Thursday, June 29, 2006

Stress, Asthma Exacerbations And Children

Young boy, sparked out and asleep in a plastic laundry tubChildren are remarkably resilient. Children can also be mimosaphants: a creature with the delicacy of a mimosa when its own sensitivities are threatened, but the grace of an elephant when dealing with the sensitivities of others. Perspective is difficult enough for adults: young children are still struggling with the concept that things exist, even when they put their hands over their eyes. Anyone who has put their feet up 'while the children are playing', and then had to separate sparring toddlers who are trading death threats and landing their lumps while tearfully protesting, "She started it", or has had to handle a 30 minute tantrum because the gravy is touching the potato, knows that children can be stressed by both small and large events.

A child can be in a frenzy of excitement, popping veins, flushing a dark shade of red and generally knotting her physiology before she collapses asleep in the nearest receptacle, a few minutes later. At other times, when some children are upset or distressed, they can withdraw and seem very subdued. Despite their renowned resilience, do children experience consequences for stress-related events: does the nature of the stress matter?

Sandberg and her colleagues studied children with asthma, between the ages of 6-13: they looked at the impact of negative life events that would be distressing or unsettling to most children of comparable age (Sandberg et al., 2004). Examples of these events include births, changes in family relationships (break-ups and new relationships), separations from family, illness, and hospitalisation.

The researchers conclude that there is a strong correlation between stressful negative life events and asthma exacerbations in children. The most striking finding is that within the first 48 hours of such an event, there is almost five times the likelihood of a new asthma attack (the reported effective increase of risk is 4.69). The risk subsides within 3-10 days but flares up again, 5-7 weeks after the event, this time to almost double the risk (reported, 1.8).

The researchers speculate that the initial increase in risk might be an amalgam of inflammatory and airway responses initiated by the stress-relase of hormones, brain chemicals, and their influence on the nervous system. The second spike in risk suggests that there are delayed effects of stress on the immune system, although the mechanisms of that are unclear. However, it is apparent from this and similar studies (e.g., Liu et al., 2002; Laube et al., 2003) that there is an immunological response to the stress of a negative life event as well as on-going stress.

There is some variable scientific support for the relationship of stress, emotional triggers and asthma: McEwen’s recent elaboration of the theory of allostasis and allostatic load (1998; McEwen et al, 1999) may have some merit as a partial explanation. Allostasis is the state whereby we maintain stability (or homeostasis) through change, and it allows us to adjust to different states of the body such as resting or active. Allostatic load describes the ‘wear and tear’ that the body experiences as a consequence of repeated cycles of allostasis in addition to the inefficient turning-on or shutting-off of these responses.

Allostatic load moves beyond the concept of chronic stress to explain why there are many contributing factors in an individual’s life that influence the level, timing, and regulation of the mediators of allostasis. Allostatic load can reflect genetically-, developmentally- or behaviourally-programmed inefficiency in handling the common challenges of daily life related e.g., the sleep-wake cycle, smoking, or inactivity.

Recent studies propose that there are different immunological consequences to stressors (Okumura, 1998; Niaura et al, 2000; Hashiro et al, 1998; Kemeny, 2003). For people with asthma, there are indications that it may be useful to distinguish emotional arousal and stress, and that within the arena of stress there are different behavioural opportunities and responses that carry different immunological consequences. E.g., if a child is worried, there may be different immunological consequences depending upon whether the child responds with hostility or helplessness.

Current research suggests that we may eventually have to accept that, for children, the toxic impact of environmental exposure to verbal and physical aggression is as great as that of environmental exposure to tobacco smoke. It seems that there are useful distinctions to be made between emotional triggers and stressful negative events, and the immunological consequences of an individual’s response to them. Latest developments in stress relief and stress management can help people with asthma to reduce the impact of a negative life event, and to learn new strategies for coping with ongoing stress. Better stress management makes a significant contribution to the success of an asthma self-management care plan. Parents may increasingly be advised to help their children to practise quiet time and to encourage activities that promote their resilience.

References

Hashiro, M. & Okumura, M. (1998). The relationship between the psychological and immunological state in patients with atopic dermatitis. Jnl. of Dermatol. Sci. 16 (3): 231-235.

Kemeny, M.E. (2003). The psychobiology of stress. Current Directions in Psychological Science 12 (4): 124-129.

Laube, B.L., Curbow, B.A., Fitzgerald, S.D. & Spratt, K. (2003). European Respiratory Jnl. 22: 613-618.

Liu, L.Y., Coe, C.L., Swenson, C.A., Kelly, E.A., Kita, H. & Busse, W.W. (2002). School examinations enhance airway inflammation to antigen challenge. Am J Respir Crit Care Med 165:1062–1067.

McEwen, B. S. (1998). Protective and Damaging Effects of Stress Mediators. New England Jnl.Med. 338: 171-179,

McEwen, B., & Seeman, T. (1999). Protective and damaging effects of mediators of stress. Elaborating and testing the concepts of allostasis and allostatic load. Ann NY Acad Sci 896: 30–47.

Niaura, R., Banks, S.M., Ward, K., Stoney, C.M., Spiro, A. III, Aldwin, C.M. Landsberg, L. & Weiss, S.T. (2000). Hostility and the metabolic syndrome in older men: The Normative Aging Study. Psychosomatic Medicine 62, 7-16.

Sandberg, S., Järvenpää, S., Penttinen, A., Paton, J.Y. & McCann, D.C. (2004). Asthma exacerbations in children immediately following stressful life events: a Cox’s hierarchical regression. Thorax 59: 1046-1051.

Wednesday, June 28, 2006

The Defective Yeti Guide To Parenting

Iron sign, the text warns: Danger - Keep children under controlTony Plant of Happystance has ruined my soft covers. The stains are all his fault because he introduced me to Matthew Baldwin of Defective Yeti who rapidly became one of my favourite bloggers. Tony's penance is letting me borrow one of his posts. Matthew would be a menance to traffic if he had a radio spot and I have long since given up drinking anything while reading his posts - I've had too many unexpected returns of tea/coffee/ginger beer that have burned or severely irritated my nose.

Matthew writes on a number of topics. He is an avid gamer and has made recommendations that make frequent appearances in both my own gift wish-lists (seriously, you still don't use these?) and my purchasing decisions for others.

One of Matthew's most frequent topics is his son, aka The Squirrelly. You will have a rough idea of Matthew's robust approach to parenting if I quote from the account of a check-up at the paediatrician's office:
So, yes, we're having the standard toddler War Of The Wills, but, fortunately, The Squirrelly is exceptionally easy-going. His tantrums are infrequent, and rarely last more than a handful of seconds. When we took him in for his two-year checkup, the pediatrician asked "does he ever have tantrums that last longer than half an hour?" and we were all, like, "Half and hour?! [**** (edited)] no -- if he did we would have just left him in your elevator, sprinted back to the car, and driven to Ontario at 85 miles an hour."
Matthew recently joint authored an hilarious parody of the Elizabeth Verdick children's books on ethics: if you haven't seen Files Are Not For Sharing, then take a look. I'm mentioning this because with the excellent Flea's occasional fantasies about staging a media event to destroy thermometers in his war against fever phobia, I'm sure there is an excellent spoof somewhere that is just waiting to be born. The Defective Yeti and Flea Guide To Child Health: they tell it like it is.

Tuesday, June 27, 2006

Grand Rounds 2:39 Is Up!

the bare limbs of a hoar-frost rimmed tree are highlighted by a mixture of fog and sun against a clear blue sky: different elements co-operating to make a striking image
This week's edition of Grand Rounds is hosted and selected by Stuart Henochowicz from the Medviews. I am utterly fascinated by the medblog insight into the working lives of people whose jobs make an obvious and direct difference. This week's online peek into the diverse world of medical researchers, healthcare workers, patients and policy makers is as interesting as ever. It put me in mind of the above image from Flickr - like everything else, good medicine relies on techno-stars but depends upon good communication and co-operation.

All of human life is there, from the need for Border Patrol Agents to learn how to cope with a birth in progress to Keith Carlson and how he works with the families of patients who have become friends and who have died.

I commend Grand Rounds to you.

Video Reminders About Coping With Asthma And Allergy

Courtesy of You Tube, Pharmacist Dr. Stefani Ferreri has made a video reminder about conventional management of asthma and allergies along with advice about using inhalers and choosing over-the-counter medications. In this action-packed video of less than 5 minutes duration, you'll also hear tips on hypoallergenic household cleaners and laundry aides, plus more general tips for coping with allergy and asthma.



I have got to make one of these videos - they are simultaneously Pearl & Dean, local advertising, in quality, while also being similarly endearing and entertaining.

Monday, June 26, 2006

Follow-Up On 'Buteyko Twins' From NZ Television

side head shot of beautiful boy with eyes closed, mouth closed, calmly just breathing1 in 4 children in New Zealand has asthma: the financial costs are enormous, and the strain on families is incalculable. My BIBH colleague Glenn White has just posted a follow-up to his previous involvement in a video about Buteyko Breathing and asthma that was broadcast in New Zealand.

