Child heath and human development yearbook

105 Colin Pritchard and Ann Sharples Chapter IX Childhood Obesity and Depression: Connection between these Growing Problems in Growing Children 123 Gloria M.. Postolache Chapter XII M

C HILD H EALTH AND H UMAN

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Contents

Chapter I Principles of Eating and the Individual with Rett Syndrome 3

Judy Wine, Yael Yoshei and Meir Lotan

Chapter II Ethics and Holistic Healthcare Practice 25

Michael de Vibe, Erica Bell, Joav Merrick, Hatim A Omar and Søren Ventegodt

Chapter III Domestic Violence and Small Children: Key Directions for

Holistic Healthcare 33

Erica Bell

Chapter IV Therapeutic Horseback Riding (Hippotherapy) for Individuals

with Rett Syndrome: A Review with a Case Study 47

Maciques Rodríguez Elaime and Meir Lotan

Chapter V A Community in Transition: Incidence and Characterization of

Injuries among Israeli Bedouin Children Presenting to the

Primary Care Clinic 69

Elissa Lane Freedman, Zaid Afawi, Joav Merrick and Mohammed Morad

Chapter VI Information Technology and Medical Education: A Survey of

Perceived Computing Skills among Medical Students in

Northern Nigeria 85

Zubairu Iliyasu, Isa S Abubakar, Mohammed Kabir and Muktar H Aliyu

Contents

vi

Chapter VII Attitudes of First-Year Israeli Tourism and Hotel Management

Undergraduate Students toward Persons with Disability: A Pilot

Study 97

Tagrid Morad, Zaid Afawi, Joav Merrick, Jemila Caplan Kester and Mohammed Morad

Chapter VIII All Causes and Violent Deaths of Children (0-14) in England

and Wales 1974-2002 Compared to the Major Western Nations:

Indicators of Improved Child Protection? 105

Colin Pritchard and Ann Sharples

Chapter IX Childhood Obesity and Depression: Connection between these

Growing Problems in Growing Children 123

Gloria M Reeves, Teodor T Postolach and Soren Snitker

Anupama Kewalramani, Mary E Bollinger and Teodor T Postolache

Chapter XI Jet Lag: A Modern-Day Malaise 155

Tatiana Menick, Joseph J Soriano and Teodor T Postolache

Chapter XII Mindfulness Meditation in Patients with Mood Disorders

Feasibility, Safety and Efficacy: An Empirical Review 167

Kalina Boteva

Chapter XIII Thinking Outside of the Light Box: Applications of

Cognitive-Behavioral Theory and Therapy to Seasonal

Affective Disorder 193

Kelly J Rohan and Yael I Nillni

Chapter XIV Prepartum Depressive Symptoms Correlate Positively with

C-Reactive Protein Levels and Negatively with Tryptophan

Levels: A Preliminary Report 207

Debra A Scrandis, Patricia Langenberg, Leonardo H Tonelli, Tehmina M Sheikh, Anita C Manogura, Laura A Alberico, Tracey Hermanstyne, Dietmar Fuchs, Hugh Mighty, Jeffrey D Hasday, Kalina Boteva and

Teodor T Postolache

Chapter XV Mood Changes after Brief Exposure to Chemosensory Stimuli

in Patients with Seasonal Affective Disorder 219

Solomon S Williams, Norman E Rosenthal, Avery N Gilbert, John W Stiller, Todd A Hardin, and Teodor T Postolache

Chapter XVI Mood Oscillations and Coupling between Mood and Weather

in Patients with Rapid Cycling Bipolar Disorder 229

Steven M Boker, Ellen Liebenluft, Pascal R Deboeck, Gagan Virk and Teodor T Postolache

Chapter XVII The Body Speaking of Blues and Worries: Fibromyalgia in

Children and Adolescents 255

Lynn Hugger, Zinoviy Gutkovich and Harriet Knapp

Chapter XVIII The Antisuicidal Efficacy of Lithium: A Review of the Clinical

Literature and the Underlying Pharmacology 277

Colleen E Kovacsics, Harish K Goyal, Koshy J Thomas and Todd D Gould

Chapter XIX Suicidality in the Juvenile Justice Environment 301

Srirangam S Shreeram and Aditi Malik

Chapter XX Mood Disorders and Suicide in the Correctional Population:

The Importance of Recognizing Comorbidity 323

Alan A Abrams, Maheen Patel, Tyler Jones, Yu-Fei Huang, Nesibe Soysal, Lobna Ibrahim, Constance N Flanagan, Cessare Scott, KyleeAnn Stevens, Gavin Rose and Alan Newman

Chapter XXI Suicide in the Muslim World 339

Farooq Mohyuddin

Chapter XXII Ethnic Differences in Adolescent Suicide in the United States 347

Theodora Balis and Teodor T Postolache

Chapter XXIII Allergen Specific IgE: No Relationship with Prior History

of Suicide Attempts and Instability in Patients with Recurrent

Teodor T Postolache, Darryl W Roberts, Patricia Langenberg, Olesja Muravitskaja, John W Stiller, Robert G Hamilton and Leonardo H Tonelli

Chapter XXIV Acute Stress Promotes Aggressive-Like Behavior in Rats Made

Allergic to Tree Pollen 379

Leonardo H Tonelli, Akina Hoshino, Morgan Katz,

and Teodor T Postolache

Chapter XXV Changes in Severity of Allergy and Anxiety Symptoms Are

Positively Correlated in Patients with Recurrent Mood Disorders Who Are Exposed to Seasonal Peaks of

Aeroallergens 389

Teodor T Postolache, Patricia Langenber, Sarah A Zimmerman, Manana Lapidus, Hirsh Komarow,

Contents viii

Jessica S McDonald, Nancy Furst, Natalya Dzhanashvili, Debra Scrandis , , Jie Bai, Bernadine Postolache,

Joseph J Soriano, Bernard Vittone, Alvaro Guzman, Jong-Min Woo, John Stiller, Robert G Hamilton and Leonardo H Tonelli

Chapter XXVI Obesity and Sport Participation 405

Dilip R Patel and Donald E Greydanus

Chapter XXVII Obesity and Hypertension in Adolescents 413

Alfonso D Torres and Colette A Gushurst

Chapter XXVIII Hyperandrogenism and Obesity: Ominous Co-Morbidities 423

Amit M Deokar, Shawn J Smith, Amanda J Goodwin and Hatim A Omar

Chapter XXIX Bariatric Surgery and Adolescent Obesity 435

Tara B Mancl and Alan A Saber

Chapter XXX Endocrinologic Issues in Obesity 443

Manmohan Kamboj

Chapter XXXI Psychological Issues in Obesity 453

Helen D Pratt

Chapter XXXII Overweight Children and Adolescents: Impact on

Psychological and Social Development 463

Kimberly K McClanahan, Marlene B Huff and Hatim A Omar

Chapter XXXIII Pharmacotherapy for Obese Adolescents 475

Donald E Greydanus, Cynthia Feucht, and Dilip R Patel

Chapter XXXIV Eating Disorders in Adolescents with Obesity 487

Vinay N Reddy

Chapter XXXV Sexuality and Obesity in Adolescence 497

Helen D Pratt, Donald E Greydanus and Kazue Ishitsuka

Chapter XXXVI Concepts of Contraception for Adolescents with Obesity:

Pathways of Judicial Moderation 507

Donald E Greydanus, Hatim A Omar and Artemis K.Tsitsika

Chapter XXXVII Nutrition and Adolescent Obesity 519

Vinay N Reddy

Chapter XXXVIII Dermatologic Aspects of Obesity 529

Donald Hare

Chapter XXXIX Down Syndrome and Obesity 539

Joav Merrick and Isack Kandel

Chapter XL Environment and School Transportation: A Review of

Evidence from Health and Equity Perspectives Important in

Obesity Prevention 545

Chanam Lee and Xuemei Zhu

Chapter XLI Insights into Bangkok Elementary Students’ Food Choice

Chulanee Thianthai

Chapter XLII Israeli Adolescents and Obesity 571

Mohammed Morad, Isack Kandel, Jason Ahn, Brian Seth Fuchs and Joav Merrick

About the National Institute of Child Health and Human Development in Israel

(NICHD-IL) 579

Preface

The early years in the life of a child are critical for cognitive, social and emotional development It is therefore important that we make sure that children grow up in an environment, where their social, emotional and educational needs are met Children who grow up in an environment, where their developmental needs are not met are at risk for compromised health, well-being and sometimes also developmental delays Failure in the first years of life or lack of invested time or resources (both family and society) during may have long term effects on not only development, but also the health, welfare and education systems Society must therefore work to ensure that children develop in safe, loving, and secure environments They are our future and our success or failure

