Bottom-up and top-down approaches to understanding oppositional defiant disorder symptoms during early childhood: a mixed method study

Background: Children with clinical levels of conduct problems are at high risk of developing mental health prob lems such as persistent antisocial behavior or emotional problems in adolescence. Serious conduct problems in child hood also predict poor functioning across other areas of life in early adulthood such as overweight, heavy drinking, social isolation and not in employment or education. It is important to capture those children who are most at risk, early in their development. The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) is commonly used in clinical settings, to identify children with conduct problems such as oppositional defant disorder (ODD).This paper presents a cross-sectional study in a clinical setting, and describes behaviors in 3- to 8-year-olds with ODD. Our aim was to investigate whether there were problematic behaviors that were not captured by the diagnosis of ODD, using two diferent methods: a clinical approach (bottom-up) and the nosology for the diagnosis of ODD (top-down). Method: Fifty-seven children with clinical levels of ODD participated in the study. The mothers were interviewed with both open questions and with a semi-structured diagnostic interview K-SADS. The data was analyzed using a mixed method, convergent, parallel qualitative/quantitative (QUAL+QUAN) design. For QUAL analysis qualitative content analysis was used, and for QUAN analysis associations between the two data sets, and ages-groups and gen der were compared using Chi-square test. Results: In the top-down approach, the ODD criteria helped to identify and separate commonly occurring opposi tional behavior from conduct problems, but in the bottom-up approach, the accepted diagnostic criteria did not cap ture the entire range of problematic behaviors-especially those behaviors that constitute a risk for antisocial behavior. Conclusions: The present study shows a gap between the diagnoses of ODD and conduct disorder (CD) in younger children. Antisocial behaviors manifest in preschool and early school years are not always sufciently alarming to meet the diagnosis of CD, nor are they caught in their entirety by the ODD diagnostic tool. One way to verify suspicion of early antisocial behavior in preschool children would be to specify in the ODD diagnosis if there also is subclinical CD.publishedVersio

Symptoms and Well-Being in Older Hospitalized Patients with Cognitive Impairment, As Self-Reported and Reported in Patient Records: A Quantitative Exploratory Subgroup Analysis

Introduction: Given the aging population and the high prevalence of cognitive impairment in older hospitalized patients, it is essential to provide good fundamental care to these vulnerable patients, who easily might be affected by poor outcomes as delirium. Risk factors for delirium are, for example, cognitive impairment, old age, pain, and sleep deprivation. Different symptoms are often unidentified in hospitals, and associated with poor well-being, but this is rarely studied in older patients with cognitive impairment. The study aim was to examine symptoms and sense of well-being in older hospitalized patients with cognitive impairment, as self-reported and reported in patient records. Methods: Exploratory quantitative subgroup (n = 25) analysis of a point-prevalence study (n = 210). Inclusion criteria were age ≥65, and cognitive impairment. Data were collected through structured interviews, validated instruments, and patient records. Associations between well-being and symptoms, and concordance between the occurrence of self-reported symptoms and symptoms reported in patient records were analyzed. Results: The patients reported severe and distressing symptoms that were sparsely reported (14%) in their records. As well were cognitive impairment, and the patients’ own descriptions of their well-being. Some symptoms and the total symptom burden were associated with poor well-being. Discussion/Conclusion: To our knowledge, this hypothesis-generating study is one of few studies that describe both symptoms and well-being as self-reported and reported in patient records, in vulnerable patients due to old age, cognitive impairment, and hospitalization. Despite the limited sample size, the results indicate that symptoms were more insufficient alleviated in these patients compared to patients with normal cognitive function in other studies. To our knowledge, this has not been shown previously. Additionally, patients’ own experiences were sparsely reported in their records. A larger sample size and longitudinal design has the potential to determine if symptom alleviation differs between patients with and without cognitive impairment, and if a total symptom burden increases the risk of poor outcomes as delirium in vulnerable patients

Diagnostic accuracy and clinical applicability of the Swedish version of the 4AT assessment test for delirium detection, in a mixed patient population and setting