The seven minute segment was part of a news programme that was broadcast on World Asthma day May 2. The segment featured two 8 year old girls with asthma: and I said that I would keep you posted on their outcome and any further video segments. Glenn has now forwarded a link to the follow-up that was broadcast recently. Prior to the course, both girls were experiencing daily asthma symptoms requiring reliever medication. One was taking Symbicort as a preventer medication. Both were unable to breathe through their noses and experienced daily nose bleeds.

By week five the girls no longer needed reliever medication and were able to overcome rare asthma symptoms using the Buteyko Method. Improvement in peak flow readings at six weeks is shown for one of the girls: her peak flow almost doubled. Glenn expects that the girls will continue to improve as they continue to do their exercises, and, in the near future, that the girl who is using preventer medication will be able to start to step down her dose with the guidance of her doctor.

Recently, McHugh and his colleagues published a case-series of Buteyko and children. The results were interesting enough for the authors to call for a large-scale RCT of Buteyko and children to add to the clinical trials that have been run with adults. Jill McGowan has recently submitted her PhD thesis on her large-scale trial with the Buteyko Method and we are awaiting the publication of her results.

The TV clips are interesting but some of the techniques that are shown are safe for the participants because they were assessed by a practitioner. Please do not attempt these techniques without appropriate consultation or the agreement of your doctor/asthma nurse.

Since When Have Bureaucracy And Databases Been Synonyms For 'Solution'?

A drop of water bounces off jelly: it won't survive another impactWhen my great-grandfather was very angry, he would emit a strangled cry of, "Gentlemen of the jury!" as an appeal for clemency for what he was about to do, seize some crockery and let fly at the walls before slamming out of the house. Sometime later, he would return, fresh from his walk, bearing packages of thick pottery. My grandmother would accept the packages with the laconic enquiry, "Do these bounce?" to which he would reply, "You wish, child", and then everybody would settle down.

I was reminded of this piece of family history when I read The Telegraph's story that Family life faces State 'invasion' from a new database that will track all 12 million children in England and Wales from birth. The powers to create this database flow from the Children's Act of 2004 and changes that were introduced following Victoria Climbie's death from abuse. The database is characterised as "the biggest state intrusion in history into the role of parents". There is a lot of anger around the catalogue of incompetence and failure of government agencies to do their job properly that contributed to Victoria Climbie's death. But this solution, like its predecessors, doesn't bounce.

Bureaucracies that are already so over-stretched that they can not monitor the children who are known to be at risk are to be swamped with data on all children, and to be given additional monitoring and intervention powers. There is well-founded concern that electronic files will:
undermine family privacy and destroy the confidentiality of medical, social work and legal records.
People who come into contact with children, such as doctors, schools and the police will have to report a wide range of "concerns". Two warning flags on a child's record could trigger an investigation.

The data that will be collected are so eclectic that they verge on the surreal.
[M]inisters are proposing substantially to enlarge the state's role in the upbringing of children, monitoring everything from how they are doing in class to whether they are eating enough fruit and veg.
Fruit and veg consumption? Why not fish, or functional foods like eggs and milk with high levels of Omega 3? How will this be done? Will food diaries be kept by the children, or is there a more high-tech solution that monitors our shopping habits?
There will also be a system of targets and performance indicators for children's development. Children's services have been told to work together to make sure that targets are met.
Would these be the same agencies that are taking on water in their current attempts to deal with children's mental health needs and educational issues?

Dr Eileen Munro of the London School of Economics is quoted as saying that:
if a child caused concern by failing to make progress towards state targets, detailed information would be gathered. That would include subjective judgments such as "Is the parent proving a positive role model?", as well as sensitive information such as a parent's mental health.
...The country is moving from 'parents are free to bring children up as they think best as long as they are not abusive or neglectful' to a more coercive 'parents must bring children up to conform to the state's views of what is best'.
I agree that Bureaucracy Can't Bring Up Children. The leader writer argues that:
parents are generally better providers of health, education, welfare and social security than any government department. They should be allowed to get on with it.
If we don't need to quantify that "generally", then, of course, this is true: similarly for the incontrovertible truth of parents being preferable to intervention by government departments. But this Vera Lynn statement (Dr. Crippen defines this as something so self-evidently right that is beyond criticism) smacks of truthiness.
[T]he quality by which a person purports to know something emotionally or instinctively, without regard to evidence or to what the person might conclude from intellectual examination.
It is equally true that for many children, the current system isn't working. Jonathan Bamford of the Information Commissioner's Office sums up the scheme when he argues that keeping check on 11-12 million children when 3-4 million are in some way "at risk" is "not proportionate". What are the criteria for "at risk" here? Because at 3-4 million, the figures are even more alarming than those that were recently reported for mental health and educational problems. A recent evaluation of Sure Start reported that its performance is disappointing, possibly because the resources may be being directed to less socially deprived groups at the expense of the most socially deprived groups. Why would this database scheme and reporting system be any different? We already do not have the resources to provide interventions when it is known that there is probable need for them.

Ignoring the practicalities, ethics and usefulness of such a database, and the harm that it does to notions of self-reliance and autonomy, the scale of resources that would be needed to act upon it defies the imagination. The database invites unfortunate comparisons to the activities of the Stasi (security and intelligence forces). When Stasi archives were opened after reunification, German citizens learned about reporting not only by close friends but also by their spouses and children. Estimates of the number of informers range widely from 1 in 5 to 1 in 50.

There is a lot of understandable anger about children's health and welfare: if the statistics are credible, it is a public health scandal. But no matter how benign or plausible the intent, this solution doesn't bounce.

Saturday, June 24, 2006

What Would Mental Health Treatment For A Million Children Cost?

2 children: slogan is that sometimes parents forget to tell the children that it is OK if they are not shining stars
I took a speed reading course and read War and Peace in twenty minutes. It involves Russia.
Woody Allen pretty much sums up the level of media coverage and examination of the recent Child and adolescent mental health report (CAMHR). We had plenty of coverage of the 400 children who were swindled out of their World Cup Experience. We've even had an intervention by the Prime Minister that resulted in a much-publicised warm fuzzy outcome. Of course, it is easier to deal with that than to attempt to resolve our imploding public services, increasing crime, poverty, poor housing, the chaos of the classroom, the scandal of our care system and the many issues that influence the mental health of children. Yes, these are difficult issues, but this government was elected because of their emphasis on these issues: or was the manifesto nothing but a catalogue for a fantasy auction of extravagant promises (I am indebted to Wat Tyler for this metaphor)?

After the dispiriting news that 1 million children in the UK have a mental health or behavioural disorder that is severe enough to warrant treatment, I have been waiting in vain for a news programme or a newspaper to cost this treatment. In addition, I haven't seen any estimate of the social and financial costs of these mental health disorders among children and adolescents. I'm assuming that there are additional medical, social, educational, looked-after (e.g., fostering, care-homes) and (for an unspecified number) criminal costs (Police Cautions and Anti-Social Behavioural Orders aren't cheap: mostly an ineffective laughing-stock but not cheap). We need to know what these costs are before we can establish a baseline against which we can assess the costs of the programmes that are currently being run, programmes that may be extended, and some innovative programmes that are yet to be implemented.

Sure Start has already spent £3 billion since 2002 but to little approbation. The complexity of estimating placement costs for children is so great the Loughborough University has developed a special calculator package to take a number of variables into account. The report tells us that 45% of looked-after children have mental health problems: these may be exacerbated by the experience of what brought them into Local Authority Care and their placement. 68% of children of looked-after children are placed into foster care. A disproportionate number of looked-after children have educational problems. Because of the mix of agencies involved in funding the care of these children, it is not feasible to find a ready summary of the costs or even an estimate.

Children with a range of learning, conduct, emotional or behavioural disorders may be statemented and eligible for a Classroom Assistant (CA). However, spending on CAs is complex because some are paid for by schools, and some e.g. bilingual instructors/assistants or Learning Support/SEN Assistants may be managed by schools, and paid for from centrally held funds. Spending on Special Schools (for children whose needs can not be met, even with support, in the mainstream) is also complex. It is not entirely clear what happens to children who may have special educational needs but have never been evaluated for a statement because their Local Authority does not have the resources to provide a timely statement or the resources to meet any recommendations.

There is a report on Special Educational Needs in England: January 2006: it contains some interesting statistics but does not supply any costings or references to where they might be found. There is a proud assertion on pg. 7 of this document that the report is from National Statistics and is
produced to high professional standards set out in the National Statistics Code of Practice. They undergo regular quality assurance reviews to ensure that they meet customer needs. They are produced free from political interference.
Sadly, they are also produced free from grammar checks. See also on pg. 7
Pupil numbers shown in the tables are rounded to the nearest 10, therefore totals may not always equal the sum of there [sic] component parts.
Misplaced pedantry? Certainly, but assertions like that invite it and raise questions about the quality of the quality assurance reviews.

What do we learn about children with special educational needs (SEN) in England? In January 2006:
  • 1,293,300 (15.7% of)pupils with SEN across all schools do not have statements
  • 236,700 (2.9% of) pupils across all schools had statements of SEN
  • the incidence of pupils with SEN but without statements is greater for boys (approx. 1 in 5) than it is for girls (approx. 1 in 8)
  • the incidence of pupils with statements of SEN is substantially higher for boys than it is for girls
  • approximately 1 in 37 boys has a statement compared to 1 in 100 girls.
These are distressing statistics: for some of the schoolchildren involved, it is probably a distressing reality. What is the cost of the support that is provided? What is the cost of doing nothing, both for these children and their classmates?