The French historian Philippe Aries made us aware about the sentimentalization of childhood emerging in the nineteenth and twentieth century Before this time children were just perceived as “small adults” documented with his analysis of art over time, where children indeed were depicted as small adults So slowly in the last two centuries childhood and later adolescence were discovered as separate entities and periods with their own development, concerns and problems We have therefore in the last century seen pediatrics, adolescent medicine and even geriatrics emerge as specialties concerned with different aspects of human development

This last century also saw advances in public health with decreased infant and maternal mortality in the Western World (or sometimes called the North), but in the new millennium the developing world (or South) are still struggling with disease and health concerns due to lack of resources Since the global expansion of AIDS (Aquired Immunodeficiency Syndrome) mortality has increased (so far millions of people have died due to AIDS related causes) and resulted in a growing number of children becoming orphans It is estimated that

by year 2010, AIDS will leave 20 million children alone in Africa without one or both parents, which is double the current situation of 11 million orphaned children At present 33.5 million people globally are HIV infected, which is estimated to increase to 45 million by year 2010 and most will be unable to effort the treatment

Poverty and human development were the themes of a recent research project undertaken

by the World Bank and published in three books This study describes the case studies from

14 countries In all three books information were gathered from more than 60,000 poor men and women from sixty countries, the true experts on poverty with many stories to tell together

Joav Merrick xii

with relevant and important observations The study was different from other poverty studies

in the fact that participatory and qualitative research methods were used The voices of the poor from the whole world can be heard from each page you read So with progress and positive development we still have to struggle with poverty and the results of poverty Poverty is even today in developed countries like United States and Israel (about 30% of children living in poverty) a major public health problem of a magnitude that is markedly different than Scandinavian countries (3%)

Chapter I - Rett syndrome (RS) is a genetic disorder affecting mainly females The individual with RS experiences a wide range of functional limitations, in many cases leaving her in need of constant care The individual with RS may have a variety of eating disorders, frequently leading to a very small and slim physique Given that increased food consumption can yield positive results on both the functional abilities and the emotional state of individuals with RS, it is important that focused attention be given to the feeding ability of these individuals The present article will address the principles of eating with individuals with RS The article is an amalgamation of up-to date knowledge on feeding for individuals with disabilities from our clinical experience with individuals with RS The article suggests different ways to evaluate and to positively influence the activity of eating with persons with

RS by discussing the person herself, the setting, and the handling by caregivers

Chapter II - The paper aims to contribute to integrated discussion of ethics in holistic healthcare Methods: Noting key aspects of the literature on ethics in holistic healthcare, the authors then focus on describing the working ethical statement for holistic healthcare practitioners produced for the International Society of Holistic Health (ISHH) Ethical principles, aims of holistic practice, and ethical guidelines are presented The relationship of ethics to quality of care is outlined Conclusions: The authors conclude that many of the ethical principles and guidelines, as well as expectations of quality and safety, that apply to mainstream healthcare, also apply to holistic practitioners However, the multidisciplinary contexts of whole-of-patient healthcare present new challenges of application of these familiar ethical understandings

Chapter III - This analysis paper aims to identify key directions for developing holistic healthcare that is more responsive to the special needs of small children 0-5 exposed to domestic violence It takes a ‘whole-of-patient’ as well as a ‘whole-of-systems’ approach to how health and allied health practitioners, service administrators, policy decision-makers, and researchers could work together to better meet the needs of these clients Its focus is on mutually compatible health and allied health reforms, at the levels of research, practice, and policy This analysis paper is based on select literature identified using the terms ‘children AND domestic violence’ in the databases SCOPUS and PUBMED The emphasis was on papers for the period 1995-2006 Domestic violence is a prevalent social problem with known effects on small children that require early intervention if they are not to become more costly for the individual and society later Much progress has been made, however, unless new approaches are energetically pursued, we may be facing another twenty years of program evaluations that do not give us the holistic evidence base needed for strong service development

Chapter IV – Individuals with Rett syndrome (RS) frequently present a constant ongoing need for therapeutic intervention One of the therapeutic approaches suggested for this

population is therapeutic horseback riding Experience has shown that this type of intervention is extremely enjoyed by the individual with RS The current article presents the possible benefits of applying Hippotherapy for individuals with developmental disabilities, the characteristics of RS compatible with this type of intervention and a case study describing the application of Hippotherapy for individuals with RS It should be emphasized that the present article is not a research article, but rather a review of the literature on RS and therapeutic horseback riding, with a case study to illustrate the implementation of the theoretical background The article presents clinical experience in these fields; therefore scientific generalization should be cautiously made

Chapter V - Objectives: To review the incidence and character of minor trauma that presented to family practice clinic and associated demographic variables Design: A retrospective data analysis was conducted using data collected from the CLICKS computerized medical records of primary care consultations at The Clalit Health System’s Shatal Clinic in Beer Sheva, Israel A systematic sample of every tenth child was taken from the alphabetical listing of all Bedouin children between the ages of zero and fourteen, registered at the clinic (n=156) Results: Of the 156 children sampled, 67 (42.9) had at least one injury and 31 (20.4) children had more than one childhood injury recorded in their medical record Boys had a higher incidence of two or more childhood injuries compared to female children (23/80 (28.8) vs 8/72 (11.1), p = 007) Girls had proportionally more injuries in early childhood with mean age at first injury 1.4 years younger for girls (4.0 ± 2.8

vs 5.4 ± 2.5, p=.035) Children of older parents in smaller families had more accidents No significant association was found between family size or birth order and injury Conclusions: Unintentional injuries have a huge morbidity and significant mortality world wide The populations most vulnerable to the burden of injuries are found in the less developed societies Current research has targeted at western society and the proven strategies for prevention inappropriate for the mechanisms of injury that are specific to the Bedouin culture Further research is necessary to identify demographic characteristics and behaviors that are correlated with injury in Bedouin children Chart review was not adequate for the study of demographic and SES factors affecting injury

Chapter VI - The application of information communication technology (ICT) to medical education and health care is increasing worldwide But little is known about the computer skills of medical students in developing countries We investigated the knowledge, attitude and ICT skills of medical students of Bayero University Kano, Nigeria A pretested, structured questionnaire was administered to 300 medical students in their pre-clinical and clinical years of study Of the 300 medical students, 22.0% owned a personal computer and 32.3% had previous formal computer training One hundred and sixty three (54.3%), 77 (25.7%) and 60 (20.0%) had good, fair and poor knowledge of computing respectively There was a significant gender gap with male dominance of computer knowledge (85.9% vs 67.4%) (P=0.0001) Also, computer ownership (95.4% vs.75.5%) (P=0.0001) and formal training (89.7% vs 57.1%) (P=0.0001) positively influenced knowledge Only 112(37.3%) students had positive attitude towards application of computing to medicine This was positively affected by being male (45.4% vs 20.0%) (P=0.0001), computer ownership (54.6% vs 32.6%) (P=0.001) and formal training (50.5% vs 31.0%)(P=0.001) Only 89(29.7%) of the students had good computing skills The remaining 107 (35.7%) and

Joav Merrick xiv

104(34.7%) students had fair and poor skills respectively Computing skills were positively influenced by increasing years of study (74.4% vs 56.8%) (P=0.04), computer ownership (95.5% vs 57.0%) (P=0.0001) and formal training (85.6% vs 55.7%) (P=0.0001) In conclusion, although most medical students had basic ICT knowledge, the level of self-assessed basic computing skills was low Integration of ICT into the medical school curriculum could help enhance the ICT skills of future physicians in northern Nigeria

Chapter VII - To explore the attitudes of undergraduate students of tourism and hotel management toward people with disabilities Design: A survey of all first year students of the tourism and hospitality mangement department was completed using a short validated questionnaire with 15 topics reflecting the full range of attitudes toward the disabled Results:

Of the 33/68 (48.5%) completed the questionnaire, while one was incomplete 70% of the respondents demonstrated indepth understanding of the needs and rights of the disabled and the majority stressed their agreement with the need to make all places accessible without need for extra expenses by the disabled Students believed that the presence of the disabled in the sphere of tourism had no negative effect on the industry image and use While only half of the respondents feel comfortable in the presence of the disabled, 50% had reported that the disabled have the same abilities to enjoy and get excited as those without disabilities Conclusions: Today students, future managers have to change their attitudes toward the disabled and most of the work has to be done during their academic studies and the educational system has to be responsible for such a change

