 consecutively referred children aged 7-13 years were interviewed with the semistructured interview schedule for affective disorders and schizophrenia, present and lifetime version (Kiddie-SADS-PL) at time of admittance.

RESULTS

One or more ND was diagnosed in 226 children (55.5%; 69.9% boys): ADHD (44.5%; 68.5% boys); TD (17.7%; 77.8% boys) and ASD (6.1%; 76% boys). Among children with ND 70 (31.0%) had only one ND with no comorbid disorder, 49 (21.7%) had more than one ND (homotypic comorbidity) and 131 (58%) had a non-ND psychiatric disorder (heterotypic comorbidity). Anxiety disorders were the most frequently occurring heterotypic comorbidity in all three ND. Comorbid depressive disorder was associated with older age, and comorbid anxiety disorder with female gender.

CONCLUSION

In children referred to CAMHS, ND constitute the most frequently occurring group of disorders, with high rates of both homotypic and heterotypic comorbidity. This needs to be taken into consideration in health service planning and treatment delivery.

Evaluation of Potential Antigenicity of Active-Site-Inhibited Recombinant Human FVIIa (FFR-rFVIIa) in an Immune-Tolerant Rat Model

Recombinant human FVIIa (rFVIIa) was inactivated by coupling Phe-Phe-Arg-CO- (FFR) covalently to the active site of the enzyme. To test the chemically-modified human protein for potential antigenicity prior to clinical trial an immune-tolerant rat model was established. Intraperitoneal injection of the parent compound, human rFVIIa, within 30 h after birth, followed by repeated subcutaneous challenge with rFVIIa in Freunds incomplete adjuvant resulted in 79% non-responding rats at day 32. Monthly subcutaneous challenge showed that the induced tolerance was stable over the 3 months study period in 80% of the rats. The clinically relevant route, intravenous administration, was used for evaluating the potential antigenicity of FFR-rFVIIa. Repeated intravenous administration of different dosages of FFR-rFVIIa did not break tolerance, indicating that FFR-rFVIIa might not be antigenic, for a limited number of intravenous administrations in a clinical setting.

Novel occupational therapy intervention in the early rehabilitation of patients with brain tumours

Statement of context

The Danish Health Authority recommends that patients with brain tumours should have their rehabilitation needs evaluated prior to hospital discharge.

Critical reflection on practice

To our knowledge, no specific recommendations for specialised occupational therapy intervention in patients with glioma have been published. We rationalise how occupational therapy practices founded on shared decision-making and common goal-setting are implicated to patients with brain tumours and elaborate on how an occupation-centred approach with occupation-focused and based intervention has the potential to impact a patient’s performance ability and satisfaction in performing occupations established by the Canadian Occupational Performance Measure. This practice was embedded in a randomised controlled trial investigating the effectiveness of intensive rehabilitation efforts and involving occupational therapy compared with standard care in patients with glioma (ClinicalTrials.gov Identifier NCT02221986).

Implications for practice

Occupational therapy makes an important contribution in neurorehabilitation, which may also apply to patients with brain tumours.

Catheter Perforation of Distal Oesophagus with Duodenal Re-Entry of Catheter

An unusual case of perforation of the oesophagus is presented. A nasogastric tube had perforated the oesophagus and re-penetrated into the duodenum, and thereby re-entered the gastrointestinal tract without perforating the peritoneum and without causing the classical clinical signs of oesophageal perforation. Treatment was started 31 days after the perforation.

Convergent and divergent validity of K-SADS-PL anxiety and attention deficit hyperactivity disorder diagnoses in a clinical sample of school-aged children

Background The Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime Version (K-SADS-PL) is a commonly used diagnostic interview both in research and clinical settings, yet published data on the psychometric properties of the interview generated diagnoses are scarce. Aims To examine the convergent and divergent validity of the Norwegian version of the K-SADS-PL current diagnoses of anxiety disorders and attention deficit hyperactivity disorder (ADHD). Method Participants were 105 children aged 7-13 years referred for treatment at child mental health clinics and 36 controls. Diagnostic status was determined based on K-SADS-PL interviews with the mothers. Child and mother reported child symptoms of anxiety on the Multidimensional Anxiety Scale for Children and teachers reported anxiety symptoms on the Teacher Report Form. Mother and teacher reported on symptoms of ADHD on the Disruptive Behavior Rating Scale. Results Rating scale data from multiple informants in a clinical sample and healthy controls supported the convergent and divergent validity of K-SADS-PL anxiety diagnoses combined, and, specifically, the diagnoses of separation anxiety disorder, social phobia, and specific phobia. Support was also observed for convergent and divergent validity of ADHD diagnoses, including the predominately inattentive subtype. Conclusion The K-SADS-PL generates valid diagnoses of anxiety disorders and ADHD.

Non-obsessive-compulsive anxiety disorders in child and adolescent mental health services--Are they underdiagnosed, and how accurate is referral information?