Not all children with SEN will have mental health problems, and the reverse holds true; however, there may be a substantial overlap. For example, the CAMHR finds that:
60 per cent of all looked after children had some difficulty with reading, mathematics or spelling. Those with mental health problems were twice as likely to experience problems: in reading, 37 per cent of children with mental health problems experienced difficulties, compared to 19 per cent of children with no mental health problem. In mathematics, the figures were 35 per cent compared to 20 per cent, and for spelling, 41 per cent compared to 24 per cent. (p.g. 15)
Multiple agencies exist to address these problems and there is the perception that a lot of help is available: a lot of money is spent on these agencies although it is difficult to find a collated figure. There seems to be significant regional variation in resources. It is invidious to play off one group of needy children against another but there is the frequent criticism that it is the better-informed, more articulate parents who are the ones who can obtain a statement for their children (I don't know where people obtain the supportive statistics from, so I would be grateful for any pointers).

CAMHR tells us about the miserable overlap between educational problems and involvement in crime.
Although not a precursor to criminal behaviour in later years, there is a positive correlation between time lost from education and crime, with half of all male prisoners having been excluded from school. Many of these children suffer from conduct disorders and there is evidence that they may also exhibit problems with social understanding, and disorders on the autistic spectrum. However, these disorders often remain undetected...These children are therefore not receiving the necessary treatment...(pg 16)
The remainder of the paragraph tails off into the usual pieties without addressing the issue of whether or not there is an agreed treatment programme, and whether there are sufficient resources to deliver it.

Somebody, somewhere, on a relevant think-tank or committee, must have come up with an approximate cost of a portfolio of mental health interventions for children. There has been a lot of publicity about The Depression Report: A New Deal For Depression And Anxiety Disorders (pdf) that claims 16 one-hour sessions of cognitive-behavioural therapy (CBT) would cure half of all those with severe agoraphobia, obsessive-compulsive disorder, depression or anxiety, at a cost of £750 per person. There is even a summary of the proposal and its costs.
The report proposes a highly structured programme with 250 teams of specially trained clinical psychologists and psychological therapists. (Counsellors don't get the same results.) To reach the 800,000 who would benefit would take seven years and cost £600m; the money would be recouped from incapacity benefit savings.
The costs are crude, because at the examplar and examplary 50% success rate, the cost is presumably £1500 per successfully treated patient. And the costings/savings pre-suppose that the person is not working and in receipt of incapacity benefit.

However, at least the above is an attempt at costing a large-scale mental health intervention and discusses an implementation time-scale. I would like to see a comparable attempt at costing appropriate mental health interventions for children and a discussion of the time-scale of such a programme. The statistics in CAMHR indicate that children with mental health problems tend to live with adults with medical, mental health or social problems. A guess-timate would be that the child and at least one other family member may need a mental health intervention (let's ignore the issue of whether the CBT initiative would be appropriate here): so, that would be £1500, albeit the statistics indicate that the intervention would fail for one of them. Not all families would need 2 interventions, some would need more, others only the one; this is a working guess-timate. So, that would be an investment of £1.5 billion to offset against continued ill-health and the loss of revenue from children who go on to be unemployed, under-achieving, low-waged or otherwise living in poverty (it leaves out the savings from children who don't get involved in crime).

The SEN costs are harder to guess-timate. According to the NUT briefing on the costs of inclusion and Pupils With Special Educational Needs-June 2006 (pdf), the cost of the statementing process is between £6000-8000 per child. So, that's around £7.8 billion to £10.4 billion.

What is the cost of doing nothing and muddling on with the present provision? Although teachers welcome inclusion in mainstream classes, a specially commissioned study summarised in the NUT paper reveals that many teachers report such a lack of resources that they are providing "inclusion without education" with suspicions that inclusion is done "on 'the cheap'" (pg. 6). The study also reported that:
for many teachers the 'Costs of Inclusion' proved a very personal one. The strain of coping with the demands of pupils with acute SEN in an environment where there is little additional back up or outside resources to help proved all too much. Many either changed jobs or left the profession all together. (pg. 6)
The study describes a bleak situation for the teachers who remain.
Competitive market driven policies impact on the most vulnerable children and penalise the most dedicated teachers. The most striking aspect of this study is the goodwill of teachers who believe in inclusion and try to make it work but do not find their goodwill repaid by the level of professional support they deserve. (pg 7)
I give up at this point, I can't cost this, but somebody must be able to give a ballpark for this. Presumably, there are cascade costs for the general demoralisation of schools which may have an impact on the mental health of children.

Even where children have a statement of SEN, the recurring annual costs of support and re-assessment are not clear. I would be grateful for an estimate of this. However, so far, the costs of statementing and the costs of something like Layard's proposed CBT intervention are cumulatively between £9.3 billion to £11.9 billion. And this does not include the cost of SEN accommodations, social support, care costs etc. So, this may be the equivalent of being able to say that War and Peace is set in Russia and involves Napoleon, but at least it's more of a starting point than I've seen in the general media.

Friday, June 23, 2006

Paediatric Grand Rounds Needs Your Submission

Mocked-up Magazine Cover For Paediatric Grand Rounds

As the host of the next Paediatric Grand Rounds I invite you to send in your submissions for the next issue. I'm looking for posts on anything that concerns paediatric health. At the risk of sounding cliched, it takes a village, so I welcome contributions from family doctors, paediatricians, nurses, counsellors, scientists, teachers, parents, etc, etc.

Please send the posts to

breath.spaATSIGNgooglemail.com

I'm in the UK, so please send your contributions by Saturday, July 1, 15:00 London time. If it helps, you can look up the time differences at Time and Date.

I look forward to your submissions and building on the excellent work of the previous hosts.

Wednesday, June 21, 2006

1 in 10 Children Has A Mental Health Problem That Needs Treatment: At Least It's Not An Epidemic

Young man in a hooded top: with attitudeWhat-E-ver. Attitude before platitudes.

I was initially quite cheered that this story about children's mental health wasn't described as an epidemic. However, when so many health issues are blared with brass trumpets and the sound of the falling walls of civilization as we know it, it is a little surprising to see almost a complete absence of hyperbole in a summary of a report that headlines One in ten youngsters suffers mental problems as behavioural disorders double in 30 years. The British Medical Association's Board of Science has published a report that finds:
  • 1 in 10 children between the ages of 1-15 has a mental health disorder - ranging from sleep problems to excessive temper tantrums and depression
  • more than one million children are suffering from mental disorders severe enough to require treatment
  • more than 700,000 children are affected severely enough by behavioural disorders to require treatment, which disrupts school classes and family life
  • the proportion of boys with conduct disorders has risen from 7.6 per cent in 1974 to 16 per cent in 2004. Among girls, the proportion has risen from 6 per cent in 1974 to 7.9 per cent in 2004, it's suggested that they may be under-diagnosed
  • ADD affects a further 5.1 per cent of boys and 0.8 per cent of girls
  • 16 per cent of children from families with a weekly household income of less than £100 suffered from mental health disorders. Only 5 per cent are affected in families with a weekly income above £600 a week.
Vivienne Nathanson, head of science at the BMA is quoted as saying:
There is a huge need for robust measures to ensure children and adolescents are able to cope. Children from deprived backgrounds have a poorer start in life on many levels but without good mental health they may not have a chance to develop emotionally and reach their full potential...Healthcare professionals are realising just how important diet and exercise are in preventing mental health problems and it is vital more research is carried out. Anecdotal evidence suggests behaviour and concentration deteriorate with processed sugary food.
Now, I'm all in favour of research that tests whether received wisdom is true, but in with the stuff that my granny could have told me, I also like to see findings that might have elicited a, "Who'd have thought?": the latter is distinctly lacking in this summary. Vivian Nathanson's follow-up comment piece, No single cause: no easy answers to help youngsters is no more illuminating.
The stresses and complexities of modern-day life also play a part. Just because a child is brought up in a deprived environment or is a victim of a family break-up does not necessarily mean they will develop a mental health disorder but those life events may trigger a pre-disposition to developing a problem or just reduce the ability of the child to cope. We can say for certain that deprivation, family and financial instability and poor environmental surroundings do not help children flourish.
I agree but for heaven's sake! This is the 21st century and this is sounding like the founding document for a Workhouse.
The care and training of children are matters which should receive the anxious attention of Guardians. Pauperism is in the blood, and there is no more effectual means of checking its hereditary nature than by doing all in our power to bring up our pauper children in such a manner as to make them God-fearing, useful and healthy members of society. From the Poor Law Handbook of the Poor Law Officers' Journal in 1901.
I don't think that any of us were in any doubt that this is a wicked problem. (Wicked problems were first identified in the area of public policy and are described as "a set of problems that cannot be resolved with traditional analytical approaches". It is the nature of wicked problems that unanswered questions and chronic issues can take years to work out or never be satisfactorily resolved.) However, I'd have liked some exploration of other countries where divorce, single parenthood, family breakdown and reconstitution don't seem to lead to the same disastrous consequences as are reported in the UK. As for the observations about healthy eating and lifestyle, I think we are beyond anecdotal evidence: Tony Plant offers a good overview of the research in Fish v. Drugs for Children and Criminals and (courtesy of Gladwell) explores some of the more complex issues that influence food choices.