Chapter VIII - In most Major Western Nations (MWN) there is considerable media criticism of failing to prevent the extremes of child abuse, namely a dead child Testing whether services have prevented these extremes is trying to prove a `negative’, conversely measuring the `failure’ rate, children’s (0-14 years) deaths is a surrogate indicator of the level

of societal child protection Method: Utilising WHO mortality date, changes in all cause and violent-liked deaths in England and Wales were compared against the other nine MWN 3-year average per annum rates for 1974-76 v 2000-02 Violent-linked deaths included homicide, undetermined and accident and adverse event (AAE) deaths, thus accounting for any notional `hidden’ abuse deaths Results: The current two highest rate of all cause children’s (0-14 years) deaths were in USA at 2539pm (death rates per million), representing

a fall of 55% and England and Wales 1921pm, a fall of 65% , with the lowest Japan at 1297pm, a 65% fall and France 1600pm a decline of 64% In the 1970’s England and Wales baby (<1 years) homicide rates were 2nd highest at 57pm, but fell to 17pm, a 74% fall, whereas the USA were now highest at 84pm, a 56% increase Baby AAE deaths fell in every country, England and Wales falling from 341pm to 71pm, a 76% reduction Both these results were significantly better than eight other MWN, although England and Wales baby undetermined deaths at 26pm, were high compared to the other MWN Initially England and Wales’ children’s combined `violent-linked’ deaths were 203pm p.a., now 61pm, a 70% decline, with only Italy having lower rates The highest rates were the USA at 185pm We concluded that the major reductions in both all cause and violent-linked deaths should be a boost to the morale of front-line children’s service staff, especially in England and Wales and correct the erroneous public image However there must be continuing concerns about USA children’s homicides

Chapter IX - Depression and obesity have been recognized as major public health issues

in youths Although they have traditionally been compartmentalized as separate physical and emotional health conditions, evidence suggests interactions and common pathways between them, implying that successful treatment should ideally target shared underlying mechanisms The purpose of the present article is to review the pediatric diagnostic criteria for depression and obesity, highlight similarities in their clinical presentation, identify common pathways and underlying mechanisms, describe their developmental trajectories, and suggest areas for future study to guide development of innovative prevention and treatment initiatives

Chapter X - The high rate of comorbidity of asthma and mood disorders would imply the possibility of potential shared pathophysiologic factors Proposed links between asthma and mood disorders include a vulnerability (trait) and state connection Vulnerability for both asthma and mood disorders may involve genetic and early developmental factors State-related connections may include obstructive factors, inflammatory factors, sleep impairment, psychological reactions to chronic medical illness, as well as exacerbation of asthma in individuals with chronic stress Treatment for asthma may also exacerbate mood disorders New research suggests involvement of the central nervous system in asthma and allergy Further characterization of clinical, psychological, cellular and molecular interconnections between asthma and mood disorders is needed to better evaluate and treat these patients A close collaboration between mental health professionals and allergists could result in improved symptom control, quality of life, overall functioning and ultimately, decreased mortality

Chapter XI - Jet lag, a circadian rhythm sleep disorder associated with transmeridian travel, is the result of many factors, the most important being misalignments between the light-dark cycles of origin and destination, and between the social demands at the place of destination and internal, biological, representations of day and night which govern our abilities to fall asleep, stay alert and perform Most of the time, sleep deprivation compounds the misalignment effects The demands and duration of the trip, as well as the direction and number of time zones crossed and prior vulnerability to jet lag should determine if and how

to treat jet lag Treatment options include simple measures involving bright light exposure and avoidance, bright light treatment, timed meals, and exercise, and, sometimes, melatonin, short-acting hypnotics, and alertness promoting beverages and pharmacological agents Given the long-term health implications of circadian rhythm sleep disorder, and their impact

on individuals and society, further research and more effective treatments are needed

Chapter XII - Since 1979, when mindfulness-based stress reduction (MBSR) was first introduced at a mainstream medical center, there has been a rapidly growing interest in the science and clinical applications of mindfulness meditation MBSR is efficacious in improving quality of life and decreasing symptoms of depression in a wide variety of medical patient populations Mindfulness-based cognitive therapy (MBCT) incorporates elements of mindfulness meditation and cognitive therapy and was specifically designed for relapse prevention in depression The objective of this study is to review the feasibility, safety, and efficacy of mindfulness based interventions in patients with mood disorders Systematic searches for clinical studies were conducted on several databases and one relevant website Fifteen articles met criteria for inclusion in this review MBCT is feasible for patients with major depressive disorder (MDD), bipolar affective disorder (BAD), and history of suicidal

Joav Merrick xvi

thinking or behavior The intervention has a low dropout rate and high degree of acceptability MBCT is probably efficacious for decreasing the risk of relapse in patients with three or more depressive episodes Preliminary evidence suggests that MBCT might be helpful in reducing symptoms of depression in moderately to severely depressed patients with MDD or BAD, in reducing anxiety and depressive symptoms in bipolar patients, and in possibly decreasing cognitive vulnerability to suicidality MBSR is less well studied in mood disorder patients MBCT and possibly MBSR have a potential as clinically valuable interventions in the treatment of mood disorders Further research into their efficacy, feasibility, and safety is recommended

Chapter XIII - The purpose of this paper is to review: 1) current evidence that constructs proposed in cognitive and behavioral theories of depression have relevance to winter seasonal affective disorder (SAD) and 2) the results of preliminary randomized clinical trials testing the acute and long-term efficacy of cognitive-behavioral therapy (CBT) for SAD, alone and

in combination with adjunct light therapy, as compared to solo light therapy Research supports that factors related to a cognitive vulnerability to depression as well as low rates of response-contingent positive reinforcement in the winter and learned emotional and psychophysiological reactivity to light-relevant stimuli are operative in SAD and may represent a point of intervention via a SAD-tailored CBT Preliminary randomized clinical trials suggest that CBT for SAD is acutely efficacious and may be prophylactic with regard to preventing winter depression recurrence To advance the theoretical understanding of the psychopathology SAD, we advocate for an integrative biological-psychological conceptualiz-ation of SAD and for multi-disciplinary research to study interactive biological-psychological mechanisms in SAD onset and maintenance To advance the treatment of SAD, we advocate for a greater focus on testing long-term outcomes in SAD treatment research In contrast to establishing only acute treatment efficacy, a longer-term perspective reflects the recurrent nature of the disorder and should lead to the development of empirically-validated treatments that prevent winter depression recurrence

Chapter XIV - Prepartum and postpartum depression have negative, and sometimes devastating, effects on women and their families As inflammatory processes are related to depression in general, we hypothesized that inflammatory perturbations, prepartum and postpartum, contribute to triggering and worsening of symptoms of peripartum depression

We conducted a longitudinal preliminary study on 27 women at high risk for developing postpartum depression measuring SIGH-SAD scores at three time points: 35-38 weeks gestation, 1-5 days postpartum, and 5-6 weeks postpartum Serum C-reactive protein and interleukin-6, both markers of inflammation, as well as tryptophan, kynurenine, and the kynurenine/tryptophan ratio, as consequences of inflammation and pathophysiological steps towards depression, were measured at each time point C-reactive protein levels were found

to be positively related to atypical and total depression scores in the prepartum period and with atypical depression scores in the early postpartum period Tryptophan was found to be negatively associated with total depression scores in the prepartum, as well These findings warrant further investigation that could lead to novel interventions to decrease poor outcomes from peripartum depression

Chapter XV - As previous reports related olfaction to both mood and seasonality in humans, and as previous studies suggest that lemon odor may influence mood and behavior,

we hypothesized that brief exposure to the scent of lemon would alter mood in patients with seasonal winter depression Twenty-four patients with seasonal affective disorder (17 females and 7 males, aged 43±10 years) were briefly exposed to lemon and a control odor (fir tree) using a cross-over randomized nested design Mood change following exposure to lemon scent was compared to mood change following exposure to fir tree using Wilcoxon nonparametric tests There was a significant, although small, difference between change in mood after sniffing lemon odor (improvement) versus after sniffing fir odor (worsening) {Wilcoxon matched- pair signed rank test, Z = -2.58, N = 23, p = 0.01} Studies evaluating potential antidepressant or antidepressant-augmenting effects of odorants will require longer repetitive exposures., , and randomized placebo controlled trials, Our limited conclusion is that even very brief exposure to chemosensory stimuli may influence mood reports in patients with seasonal depression