BACKGROUND

Previous studies have reported low prevalence of non-obsessive-compulsive (OCD) anxiety disorders in child and adolescent mental health services (CAMHSs), suggesting that these disorders may go unrecognized. Possible reasons may be lack of routinely used standardized diagnostic instruments, and/or an under-reporting of anxiety symptoms in the referral information.

AIMS

To examine the frequency of non-OCD anxiety disorders in referred children based on a standardized diagnostic interview, to compare the results with data from the Norwegian Patient Register (NPR), and to explore the correspondence between anxiety as a referral symptom and anxiety as a diagnosis, and the influence of heterotypic co-morbidity on this correspondence.

METHODS

Parents of 407 consecutive referrals to CAMHS aged 7-13 years were interviewed with the semi-structured diagnostic interview Kiddie-SADS-PL at the time of admittance. Referral symptoms were collected from national referral forms.

RESULTS

A total of 133 referred children (32.7%) met the criteria for a non-OCD anxiety disorder compared with about 5% in the NPR. Half of those who met diagnostic criteria for an anxiety disorder did not have anxiety as a referral symptom. Co-morbid ADHD or disruptive disorder was significantly associated with a lower probability of having anxiety as a referral symptom.

CONCLUSIONS

The use of a standardized diagnostic interview in consecutively referred children yielded significantly higher rates of anxiety disorders than the NPR prevalence rates. Co-morbid ADHD or disruptive disorder may contribute to the underdiagnosing of anxiety disorders. Diagnostic instruments covering the whole range of child psychiatric symptoms should be implemented routinely in CAMHS.

Selective mutism: follow-up study 1 year after end of treatment

Cognitive behavioral therapy (CBT) is generally considered the recommended approach for selective mutism (SM). Prospective follow-up studies of treated SM and predictors of outcome are scarce. We have developed a CBT home and school-based intervention for children with SM previously found to increase speech in a pilot efficacy study and in a randomized controlled treatment study. In the present report we provide outcome data 1 year after having completed the 6-month course of CBT for 24 children with SM, aged 3-9 years (mean age 6.5 years, 16 girls). Primary outcome measures were the teacher rated School Speech Questionnaire (SSQ) and diagnostic status. At follow-up, no significant decline was found on the SSQ scores. Age and severity of SM had a significant effect upon outcome, as measured by the SSQ. Eight children still fulfilled diagnostic criteria for SM, four were in remission, and 12 children were without diagnosis. Younger children improved more, as 78% of the children aged 3-5 years did not have SM, compared with 33% of children aged 6-9 years. Treatment gain was upheld at follow-up. Greater improvement in the younger children highlights the importance of an early intervention.

Somatic symptoms in children with anxiety disorders: an exploratory cross-sectional study of the relationship between subjective and objective measures

Symptoms of childhood anxiety disorders include activation of bodily stress systems to fear stimuli, indicating alterations of the autonomic nervous system (ANS). Self-reported somatic symptoms are frequently reported, while studies including objective measures of ANS are scarce and show inconsistent results. Even less studied is the relationship between subjective and objective measures of somatic symptoms in anxious children. Increased knowledge of this relationship may have relevance for treatment programmes for anxiety disorders. This cross-sectional study examined subjective and objective measures of ANS responsiveness in a clinical sample of children with anxiety disorders (7-13 years; n = 23) and in healthy controls (HC; n = 22) with equal distributions of gender and age. The subjective measure used was the Multidimensional Anxiety Scale for Children, which includes a subscale on somatic symptoms. The objective measures consisted of an orthostatic challenge (head-up tilt test), and an isometric muscular exercise (handgrip) while the participants were attached to the Task Force Monitor, a combined hardware and software device used for continuous, non-invasive recording of cardiovascular variables. The anxiety disorder group reported significantly more somatic symptoms than HCs (both by mother and child reports). In contrast, no relevant differences in cardiovascular variables were demonstrated between the anxiety group and HCs. Finally, there were no significant correlations between subjective and objective measures in either group. Because of the small sample size, the findings must be interpreted carefully, but the results do not support previous reports of functional alterations of the ANS in anxious children.

A randomized controlled trial of a home and school-based intervention for selective mutism - defocused communication and behavioural techniques

BACKGROUND

Randomized controlled psychosocial treatment studies on selective mutism (SM) are lacking.

METHOD

Overall, 24 children with SM, aged 3-9 years, were randomized to 3 months treatment (n = 12) or wait list (n = 12). Primary outcome measure was the School Speech Questionnaire.

RESULTS

A significant time by group interaction was found (p = .029) with significantly increased speech in the treatment group (p = .004) and no change in wait list controls (p = .936). A time by age interaction favoured younger children (p = .029). Clinical trail registration: Norwegian Research CouncilNCT01002196.

CONCLUSIONS

The treatment significantly improved speech. Greater improvement in the younger age group highlights the importance of an early intervention.

Evaluating the Impact of Audits and Feedback as Methods for Implementation of Evidence in Stroke Rehabilitation

Introduction:

This paper evaluates audits and feedback as methods to increase implementation of evidence in stroke rehabilitation.