Background: Delirium is common in older hospitalized patients. It has serious consequences e.g., poor health outcomes, mortality and increased costs. Despite that, many cases are undetected. Early detection of delirium is important in improving outcomes and use of assessment tools improves detection rates. The 4AT is a brief screening tool for delirium detection, which has not previously been translated into Swedish. The study aim was to evaluate diagnostic accuracy and clinical applicability of a Swedish version of the screening tool 4AT for delirium detection. Method: This diagnostic test accuracy study used a quantitative and a qualitative approach and evaluated the patients’ and the health care professionals’ experiences of the tool. Study included 200 patients ≥65 years from a university hospital and a county hospital in two Swedish regions. Medical specialties were geriatric stroke/neurology, geriatric multimorbidity, severe cognitive impairment, orthopaedic, and urology. The translated 4AT was tested against the reference standard DSM-IV-TR criteria, based on the Organic Brain Syndrome scale and patient records. The 4AT was assessed simultaneously and independently by two assessors. Additionally, data was collected through patient record reviews, and questions about applicability to the patients (n = 200) and the assessors (n = 37). Statistical analyses, and qualitative content analyses were conducted. Results: By reference standard 18% had delirium, and by 4AT 19%. The overall percent agreement was 88%, AUROC 0.808, sensitivity 0.70 (95% CI 0.51–0.84) and specificity 0.92 (95% CI 0.87–0.96). In the ward for severe cognitive impairment (n = 63) the 4AT was less sensitive and less specific. In the other wards (n = 132) sensitivity was 0.77 (95% CI 0.50–0.93), specificity 0.93 (95% CI 0.87–0.97), and AUROC 0.848. Interrater reliability (Kappa) was 0.918, p = \u3c 0.001 (n = 144). The 4AT was well tolerated by patients, easy to use for health care professionals, and took a few minutes to conduct. Conclusion: The Swedish version of 4AT is an accurate and applicable tool to use in clinical practice for detecting delirium in hospitalized patients across different medical specialities, and to use by different professionals and levels of seniority. To improve patient outcomes, we recommend the 4AT to be incorporated in clinical practice in health care settings in Sweden

When Breast Cancer Returns. Women's experiences of Health, Illness and Adjustment During the Breast Cancer Trajectory

Although a recurrence of breast cancer is associated with significant distress, affecting health-related quality of life (HRQOL), little is known about women’s experience during the recurrent breast cancer trajectory. The primary aim of this thesis was to explore women’s experiences of health, illness and adjustment to a recurrence of breast cancer. Both deductive and inductive methods were used. The first aim was to explore whether HRQOL factors predicted recurrence. The second aim was to explore distress, symptoms and HRQOL, over time in women with recurrent breast cancer. The third aim was to explore what major concerns these women experienced and how they deal with their situations living with recurrent breast cancer. The four papers included in this thesis are based on selected quantitative data (Papers I–III) and qualitative data (Paper IV). Exploratory findings suggest that changes in physical well-being and nausea/vomiting may predict recurrence. Women with recurrent breast cancer experience multiple, concurrent, and persistent symptoms. Nearly ninety percent of the patients reported fatigue at the time of recurrence. Women with a strong sense of coherence reported a lower prevalence of symptoms and experienced lower levels of distress and better perceived adjustment to their illness, as well as perceived a better health and quality of life. Distress had a major impact on HRQOL. Over time, women adjusted to the many implications of a life-threatening illness through personal transition. By making sense of living with a threat to their lives, the women adjusted to their recurrence. The findings highlight the major existential impact of a recurrence. Promoting health is possible, even in severe illness and in unchangeable and almost unbearable situations. Opportunities to manage adversity remain. Women may transcend their illness by finding new meaning through discovering or re-discovering significant values in life, and creating wellness by being in the present moment

Experience-based co-design projects in paediatric care processes; Parents’ perceived quality

PurposeThe purpose of this paper is to examine and describe parents experiences of pediatric care processes and what dimensions of quality that are illuminated as improvement areas when having joint improvement projects with healthcare staff. DesignThe overall research approach is action research in two experience-based co-design EBCD projects. The data for this paper was collected in open-ended interviews and collaborative reflections with parents and during the improvement project. The interviews were analysed by a qualitative content analysis. FindingsThis paper shows that parents’ experiences were related to both technical and functional dimensions of quality. Sub dimensions of quality such as interaction, expertise and support were mentioned and illuminated as improvement areas. If patients/relatives are not invited to improvement projects, healthcare staff will miss out on improvement opportunities. OriginalityPractical examples of parents’ involvement can contribute to learning reflections and strengthen a customer’s view of the patient. It is also contributes to the area of service management in healthcare

Experience-based co-design projects in paediatric care processes; Parents’ perceived quality

PurposeThe purpose of this paper is to examine and describe parents experiences of pediatric care processes and what dimensions of quality that are illuminated as improvement areas when having joint improvement projects with healthcare staff. DesignThe overall research approach is action research in two experience-based co-design EBCD projects. The data for this paper was collected in open-ended interviews and collaborative reflections with parents and during the improvement project. The interviews were analysed by a qualitative content analysis. FindingsThis paper shows that parents’ experiences were related to both technical and functional dimensions of quality. Sub dimensions of quality such as interaction, expertise and support were mentioned and illuminated as improvement areas. If patients/relatives are not invited to improvement projects, healthcare staff will miss out on improvement opportunities. OriginalityPractical examples of parents’ involvement can contribute to learning reflections and strengthen a customer’s view of the patient. It is also contributes to the area of service management in healthcare