Chapter XVI –Rapid Cycling Bipolar Disorder (RCBD) outpatients completed daily mood self ratings for 3 consecutive months These ratings were matched with local measurements of atmospheric pressure, cloud cover, and temperature Several alternative second order differential equation models were fit to the data in which mood oscillations in RCBD were allowed to be linearly coupled with daily weather patterns The modeling results were consistent with an account of mood regulation that included intrinsic homeostatic regulation as well as coupling between weather and mood Models were tested first in a nomothetic method where models were fit over all individuals and fit statistics of each model compared to one another Since substantial individual differences in intrinsic dynamics were observed, the models were next fit using an ideographic method where each individual's data were fit separately and best fitting models identified The best fitting within individual model for the largest number of individuals was also the best fitting nomothetic model: temperature and the first derivative of temperature coupled to mood and no effect of barometric pressure or cloud cover But this model was not the best fitting model for all individuals, suggesting that there may be substantial individual differences in the dynamic association between weather and mood in RCBD patients Heterogeneity in the parameters

twice of the differential equation model twice of homeostatic equilibrium as well as the coupling twice of mood

to an inherently unpredictable (i.e., nonstationary) process such as weather provide an alternative account for reported broadband frequency spectra of daily mood in RCBD

Chapter XVII - Fibromyalgia is a poorly understood pain disorder that can become disabling Much less is known about fibromyalgia in children and adolescents and this paper will add to this body of literature Recognition and treatment of children and adolescents provides an important opportunity to prevent illness from becoming a way of life Fibromyalgia, is a pain disorder that can become a way for the body to speak what the mind does not know The authors clinical experience indicates that fibromyalgia symptom severity can exist on a continuum from mild to severely disabling and those unconscious conflicts can move fibromyalgia from a mild pain disorder to a chronically disabling condition It requires bridging the mind and body, both in understanding the mechanisms of the disorder and in guiding the treatment The authors elucidate physiological and psychological mechanisms for this complex syndrome as well as a model for treatment intervention with children and adolescents In doing so, they make bridges between literatures of medicine, neuropsychology, cognitive behavioral therapy and psychoanalytic theories; thereby

Joav Merrick xviii

paralleling the treatment process which moves from the physical through different layers of psychological depth They provide a detailed clinical discussion of a young girl with a complex case of fibromyalgia that illustrates an application of this type of clinical theorizing applied to an individual and family treatment on an inpatient psychiatric unit

Chapter XVIII - The results of a large number of studies suggest the efficacy of lithium

in the prevention of suicide These studies include retrospective, prospective, and discontinuation studies, as well as comparison studies with other medications Despite this extensive clinical data, it remains unclear what molecular mechanisms underlie the antisuicidal efficacy of lithium Lithium has a number of undesirable side effects that often limit its clinical use Determining the molecular mechanisms that underlie the therapeutic effects of lithium is a critically important task It may be possible to develop a novel drug that mimics the efficacy of lithium in the prevention of suicide, but possesses a more limited side effect profile than lithium We review molecular effects of lithium that may be related to its antisuicidal efficacy, focusing particularly on serotonin neurotransmission

Chapter XIX - This article provides an overview of the prevalence, risk factors, and screening instruments for suicidal thoughts and suicidal behaviors in the juvenile delinquent population Factors specific to the juvenile justice environment and their interactions with suicidality in adolescents are examined Methods: A search of the MEDLINE and SearchMedica Psychiatry databases was conducted for articles published since 1980 in the areas of suicide and suicidal behavior in the juvenile offender population as well as the general adolescent population Results: Several studies reported an increased rate of suicide and suicidal behavior in juvenile delinquents as compared to the general adolescent population Risk factors can be grouped in four major categories - Demographic factors –female gender, race (Native American >Hispanic>White>Black); Psychiatric illness- mood disorders, substance abuse, conduct disorder, history of suicidal behavior; Psychological factors- impulsivity, history of sexual abuse; Environmental factors- housing with adults, room confinement, locked sleeping rooms, short term facility Conclusion: The environment (juvenile detention) is but one of several factors that might explain the increased rate of suicides in juvenile facilities A continuum of universal screening at intake, adequate psychiatric treatment including medication management and therapy, appropriate facility level changes, adequate housing, staff training and restricted use of confinement are likely to

be very helpful

Chapter XX - The identification or recognition of mental disorders in the Criminal Justice System (CJS) is fraught with difficulties Some obstacles are merely definitional, e.g delimiting where the boundaries of Impulse Control Disorder NOS or Paraphilia NOS might exist More significant hurdles are the reliance on inaccurate self-report, persistent substance induced altered CNS functioning in many detainees, and the atypical presentation of individual psychiatric disorders in persons with multiple comorbidities, combined with troubled and deviant life histories Identification and treatment of mood disorders in the CJS

is presently an area requiring further development through studies on the multiply comorbid, both in and out of custody Recent studies on pediatric mood disoders suggest that there may

be a subgroup that end up in the CJS as they get older Predicting suicide in the criminal justice system is similarly difficult because of the low specificity of predictive methods Many inmates have multiple risk factors, and multiple psychiatric comorbidities Nonetheless

suicide and attempted suicide are rare events in the CJS Programs of suicide prevention in the criminal justice system have been successful

Chapter XXI - Suicide is a cause of significant mortality and morbidity around the world There has been research on the various risk factors and protective factors for suicide One protective factor that has been of interest is the possible negative correlation between religion, religiosity/moral objections to suicide and suicide rates There are several reports that the rate of suicide is lower in Muslim majority countries (Islamic countries) The various hypotheses about the lower suicidal rate include the impact of the Quran’s injunction against suicide, the prospect of an eternal life in hell, the social integrative and regulative benefits of religion, and underreporting of suicide due to stigma/criminal penalties Despite the disagreement on the causal factors many of the studies have suggested that Muslims are at a lower risk for suicide compared to other populations Some of this data comes from studies of Muslims in countries with mixed religious population Scarcity of research about the incidence of suicide in Muslim majority countries precludes a definitive conclusion This is a preliminary review of the subject with a key objective of pointing out directions for future research and the clinical implications We will discuss the state of current knowledge about Islam as a possible protective factor against suicide

Chapter XXII - Suicide is the third-leading cause of death for adolescents between 15 and 24 years of age in the United States and its rate has been increasing Factors that contribute to rate of, risks for, or protection against depression and suicide may be different for people from cultures with different values and health beliefs Although typically seen as affecting Caucasians more than other groups in the U.S., the rates of suicide among African Americans, Latinos, and others have been increasing 87 studies were reviewed looking at rates for suicide/suicidal ideation, risk factors for suicide, protective factors/coping mechanisms, service delivery/barriers to care, and specific treatment or management of suicidal thoughts for adolescents from different ethnic groups in the U.S The following ethnic groups in the U.S were compared: African American, Latino, Asian American, Native American/Alaskan Native, and Hawaiian American Although studies report conflicting rates, most studies still show an overall higher risk for suicide among Caucasian youth than any other group Rates for suicide are growing for African American teens (perhaps more in boys), Latino teens (especially Latina girls), Asian American youth, Native American youth, Alaskan Native youth, and Hawaiian American youth Details about these differences are discussed along with recommendations for clinicians working with youth at risk for suicide from minority cultures in the U.S

Chapter XXIII - Suicide and decompensation of mental illness peaks in spring and to a lesser extent in fall Several recent studies reported that suicide and decompensation peaks coincided with spring and fall aeroallergen peaks Allergic symptoms occur as the result of a complex biochemical cascade initiated by IgE antibodies (sensitization) and allergens (triggers) Animal models have shown molecular/neurochemical changes in the brain as well

as relevant behavioral changes associated with this IgE mediated biochemical cascade These factors suggest that seasonal allergy could precipitate suicidality and mood instability In the current study, we compared the prior suicide attempt and decompensation history in allergen sensitive and nonsensitive persons diagnosed with mood disorders Patients with Major Depressive Disorder or Bipolar I or II Disorder (n=80) completed several instruments

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(Columbia Suicide History Form, Beck Scale of Suicidal Ideation and Beck Suicide Intent Scale) Serum was screened for allergen-specific IgE antibody t-Test analysis was used to compare the history of suicide attempts and instability between the two groups, aeroallergen positive and negative Further, we compared the ratio of attempts and decompensations during the allergy season to suicides in both groups occurring during the rest of the year There were no statistical differences in any measurement performed between the psychologically ill and well groups In contrast to previous studies that found an association between completed suicide and allergen exposure or prior history of allergy, the current study found no association between number or timing of prior suicide attempts and markers of allergic sensitization in patients with recurrent mood disorders

Chapter XXIV - It has been reported that allergies are associated with depression and possibly suicide in women Aggression is an important behavioral component that predisposes depressed individuals to suicidal acts In the present study we examined the relationship between allergies and aggression to determine a potential contribution of allergies in factors of risk for suicidal behavior Because stress plays a critical role in the manifestation of clinical symptoms of allergies and also in suicidal behavior, we also studied the role of acute stress Female inbred Brown Norway rats known for their susceptibility to respiratory allergies were sensitized and challenged with a mixture of tree pollen and evaluated in the resident-intruder test for detection of aggressive behaviors They were also subjected to acute stress by sessions of inescapable forced swimming and re-evaluated in the resident intruder test Animals made allergic to tree pollen and subjected to acute stress displayed increased aggressive-like behavior as compared with control-saline treated animals

or to their own aggressive scores previous to the stress session These results suggest that allergies and stress increases aggressive-like behavior, indicating that these conditions may

be important factors promoting altered emotional reactivity with the potential to influence suicidal behavior