Method:

The study used an action research approach and theories of knowledge translation. A sample of 22 occupational therapists participated from two Danish hospitals that admitted stroke patients. Data collection methods included audits of occupational therapy medical records, documentations of daily practice, and collaborative discussions. Active feedback and discussions of the findings took place, at a group level in four local clinical audits. Data analysis of daily self-reported recordings and audits was descriptive. Audit data were analysed using descriptive statistics. A phenomenological hermeneutical interpretive methodology was used for analysing qualitative data.

Findings:

Audits and feedback were based on clear standards and contextual developing action plans. Daily practice in both settings adapted to the clinical guidelines. Implementations of the standardized assessment tools seemed to be the most successful.

Conclusion:

The effects of audit and feedback profited from the active participation of the therapists, as well as local gatekeepers having formal responsibilities for implementing change. The process was strengthened by providing the audits and feedback more than once. The effect of audits and feedback was positively influenced by being in line with current conceptual frameworks, local policies, and values.

Associations between sleep problems and attentional and behavioral functioning in children with anxiety disorders and ADHD

This study examined associations between sleep problems and attentional and behavioral functioning in 137 children aged 7 to 13 years with anxiety disorders (n = 39), attention deficit hyperactivity disorder (ADHD; n = 38), combined anxiety disorder and ADHD (n = 25), and 35 controls. Diagnoses were made using the semistructured diagnostic interview Schedule for Affective Disorders and Schizophrenia for School-age Children-Present and Lifetime Version. Sleep problems were assessed using the Children's Sleep Habits Questionnaire, attention was measured by the Attention Network Test, and behavioral problems were measured by teacher ratings on the Achenbach System of Empirically Based Assessment, Teacher Report Form. Sleep problems were associated with reduced efficiency of the alerting attention system for all children and with increased internalizing problems in children with anxiety disorders.

Persistence of sleep problems in children with anxiety and attention deficit hyperactivity disorders

This study examines the persistence of sleep problems over 18 months in 76 referred children with anxiety disorders and/or attention deficit hyperactivity disorders (ADHD) and 31 nonreferred controls, and explores predictors of sleep problems at follow-up (T2) in the referred children. Diagnoses were assessed at initial assessment (T1) using the semi-structured interview Kaufman Schedule for Affective Disorders and Schizophrenia. Sleep problems were assessed using the Children's Sleep Habit Questionnaire at T1 and at T2. Persistence rate of total sleep problems in the clinical range was 72.4 % in referred children, and did not differ significantly between children with a T1 diagnosis of anxiety disorder (76.0 %), ADHD (70.6 %), anxiety disorder and ADHD (68.8 %) or nonreferred controls (50.0 %) The total sleep problems score at T1 significantly predicted the total sleep problems score at T2, whereas age, sex, parent education level and total number of life events did not.

Selective mutism: a home-and kindergarten-based intervention for children 3-5 years: a pilot study

The aim was to examine the outcome of a multimodal treatment for selective mutism (SM). Seven children, aged three-five years, who were referred for SM were included. The treatment started at home and was continued at kindergarten for a maximum of six months, with predefined treatment goals in terms of speaking levels, from I ("Speaks to the therapist in a separate room with a parent present") through to VI ("Speaks in all kindergarten settings without the therapist present"). The outcome measures were the teacher-reported School Speech Questionnaire (SSQ) and the treatment goal obtained (I-VI) six months after the onset of treatment, and the SSQ and Clinical Global Impression Scale (CGI) at one-year follow-up. Six children spoke in all kindergarten settings (VI) after a mean of 14 weeks treatment. One child, with more extensive neuro-developmental delay, spoke in some settings only (V). The mean SSQ score was 0.59 (SD = 0.51) at baseline compared with 2.68 (SD = 0.35) at the six-month evaluation and 2.26 (SD = 0.93) at one-year follow-up. The mean CGI score at baseline was 4.43 (SD = 0.79) compared with 1.14 (SD = 0.38) at follow-up. Home- and kindergarten-based treatment appears to be promising.

Motor impairment in children with anxiety disorders

This study examined the frequency and degree of motor impairment in referred children with anxiety disorders (AnxDs), compared with children with attention deficit/hyperactivity disorder (ADHD), children with comorbid AnxDs and ADHD, and nonreferred controls. All participants (n=141; 90 males, 51 females; mean age: 10 years, 1 month; range: 7-13 years) had an IQ greater than 70. Diagnoses of mental disorders were established using the Schedule for Affective Disorders and Schizophrenia for School-Aged Children (Kiddie-SADS). Motor ability was assessed using the Movement Assessment Battery for Children (M-ABC). We found that children with AnxDs exhibited significantly higher total impairment scores on the M-ABC than controls, but were not significantly different from children with ADHD or children with comorbid AnxDs and ADHD. All clinical groups exhibited similar profiles of motor impairment. A total of 19 (46%) children with AnxDs scored below the 5th percentile on the M-ABC, indicating that motor function is impaired in many children with AnxDs to a degree that probably interferes with their activities of daily living. These results support the notion that assessment of motor function is important in understanding the daily challenges of children with AnxDs.

