p. 1-135 / Submitted by Santiago Fabio (fabio.ssantiago@hotmail.com) on 2013-04-25T17:45:54Z No. of bitstreams: 1 777777.pdf: 719650 bytes, checksum: 429e53d50a8449aa564695604b56d4c5 (MD5) / Approved for entry into archive by Maria Creuza Silva(mariakreuza@yahoo.com.br) on 2013-05-04T17:35:35Z (GMT) No. of bitstreams: 1 777777.pdf: 719650 bytes, checksum: 429e53d50a8449aa564695604b56d4c5 (MD5) / Made available in DSpace on 2013-05-04T17:35:35Z (GMT). No. of bitstreams: 1 777777.pdf: 719650 bytes, checksum: 429e53d50a8449aa564695604b56d4c5 (MD5) Previous issue date: 2009 / Introdução: Violência familiar contra a criança foi um tema recentemente inserido na literatura e tem se tornado relevante por ser um problema de saúde pública. As diversas manifestações da violência contra a criança podem resultar em disfunção familiar, o que pode ser um indicador de estresse psicossocial para a criança. A resposta da criança ao estresse vivenciado dentro da família pode afetar seu próprio nível de saúde através de alterações psiconeuroimunológicas importantes, afetando o desenvolvimento e agravamento de doenças, como a asma. Ainda são escassas as explicações sobre a plausibilidade biológica do fenômeno bem como de pesquisas que estimem sua magnitude. Explicações epidemiológicas e psiconeuroimunológicas são necessárias para ampliar o entendimento da relação entre violência familiar contra a criança e saúde infantil. Objetivos: Sumarizar o conhecimento existente na literatura epidemiológica sobre a violência familiar contra a criança, nas modalidades física e psicológica, e descrever as conseqüências para a saúde infantil, principalmente, para o desenvolvimento da asma e seu agravamento. Método: Foi realizada uma busca nas bases de dados eletrônicas Pubmed, Scopus e Scielo referente aos últimos 15 anos, utilizando como termos chaves “violência familiar contra a criança”, disfunção familiar, “psiconeuroimunologia e estresse”, “violência familiar e saúde infantil”. Informações foram agrupadas da seguinte forma: descrição dos tipos de violência familiar contra a criança, aspectos históricos, seus determinantes, magnitude, conseqüências para a saúde infantil, descrição de modelos teóricos explicativos para violência e asma, descrição das evidências psiconeuroimunológicas para esta relação. Resultados: Violência familiar contra criança é um fenômeno de alta magnitude no Brasil e está relacionado com diversos desfechos de saúde, dentre eles problemas nutricionais, lesões físicas, problemas emocionais e de comportamento e asma. Alguns fatores contribuem para sua ocorrência e manutenção, tais como fatores relacionados desde a família até a cultura. Estilo autoritário de disciplinamento é o mais associado a problemas de saúde infantil, acrescido de problemas de disfunção familiar, representados por problemas de saúde mental, deficiência física na família, depressão pós-parto, idade materna jovem, uso de álcool e drogas ilícitas pelos pais. Modelos multifatoriais são aqueles que mais tem ganhado espaço na literatura sobre asma e violência. Na explicação da relação entre fatores do contexto familiar e a asma pediátrica, sumarizou-se alguns mecanismos psiconeuroimunológicos, integrando sistema nervoso autônomo, eixo hipotálamo-pituitário-adrenal (HPA), sistema imunológico, estresse oxidativo e respostas geneticamente modificadas. Conclusões: São escassas evidências científicas sobre o efeito da violência familiar contra a criança sobre a asma, principalmente, na realidade brasileira. Este estudo contribui para identificar a alta magnitude deste fenômeno e ratificar a necessidade em continuar estudando as conseqüências para a saúde infantil, principalmente, para o desenvolvimento da asma. / Salvador

Childhood onset growth hormone deficiency (CO-GHD) may contribute to low bone mass and alterations to body composition. This thesis consists of a series of studies utilising dual-energy X-ray absorptiometry (DXA), peripheral quantitative computerized tomography (pQCT) and biochemical assessment of bone health and body composition of CO-GHD. In addition, metabolic profiles, glucose metabolism as well as quality of life have been studied in these subjects. Furthermore, an interventional study of weight bearing exercise (WBE) was performed to explore its role in influencing the bone health of children and adolescents with CO-GHD. Chapter 1, relevant literature reviews explore: bone structure, growth, development and strength; GH/IGF-1 system and its actions; CO-GHD and its impacts during childhood and transition; and WBE and its mechanism and impacts on bone health. Chapter 2 presents the rationale and specific aims of this thesis. Chapter 3, a retrospective multicentre