Chapter XXV - Considering clinical and animal evidence suggesting a relationship between allergy and anxiety, we hypothesized that, from low to high aeroallergen exposure, changes in anxiety symptom scores in patients with primary mood disorders will correlate with changes in allergy symptom scores We also anticipated that sensitization to tree pollen,

as determined by allergen specific IgE antibodies, will predict a greater worsening of anxiety during exposure to tree pollen 51 patients with unipolar or bipolar disorder (age: 19-63 years, 65% female) were recruited Tree- pollen IgE positive subjects (12) were included as the experimental group and patients negative to a multi-allergen serological test (39) were included in the control group Self reports of anxiety and allergy symptoms were obtained once during the peak airborne pollen counts and once during the period of low airborne pollen counts, as reported by two local pollen counting stations Using linear regression models, we confirmed a significant positive association between allergy scores and anxiety scores (p<0.04); however, the IgE specific tree pollen positivity was not significantly associated with changes in anxiety scores Because changes in anxiety scores relate to changes in depression scores, the relationship between allergy and anxiety involves states rather than only traits, and as such, our results lead to future efforts to uncover potential anxiety triggering, exacerbating or perpetuating role of allergens in vulnerable individuals

Chapter XXVI - Obesity is increasingly prevalent in adolescents with significant lifelong medical complications The exact prevalence of obesity among adolescent athletes is not known; however, there is research that suggests obesity prevalence varies by the type of sports A few studies suggest that youth sport participation can be an effective tool in the management of obesity in children and youth Regular physical activity and sport participation that is fun is strongly recommended This discussion considers the role of sports

in helping obese adolescents and also what physical activity is recommended It is concluded that sports participation can be an important part of effective management of obese youth and setting the stage for a lifelong pursuit of physical activity to control and/or reduce obesity in the adolescent and adult population

Chapter XXVII - The link between obesity and hypertension is examined in this discussion Underlying mechanisms include increase in sympathetic activity, sodium balance, renal tubular sodium reabsorption, glomerular filtration rate (GFR) and development of insulin resistance The role of leptin is examined in the development of hypertension in obese adolescents Also considered in this review are the definitions of hypertension and principles

of management for obese youth with hypertension Pharmacologic agents used for management of hypertension include diuretics, alpha blockers, beta blockers, angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin-2 receptor blockers (ARBs), and long acting calcium channel blockers The importance of weight control, caloric restriction, and exercise in the management of obesity in youth is also stressed

Chapter XXVIII - This review has a two-fold objective One, it addresses the association

of hyperandrogenism and obesity and the complex metabolic derangements that are part of the problem Clinical management of these co-morbidities is challenging and complex Second, this article will aid health care providers with the key features to an early diagnosis and intervention to decrease the morbidities in the short as well as long term Method: Systematic review of articles and information on the topic of interest that were published in the last 15 years Conclusion: Obesity and hyperandrogenism are integral parts of Metabolic Syndrome/Polycystic Ovarian Syndrome (PCOS)/Hyperandrogenism, Insulin resistance, and Acanthosis Nigricans (HAIR-AN) With the childhood obesity epidemic, the metabolic syndrome and the associated abnormalities are routinely seen in clinical practice and these have a tremendous economic burden on the society and the quality of life

Chapter XXIX - Obesity is the most prevalent metabolic disorder in the United States with adolescents and children being the fastest growing segment of the population affected by this disorder The initial management of obesity entails modification of diet and exercise as well as a trial of medications Unfortunately, this usually has unsatisfactory results; as a result, bariatric surgery has been used in the adult population and seems to offer improved long term results Because the results have been quite favorable in the adult population, specialists are also looking at bariatric surgery for the adolescent population This appears to

be a safe approach in conjunction with diet and exercise and it offers improved long term results This article discusses the use of bariatric surgery in obese adolescents

Chapter XXX - There has been a profound increase in the prevalence of obesity over the last 20 to 30 years causing the coining of the term “obesity epidemic” in children, adolescents and adults It is believed to be due to a complex interaction of social and environmental factors in the overall lifestyle pattern The increased rate of obesity is seen to be associated

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with increasing incidence of type 2 diabetes mellitus in adolescents, along with perturbations

of the other endocrine axes, as well as, higher risk of long term complications It is therefore

of the utmost importance that concerns about overweight and obesity be addressed from early childhood and adolescence to avoid resultant significant morbidity and/or mortality

Chapter XXXI - Obesity has been deemed a public health epidemic, which carries with it high financial and psychological stakes, social consequences, and ethics of public, mental, and medical health care research pushing for all adolescents, who are “obese” to lose weight This article reviews the psychological aspects of overweight in adolescents No single factor has been shown to cause obesity; most researchers agree that the causes of obesity are multifaceted and complicated Adolescents who are overweight may experience the deleterious effects of obesity on psychological functioning Concepts of beauty, perceptions

of body image and satisfaction all contribute to the psychological attitudes and beliefs about personal value, worthiness, self image, body satisfaction, and dieting Not all adolescents who are at-risk-for-overweight or are overweight are unhealthy Clinicians should consider that just as they warn the obese about the risks of obesity, they must expend as much energy evaluating the risks of successful weight loss They must also remember that there are other standards of beauty and body size among ethnic groups and other cultures The weight for height by body type tables that are used to calculate BMI should be changed to reflect the body types and fat distributions of Latino- and African-Americans

Chapter XXXII - The global epidemic of childhood and adolescent overweight has become a major public health concern Not only are these youth more likely to become obese

as adults, and thus more prone to obesity-related diseases than their non overweight peers, they are also likely to suffer emotional and social effects associated with overweight Overweight in youth has been linked to depression, low self-esteem, eating disorders, negative body image, and stigma It appears to be bi-directional in nature, with overweight sometimes predicting certain psychological effects and psychosocial issues sometimes predicting overweight Effective assessment and treatment of psychological and mental health issues in overweight youth will help overweight youth deal more effectively with their social and psychological milieus Additionally, interventions for mental health concerns may have the added health benefit of increasing weight loss, thus decreasing obesity-related disease for which the overweight adolescent is prone

Chapter XXXIII - This discussion reviews various medications currently used and being studied for weight loss induction in adults and adolescents The search for medication to induce weight loss was stimulated by the US FDA’s 1959 approval of phentermine, a sympathomimetic amine, for short-term weight loss despite limited research supporting its claims of causing weight loss In addition to noradrenergic products like phentermine, other reviewed medications include herbal products (such as Korean herbal formula based on Taeumjowi-tang), sibutramine (mixed noradrenergic-serotonergic chemical), orlistat (lipase inhibitor), metformin (biguanide), rimonabant (CB1-selective cannabinoid receptor antagonist), and others Only two non-amphetamine-related medications are FDA-approved for adolescents: sibutramine for those 16 years of age and older, and orlistat for those 12 years of age and older Pharmacotherapy for morbidly obese adolescents should only be used

as part of a comprehensive weight loss program that involves diet, exercise, and behavioral

modification The side effects of these products should always be considered as well as the potential for serious adverse events

Chapter XXXIV - Although obesity is not classified as an eating disorder, there are associations between obesity and anorexia nervosa, bulimia nervosa, and binge eating disorder This article reviews some of these associations For example, a proportion of patients with anorexia nervosa eventually become bulimic and some of these patients eventually become overweight, while anorexia is often seen in a previously obese patient who loses weight successfully and then cannot stop losing weight or continues to try to lose weight even after reaching an otherwise normal weight range There are possible genetic components for obesity as there are for anorexia nervosa and bulimia nervosa, but there are also associations with the family environment, particularly with family dietary habits Obese patients should be screened for the presence of an eating disorder, especially bulimia nervosa and binge eating disorder Obese patients who successfully lose weight should also be carefully observed for the possible development of anorexia nervosa Principles of management are also reviewed

Chapter XXXV - Adolescence is a critical period of growth and development in an individual’s maturation from puberty to adulthood A key component of normal adolescence

is the process of healthy sexual development that is influenced by an inevitable passage through the stages of maturation from infancy to adulthood Primary care clinicians should understand and appreciate the importance of sexuality in the lives of their adolescent patients Obesity is one of the factors that influences sexuality in adolescents The purpose of this paper is to succinctly discuss the relationship between obesity and adolescent sexuality In this regard, it is vital to examine whether obesity alone can derail healthy adolescent sexual development Not all overweight adolescents experience severe negative outcomes because

of their obesity However, for those who do experience negative sexuality issues, the sensitive and caring clinician can help direct them to helpful resources to address these critical issues