Paediatric functional abdominal pain: significance of child and maternal health. A prospective study

AIM

First, to what extent do general paediatric outpatients with functional abdominal pain experience other somatic and mental health symptoms compared with children in a population-based sample? Second, to what extent are such symptoms in both patients and their mothers associated with persistent child abdominal pain and functional disability?

METHODS

Ninety-four referred patients [mean age (SD) 11.1 (1.9) years, 62% girls] were assessed by questionnaires and a paediatric consultation at baseline and at follow-up after 6-9 months (94% follow-up participation). At baseline, somatic and mental health symptoms in the patients were compared with a population-based sample of 14,000 school children. Outcome at follow-up was patient self-reported abdominal pain and disability. Prognostic factors explored included patient and maternal somatic and mental health symptoms.

RESULTS

The patients experienced significantly more somatic [e.g. headache (OR: 9.2; 95% CI: 5.9-14.6)] and emotional symptoms than the school children. Patient's older age and peer problems at baseline were significantly associated with more abdominal pain at follow-up, whereas patient's older age, emotional symptoms, prosocial behaviour and maternal somatic symptoms were associated with disability.

CONCLUSION

Our results highlight the importance of focusing wider than just the patient's symptoms of abdominal pain in clinical practice and research.

Childhood predictors of recurrent abdominal pain in adolescence: A 13-year population-based prospective study

OBJECTIVE

To investigate maternal and child emotional symptoms, physical health problems, and negative life events measured at children's age 18 months and 12 years as potential predictors for self-reported recurrent abdominal pain (RAP) in adolescents (14 years).

METHODS

A population-based prospective study conducted at child health clinics (preventive health care) in Norway followed a cohort of 916 mothers with children from children's age 18 months until adolescence. Child self-report was obtained from 12 years of age. Outcome measure was adolescent self-reported RAP.

RESULTS

Of 456 adolescents, 58 (13%) reported RAP. Of these, 36 (62%) were girls. By multivariate analyses, the following maternal factors predicted RAP in adolescence: psychological distress at children's age 18 months (OR, 2.5; 95% CI, 1.3-4.8) and a maternal history of psychological distress at children's age 12 years (OR, 3.2; 95% CI, 1.7-6.2). The following child factors measured at age 12 years predicted RAP in adolescence: abdominal (OR, 2.5; 95% CI, 1.3-4.9) and extraintestinal pain (OR, 2.3; 95% CI, 1.2-4.4) by maternal report, self-reported frequent extraintestinal pain (OR, 2.9; 95% CI, 1.4-5.9), and self-reported depressive symptoms (OR, 2.4; 95% CI, 1.1-5.1). Negative life events and physical health in mothers and toddlers did not predict RAP.

CONCLUSIONS

This is the first cohort study that finds maternal psychological distress in early childhood to predict RAP in their offspring 13 years later. Our results support that maternal psychological distress and preadolescent children's depressive and somatic symptoms may play a role in the development of RAP.

Prevalence and characteristics of significant social anxiety in children aged 8-13 years: a Norwegian cross-sectional population study

BACKGROUND

Social anxiety has been frequently studied in both population- and clinical-based adult and adolescent samples. Corresponding research in children is scarce and is dominated by clinical studies. The aim of the present population-based study was to examine the prevalence of significant social anxiety (SSA) in preadolescent children and compare their characteristics with those of children without SSA. The spectrum of social anxiety is explored by comparing children with different levels of social anxiety, as defined by 1-2 versus 3-5 social situations feared.

METHOD

The sample consisted of 14,497 parents and their 3rd-7th grade children (8-13 years old) who participated in a health profile study, including questions covering DSM-IV criteria A-D for social anxiety disorder (SAD). Socio-demographic data, social and school functioning, somatic complaints, parent-child relationships, and use of health services were added to a logistic regression model to explore characteristics associated with children with, and without SSA. Associated emotional and behavioural problems were measured by the Strengths and Difficulties Questionnaire (SDQ) using parent and self-report.

RESULTS

Parents described 2.3% of all children as significantly socially anxious and 0.9% feared at least three social situations. The majority of children with SSA managed their everyday life well. However, compared with children without SSA, children with SSA struggled more often in different areas of life and showed a significantly higher prevalence of associated emotional and behavioural symptoms. Our findings also support the notion of social anxiety as a spectrum concept.

CONCLUSIONS

Social anxiety problems start in childhood and can be impairing, even in non-clinical populations and in reasonably young age groups. Increased awareness of different aspects of social anxiety is needed to identify children who are at risk and to devise appropriate interventions to improve the immediate and long-term outcome.