Using an adapted approach to the Kano model to identify patient needs

Purpose – The purpose of this paper is to study how an account of multiple patient roles whenusing the Kano model in healthcare improvements can support identification of a wide range ofpatients’ needs.Design/methodology/approach – The study presented in this paper was part of a longitudinalaction research study. The empirical material was collected by various methods (interviews, a focusgroup, participative observations, and a survey) over a two-month period within the Children’s andWomen’s Healthcare department in a Swedish hospital. The respondents included the managementteam, healthcare professionals, patients, and the patients’ partners.Findings – The study shows that incorporating a view of multiple patient roles into application of theKano model, and using input on customer needs obtained from patients, relatives, and healthcareprofessionals, helps to identify a wide range of patients’ needs.Originality/value – The view on patients within healthcare is being transformed from one based onservility to that of patients as customers. This paper elaborates on a hands-on way of applying theKano model based on a view of multiple patient roles as a means to support this new patient view. Theapplication builds on input from various groups (such as patients and healthcare professionals), and,by using input from various stakeholders. This approach appears to overcome a gap, identified inearlier research, of either relying solely on patients, or solely on healthcare professionals, whenidentifying patients’ need. Rather input from several groups – patients, relatives, and professionals –are suggested to be used in combination

“Since his birth, I’ve always been old” the experience of being parents to children displaying disruptive behavior problems: a qualitative study

Background: Being parents of children who display disruptive behavior problems (DBP) can pose several challenges. Interventions for children with DBP are primarily outpatient group parent training (PT) programs. The purpose of this study was to explore how parents of children with disruptive behavior problems, diagnosed with oppositional defiant disorder (ODD), describe the difficulties they face in their family and parenting situations. Methods: Nineteen parents of children aged 3 to 8 years who had searched for help and signed up for a parent training program provided by Child and Adolescent Mental Health Service participated in the study. Semistructured diagnostic interviews and a modified background interview adapted for the purpose of the study were conducted before parents entered the program. All children included in the study met the DSM criteria for ODD. The interviews were audiotaped and transcribed. Thematic analysis was used to examine, identify, and report patterns of meaning in the data. The analysis was conducted inductively using a contextual approach. Results: Parents described their own vulnerability, how they were affected by the parent-child interaction, and the challenges they perceived in their parenting practices. The study contributes to an understanding of the complexity that parents of children with ODD perceive in everyday life. Conclusions: The parents in the study highlight the need to address parents’ own mental health problems, parental alliance, capacity for emotion regulation, perceived helplessness as parents, lack of parental strategies, sense of isolation, and absence of supportive social networks. All these factors could be important when tailoring interventions aimed to help and support parents of children who display DBP, and specifically ODD

Bottom-up and top-down approaches to understanding oppositional defiant disorder symptoms during early childhood: a mixed method study

Background: Children with clinical levels of conduct problems are at high risk of developing mental health prob lems such as persistent antisocial behavior or emotional problems in adolescence. Serious conduct problems in child hood also predict poor functioning across other areas of life in early adulthood such as overweight, heavy drinking, social isolation and not in employment or education. It is important to capture those children who are most at risk, early in their development. The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) is commonly used in clinical settings, to identify children with conduct problems such as oppositional defant disorder (ODD).This paper presents a cross-sectional study in a clinical setting, and describes behaviors in 3- to 8-year-olds with ODD. Our aim was to investigate whether there were problematic behaviors that were not captured by the diagnosis of ODD, using two diferent methods: a clinical approach (bottom-up) and the nosology for the diagnosis of ODD (top-down). Method: Fifty-seven children with clinical levels of ODD participated in the study. The mothers were interviewed with both open questions and with a semi-structured diagnostic interview K-SADS. The data was analyzed using a mixed method, convergent, parallel qualitative/quantitative (QUAL+QUAN) design. For QUAL analysis qualitative content analysis was used, and for QUAN analysis associations between the two data sets, and ages-groups and gen der were compared using Chi-square test. Results: In the top-down approach, the ODD criteria helped to identify and separate commonly occurring opposi tional behavior from conduct problems, but in the bottom-up approach, the accepted diagnostic criteria did not cap ture the entire range of problematic behaviors-especially those behaviors that constitute a risk for antisocial behavior. Conclusions: The present study shows a gap between the diagnoses of ODD and conduct disorder (CD) in younger children. Antisocial behaviors manifest in preschool and early school years are not always sufciently alarming to meet the diagnosis of CD, nor are they caught in their entirety by the ODD diagnostic tool. One way to verify suspicion of early antisocial behavior in preschool children would be to specify in the ODD diagnosis if there also is subclinical CD