Chapter XXXVI - All sexually active youth, whether obese or normal weight, should be offered counselling regarding contraception and appropriate contraceptive methods However, obese youth who are sexually active may be less likely than their normal weight peers to use contraceptives correctly Methods of contraception for obese adolescents are reviewed in this discussion Combined oral contraceptives (COCs) and the contraceptive patch have higher failure rates in obese versus normal weight females, though failure rates are lower than noted with barrier contraceptives The risk for venous thrombosis is higher in obese youth on COCs Progestin-only pills and the levonorgestrel intrauterine system appear

to be safe and effective methods in obese females Depot-medroxyprogesterone acetate, intravaginal ring, and implants are also considered

Chapter XXXVII - The prevalence of obesity has increased to epidemic proportions in the United States in recent years Obesity in the Western world is a disease of poverty that is seen much more often in minority populations Obesity-related illnesses, such as type II diabetes, are now seen frequently in adolescents and even in younger children Caloric intake has increased in adolescents over the last two decades along with changes in dietary composition fueled by advertisements of unhealthy foods by various food producers Nutritional modification is an essential part of any weight-loss program This article discuss

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various diet changes that are important to reverse this current trend of increasing obesity in all populations and ages Highly-restrictive diets should be reserved only for the morbidly obese child or for those with obesity-related problems such as sleep apnea

Chapter XXXVIII - Obesity presents special challenges for skin care and is associated with several conditions that need careful attention Among the conditions reviewed here include acanthosis nigricans, papillomatosis of Gougerot and Carteaud, polycystic ovary syndrome, striae distensae, Cushing disease, and Cushing syndrome in relation to their dermatologic aspects Various treatment modalities reviewed include bathing, soaps, cleansers, shampooing, emollients, topical corticosteroids, topical antibacterials, antifungals, and topical retinoids

Chapter XXXIX - Obesity in childhood has particular concern, because if it continues into adulthood, the result will be increased morbidity and decreased life expectancy An increase in obesity in the general population in the developed world has been documented in recent years This trend is also seen in persons with intellectual disability and in particular in persons with Down syndrome (DS) Persons with DS are prone to obesity already at an early age and several studies have shown a high prevalence in this population compared to persons with intellectual disability without DS and the general population Persons with DS have a low resting metabolic rate and low dietary intake of individual nutrients and therefore exercise and vitamin-mineral supplement diet must be instituted in this population to prevent

or minimize obesity and its adverse consequences

Chapter XL - Obesity rates among children around the world have reached an epidemic level Having an option to walk or bike to school is important for mobility, health and equity purposes However, fewer students are walking or biking to school today than a generation ago, and fewer students live within a walkable distance to schools This review highlights the existing evidence from multiple disciplines on health and equity issues related to school transportation It then assesses the literature dealing with the built environmental correlates of walking or biking to school Travel distance and safety were found to be the strongest predictors of walking or biking to school Studies suggested that about one-half to one mile (0.8-1.6 km) between home and school was generally considered walkable Other factors such as roadway conditions, sidewalk continuity, bike lane availability, signals, lighting, and neighborhood design appeared important but with some inconsistencies in the findings Many commonly reported environmental barriers were related to transportation infrastructure, such

as high-volume and high-speed roadways, unsafe street crossings, and railroads Compared with distance, safety and transportation infrastructure, neighborhood characteristics such as density, land use, and overall street patterns appeared less significantly associated with school transportation This review revealed evidence supporting the link between school transportation and the built environment It also discovered many remaining questions for future research, such as interactions and causalities between personal and environmental factors, environmental influences from multiple spatial scales, and differences between objective and perceived measures

Chapter XLI - Research has focused on adolescent’s food choice with the hope of finding key factors preventing obesity We aimed to specifically spot relevant key factors that influence Bangkok children, aged 9-11 years old, their food buying preferences and behaviors in schools Nutritional anthropological research methodology namely, participant

observation, in-depth interviews, and buying and eating behaviors-related observation questionnaires were carried out among 27 participating elementary schools in Central Bangkok This research aimed to discover detailed factors associated with individuality, sociality, environmental, and external influence over children’s food choices First, individuality factors associated to children’s food choices involved the amount of daily allowance, children’s food preferences, students’ perception towards food ability in correlation with the frequency of school breaks, and children’s rationale of food prices (reasonable/affordable range) Second, sociality factors concerned how individual(s) have shaped children’s knowledge of food, food-related beliefs, and individual(s) that accompany/are present at the moment when children are buying foods Third, environmental factors discovered were the location, distance, and quality of where food is being sold, shelving/how food is being displayed, and the availability of food knowledge the school displayed/provided for their students Last, external factors identified the variety of mass media channels, which triggered children to desire new food items, were tested and shown no influence over children’s food choice on school days In conclusion, the insights gained can enlighten ways in which in-depth understanding of children’s food choice and behaviors can

be obtained in order to create a more efficient and culturally suited future obesity prevention plan

Chapter XLII - Childhood and adolescent obesity are risk factors for poor health later in life as well as decreased life expectancy This short communication reviews literature on obesity in Israel and examines several recent studies, which have clearly demonstrated rising rates of childhood and adolescent obesity similar in magnitude to those trends observed

in other Westernized nations It is incumbent upon relevant authorities within Israel to reverse these trends so as to prevent the long-term adverse health consequences associated with childhood and adolescent obesity We recommend initiating a national educational campaign to promote exercise and healthy eating This campaign would target children and adolescents and would rely upon evidence based guidelines for diet and exercise

Child Health and Human Development

Chapter I

Principles of Eating and the Individual

with Rett Syndrome

Judy Wine1,2, Yael Yoshei1,3,4 and Meir Lotan∗1,5,6

Chaim Sheba Medical Center, Tel HaShomer, Ramat Gan

Academic College of Judea and Samaria, Ariel, Israel

Abstract

Rett syndrome (RS) is a genetic disorder affecting mainly females The individual with RS experiences a wide range of functional limitations, in many cases leaving her in need of constant care The individual with RS may have a variety of eating disorders, frequently leading to a very small and slim physique Given that increased food consumption can yield positive results on both the functional abilities and the emotional state of individuals with RS, it is important that focused attention be given to the feeding ability of these individuals The present article will address the principles of eating with individuals with RS The article is an amalgamation of up-to date knowledge on feeding for individuals with disabilities from our clinical experience with individuals with RS The article suggests different ways to evaluate and to positively influence the activity of eating with persons with RS by discussing the person herself, the setting, and the handling by caregivers

∗ Correspondence: Meir Lotan, BPT, MScPT, Department of Physical Therapy, Academic College of Judea and Samaria, Ariel E-mail: ml_pt_rs@netvision.net.il

Judy Wine, Yael Yoshei and Meir Lotan

There is a multitude of factors involved in the eating habits of individuals with RS that influence its correctness and speed In order to decide on appropriate intervention, all of these factors must be taken into consideration (see figure 1)

Factors affecting the feeding ability of the individual with RS

Oral/motor function Level of development

Cognitive level Motor control

Epilepsy Constipation Posture & positioning Behavior

Orthopedic state Communication

Functional abilities Respiratory problems

Safe and satisfying feeding

Figure 1 Factors affecting the feeding ability in persons with Rett syndrome

In order to emphasize the severity of this issue among individuals with RS, it may be noted that 74% of the individuals with RS present gastroenterological problems (6)

Assessment

When considering the issue of feeding as it relates to people with developmental disabilities in general and to individuals with RS in particular, it is recommended that the subject be approached according to work done by Evans and Klein (7) adapted for RS:

1 The execution of a comprehensive assessment,

2 The use of a problem-solving approach,

3 The individual’s functioning within the overall framework of her disabilities and challenges

4 Mutual discussion and consent among therapists and caregivers (including parents) regarding the intervention regime

The assessment of the individual with RS can be divided according to the three main purposes of eating intervention:

• Safe eating

• Sufficient food intake

• Social acceptability/esthetics

Safe eating relates to a state where the individual is not in danger of aspiration while

eating or drinking A decision regarding the danger during meal time is considered after gathering data from different sources, such as:

• Medical history (past lung infections and their frequency)

• Medical examination (examination of the respiratory system before and after eating)

• A questionnaire completed by the staff members familiar with the individual’s eating habits and functional abilities

• Observations regarding the ability to intake different food and liquid items

• Evaluation of the swallowing mechanism (in instances where the initial non-intrusive evaluation indicates that the individual is experiencing some difficulties in handling food intake, the execution of a video-fluoroscopy examination should be considered)