review of management of young adults with CO-GHD in four paediatric centres in Scotland during transition. Medical records of 130 eligible CO-GHD adolescents (78 males), who attained final height between 2005-2013 were reviewed. Of the 130, 74/130(57%) had GH axis re-evaluation by stimulation tests /IGF-1 measurements. Of those, 61/74(82%) remained GHD with 51/74(69%) restarting adult rhGH. Predictors of persistent GHD included an organic hypothalamic-pituitary disorder and multiple pituitary hormone deficiencies (MPHD). Despite clinical guidelines, there was significant variation in the management of CO-GHD in young adulthood across Scotland. Chapter 4, a cross-sectional control study of bone DXA measurements in (n=21) subjects with CO-GHD treated with rhGH and had attained final height from 2005 to 2013 in a single tertiary paediatric centre compared to (n= 21) heights/age matched healthy controls. By applying different models of DXA adjustment, our analysis revealed lower TB-BMC for bone area in males with CO-GHD and lower LS-BMAD SDS in females with CO-GHD compared to matched controls. In addition, subjects with CO-GHD had lower LM for height and higher FM for height compared to controls, and this was more pronounced in males than females (p=0.04). The time of onset and aetiology of CO-GHD have a larger influence on accrual of bone mass in these patients. These findings indicate that adolescents with CO-GHD have a low bone mass, despite prior long term rhGH replacement therapy. In chapter 5, we investigated bone health of subjects with CO-GHD at time of initial evaluation and retesting at final height. A total of 25 children (first time assessment group) undergoing GH stimulation tests for investigation of short stature (naive GHD-15, normal-10), and 11adolescents with CO-GHD (retesting group) undergoing biochemical re-evaluation at final height after withdrawal of rhGH therapy (persistent GHD-7, GH-sufficient-4) were recruited from Royal Hospital for Children between 2012-2013. By using further bone health assessment methods in addition to DXA (including p.QCT, mechanography, bone profiles and biomarkers), the bone density and body composition did not differ when we compared GHD to matched height but normal GH at initial evaluation and retesting. However, naive GHD had lower muscle force as assessed by mechanography compared to the normal. In addition, bone resorption biomarker CTX was significantly higher in naive GHD vs. normal and that was significantly correlated to PTH levels in both first time assessment and retesting groups. Our results suggest that muscle force and serum PTH may be important determinants of bone health in subjects with CO-GHD. Chapter 6 investigates lipids, adipokines (leptin- adiponectin- resistin) and glucose homeostasis and their relationship with bone and body composition in children and adolescents with CO-GHD at times of initial evaluation and retesting at final height (same population as chapter 5). Lipid profiles, adipokines and glucose homeostasis were not different between those with GHD and those who had normal GH levels across the groups of first time assessment and retesting. In the retesting group, those who were older at the time of diagnosis of CO-GHD with a shorter duration of rhGH therapy were more likely to have higher cholesterol(r=0.9, p<0.001), leptin (r=0.8, p<0.001), and lower osteoclacin (r=-0.7, p=0.01) at final height. Leptin levels correlated positively with osteocalcin at diagnosis (r=0.51, p=0.01) but inversely at retesting (r=-0.91, p<0.01). The conclusion was that the timing and duration of childhood rhGH therapy might influence adiposity parameters and bone metabolism in subjects with CO-GHD. In chapter 7 the study participants of chapter 5 were asked to complete either Short Form-36 (SF-36) or Adult Growth Hormone Deficiency Assessment (AGHDA) quality of life (QoL) questionnaires at the time of assessment of their GH axis. Our analysis showed that the overall QoL was not altered in children with naive GHD with a total score of SF-36 [93 (77, 96) naive GHD vs. 90 (84, 93) normal, P=0.56] (higher scores reflect better QoL). However, naive GHD had less energy and vitality scores compared with normal (75 (65, 100) vs. 95 (65,100) respectively, p=0.04), when the normal scored lower in the subscale of emotional well-being compared to those with naive GHD (78 (55, 84) vs. 90 (68, 96) respectively, p<0.001). In the retesting group, those with persistent GHD scored better in the AGHDA than GH sufficient (6 points (2, 8) vs. 9 points (7, 17) respectively, though not significant (p= 0.10) (higher scores reflect poorer QoL). Unexpectedly, subscale analysis showed that GH-sufficient