There is an unhelpful side-bar by Caron Kemp in the main article that gives an insight into a single mother's difficulties when caring for an autistic child. Fair enough. What was completely unhelpful was the mother's concluding declaration:
The main thing is that the children don't need to change, but society needs to.
What? What do you think that the specialist interventions, treatments and 'lack of help' that the mother criticises are intended to do? They are intended to change the children's behaviour and responses. Since when have they not contributed to who we are?

The sidebar is shoddy reporting, poor editing or the regurgitations of a generic complaint with no need to explain the thinking behind the comment (in some ways, this is related to what Dr. Crippen has dubbed the Vera Lynn Syndrome:something so self-evidently 'good' that it requires no explanation). But I'm going to ask the question, in what ways does society need to change? To indulge in shoddy writing and strawmen, I wanted to run the Pinker-esque exercise of using thought experiments from Robert Nozick. But I'm hampered because I don't know what the mother is complaining about beyond 'lack of help when they have incidents'. What does the mother want? Social change that supports more generous attendance allowances or carers' benefits that might actually pay for additional help? A specialist day-school with home-helps? Respite care? More child mental health staff beyond the reported 40% increase since 2002? What? I can't believe that I'm about to say that the Daily Mail published We don't need to wipe out autism...we need to care more: an article that was much better written and contained a straightforward statement of needs.
...the 'problem' lies not with autism itself but with the way in which our society responds to it. As just one example there needs to be far more Government provision for the respite care that is so pitifully inadequate at present.

...we can afford to pay carers so we can spend some time getting on with other things and I believe that all parents of children with autism should be entitled to do the same.

There are an estimated 90,000 children with autism in the UK, but only 7,500 special places available for them in the education system.
I still have a problem with 'society' and 'government spending priorities' being used as if they are synonyms but I like the explicit recommendations although I am disappointed by the lack of any costings.

As summarised, the account in the Independent is disappointing: it's possible the full report is both more nuanced and interesting. In which case, the Independent's Health Editor's summary and Vivienne Nathanson's comment deserve a "Should try harder. Could do better". This is a wicked problem but we deserve some sensible proposals: something beyond, "We need more investment and more research" and the injunction that society should change. The poverty of imagination is one of the true scandals here. A different scandal is the complete lack of any attempt to cost this treatment for a million children: I shall have to apply a lot of ice to my temples and think about this.

Tuesday, June 20, 2006

Long-Acting Beta-Agonists Are Detrimental Both For Children And Adults: A Note About The Meta-Analysis

Bronze sculpture of a figure with a migraine by Jose SacalIt's a headache for patients, doctors and many others. There are more warnings about the safety of long-acting beta-agonists (LABAs) for both children and adults. The two LABAs listed in the e-British National Formulary are salmeterol (aka Serevent: ingredient of the combination medication Seretide) and formoterol (aka Foradil; Oxis; ingredient of the combination medication Symbicort). The warnings are issued by the authors of Meta-Analysis: Effect of Long-Acting [Beta]-Agonists on Severe Asthma Exacerbations and Asthma-Related Deaths. Until there is time to post a discussion of the full paper, the take-home message is that patients who used LABAs were 3.5 times more likely to die from asthma and 2.5 times more likely to be hospitalised compared with those taking a placebo. There was no significant difference between the effects for children and adults. The researchers say that although LABAs relieve asthma symptoms, they may also promote bronchial inflammation and sensitivity without the advance warning of increased symptoms: and that these reactions may occur even when used with inhaled corticosteroids. More formally, the authors write:
In summary, long-acting ß-agonist use increases the risk for hospitalizations due to asthma, life-threatening asthma exacerbations, and asthma-related deaths. Similar risks are found with salmeterol and formoterol and in children and adults. Concomitant inhaled corticosteroids do not adequately protect against the adverse effects. The use of long-acting ß-agonists could be associated with a clinically significant number of unnecessary hospitalizations, intensive care unit admissions, and deaths each year. Black box warnings on the labeling for these agents clearly outline the increased risk for asthma-related deaths associated with their use, but these warnings have not changed prescribing practices of physicians...This information could be used to reassess whether these agents should be withdrawn from the market.
The authors estimate that LABAs contribute to in excess of approximately "1 death per 1000 patient-years of use". The authors estimate that:
salmeterol may be responsible for approximately 4000 of the 5000 asthma-related deaths that occur in the United States each year
.

There is an editorial in the same issue of the journal that makes the usual cautions about meta-analyses while looking to future guidance from pharmacogenomics:
With respect to LABAs, Salpeter and colleagues were not able to completely address the potential contribution of disease severity, co-treatments, adherence, and race to serious adverse outcomes. The report does, however, underscore the fact that LABAs are powerful and complex medications that we must use with care even as we await additional information to help us refine the decision to use them. Physicians must be alert to factors (for example, race) that may predict an unfavorable reaction to LABAs, carefully monitor patients receiving these drugs, and act promptly when patients do not respond favorably. Therapeutic decisions increasingly require tailoring therapy to individual needs and, some day perhaps, to pharmacogenomic profiles.

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Buteyko Saves Money On Asthma Drugs In Doctor's Study

Line of 3 deer with the slogan, The deer now have guns

On the same day as a report on the detrimental effects of long-acting beta-agonists, the BBC has just reported the results of a Cornish GP's successful pilot study into the Buteyko Breathing Method for his patients with asthma. Scaling up his results, Dr Manley estimates that the Buteyko Method could save the NHS almost £270 million per year on its drugs-bill for asthma.
The cost saving for asthma treatment was just more than £2,000 in the first year after the course which was for 13 patients.

Now if you translate that nationally - we spend more than £500m a year on asthma treatment - you'd be looking to save something of the order of £268m
These calculations are just for the drugs savings: time and more studies will give a clearer picture of savings on the cost of hospitalisation and the more indirect costs such as lost productivity through days off work etc.

This is an interesting pilot study that was run in collaboration with our BIBH colleagues, Simon Paddon and Nikki Jewell. There have been several positive studies and clinical trials of the Buteyko Method. One large-scale study in Scotland has been submitted for a PhD thesis and we are currently waiting for the publication of its results. The more study and trials results there are, the more support there is for the value of the Buteyko Method. It is time for research funding to be allocated for a large-scale UK randomised control trial both of mild-to-moderate asthma and severe asthma. Following the recent case-series on using the Buteyko Method with children, it is particularly important to run an RCT with an appropriate number of participants to give the findings some statistical power.

Monday, June 19, 2006

Smokeless Tobacco: A Useful Compromise Or Smoke And Mirrors?

Cookie Monster smokes a cigarette
I hate smoking with a passion. I believe that tobacco-related diseases are a public health scandal that contribute to the sum-total of human misery. I know that many people (like my mother) struggle and fail to give up smoking over repeated attempts, while others give it up quite easily. I accept that adults are free to make their own choices about risky behaviours like tobacco-smoking; I don't accept that children should be subjected to environmental exposure to tobacco smoke.

Cigarettes and the rituals that surround them are highly addictive. The tobacco companies spend large sums of money on advertising to support an addiction and behavioural habit that they know is unhealthy. The simple message from some anti-tobacco organisations is that the only solution to tobacco-related public health problems is to eliminate cigarettes from the marketplace. However, few people believe in the merits of prohibition as a practical strategy. Education programmes are useful, but they do not seem to reach the people who need them most.

So, if you are one of the people who can't give up but you don't want to smoke in your home where there are children (or, even other adults who object), what can you do? According to tobacco companies in the US, one of the possible solutions is smokeless tobacco. Smokeless tobacco, less lethal cigarettes or a comparatively benign system of nicotine delivery that does not involve smoking a cigarette with all of its 4000 combustion by-products.

One of these smokeless products is pouch tobacco: a product that will allow unobtrusive tobacco use but does not have the social stigma of spitting. Speaking to the New York Times, Jonathan Foulds, director of the Tobacco Dependence Program at the University of Medicine and Dentistry of New Jersey, School of Public Health, emphasises that:
the scientific literature is overwhelming that smokeless tobacco is less harmful than lighted cigarettes. According to a review of the literature by epidemiologists published in late 2004, so-called low-nitrosamine smokeless-tobacco products carry a much lower risk of death by disease than regular cigarettes do. "In comparison with smoking, experts perceive at least a 90 percent reduction in the relative risk" of low-nitrosamine smokeless-tobacco use. .. Or, as the tobacco-policy expert David Sweanor, who teaches law and medicine at the University of Ottawa, puts it, "It's the smoke, stupid."
So, is smokeless tobacco a useful tool for people who can't bring themselves to give up or is it a smoke and mirrors exercise designed to distract us from the issue that there is no safe level of tobacco consumption, just safer? If people are addicted to nicotine then a switch from cigarettes to either nicotine patches or smokeless tobacco, is less damaging. But, there is also a risk, by extension from alcopops, that smokeless products attract children and addict them to nicotine from which they might "graduate" to cigarettes.