• Evaluation of the state of the respiratory system (when suspicion arises regarding the proper functioning of the swallowing mechanism due to recurrent lung problems, lung x-rays at random or on a regular basis should be taken)

Sufficient food intake is measured by the amount and type of food that the individual with

RS consumes, together with its compatibility with her daily caloric expenditure and her growth curve Deviation from the norm should provide the impetus for the initiation of a process intended to identify the difficulties exhibited by the person with RS and the application of appropriate measures aimed at improving the individual’s condition

Judy Wine, Yael Yoshei and Meir Lotan

6

Therapeutic Intervention during Mealtime

Swallowing, or the ability to swallow food and fluids is a complex action which depends

on an array of mechanisms The tongue’s motion and the closing of the lips begin the swallowing process, as they move the food to the rear area of the mouth and pharynx Sensory receptors in the pharyngeal area transfer information to different nerve centers, which start the reflexive swallowing process, while the food continues from there to the esophagus A large number of persons with swallowing problems, including many individuals with RS, are not capable of halting the respiratory process during the swallowing process (as most people with a normally functioning system do) If there is food inside the individual’s mouth that she is not able to swallow between breaths, she must be able to block the entry of food to the esophageal area before attempting to swallow again This action demands skilled and separate tongue movements, which generally cannot be executed by people with swallowing problems as part of their complex neurological profile In such cases the joint air and food inhalation is expressed by coughing and could lead to suffocation If the individual cannot achieve good lip closure, the formation of negative pressure which is necessary for the efficient flow of food to the esophagus while swallowing is affected If the head and neck are not in the correct position (for example, hyperextension of the neck) then swallowing efficiency is affected and a high risk for aspiration exists It may be stated that the most important physiological assistance for normal swallowing is a slight forward flexion

of the neck Many individuals with RS present postural problems, and therefore may have a hyper extended neck when sitting This position causes the cervical vertebrae to protrude forward and press on the end of the esophagus, thus blocking the food pathway to a certain extent However, exaggerated flexion (forward bending) of the neck also interferes with the closing of the epiglottis and causes food to be shoved into the bronchioles

Aspiration can be either active (coughing, interruption in breathing, cyanosis, noisy breathing) or without external indication (silent aspiration) Slow swallowing can derive from sensory abnormalities, oral-motor problems, reaction to medication, or a decreased state of awareness Aspiration might occur when the eating process is slow and it becomes necessary

to inhale before the food has completely left the mouth/pharynx area (in such cases spooning small amounts might be the solution)

Additional eating problems which might interfere with swallowing are manifestations such as vomiting, spitting, gagging, and coughing These problems, when reoccurring, may cause issues of malnutrition and/or dehydration It is important to diagnose the cause and not

to loosely hang the blame on personal or behavioral issues (“Joanne doesn’t like the rice”,

“Tami is really stubborn today”)

• Vomiting (Gag reflex) – Abnormal gag reflex was found among 20% of individuals with RS (8) The gag reflex is usually located in the last third of the mouth, i.e in the soft palate area, in people without neurological problems; the purpose of the gag reflex is to prevent unwanted and/or undesirable substances from being swallowed The reflex can be produced by either internal stimulation (e.g sickness) or external stimulation, for example, pressure or weight of different foods and substances in the mouth Some individuals with RS have an inappropriately strong gag reflex and may

feel ill as a result of stimulation in the area, in some cases, without the ability to cough The therapist or caregiver should be sensitive to such a problem and if vomiting movements are noticed, a wash with water (if the food is the apparent cause) can be helpful An opposite problem is the lack of the gag reflex, which implies that the bronchioles of the person with RS are defenseless A postural change

of the eater that will create a change in head position (forward or backward) will change movement of the food in the mouth, and may positively affect the pattern of movement of the head and shoulders, thus reducing the recurrence and severity of the gag reaction

• Spitting – In general, this is defined as a strong emission of food in a voluntary manner from the mouth (9) In fact in some cases an individual may be defined as a

"spitter" even if she did not voluntarily emit the food It is a well known fact that individuals with RS show respiratory irregularities (4) expressed in some cases as explosive exhalation A second reason for apparent deliberate spitting is a situation, where the person's mouth is full with food and there is a need to inhale Such a situation might be resolved through the exhalation of air with food particles thereby forcefully spraying food out of the mouth Additional reasons for the spitting of food can be either sensitivity in the mouth area or excessive drooling Our clinical experience has shown that in some cases deliberate spitting is behavioral as the individual with RS enjoys the attention she gets as a result of this behavior

• Intestinal problems have an effect on swallowing and on eating speed; for example, reflux and the slow emptying of the stomach will extend meal times Chronic reflux may cause ulcers or bleeding, and pain during mealtime, thereby affecting esophagus/respiratory timing, which will in turn have a jeopardizing effect on the individual’s health The slow emptying of stomach content if later accompanied by lying down will probably lead to reflux, and to the individual’s refusal to eat The slow emptying of the stomach caused by the hypoactive para-sympathetic system (4)

is commonly accompanied by constipation problems and/or fecal intestinal blockage (two well known manifestations in the digestive system of individuals with Rett syndrome)

Appropriate Environment during Mealtime

When trying to create the most appropriate environment during mealtime, one should consider the following factors:

• Physical environment – The individual’s head, back, and legs should be well supported, and if necessary, the sides of her trunk as well The head should be erect,

in midline, and slightly tilted forward The caregiver (feeder) should sit in front (if eye contact is desired) or to the side of the individual (if support to the jaw is required) If the individual is actively seeking eye contact with the caregiver yet is in need of support when eating, a mirror can be placed in front of her to enable both eye contact and proper support

Judy Wine, Yael Yoshei and Meir Lotan

8

• Sensory environment – If the individual with RS is sensitive to noises (most RS individuals have a sensitive auditory system) a loud environment can cause sensory overflow, thereby leading to muscle tone increase If the individual’s reaction is misunderstood by her caregivers the situation may be incorrectly interpreted as a behavioral problem If the individual with RS is restless during mealtimes, all types

of sensory stimulation which may be considered as possible disturbing elements (such as different scents, sounds, sights, and tactile stimulations) should be taken into consideration and modified until the individual is calm and is able to function in accordance with her maximal ability

• Communicative environment – Food is usually an extremely positive motivator for the individual with RS Thus mealtime is frequently the ideal time to develop and put into practice both manual and communicative skills For example, the caregiver could wait for the individual to signal her wish to eat or drink, and then respond accordingly by giving the desired item, thereby enhancing her control over the situation and supporting communicative interaction It is recommended to await the individual’s choice in regards to different food possibilities and then to serve her according to her choice Mealtimes is a good opportunity to improve the eater’s eye contact, vocal abilities, and hand usage in a communicative manner A possible recommendation is the preparation of tablemats that present the different utensils and food possibilities and might serve at the same time as mealtime communication boards

• Facilitating caregiver support– It has been recommended that each person in need of

an augmentative communication system have a Personal Communication Passport (10,11), in addition to all his/her other communication tools The purpose of the Personal Communication Passport is to present important and relevant information about the person in a clearly written and interesting way so that it is accessible to all those who are in contact with the person Within this Passport there can be a page on

"eating" which describes the seating and eating methods, the required utensils, and the handling to be provided by the feeder On this page the person’s personal preferences as well as dislikes in regards to food and drink should be specified Personal reactions during emergency situations can also be described The page should be prepared as a joint venture of the parents and habilitation\educational staff

in consultation with the RS individual It will serve to ensure that the same forms of assistance will be given to the individual with RS during mealtimes, even with changing caregivers and across settings

Of the above mentioned aspects of feeding two are of immense importance as they are potentially the source of many eating problems and dealing with them may in many cases prevent or alleviate these problems themselves These elements are the positioning and the caregiver's handling of the individual (special attention must be paid to them as they are potential sources of influence on oral-motor function)

Most individuals with RS present a thin and short stature Despite the fact that they are generally good eaters who enjoy their food, even though they spend an especially long time

at their meals, they generally do not put on weight relative to peers Some even suffer from

Failure To Thrive (FTT), a condition which requires enhancing caloric intake and in extreme cases even using tube feeding through a gastro-intestinal tube (G-Tube) (12) The severity of eating problems of individuals with RS usually escalates until mid-childhood age and thereafter stabilizes (13)

BMI (Body Mass Index) points to the relationship between the body height and weight of the individual (appropriate figures for the general population are 21-26 BMI) Individuals with RS have been found with average BMI values 17.5 (see table 1) This figure points to the fact in most cases (especially during childhood) the individual with RS is extremely thin relative to her height