Attention in selective mutism--an exploratory case-control study

The aim of the study was to explore the association between selective mutism (SM) and attention. In SM social anxiety seems central but language impairment and motor problems are also reported. Attention problems have been described in parental behavioral ratings, while neuropsychological studies are lacking. A neuropsychological test (the Trail Making Test) and parental ratings of attention- and anxiety problems were administered to a clinical sample of 23 children with SM (aged 7-16 years, 12 boys and 11 girls) and 46 non-referred matched controls. The SM group differed from controls on the Trail Making Test, but the group difference disappeared, when controlling for motor function and IQ. Parental ratings of attention problems were not significantly associated with the neuropsychological attention measure. Neuropsychological studies of attention controlled for IQ and motor function are needed as well as tests that measure different aspects of attention.

Is social anxiety disorder in childhood associated with developmental deficit/delay?

Children with social anxiety disorder (SAD) have been reported to display reduced social skills. Less attention has been paid to whether neurodevelopmental deficits/delays (NDD's) in language and motor function may contribute to their impaired social skills. The present study aimed to assess the extent of language and motor impairment in children with SAD. A population-based screened sample consisting of 150 children (11-12 years) was assessed with a diagnostic interview (Kiddie-SADS), the Wechsler Abbreviated Scale of Intelligence (WASI) and the Motor Assessment Battery for Children (MABC). Test results were compared across five diagnostic groups: SAD (n=29); ADHD (n=23); SAD and ADHD (n=6); "other disorder" (n=44) and "no disorder" (n=48). Delays in language and motor development as reported by mother were also investigated. Verbal IQ and motor skills were reduced and maternally reported delay was more frequent in the SAD group compared to the "other disorder" and "no disorder" group.

The association between avoidant personality traits and motor impairment in a population-based sample of 11-12-year-old children

The aim of the study was to examine the association between avoidant personality traits and motor impairment in childhood. The relationship between other personality traits and motor function was also explored. A population-based screened sample of 150 11-12-year-old children (50 socially anxious, 50 impulsive and 50 nonsocially anxious/nonimpulsive) was assessed using the Coolidge Personality and Neuropsycho- logical Inventory for Children (CPNI) and the Motor Assessment Battery for Children (MABC). Among the personality scales, avoidant personality traits were most strongly associated with motor impairment. Children with clinically avoidant personality traits (n = 31) showed a significantly poorer motor performance than children in the nonclinical avoidance group (n = 119). About 50% of the children with clinical avoidance obtained a motor score below the 5th percentile. No gender differences in motor performance were found in the clinical avoidance group. More research on the impact of motor impairment on psychological development is needed.

Is selective mutism associated with deficits in memory span and visual memory?: An exploratory case-control study

Our main aim in this study was to explore the association between selective mutism (SM) and aspects of nonverbal cognition such as visual memory span and visual memory. Auditory-verbal memory span was also examined. The etiology of SM is unclear, and it probably represents a heterogeneous condition. SM is associated with language impairment, but nonspecific neurodevelopmental factors, including motor problems, are also reported in SM without language impairment. Furthermore, SM is described in Asperger's syndrome. Studies on nonverbal cognition in SM thus merit further investigation. Neuropsychological tests were administered to a clinical sample of 32 children and adolescents with SM (ages 6-17 years, 14 boys and 18 girls) and 62 nonreferred controls matched for age, gender, and socioeconomic status. We used independent t-tests to compare groups with regard to auditory-verbal memory span, visual memory span, and visual memory (Benton Visual Retention Test), and employed linear regression analysis to study the impact of SM on visual memory, controlling for IQ and measures of language and motor function. The SM group differed from controls on auditory-verbal memory span but not on visual memory span. Controlled for IQ, language, and motor function, the SM group did not differ from controls on visual memory. Motor function was the strongest predictor of visual memory performance. SM does not appear to be associated with deficits in visual memory span or visual memory. The reduced auditory-verbal memory span supports the association between SM and language impairment. More comprehensive neuropsychological studies are needed.

A method for implementation of nutritional therapy in hospitals

BACKGROUND AND AIMS

Many barriers make implementation of nutritional therapy difficult in hospitals. In this study we investigated whether, a targeted plan made by the staff in different departments could improve nutritional treatment within selected quality goals based on the ESPEN screening guidelines.

METHODS

The project was carried out as a continuous quality improvement project. Four different specialities participated in the study with a nutrition team of both doctors, nurses, and a dietician, and included the following methods: (1) Pre-measurement: assessment of quality goals prior to study including the use of screening of nutritional risk (NRS-2002), whether a nutrition plan was made, and monitoring was documented in the records. (2) INTERVENTION: multidisciplinary meeting for the ward staff using a PC-based meeting system for detecting barriers in the department concerning nutrition, elaboration of an action plan and implementation of the plan. (3) Re-measurement: as in (1) based on information from records and patient interviews, and an evaluation based on focus group interview with the staff. Patients who gave informed consent to participate in the study (>14 years) were included consecutively. Mann-Whitney and Kruskal-Wallis test was used for ordinal data, and Pearson chi(2) test for nominative data. P values <0.05 were considered significant. The study was performed in accordance with the Research Ethics Committee.