subjects significantly lacked energy and complained of tiredness compared to those who were confirmed to have persistent GHD (5 points (3, 6) vs. 1 point (0, 1) respectively, p= 0.03). Further studies to validate QoL specific instruments in this population are needed with greater insight to elucidate factors that modify the relationship between GH status and QoL in children and adolescents. Chapter 8 was a prospective intervention, randomised controlled study of 14 subjects among the first time assessment group (GHD-10, normal-4) and five subjects with CO-GHD among retesting group (persistent GHD-4, GH-sufficent-1). Subjects were randomised into either an exercise intervention group (EX) (25 jumps off 25 cm platform step/three days/week for six months) or a control, in addition to rhGH being prescribed. The results of this study were limited by the small sample size and poor compliance. Therefore, there were insufficient data to recommend the use of weight bearing exercise in the absence of rhGH in children and adolescents with CO-GHD. Further studies with adequate sample size that can more rigorously exam the optimal exercise interventions are needed. Chapter 9 discusses the main findings of each chapter in this thesis and outlines potential limitations of the thesis methodology, and some important and interesting areas for future research in children and adolescents with CO-GHD.

Childhood obesity is becoming increasingly prevalent in the UK and globally. Over the last 10 years, there has been a rise in prevalence of risk factors for health and a decline in physical activity. Obesity is major health risk factor for a number of other chronic diseases, some of which are prevalent in children. Regular physical activity is associated with reduced adiposity, healthier metabolic status lower risk factors of diabetes and CHD and enhanced bone mineral accrual and protection against osteoporosis. Recent literature suggests that children may not be meeting the recommended daily guideline for physical activity of 60 min per day (Riddoch et al., 2007), while others suggest this guideline is insufficient to protect against risk factors in children. Assessment of programmes promoting physical activity, with robust health related outcome measures are therefore warranted Initially, sixty-one children were recruited for a 9-week exploratory trial. The trial assessed the effect of a structured high impact exercise (STEX) and a lifestyle intervention (PASS). Changes in dual-energy X-ray absorptiometry (DXA) derived body composition and bone mineral were compared to age matched controls (CaNT). The STEX intervention resulted in an additional mean increase in total body BMC of 63.3 g (P= 0.019) and an additional increase of 0.011 g.cm-2 (P= 0.018) for BMD over changes observed in controls. Neither intervention stimulated significant increases in BMC or BMD at the femoral neck or lumbar spine (P > 0.05) compared with the controls. No significant changes were found in fat mass index (P > 0.05), lean mass index (P > 0.05) or percent body fat (p = 0.09) in any groups. Structured impact exercise promoted significant and clinically relevant increases in bone measures, without significant changes to body composition. The exploratory finding therefore supported the need for a larger, definitive randomised trial to confirm the results. Following this, a large cohort of Liverpool school children (n=152) was recruited for cross-sectional analysis. Measures included 3-day physical activity using a uniaxial accelerometer, maturity status, cardia-respiratory fitness and skin-fold measurements in addition to body composition, bone mineral content and density. Analysis of variance was used to uncover any sex differences, partial correlation analysis was performed to investigate relationships between health-related variables and physical activity, with maturity offset as the controlling variable. Regression analysis was performed to find the best predictor of BMC and BMD (primary outcome variable), using LM, FM, Mass, and maturity offset as predictor variables. The results showed that children participated in the recommended amount of activity. However, body fat measures indicated that the children fell between the 85th-95% percentile for overweight. Further more BMD status of both sexes also fell below reference values. The dose-response relationship was highlighted as children who participated in < 60 mln.oay" recommendation were less physically fit (P=0.001) and fatter (P < 0.001) than children achieving this guideline. Children participating in over >90 min.day" had significantly lower percent body fat (P=0.005) and fat mass (P=0.04) than children who