There is also a concern that the introduction of "light" products can create an illusion of change that prevents people from making a full commitment to change. The usual example is that although many people buy low-fat products they do not make other changes in their diets to reduce overall calorie consumption or increase the nutritional composition of their diets. E.g., eating low-fat ice-cream instead of high-fat ice-cream keeps us eating ice-cream, it doesn't encourage us to replace ice-cream with fruit or any other nutrionally-dense, calorie-sparing foodstuff.

Again, speaking to the New York Times, Kenneth Warner, the dean of the School of Public Health at the University of Michigan and an author of the 2004 study, expressed his concern that smokeless products might serve "to tide smokers over when they are in places they are not permitted to smoke". He bases his objections to smokeless products on the research:
work sites that prohibit smoking reduce smoking rates.
He further argues that a product that subverts that goal is not a gain for public health.

Of course it is best if someone can give up tobacco altogether. However, if somebody really can't, or they choose not to, then smokeless tobacco may lessen other people's passive smoking: particularly where children are involved, reducing their environmental exposure to tobacco smoke is a significant contribution to their health and well-being. However, this 'reduced exposure' would be most effective if the smokeless tobacco was of the pouch variety rather than using less-lethal cigarettes: with the latter, there is a danger of children copying the behaviour. I'm wishy-washy enough to suggest smokeless tobacco as a useful compromise while people continue their efforts to give up smoking. However, I realise that the latter may be somewhat of a pious hope and that smokeless tobacco may be nothing more than smoke and mirrors.

Sunday, June 18, 2006

Genetic Determinism: The Dorothy L. Sayers Approach

One Way sign surrounded by a swarm of bees

Is genetics really the one-way street it is popularised to be in the media? There is media speculation about a fat gene, a beer belly gene, a creative dance gene, an addiction gene for nicotine metabolism and cigarettes and heroin), and speculation about an obsessive compulsive disorder gene. Maybe we would reap more benefit from Sure Start if we were to collect genetic material alongside the other socioeconomic data. I admit that my thinking on this is muddy and I've no idea how we would guarantee that the participants' DNA weren't kept on a national database in breach of their civil liberties. But, the current negative evaluation of the Sure Start programme tells me that we have a lot to learn. Something in me strongly rejects genetic determinism yet I am drawn to the argument that it is the tandem effect of genetics and environment that can influence our behaviour, health and many other aspects of our lives. Maybe this is the Dorothy L. Sayers approach. Lord Peter Wimsey once recounted a case where a young man had grabbed a pistol from a wall and shot someone during horse-play. Yet, the man responsible for the murder was the man who had loaded the pistol and so engineered events that this horse-play would occur and the target would die. Sure Start would be an excellent opportunity to explore genetics and environment in tandem.

What would collecting this data tell us? Well, probably a mixture of things that your granny could have told you plus some stuff that she wouldn't believe "in a million years". It would tell us whether the pistol was loaded and illuminate the circumstances under which it would be fired to devastating effect. J.P. of Contingency Table has an interesting summary:
...want to live until a ripe old age? Have parents that live long. Think you're a friendly, peaceful guy 'cause your mom raised you right? Think again. Able to try drugs just a couple times and never good [sic] hooked because of your strong will? Nope.
J.P. further suggests that our genes:
determine a probability distribution for the rest of our lives. Without a certain allele, will you live to be a hundred? It's certainly possible, but less likely. Will you end up an alcoholic even without a strong a priori susceptibility? Also possible. But also less likely.

And of course, it's nearly impossible to observe these probability distributions directly, but only in conditional form -- imagine someone with genetic tendency for high IQ being born in a wealthy US family vs. a malnourished Nigerian one. We can only observe distributions conditioned on a number of social factors. But the elucidation of these distributions will be a major legacy of genomic technology.
There is a fascinating and deliberately provocative discussion topic over on Scienceblogs: Why genetic determinism is inevitable in a meritocracy. One of the commenters asks, "what exactly is wrong with those with 'better' genes doing better?". Doubtless, there are 'better' genes (familial forms of cancer etc. and various genetic diseases): but for the rest, isn't that judgment being made from the narrow perspective of current social conditions? That is one of the significant difficulties with discussing this topic, there is a strong and dangerous undertow of rebarbative social commentary of the sort highlighted by Emerson in his essay, Fate:
Look at the unpalatable conclusions of Knox, in his "Fragment of Races,"—a rash and unsatisfactory writer, but charged with pungent and unforgettable truths. "Nature respects race, and not hybrids." "Every race has its own habitat." "Detach a colony from the race, and it deteriorates to the crab." See the shades of the picture. The German and Irish millions, like the Negro, have a great deal of guano in their destiny. They are ferried over the Atlantic, and carted over America, to ditch and to drudge, to make corn cheap, and then to lie down prematurely to make a spot of green grass on the prairie.
I was reminded of this particularly unpleasant commentary when I was reading the excellent series of articles in the New York Times about diabetes in New York. There is a strong demographic trend that means that the poor, and people from Central America, are disproportionately those who are affected by diabetes (among other groups). There are many other examples of chronic illnesses that affect people only when they completely change their environment and behaviour; including their family support and their general status in society. There is a lot to learn about the interaction of genes and environment in vulnerability to chronic illnesses.

Pharmacogenomics is an expanding field. We are learning more and more about why drugs are effective for some populations but not others. Writing about behavioural genomics, Peter McGuffin and his colleagues predict that:
identifying genes involved in behavioral disorders will do much to improve public perception and tolerance of behavioral disorders.
It's an optimistic prediction. Sure Start is currently failing its evaluation not because it isn't making a difference, but because it isn't making a difference to the most disruptive and socially-expensive groups. Do Sure Start interventions help people with a significantly different genetic make-up? Is there a reasonable prospect of designing interventions that would (for instance) improve the physical health and social success of people without the so-called resilience gene under prevailing social and environmental conditions? Are there (currently unimagined) circumstances under which this genetic variation would be advantageous? Is our current state of genetic knowledge too poor for us to make any assumptions about genetic determinism or behavioural genomics? Dorothy L. Sayers would remind us that the gun may be loaded, but the situation has to be engineered before it destroys the life of the intended party.

Paediatric Grand Rounds 1:5 Is Up!

Extravagantly joyful baby with arms upraisedThis baby may well be jumping for joy as the news leaks out that Paediatric Grand Rounds 1:5 is up, courtesy of Clark Bartram at Unintelligent Design.

There are several controversial topics in this collection of posts. It certainly is one thing to talk to adults about lifestyle choices that have an impact on their health, it is another to discuss adult behaviours and adult-supported lifestyle choices that have a profound impact on children's health: here, I particularly have in mind Flea's post about a drug-seeking mother and Megan's account of finding gallstones in two young patients.

There are several excellent posts on parents perspectives (scroll down to the June 5th entry) and perspectives on neuro-developmental disorders. There are illustrations of contents of a newborn's nappy that might startle the unwary parent and a touching video made for a child recovering in PICU after a kidney transplant.

I commend Paediatric Grand Rounds 1:5 to you.

Friday, June 16, 2006

Sure Start, Off To A Rough Start And Not Improving

Black and white image of a revolving door: text on the floor reads, 'I'm afraid of revolving doors'
Sure Start is another well-intended programme trapped in the revolving door of social engineering. Children's health and wellbeing can be damaged by their home environment and what is happening in their neighbourhoods. Sure Start was intended to improve children's welfare through improving parenting skills and creating a secure and happy home environment. Today's Guardian offers the bleak assessment that Sure Start 'harms children who need it most'. The scheme offers services to more than 660,000 children in England, but is said to be
setting back the behaviour and development of young children in the most deprived households.
It is not that the scheme is actively 'harming' children: the results need a fair amount of interpretation. It seems as if the problem is that
moderately deprived families fared better under the scheme, with non-teenage mothers exhibiting better parenting skills and children displaying greater social skills.

The researchers believe that moderately deprived families may be more ready to take advantage of Sure Start services, leaving the most deprived with fewer resources and less access to support.
I don't understand the criteria for judging deprivation (the criteria for greater social deprivation seem to be status-based rather than based on income or assets; i.e., the "relatively more socially deprived" are listed as teenage mothers, lone parents, workless households). However, after consulting the source article, Effect of Sure Start local programmes on children and families: early findings it is not clear that this is the case. The researchers' conclusions are more tempered than the Guardian's account would suggest.
Socially deprived families with greater personal resources may have been better able to take advantage of [Sure Start Local Programmes (SSLPs)] services and resources, which may have left those with fewer personal resources (such as young mothers and lone parents) with less access to services than would otherwise have been the case. Relatively more socially deprived parents may also find the extra attention of service providers in SSLP areas stressful and intrusive. (italics added)
There was an evaluation last December. If it is obvious that the right questions were not asked previously that would result in something other than the guesswork of may and the nebulous less access. I understand the need for tempered writing but this is an evaluation report on a project that has consumed more than £3 billion over four years. It is annoying that there is no explanation for the mechanism whereby children and families from the "relatively more socially deprived" category experience "adverse effects".
More children and families were affected beneficially than adversely, as teenage mothers formed a minority of the sample (14%), as did lone parent families (33%) and those living in households were nobody worked (38%). However, because the most socially deprived groups account disproportionately for many problems in society (such as school problems and crime), the apparent adverse effects of SSLPs might have greater consequences for society than the beneficial effects.
Maddeningly, we do not have a discussion of these "apparent adverse effects"; it is an exercise for the reader to guess what the magnitude of the "behavioural problems" might be and lower levels of "verbal ability".