RESULTS

In this study 141/122 patients were included before/after the implementation period with a mean weight loss within the last 3 months of 6.2 and 5.2 kg, respectively. Before the study we found that BMI was not measured. More than half of the patients had a weight loss within the last 3 months, and 40% had a weight loss during hospitalization, and this was not documented in the records. About 75% had a food intake less than normal within the last week, and nearly one-third were at a severe nutritional risk, and only 33% of these had a nutrition plan, and 18% a plan for monitoring. Barriers concerning nutrition included low priority, no focus, no routine or established procedures, and insufficient knowledge, lack of quality and choice of menus, and lack of support from general manager of the hospital. The staff introduced individually targeted procedures including assigning of responsibility, a nutrition record, electronic calculator of energy intake, upgrading of the dieticians and special diets, communication, and educational programs. A great consistency existed between barriers for targeted nutrition effort and ideas for improvement of the quality goals between the different departments. Quality assessment after study showed an overall significant improvement of the selected quality goals.

CONCLUSION

The introduction of a new method for implementation of nutritional therapy according to ESPEN screening guidelines seems to improve nutritional therapy in hospitals. The method included assessment of quality goals, identification of barriers and individual targeted plans for each department followed by an evaluation process. The model has to be refined further with relevant clinical endpoints.

Social anxiety disorder in 11-12-year-old children: The efficacy of screening and issues in parent-child agreement

OBJECTIVE

To investigate the level of diagnostic and discriminative accuracy of The Social Anxiety Scale for Children - Revised (SASC-R) for identifying social anxiety disorder (SAD) in a community-based sample of 11-12 year-old children. Parent-child diagnostic agreement was also examined.

METHOD

A questionnaire including SASC-R and items on impulsive behavior was sent to a population based sample of children, born in 1992. A total of 2568 parents returned their questionnaires (rr: 70%), and 1297 (51%) consented to further participation. An index group [50 high-scoring children on social anxiety (SA-group)] and two contrast groups [(50 high-scoring children on impulsive behavior (Imp-group) and 50 low-scoring children on SA and Imp, (Ls-group)] were selected for participation.

RESULTS

SAD was assigned 35 (23%) of 150 children; 28 (80%) from the SA-group; 7 (20%) from the Imp- group and 0 from the Ls-group. The SASC-R showed relatively high discriminative accuracy for SAD, but was also influenced by other diagnoses. Mother-child agreement was fair (kappa = 0.46), and mother-only diagnoses were frequent. Both child and parent information are important when diagnosing SAD in this age group.

Prevalence of patients at nutritional risk in Danish hospitals

BACKGROUND & AIMS

Undernutrition is associated with increased morbidity and mortality and is common in patients admitted to hospital. We examined (1) the prevalence of patients at nutritional risk, (2) whether these patients were identified by the staff, and (3) whether a nutritional plan and monitoring was made for patients at nutritional risk.

METHODS

A cross-sectional study in 15 randomly selected departments (>200 beds, departments of internal medicine, gastro- and orthopedic surgery) in Danish hospitals. The patients were characterized by scoring the components 'undernutrition' and 'severity of disease' in 4 categories (absent, mild, moderate or severe). The patient could have a score of 0-3 for each component (undernutrition and severity of disease), and any patient with a total score > or = 3 was considered at nutritional risk. Undernutrition was evaluated by 3 variables (BMI, recent weight loss, recent food intake).

RESULTS

Out of 590 patients, 39.9% were nutritionally at risk, with the highest prevalence in departments of gastro-surgery (57%). BMI was <18.5 in 10.9%, and between 18.5 and 20.5 in 16.7% of the patients. In 7.6% the records contained information about nutritional risk, in 14.2% about a nutrition plan of which only 55.2% included a plan for monitoring. Measurements of BMI were found in 3% of the records. Both severity of disease (P < 0.02) and weightloss (P < 0.04) were predictive for making a nutrition plan.

CONCLUSIONS

Nearly 40% of patients in departments of internal medicine, gastro- and orthopedic surgery are at nutritional risk, and only a minor part of these patients are identified. As a consequence only few patients at a nutritional risk have a nutrition plan and a plan for monitoring.

Evaluation of potential antigenicity of active-site-inhibited recombinant human FVIIa (FFR-rFVIIa) in an immune-tolerant rat model

Recombinant human FVIIa (rFVIIa) was inactivated by coupling Phe-Phe-Arg-CK- (FFR) covalently to the active site of the enzyme. To test the chemically-modified human protein for potential antigenicity prior to clinical trial an immune-tolerant rat model was established. Intraperitoneal injection of the parent compound, human rFVIIa, within 30 h after birth, followed by repeated subcutaneous challenge with rFVIIa in Freunds incomplete adjuvant resulted in 79% non-responding rats at day 32. Monthly subcutaneous challenge showed that the induced tolerance was stable over the 3 months study period in 80% of the rats. The clinically relevant route, intravenous administration, was used for evaluating the potential antigenicity of FFR-rFVIIa. Repeated intravenous administration of different dosages of FFR-rFVIIa did not break tolerance, indicating that FFR-rFVIIa might not be antigenic, for a limited number of intravenous administrations in a clinical setting.