Studies have shown that many individuals with Rett syndrome were in fact in a mild to moderate state of malnutrition (14) and that their calorie intake was 70% of normal caloric intake (15) Studies also showed that the stereotypical hand movements accounted for a high burning of calories enhancing the need for a high caloric intake (16) Since this imbalance is extended over a period of years, the individual with RS may reach malnutrition with its harmful effects Often, the duration of mealtime (due to swallowing problems) may bring on the decision of inserting a G-Tube (gastrostomy) The Australian RS research group reported that 12.5% of the individuals used nutritional aids such as G-Tubes (6)

Table 1 BMI values of individuals with RS (6)

Age groups BMI

0-7 Year(s) 15.4 7-12 Years 15.5 12-17 Years 16.6 17+ Years 21

It was found that an eating program via a G-Tube helps to put on weight and sustain a proper growth rate in individuals with Rett syndrome In addition, it has been found that an increase in caloric intake resulted in a calmer, more sociable disposition, as well as in the ability to become more physically active (12)

On one hand, the goal is having the individual with RS take in as many calories as possible through a balanced diet in order for her to grow properly, be calm, be physically active, and build up her immunity to diseases On the other hand, we are interested in sustaining the self feeding abilities of individuals with RS in order to enhance functional skill and prevent them from loosing those skills which they already possess Therefore a balanced feeding program should be created for each individual with RS Such a program must maintain daily exercises aimed at preserving functional eating abilities at the same time as it ensures sufficient caloric intake It should be emphasized that a normative eating program can

be implemented even with the insertion of a feeding tube, by using the G-tube to supplement caloric intake

Judy Wine, Yael Yoshei and Meir Lotan

10

Practical Aspects around Mealtime

The caregiver involvement begins after proper planning and decisions are made based on the results of the initial evaluation Factors to be considered include the physical condition of the individual (oral-motor abilities, oral structure, body movement patterns, level of assistance required at mealtime), behavioral and social abilities and environmental considerations (such as the availability of equipment, training and/or professional knowledge

of the caregiving team, etc)

According to these indicators we determine the correct therapeutic posture One may photograph the individual in the correct position during mealtime and provide proper instructions to caregivers A good tactic is to write these instructions out on a large poster, preferably with accompanying diagrams; this poster can then be hung on the wall both as a reminder to staff and family and as a teaching tool in the event that a new caregiver joins the team Correct eating posture should:

• Enable correct arrangement of the eating area (of the seating system, position of the individual relative to the table, and the position of the caregiver in relation to the individual)

• Sustain and improve midline orientation

• Provide support for the back/trunk and for the lower extremities

• Allow the individual to function at her highest possible level of ability

Individuals with RS generally love eating, and food can be used as a powerful motivational factor for them, with the intent of reaching additional therapeutic goals through the use of food As mentioned above, despite their great appetite, individuals with RS consume about 50 calories less than the average per day, which results in some instances in malnutrition (12) It is important to remember that the limited communicative abilities of individuals with RS generally prevent them from expressing their hunger Therefore if the individual with RS is thin, larger amounts of food and high caloric food supplements should

be suggested, despite the prolonged mealtime However mealtime should not exceed 30-40 minutes, and therefore it is sometimes necessary to add another meal per day It is reiterated that individuals with RS who were given sufficient caloric intake were found to be calmer, more aware of their surroundings, more active and they also displayed proper growth curves (12)

When an individual with RS has been noted to have reached an extremely low weight, despite constant feeding attempts, it is recommended that high-caloric food and liquid supplements be introduced, for example enriched liquid drinks such as Ensure or Pedishure® jello, ice cream, milkshake, whipped cream, olive oil, and more At times, a high-caloric diet may prevent the use of a G-tube

It is common for the majority of individuals with RS (also those who have not been evaluated as having swallowing problems) to aspirate occasionally (the intake of food into the respiratory system) This constitutes a dangerous situation, especially if concealed aspiration is performed (when unaccompanied by coughing) as the caregiver is thus unaware

of its existence and complications can occur, including pneumonia, a life-threatening illness

In cases of recurring lung pathology:

• It is important to undertake an evaluation by a specialist, in order to determine the occurrence and frequency of aspiration, (The foremost factor to be suspected and examined in individuals with RS presenting lung problems would be aspiration)

• A liquid thickener should be used (such as Thick and Easy, Thick-It® ThickenUp®,

or No More Lumps) to reduce the risk of aspiration

• An individual with RS who aspirates must be fed thickened pureed foods devoid of lumps

• The positioning of the head should be re-evaluated and backward tilting of the head should be prevented during mealtime (since this is the posture wherein the bronchioles are at their most open/vulnerable position)

• It is necessary to keep the body erect, with the head stable If the seating system does not support the required postural modifications, the hand of the caregiver not occupied with feeding can be wrapped around the shoulders in order to support the back of the neck from behind, as a tactic for achieving proper stability and positioning

• If there is a lack of control of the jaw movements, the jaw may be stabilized to enhance proper chewing and swallowing with the help of the caregiver's free hand It

is important to keep steady pressure via the support and to keep the head and neck at the right position Examples for the proper support can be found at http://www.dinf.ne jp/doc/english/global/david/dwe002/dwe00238.htm (17)

• It is important to try to place the food either on the tongue or between the upper and lower molars, as placing the food in these areas will enhance complex mouth action involving the teeth, tongue and jaws, for the purpose of encouraging chewing behavior

It is recommended to keep a food diary tracking the amount of calories the individual with RS consumes A food diary will also allow for the tracking of unusual events such as the making of strange sounds, epileptic attacks, manifestations of anxiety, or any other strange behavior which has occurred during or after the eating of a specific food, thus preventing needless future suffering

Previous studies have shown that individuals with RS do not have allergies on a level and frequency beyond those of the normative level (18) In spite of this knowledge, there are random reports from parents, which point to sensitivity of some individuals with RS to strawberries, wheat products, tomatoes, eggs, chocolate, corn, milk, nuts, and soy (19-21) When taking into accout the varsetile phenotypic expressions of individuals with RS, in combination with their communicative limitations than we (the caregiver/parents/therapists) must be attentive and resposible to take proper actions to improve their care, including on the gastronomical front

The individual with RS might be sensitive to a specific food item but not enough to elicit

an allergic reaction In other words, no allergic sensitivity would be found through allergy evaluation, and yet, she will react negatively to a certain food item We must identify these

Judy Wine, Yael Yoshei and Meir Lotan

Individuals with RS may present low oral muscle tone accompanied by sensory problems It is therefore advisable to provide oral stimulation prior to mealtime when needed,

in order to improve the oral functioning, thereby improving the quality of eating and shortening mealtime duration Instruction for oral treatment is given by an occupational therapist/speech language pathologist/physical therapist who is familiar with this type of intervention and should be personalized for the needs of every individual with RS (22, 23) The intervention includes a gentle, yet firm massage of the cheeks, chin, lips, and if possible, the inside of the mouth, using a gentle brush of the kind used to massage a baby's teeth It is important to remember that some individuals with RS may resist having the therapist's finger

or a brush inserted into their mouth; it is paramount that we respect the person's wishes and avoid forcing this intervention if the person feels uncomfortable

Exercise before and during mealtime can include slow and rhythmic moving of the joints, together with the application of pressure in the direction of the center of support Such procedures frequently reduce spasticity and give the individual the opportunity to achieve proper eating, as well as reduce her stereotypic hand movements As opposed to the above mentioned intervention, a hypotonic individual (usually a younger individual) with RS, will actually gain from vigorous movement before mealtime This procedure may include jumping

on a physiotherapy ball, dancing (either standing on the floor or in the therapist's arms), jumping while sitting on the therapist's knees (if age-appropriate), or rolling – the person with

RS is put in a prone position with the underarms supported with a small cylinder or folded up blanket; the therapist may use gentle backwards and forwards rolling movements which put pressure on the person's hands, arms and shoulder girdle

Immature tongue movement patterns prevent the individual with RS from performing coordinated movements which are required for the transfer of food from side to side inside the mouth, thus also preventing proper chewing (14) In order for the individual with RS to initiate proper tongue action, it is important to place the food at one side of the mouth between the molars, thereby enhancing execution of complex mouth, tongue, and lip movement

RS individuals fixate their trunks in order to prevent the unpleasant sensation which accompanies ataxic shuddering and to improve the slight control they have over their muscles The negative side effect to this gain of control is prevention of proper stabilization

of the back and head If this is the case, trunk and neck muscle strengthening exercises are warranted together with manual techniques for the upper torso and neck, aimed at releasing tight tissue and enhancing joint range of movement during treatments in between meals Since self-feeding and manual functioning are dependent on trunk control, the basic way

to achieve improved trunk stability as well as manual functioning is by activating the trunk muscles If better functioning can be attained while eating by the use of a specific exercise, it