participated in < 60 min.day" and significantly lower percent body fat (P=0.02)than all children who participated in < 90 min.day". The findings highlight the importance of the high volume ( > 90 rnin.day") and high-intensity physical activity (over 10 min.day") as a precursor to low body fat and high bone mineral in children. The one hundred and fifty-two children from the baseline cohort were allocated to 1 of 4 groups over a 12 month period. Three groups received a different physical activity intervention; a high-intensity programme ('HIPA'), a skill development programme ('FMS') or a lifestyle-based programme ('PASS'). The 'HIPA' and 'FMS' groups participated in an after-school club (2x60 min.week"), the 'PASS' group attended weekly classroom sessions (1 x week) delivered by a lifestyle coach during the school day. The control group ('CaNT') received health information. All baseline measures were repeated at 9 and 12 months (during and after) intervention. All interventions minimised fat mass accumulation, with the 'HIPA' intervention being most effective (P=0.03), implying that the high-intensity nature of the activity sessions was more effective at minimising body fat accumulation. The greatest magnitude of change in femoral neck BMC (P < 0.001) and BMD (P < 0.001) and cardiorespiratory fitness (P=0.023) was also reported by the 'HIPA' group which is likely to be attributable to the intensity of the weight-bearing activities included in the 'HIPA' programme. The findings suggested that the 'HIPA' intervention was most beneficial for health outcomes, but all interventions had significant effect on increasing time spent in physical activity. The studies within this thesis have provided a unique insight in to the current bone health status, body composition and physical activity of 9-11 year old Liverpool school children. Further data were also generated on the effect of different physical activity interventions on bone health, body composition and physical activity. The findings from this thesis conclude that a proportion of 9- 11 year old children were overweight despite meeting physical activity recommendations of 60 min.day". The high-intensity physical activity intervention had the most beneficial impact on bone health, body composition and cardio-respiratory fitness when compared to the controls. The quantity of physical activity and the time spent in high intensity activity warrants further investigation to quantify an optimal dose.

Low childhood physical activity levels, and high paediatric overweight and obesity levels, carry a considerable burden to health including cardiometabolic disease, low fitness, and reduced psychosocial well-being. Numerous school- based physical activity interventions have been conducted with varied success. This thesis therefore aimed to develop and investigate the effectiveness of the Children's Health, Activity and Nutrition: Get Educated! (CHANGE!) project, which was a school-based curriculum intervention to promote healthy lifestyles using an educational focus on physical activity and healthy eating. The purpose of the formative study (Study 1) was to elicit subjective views of children, their parents, and teachers about physical activity to inform the design of the CHANGE! intervention programme. Analyses revealed that families have a powerful and important role in promoting health-enhancing behaviours. Involvement of parents and the whole family is a strategy that could be significant to ~ncrease children's physical activity levels. There is large variation in the cut-points used to define moderate physical activity (MPA), vigorous physical activity (VPA) and sedentary time, which impacts on accurate estimation of physical activity levels. The purpose of Study 2 was to test a field-based protocol using intermittent activities representative of children's physical activity behaviours, to generate behaviourally valid, population-specific cut-points for sedentary behaviour, MPA and VPA. These cut-points were subsequently applied to CHANGE! to investigate changes in physical activity (Study 3). The CHANGE! intervention resulted in positive changes to body size and VPA outcomes after follow-up. The effects were strongest among those sociodemographic groups at greatest risk of poor health status. Further work is required to test the sustained effectiveness of this approach in the medium and long-term. Further, the development of an inexpensive and replicable field- based protocol to generate behaviourally valid and population-specific accelerometer cut-points may improve classification of physical activity levels in children, which could enhance subsequent intervention and observational studies.