Non-specific markers of neurodevelopmental disorder/delay in selective mutism--a case-control study

Selective mutism (SM) in children is frequently associated with language disorder/delay suggesting that neurobiological factors may be involved in the development of SM. Motor co-ordination problems, reduced optimality pre- and perinatally and minor physical anomalies represent other markers for neurodevelopmental disorder/delay. The present study explores these markers in referred children with SM (n=54), non-referred matched controls (n =108) and in SM subgroups with and without a communication disorder (CoD). Children with SM differed significantly from controls in parent-reported motor developmental delay, and they obtained a higher pre- and perinatal "reduced optimality score". They scored significantly lower on a motor performance test and showed a higher frequency of minor physical anomalies compared with controls. There were no differences in these respects between SM and CoD compared with SM without CoD. The results confirm that neurobiological factors may be involved in the development of SM. Accordingly, the clinical assessment of referred children with SM should include a thorough history of motor development and an evaluation of present motor skills. The interplay of shyness/social anxiety and motor function problems has to be addressed to reduce misunderstandings of the child's behaviour and to adjust demands for motor skills to the actual level of the child.

A case-control study of EAS child and parental temperaments in selectively mute children with and without a co-morbid communication disorder

Clarification of sub-groups of children with selective mutism (SM) may enhance the understanding of symptom development. The present case-control study compares temperament characteristics applying EAS temperament survey in SM children with a co-morbid communication disorder (CoD), SM children without CoD and matched controls. Temperament characteristics in the parents are compared as well. The results show that SM children with CoD are characterized by more emotional stability and higher sociability than SM children without CoD. The parents of the SM children with CoD did not differ in temperament characteristics from the control parents. The parents of the SM children without CoD differed from the controls on the Distress, Fear and Activity scales. The study suggests different familial transmission in the two sub-groups of children with SM.

MCMI-II personality traits and symptom traits in parents of children with selective mutism: a case-control study

The etiology of selective mutism (SM) in children is unknown but is regarded as multifactorial. SM is frequently associated with social anxiety and language disorder or delay. The present study addresses SM and social anxiety as a familial phenomenon by comparing self-reported personality traits and symptom traits (Millon Clinical Multiaxial Inventory) in parents of 50 SM children with control parents. Personality and symptom traits reflecting social anxiety are also explored separately in the parents of SM children with and without a comorbid communication disorder. The results confirm SM and social anxiety as a familial phenomenon. Assessment and treatment planning should take this into account. The family data also suggest different family transmissions of SM and social anxiety in the SM group with and without a comorbid communication disorder.

Multiple informants' report of emotional and behavioural problems in a nation-wide sample of selective mute children and controls

Emotional and behavioural problems and competencies in a nation-wide sample of referred selective mute children (SM) and matched non-referred controls, aged 4-16 years, were assessed by the Child Behaviour Checklist, (CBCL), Teacher Report Form (TRF) and Youth Self Report (YSR) (1). Main issues addressed were the co-variation of internalising and externalising problems reported across informants, whether there exists a pure externalising group of children with SM, and the nature of the internalising and externalising problems. The results show that the children with SM differed substantially from their peers in internalising problems as reported by the parents and the teachers. In contrast, the results on the YSR indicated an under-reporting of internalising problems. Externalising problems in SM were reported in a low to moderate degree by the parents only. No child with SM and pure externalising symptoms was found. The children with SM differed mostly from their peers on the withdrawn scale. On the item level, both the internalising and the externalising symptoms that best differentiated the children with SM from the controls support the notion of SM as an expression of social anxiety.

Selective mutism and comorbidity with developmental disorder/delay, anxiety disorder, and elimination disorder

OBJECTIVES

To assess the comorbidity of developmental disorder/delay in children with selective mutism (SM) and to assess other comorbid symptoms such as anxiety, enuresis, and encopresis.

METHOD

Subjects with SM and their matched controls were evaluated by a comprehensive assessment of the child and by means of a parental structured diagnostic interview with focus on developmental history. Diagnoses were made according to DSM-IV.

RESULTS

A total of 54 children with SM and 108 control children were evaluated. Of the children with SM, 68.5% met the criteria for a diagnosis reflecting developmental disorder/delay compared with 13.0% in the control group. The criteria for any anxiety diagnosis were met by 74.1% in the SM group and for an elimination disorder by 31.5% versus 7.4% and 9.3%, respectively, in the control group. In the SM group, 46.3% of the children met the criteria for both an anxiety diagnosis and a diagnosis reflecting developmental disorder/delay versus 0.9% in the controls.

CONCLUSIONS

SM is associated with developmental disorder/delay nearly as frequently as with anxiety disorders. The mutism may conceal developmental problems in children with SM. Children with SM often meet diagnostic criteria for both a developmental and an anxiety disorder.