Without further explanation, it is not clear if the researchers assume that the attentions of SSLP agencies are responsible for additive stress for the "most socially deprived" groups who are presumably already dealing with multi-agencies for housing costs, benefits etc. or they wouldn't be in this category. If it is additive stress, it is not particularly surprising that health-lead SSLPs were more effective than SSLPs offered by other agencies. It seems logical that health-led SSLPs benefit from better access to birth records and the already available infrastructure of Health Vistors who already make home visits: parents are already working with Health Visitors, there is no necessity to independently approach a separate agency.

The national evaluation report is dispiriting reading: as such, it seems comparable to the findings of the US Early Head Start programme. The evaluation concludes with the assertion that the study indicates that
improving parenting is one of the mechanisms by which SSLPs promote child wellbeing.
I accept that this sentiment is part of the theoretical basis for Sure Start but I'm not at all sure that this evaluation has demonstrated that it is happening. Except, of course, in those "relatively less socially deprived" groups who may be depriving others of access to services that they may experience as "stressful and instrusive". I would like the researchers to venture an opinion on whether it is the 'stress and intrusion' that is responsible for the 'harm' or the putative "less access to services": there is a case for saying that this paper has presented these two explanations without an acknowledgement that are mutually exclusive.

Despite these dispiriting findings, the Guardian reports that:
The government plans to expand the current 848 Sure Start children's centres to 3,500 by 2010, the equivalent of one centre for every community.
Why? What would it take to prove that this form of social engineering does work or doesn't work? What will be done differently to ensure value for money and value for the families and children who use SSLPs?

A long-term follow-up study of the children of depressed parents reports that:
The risks for anxiety disorders, major depression, and substance dependence were approximately three times as high in the offspring of depressed parents as in the offspring of nondepressed parents. Social impairment was also greater.
There is a growing body of evidence to suggest that environmental exposure to hostility or aggression (whether physical or verbal) is linked to poorer lung function and an increased number of asthma exacerbations in children: and the environment may be the home, school or neighbourhood. These findings may be relevant to this programme and the interpretation of its results.

It is disappointing that the authors assert that the 'harm' to the relatively-deprived families may outweigh the benefits derived by the "relatively less socially deprived" groups without explaining their thinking. There are no illustrative examples of the costs of this phenomenon. It would have been useful if this evaluation had attempted to cost the advantages of supporting "relatively less socially deprived families" who may be benefiting by increasing their resilience, with all the improved physical, cognitive, social and emotional benefits that that confers for the family and the reduced costs for society.

Interviewed for the New York Times, leading psychiatrist and resilience expert Sir Michael Rutter said:
We now have well-replicated findings showing that genes play a major role in influencing people's responses to adverse environments. But the genes don't do anything much on their own.
If Sure Start has to continue, why not do something exciting and useful like collect genetic material and test for the so-called resilience gene? Collecting data on this scale would be a valuable contribution to the work of researchers looking at the tandem effect of genetics and environment.

In 2003 Avshalom Caspi and his colleagues published a fascinating paper in Science that discussed the relationship between the gene, 5-HTT, and childhood maltreatment in causing depression. Current theories say that 5-HTT is crucial for the regulation of serotonin to the brain; and that the proper regulation of serotonin protects us against depression in response to trauma or stress.
In humans, each 5-HTT gene has two alleles, and each allele occurs in either a short or a long version. Scientists are still figuring out how the short allele affects serotonin delivery, but it seems that people with at least one short 5-HTT allele are more prone to depression. And since depression is associated with unemployment, struggling relationships, poor health and substance abuse, the short allele could contribute to a life going awry. A Question of Resilience New York Times
If we insist on experimenting with social engineering, let's gather scientific data and look at the tandem effects of genetics, environment and life experiences.

Wednesday, June 14, 2006

Not In Front Of The Children, Please?

Cleverly taped power sockets to prevent use of them: slogan reads, 'Don't even try: realize your utterlack of power'
There are times when I realise my lack of power and just don't know what to say. Recent examples are when parents are taken aback when a family doctor has suggested that their smoking is harming their children who have asthma; and when parents who are in the process of splitting-up and have a lot of rows are annoyed that their young children have an increased number of asthma flare-ups or a straying attention-span. Current research suggests that we may eventually have to accept that the toxic impact of environmental exposure to verbal and physical aggression is as great as that of environmental exposure to tobacco smoke.

If a child's parents are separated and the child stays in both households on a regular basis, I usually ask if both parents can attend the workshops so that they can learn how to implement the various recommendations when the child is staying in the different households. Most parents are only too keen to work together to help their children and even where there is animosity, this arrangement works well unless the parents are geographically distant or it just isn't possible to reconcile the work schedules. The children who are particularly sad are the ones whose parents say,
We thought his behaviour was improving. Then he started being restless, up at all hours. He's not sleeping, we don't know what's going on.
It is not unusual for general conversation to reveal that the deterioration started when X went to stay with Dad and met the new girlfriend, or v.v. for the mother and her partner.

Some parents are distraught when they discover what is happening in the lives of their children: experimentation with tobacco, alcohol, non-prescription drugs, gang activity etc.. However, it seems to be less acceptable that children manifest their own (stress) reactions to what is going on in the lives of their parents and all around them: whether the children's stress manifests as disordered sleep, distractability, irritability or even an increased number of asthma episodes.

I've previously discussed Salvador Minuchin's finding that parental conflict contributes to ill-health in children with unstable diabetes:
behavioral events among family members can be measured in the bloodstream of other family members.
When the parents were coached in techniques that allowed them to resolve their conflicts directly, and without involving the children, the children could be stabilised at home without additional medication or hospitalisation. There was an improvement in the children's medical outcome as a result of a successful intervention between people other than themselves.

Notice listing playground rulesLike cigarette smoking, I'm tempted to say to parents who have high levels of aggression or hosility to eachother, "Not in front of the children - please". And I don't believe that seething, unexpressed resentment is an improvement given recent speculation that moods and emotions are contagious. A lot of the standard advice that is dispensed in TV programmes and magazines sounds like the playground rules in the illustration - boiling down to "Play nicely children". Among the many things that I don't know, I have no advice on how to introduce a new partner in a way that doesn't unsettle a child. I wonder if paediatricians, child psychologists, family workers, or people who have personal experience of such situations have a range of tips and techniques to cover such socially awkward situations that may have an impact on children's health?

Tuesday, June 13, 2006

Obese, Asthmatic and Troubled: Plus The Libby Purves Solution To Children Who Need More Structured Care?

2 children: slogan is that sometimes parents forget to tell the children that it is OK if they are not shining starsWhat do you do for children who are obese, asthmatic and living chaotic lives? These are not children enmeshed in the poignant homelessness of those displaced by Hurricane Katrina, but those in the (sadly common) small, family drama described by Flea in My Mother, the Drug Seeker.
"Mary Ann has had a rough few years. She finally left her abusive, alcoholic husband and took her three children, aged 11, 8 and 2 to live in a battered women's shelter. Recently they had found subsidized housing on a farm in the same town where the kids had been attending school...All three children have asthma. All are obese, including the toddler. Mary Ann has battled depression and anxiety for which she had been hospitalized, as well as a history of chronic back pain."
I’m not even going to attempt to cover the impact of negative life events (e.g., upheavals, family splits) on children with asthma in this post but a crude summary would be that children are at almost five times the risk of an exacerbation within 48 hours of such events, and the susceptibility fluctuates, but they are still at double the risk between 5-7 weeks later. A long-term follow-up study of the children of depressed parents reports that:
The risks for anxiety disorders, major depression, and substance dependence were approximately three times as high in the offspring of depressed parents as in the offspring of nondepressed parents. Social impairment was also greater.
I recently suggested that if some children had their Hearts and Minds Age calculated (taking into account their personal and environmental risk factors), it would be significantly greater than their chronological age: I think that these children’s Hearts and Minds Age would be distressingly high.

I feel vaguely ridiculous when I refer to obesity as a personal risk factor for children. I do not believe that children become obese entirely through their own actions, inactions and decisions. However, once children are obese, helping them to manage their weight can seem like one long battle of personal restrictions (e.g., food choices) and curtailments (e.g., less TV or computer-gaming) that add to the stress levels and confrontations in what can already be a fraught household (anyone for Honey, We’re Killing The Kids?). A study reported no statistical association between asthma and obesity in Canadian children between 4-11 years. However, recent research in the UK suggests that
all of the obese children tested had a higher prevalence of asthma or other respiratory symptoms compared to non-obese children. Other symptoms included wheezing, exercise induced wheezing, coughing at night and speech limitation through wheezing.

Dr Shamssain says that obese and overweight children are not only at risk of asthma but other conditions such as diabetes and heart problems.
This is in line with earlier studies in the UK that reported that obesity may be a marker of recent lifestyle differences now associated with both asthma and overweight. There are significant problems in diagnosing lung disease in young children because the standard lung function tests are not suitable for them. There is some speculation that the greater degree of bronchial hyper-reactivity in non-obese asthmatic children compared to their obese counterparts suggests that obesity-related chest symptoms mimic asthma and may lead to an over-diagnosis of asthma.
Asthma, wheezing, and inhaler use were more common in obese children than in non-obese children. Symptoms were more prevalent among obese boys. Increasing BMI among children is a risk factor for asthma, which may in reality be obesity-related chest symptoms that mimic asthma.
An exchange of letters on the topic of asthma and obesity provides several references that report that
increases in BMI or birth weight are significant predictors of the development of asthma prospectively and independently of potential confounding factors, such as diet and physical activity.
A recent review concludes that there is evidence that obesity and overweight are associated with the development of asthma. The authors caution that the mechanisms of this association are unclear. They do conclude that weight reduction can result in improvements of lung function among asthmatic patients, and that this is a clinically significant strategy.

However, is this discussion relevant to the children in Flea's post? No. It sounds as if those children lead chaotic lives and that their mother is doing what she can but doesn't have the resources or energy to make the concerted intervention that would be necessary to control the children's weight and to mitigate the impact of their asthma.

Some schools are running programmes that are targeted at sedentary children or those with asthma or breathing disorders. These programmes are helpful but there is a limit as to what can be achieved if it is not practical to rely upon support at home. I run workshops for children with sleep-disordered breathing (sometimes I do this in school or pre-school settings); many of these children have asthma. If parents ask, I give general advice on sleep hygiene for children and I particularly recommend regular bed-times with a set routine, including reading or listening to stories. This can work very well for some children but it does depend upon a certain amount of household order and involvement. Sometimes one parent will establish a bed-time routine that is successful, but it doesn't fit in with the household routine of (say) the non-custodial parent when the children go for a weekend visit or a holiday and the progress is undone. Sadly, if parents are separated, there can be high levels of verbal hostility at hand-overs or in everyday communication that distress the children and contribute to stress responses that may worsen their asthma.

Back in the 1970s, there was a study of diabetic children who experienced chronic bouts of ketoacidosis despite being treated with appropriate medication. The children could be stabilised in the hospital but repeatedly relapsed upon return to the family home. Observations of the families of the children suggested that the children's metabolic disturbances were a reflection of parental conflict that involved the children ("Who is right, Daddy or Mommy?"). During stress interviews, the fatty acid levels of all the participants were measured. The parents' levels would rise during conflict but soon returned to baseline: however, for some of the children, the levels would remain elevated for hours.

The emotional demands on the children stimulated multiple physiological mechanisms that overrode the mechanism of the beta-blocker drugs that they were taking. Salvador Minuchin reported this as a poignant demonstration that:
behavioral events among family members can be measured in the bloodstream of other family members.
When the parents were coached in techniques that allowed them to resolve their conflicts directly, and without involving the children, the children could be stabilised at home without the use of the beta-blocker: they reduced the incidence of ketoacidosis and didn't require hospitalisation. There was an improvement in the children's medical outcome as a result of a successful intervention between people other than themselves.

There are support programmes such as Sure Start and Home-Start in the UK that are targeted at improving children's welfare through improving parenting skills and creating a secure and happy home environment but these have had disappointing levels of success (to be blunt, they are characteristed as "a spectacular failure").

Preliminary findings from recent studies with children suggest that the toxic impact of environmental exposure to verbal and physical aggression as expressed by poorer lung function and a greater incidence of asthma exacerbations is as great as that of environmental exposure to tobacco smoke. There are innovative programmes that have been likened to giving problem families Supernanny support, but, as explained by Tony Plant, they seem to have moved away from their “early intervention saves heartache, illness and money” stance to a more punitive one that is being set up for failure. Recently, Tony spoke about communication styles in families and how they are linked to the perception of violence and aggression in the home. In the follow-up discussion, he admitted that he sometimes wonders if some families need the assistance and reassurance of living in supportive communities, although he has some reservations about the civil liberties implications of such arrangements and the suggestion that some families or individuals might need to trade their privacy or autonomy for appropriate support.

In a different take on the idea of supportive communities, columnist Libby Purves recently discussed a Dept. of Education initiative in the UK that is investigating if some ‘looked-after children’ might benefit from being sent to boarding schools rather than being plunged into the chaotic foster system or council-run Care Homes.
[G]ood boarding provides not only educational stability but steady friends and mentors, routine and structure and quiet and probably more safety than some council homes… the long experience of a good housemaster or mistress might offer more understanding than an overstressed young social worker with a crazy caseload. For some children, boarding could be a blessed relief.
Purves anticipates that this suggestion might be derided by some social commentators.
There will be mean-minded contempt, and endless patronising assumptions about the inability of children in care to “cope”.
But she counters this argument in a typically robust fashion:
Poor little bastards, coping is often their A-star subject. They might adapt well to intelligent kindness, to the assumption of mutual courtesy between adults and children, and to classmates who have never had to learn aggression and the awful wisdom of the streets.
Keith Carson writes poignant, uplifting and disturbing posts about his experiences of working with people who have the many curses of addiction, chronic illness, chaotic lives and socio-economic deprivation. Keith's descriptions bear disturbing similarities to the family that Flea discusses. Children need to be with their family: and it is right that most social and family policy is intended to support families and to keep them together. However, for the sake of Mary Ann and her children, it does seem as if we need something more between what is currently available and the extreme measure of removing children from the family home. With a nod to Gladwell’s discussion of power-law economics, the "cost of doing nothing" is too great.

Saturday, June 10, 2006

Breathing Techniques May Reduce Inhaler Dependence In Asthma: comments on a recent paper

Young man on a hillock overlooking the sea. Caption reads, Breathe. Moving from burnout to balanceSlader, Reddel, Spencer, Belousova, Armour, Bosnic-Anticevich, Thien and Jenkins have just published a paper in Thorax that reports that breathing techniques can substantially reduce medication use by people with mild asthma. Double blind randomised controlled trial of two different breathing techniques in the management of asthma [Full Paper in pdf.] Although the participants in the trial cover a wide age-range, the selection criteria included people from the age of 15. The findings of this trial may be of some interest to parents or health professionals who would like to modify the use of medication to the most appropriate level, particularly in young people where the use of medication can cause particular concern to parents.

Summary of the study and results

Slader and her colleagues have published the results of their examination into the impact of breathing techniques on the management of asthma. They reported that breathing techniques cut the use of reliever inhalers by more than 80% and halved the dose of preventer inhaler required in the people with mild asthma who participated in the study.

The researchers compared the impact of two breathing techniques on symptoms, lung function, use of medication and quality of life among 57 adults with mild asthma. The participants, who used a preventer inhaler and required reliever inhaler at least four times a week, were randomly assigned to one or other breathing technique.

One technique focused on shallow, nasal breathing with slow exhalations (Group A), and the second technique used breathing-timing inhalations and exhalations in synch with upper body exercises such as shoulder rotations and arm curls, accompanied by relaxation (Group B).

Participants were instructed to practise their breathing exercises twice a day for around 25 minutes over a period of 30 weeks (self-reported median time spent actually practising the exercises was 12 mins in Group A and 16 mins in Group B). The participants were also encouraged to use a shorter version of their exercises in place of reliever medication, and to use their inhalers if the exercises did not work after three to five minutes.

Use of reliever medication fell by 86% in both groups, a process which began within weeks of starting the exercises, and was maintained over eight months.

At the start of the study, participants used around three puffs of reliever each day, which fell to approximately one puff every third day by the close of the study. Preventer medication dose halved among the participants.

Quality of life scores remained unchanged in both groups, but good asthma control was maintained even though inhaler use was reduced. There were no changes in lung function or airway responsiveness in either group.

As both groups came to depend less on medication by the end of the study, despite the differences in the techniques used, the authors suggest that:
the observed changes were more likely to be attributable to one or more of the shared process elements-such as the instruction to use the exercises initially in place of reliever for symptom relief-than to the breathing exercises themselves.

Comments and discussion

Interventions

Although a table summarises the interventions, it would be helpful if the researchers were to make the videos generally available for scrutiny. As described, the exercises may have otherwise engaged some of the accessory muscles for respiration, or given greater freedom of movement to the diaphragm, encouraging abdominal rather than thoracic breathing. The authors write that
[d]evising a credible control for complementary medicine interventions has been acknowledged as a difficult task[.]
However, in the absence of a fuller description of the exercises and how they were implemented by Group B participants, it is not clear that the researchers have achieved an adequately controlled breathing technique to act as a control in this trial. The "non-specific upper-body manoeuvres" may have unintentionally promoted abdominal breathing (not a variable that is assessed in this study). The "control of breathing" exercises are not specified beyond "good posture and relaxation" (both of which may give greater freedom of movement to the diaphragm). And we learn that the route of breathing was not specified with "both mouth and nasal breathing demonstrated".