Pyomyositis due to non-haemolytic streptococci

We present a unique case of a multifocal non-tropical pyomyositis due to non-haemolytic streptococci in a 36-y-old woman. The initial infection was in an area of contused muscle in the left anterior thigh and spread to the contralateral femoral and gluteal musculature. There was a previous history of Staphylococcus aureus pyomyositis and colitis ulcerosa. The patient was treated successfully with surgical drainage and parenteral antibiotics.

Elective mutism--associated with developmental disorder/delay. Two case studies

Elective mutism (EM) is not regarded as a separate diagnostic category in the ICD-9, but is included under the heading "313: Disturbance of emotions specific to childhood and adolescence." In the ICD-10 EM is acknowledged as a separate diagnosis defined as "a marked, emotionally determined lack of speech in certain situations in a child with a normal or near normal speech/language ability." The diagnosis excludes pervasive developmental disorder and specific developmental disorders of speech and language. Two patients referred for EM to a child and adolescent psychiatry outpatient clinic, showed specific developmental delays and assessment indicated slight mental retardation in one of them. The question arose regarding how extensively EM is reported in the literature as associated with developmental disorder/delay. A search was carried out in four data-bases where most references were listed under the keyword "mutism". This paper presents the two case studies, and the results of the literature inventory. It concludes that EM may be associated with developmental disorder/delay and suggests that this could be a predisposing factor for an emotionally determined lack of speech in certain situations.

Amphetamine redistributes dopamine from synaptic vesicles to the cytosol and promotes reverse transport

Whether amphetamine acts principally at the plasma membrane or at synaptic vesicles is controversial. We find that d-amphetamine injection into the Planorbis giant dopamine neuron causes robust dopamine release, demonstrating that specific amphetamine uptake is not required. Arguing for action at vesicles, whole-cell capillary electrophoresis of single Planorbis dopamine neurons shows that amphetamine reduces vesicular dopamine, while amphetamine reduces quantal dopamine release from PC12 cells by > 50% per vesicle. Intracellular injection of dopamine into the Planorbis dopamine neuron produces rapid nomifensine-sensitive release, showing that an increased substrate concentration gradient is sufficient to induce release. These experiments indicate that amphetamine acts at the vesicular level where it redistributes dopamine to the cytosol, promoting reverse transport, and dopamine release.

Is tissue factor pathway inhibitor involved in the antithrombotic effect of heparins? Biochemical considerations

Tissue factor pathway inhibitor (TFPI) is released into the circulation after intravenous or subcutaneous injection of heparin or low-molecular-weight heparin (Logiparin) in humans. The plasma concentration of TFPI is increased 2- to 4-fold by a prophylactic dose of Logiparin, and this excess TFPI remains in the circulation only in the presence of the heparin. TFPI and heparin show strong synergism in clotting assays at concentrations obtained after heparin injection in humans. Animal studies have demonstrated that TFPI by itself has antithrombotic properties. It is concluded that the release of TFPI may contribute significantly to the antithrombotic effect of heparin.

Simultaneous presence of tissue factor pathway inhibitor (TFPI) and low molecular weight heparin has a synergistic effect in different coagulation assays

Injection of heparin releases tissue factor pathway inhibitor (TFPI) to the blood and, after heparin neutralization, it has been recently demonstrated that the released TFPI has an anticoagulant activity. Using recombinant TFPI (rTFPI) we have investigated how the simultaneous presence of TFPI and low molecular weight heparin (LMW heparin) affects different coagulation assays. Coagulation was measured using the activated partial thromboplastin time, the prothrombin time and a dilute tissue factor assay. The anticoagulant activity of partly purified plasma TFPI (pTFPI) was much higher than that of TFPI. However, this high anticoagulant activity was unstable, so in order to investigate the effect of pTFPI and LMW heparin we used an inhibitory antibody towards TFPI and looked at the effect of removing TFPI from plasma. When both rTFPI and LMW heparin was added to plasma a synergistic effect was observed in all assays. In the tissue factor dependent coagulation assays, the effect of adding rTFPI or removing pTFPI was more pronounced in the presence of heparin. TFPI plays a significant role in assays where the coagulation time is prolonged for some reason. This may be caused by dilution of tissue factor, by the presence of heparin or by a defect in the coagulation cascade such as that seen in haemophilia.

Radiation resistance of microorganisms on unsterilized infusion sets

Three different methods were used for detecting and isolating microorganisms with high radiation resistance from the microbial contamination on infusion sets prior to sterilization. By all three methods, microorganisms with a radiation resistance high enough to be a critical factor in a sterilization process (D-6 value greater than or equal to 30 kGy) were found with a frequency of approximately two colony forming units (cfu) per 100 product items, even though the product items in two of the series of analyses were irradiated with doses of 3-6 kGy. The frequency of occurrence of isolates with D-6 values greater than or equal to 30 kGy was 0.45 per 1000 cfu of the total aerobic count. Eight different isolates of microorganisms had D-6 values greater than or equal to 40 kGy when irradiated in dried laboratory preparation. All but one of these were classified according to morphologic criteria as Deinococcus, and all but one had nonlinear dose-response relationships in semilogarithmic presentation.