I would have liked to read a post-study follow-up with the Group B participants to establish what they understood by "control of breathing": e.g., for some people this might have been pursed-lips breathing (although this might not have been demonstrated on the video) or prolonged exhalations and a lower respiratory rate. I would like to know if the participants alternated between mouth and nasal breathing, in conjunction with the video, or if they failed to notice the difference because no attention was drawn to it. Some of these questions might have been answered if the researchers had included an analysis of any participant enquiries or any recurrent issues at the 2 weekly reviews.

Route of breathing and end tidal CO2 measurement

The results are interesting but although the "shallow, nasal breathing with slow exhalations" sounds similar to Buteyko, it is not the Buteyko technique. For the sake of internal consistency, the videos were standardised in the two conditions. The exercises were taught as something that should be practised twice everyday and used as a rescue remedy at symptom onset.

It is not clear whether Group A were encouraged to breathe in and out through the nose wherever practical (e.g., as per the Buteyko Method) rather than just during the practice period (it seems as if there was no instruction on this point). However, where route-of-breathing (ROB)information is available, the authors report that 14/14 of Group A used nasal breathing. This report is tempered by the study criteria for ROB. The criteria were that a participant was predominantly nasal breathing if 50% or more of breaths were from the nose and 40% or fewer of the breaths were from the mouth (and vice versa for predominantly mouth ROB): where the proportion of both nasal and mouth were between 40-50%, subjects were classified as having mixed ROB. There are no additional data to determine ROB when breathing in or out.

The novel measurement method makes it difficult to cross-compare these data for ROB and ETCO2 with those of previous studies. The authors describe problems with the fragility of the device used to measure both ROB and ETCO2.
The device consisted of a headset, with a flexible arm holding two probes. The probes were positioned in front of the mouth and the nares respectively, as close as possible without touching the face. A thin, transparent sheet of plastic was positioned between the probes to minimise mixing of airflow.
Although the device was designed to be less obtrusive than commonly-used equipment, without a diagram or photograph, it is not clear that it is. There is no indication of the size of the probes nor how they were adjusted to capture the airstream from different parts of the mouth. Presumably the 2 minute recording of data typically captured the nasal cycle of breathing in through one nostril and out through another (where applicable). It is possible to envisage that insufficient data points were recorded if the nasal cycle switched during the recording period. Although the probes and were "as close as possible" to the mouth and nares there may have been contamination of the samples with room air and this might have affected the measurements. Again, without a diagram, it is not possible to determine the location of the intake port. Data from "incomplete or fragmented breaths" were discarded although respiratory instability is suggested as a distinctive feature of people with disordered breathing linked to, for example, panic disorder which may be co-morbid with asthma.

The authors report reliability testing of the device for calibration by "five repeated measures of end tidal CO2 on a single subject on the same day", however, I would argue that this is not a valid reliability test as described. If the authors meant 5 consecutive sessions within (say) a 30 minute period then they should state that. Otherwise, there may be diurnal fluctuation in ETCO2 measurements, or a difference in results following consumption of food or a caffeinated drink or a number of other variables that might influence the ETCO2 reading.

On a personal note, I would have found it easier to understand the ETCO2 readings and comments associated with them if the authors had consistently converted the units of measurement between %, mmHg and kPa rather than leaving it as an exercise for the reader or if they consistently quoted one of them. I would also have liked some discussion about the difference in ETCO2 levels obtained from control subjects and those with asthma in this study and the Osborne study to which they later refer. In the Osborne study, with a smaller age-range of subjects, the
[e]quivalent values for PETCO2 were 4.89 (0.09) kPa and 5.28 (0.09) kPa, [in the patient and control groups] respectively (mean difference 0.39 kPa (95% CI 0.12 to 0.66), p<0.01).
This Slader trial does not specify an age-range for the "20 normal (non-asthmatic, non-smoking) adults": the authors report that the
median end tidal CO2 value for these subjects was 4.86% (36.9mmHg; 4.92kPa), approximately 1% higher than for our asthmatic subjects.
At the quoted values, the asthmatic subjects in the Osborne study had a similar ETCO2 to the control subjects in this trial: 4.89kPa versus 4.92kPa respectively. Although the Bowler study has a wider age-range of subjects, the reported mean ETCO2 for the Buteyko Breathing Method and other experimental control groups during the run-in to the trial were similar (BBT, 33 ± 5 mmHg; control, 32 ± 4 mmHg) with similar results after three months (BBT, 35 ± 3 mmHg; control, 33 ± 3 mmHg). In the Bowler study,
the normal subjects had significantly higher mean ET CO2 levels (41 ± 4 mmHg) than both the BBT and the control groups.

The ROB measurements (i.e. nasal versus mouth breathing: data available in the online pdf supplement) were obtained under distraction conditions (filling out questionnaires) that are not neutral, but have previously been reported as linked to increased mental load, breath-holding and an increased ETCO2. Over the course of the study the ETCO2 measurements dropped in both groups and this might indicate some habituation to the distraction task with possibly less breath-holding and a lesser impact on ETCO2 levels. However, the authors caution that both the ROB and ETCO2 assessments have missing data; further, the participant numbers are small.

The ETCO2 readings are not broken down by sex: there is no information about variations in women who may present ETCO2 fluctuations related to their menstrual cycle.

Participants' implementation of instructions

The authors state that participants were offered face-to-face tuition but there is no report that anyone accepted that offer. A researcher contacted the participants in both groups on a regular basis to check that they were doing their exercises and to answer any questions about technique. However, neither the online supplement nor the paper reports participant enquiries.

Meuret and her colleagues studied psychophysiological responses to breathing instructions. These findings echo previous work by Meuret which suggested that "[t]echniques taught in [breathing training] must take account of respiration rate and tidal volume in the regulation of blood gases (pCO2)". They reported that overall:
  • an increase in tidal volume (TV) was counterbalanced by a decrease in ventilation rate
  • a decrease in TV was counterbalanced by an increase in ventilation rate.
They sum up their findings as follows:
We conclude that in calm people breathing instructions that might be expected to raise pCO2 levels fail to do so. Feedback of end-tidal pCO2 may be a superior way of teaching people not to hyperventilate.
It seems plausible to argue that without appropriate physiological feedback (e.g., ETCO2), the participants would not able to gauge the appropriate implementation of their breathing exercises (particularly in Group A). However, it would not have been practical to include such feedback in the experimental design used by Slader and her colleagues.

Overall, the authors attribute the reductions in medication use more to the process and other factors in the trial than to the breathing techniques. There have been several media reports that have labelled the shallow, nasal breathing method as Buteyko but the reported elements are not the whole Buteyko Method, nor are these elements of the exercises appropriately applied. I would argue that this trial was not a study of the Buteyko Method but of elements that were not necessarily taught to be used appropriately by the participants nor was there a check for effective implementation. In the absence of feedback during the exercises, it is possible that although Group A were taught a hypoventilation technique, there may have been alveolar hyperventilation (as per Meuret).

Changes in medication use

The authors summarise a Cochrane review of breathing exercises for asthma that reports a decreased use of short-acting reliever medication but
no consistent evidence of improved disease control such as reduced requirement for anti-inflammatory medication, reduced airway hyperresponsiveness, or improved lung function.
In this study, the authors report an 86% reduction in reliever use and a 50% reduction in the dosage of inhaled corticosteroids. They acknowledge that
these changes were achieved without impacting negatively on underlying disease control, as measured by lung function and airways responsiveness.
They speculate that
while breathing exercises may not confer any particular physiological benefit, the process of using breathing techniques as first line symptoms treatment may allow people to substantially reduce their use of [beta2] agonist. This itself may be beneficial by reducing adrenergic side effects, by reducing response to allergens, or by reducing mast cell tachyphylaxis.
They further speculate that some of the "subjects may have been relatively overtreated with ICS at entry" although they do not discuss how this might have influenced their results.

The authors conclude that
[t]hese improvments are of a magnitude similar to that observed in conventional clinical trials which assess pharmacological interventions to improve asthma control, and are therefore clinically important.
They re-affirm that they believe it is the process rather than the breathing-techniques that is important because it provides "a deferral strategy for [beta2] agonist use". They argue that there is some evidence to support inhaler dependence and overuse by asthmatics.

Concluding remarks

The significant reduction in medication prompts the speculation that future pharmacological trials should include a behavioural intervention as a comparison for some of their experimental groups. Although the authors of this study made a contribution towards meeting the criteria identified in the Cochrane Review, they have not given sufficient detail to qualify as "full descriptions of treatment methods" as called for by the Cochrane reviewers. There is insufficient evidence to know whether or not the instruction or implementation is similar to what might have been achieved with the face-to-face guidance of a Buteyko practitioner, although, surprisingly, the reductions in medication use are in line with those reported in studies that have assessed the Buteyko technique.

This study examined elements such as nasal breathing without explaining the theoretical underpinning as to why it is thought to be effective or valuable: similarly for the outcome measurement of ETCO2. There is no discussion of alveolar or systemic hypocapnea and why this might contribute to the symptoms of asthma: there is no discussion as to whether the hypoventilatory exercises were intended to promote eucapnea in the Group A participants.

Although this is an interesting paper and has excited some interest in various media, this trial is not an assessment of the Buteyko Method. The researchers do not claim to have examined the Buteyko Method in this trial but they do introduce various elements that are popularly associated with the Buteyko technique.