A mother's practice of feeding the family is viewed as risk behaviour in published health literature where the dominant research interest lies in its pathogenic potential in the aetiology of Child Obesity. Mothers’ 'participative knowledge' of their practice, which is their lived experience as known and given meaning by them, is absent from this literature. The aim of the thesis is to address this gap in knowledge and reflect upon its significance for health promotion. The exploration of mothers’ family feeding practices was conducted by means of a Co-operative Inquiry (Heron, 1996) which I adapted as a community participatory research study with a core group of 13 volunteer mothers. This community of mothers from a former mining community in the NW of England became in time my co-researchers in the investigation of what feeding the family entailed and meant for them. There are two phases of the inquiry. In Phase 1, methods were developed to enable mothers to collect data and to engage in reflection and dialogue so as to describe and explain their practice. In Phase 2, the Inquiry process was directed towards empowering mothers to engage in transformative experiential learning. Findings at the end of Phase 1 highlighted that the mothers’ routine practices often exposed their children to risk factors linked to childhood obesity. It also identified that their reality and lived experience systematically exposed mothers to social injustice that had the potential to undermine their health. At the end of Phase 2 however, new insights into the potential meaning of their practice, led the mothers to make changes in family feeding; and to transform an alienating environment into an empowering experience of true community. The author reflects and discusses the inquiry and its findings by drawing upon theories of knowledge, practice and health; and empirical evidence of risk factors in health inequalities. This study extends the body of knowledge about family feeding with insights into the participative reality of mothers’ practice. The Author recommends health research should embrace new theoretical frameworks for inquiry with mothers to develop a more socially just knowledge of their practice that can empower both mothers and community.

Smoking is the greatest avoidable cause of premature death in Britain today, particularly among the poorest people in society. Most smokers take up the habit during childhood, and the age at which children begin to smoke is falling over time. Although patterns of regular smoking are often established during the teenage years, rates of experimentation with cigarettes peak during preadolescence. Despite this, in the UK there has been little longitudinal research into the process of smoking uptake during preadolescence, and this research fills that significant gap. The Liverpool Longitudinal Study of Smoking (LLSS) is a unique longitudinal study that has tracked a cohort of approximately 250 children during their early years at primary school. This thesis continues and develops the LLSS by exploring the cohort's experiences of smoking during preadolescence in order to understand how children's early smoking careers develop between the ages of 9 and 11. Baseline quantitative and qualitative data collected at age 9 (in 1999) were compared with data collected at age 10 (in 2000) and at age 11 (in 2001) in order to identify key elements of change. These data were analysed longitudinally using a multiple case study approach that identified the individual trajectories of five children during preadolescence. A cross-case comparative method was then used to identify and explain the relationship between views, intentions and behaviour, and how these were shaped by the social context in which the children lived. The themes that emerged from the case studies were then explored and developed in the context of data generated by the whole cohort. Statistical analysis revealed that smoking by best friends, fathers and brothers, together with knowing someone with a smoking-related disease, at age 9 predicted smoking by age 11. The discourses that the children used to talk about smoking uptake emphasised the role of parents at age 9, but by age 11 the cohort suggested that friends were the key influence on smoking onset. Each year, anxiety about being bullied into smoking by older children also emerged as a key concern for this age group. In addition, the analysis revealed that preadolescents appropriate adult discourses around the use of smoking as a coping strategy. The use of these discourses was patterned by socioeconomic status. Children who lived in deprived areas suggested that both adults and children might smoke to counter stress and to relieve boredom. However, some of the girls living in relatively affluent areas perceived that adults smoke to control their weight. The study also considered the implications of these discourses for differential rates of smoking uptake at primary school. A key finding of this phase of the LLSS is that preadolescents construct smoking as an adult behaviour, and therefore some children smoke in order to negotiate status in anticipation of the transition to adolescence and as a strategy of resistance to the exercise of adult power. The reduction of rates of smoking among children and young people is central to the government's tobacco control strategy, and this research has significant implications for the development of both interventions and policy.

No description available.

The number of babies that require care in the Neonatal Intensive Care Unit continues to rise in the UK and parents who have a baby who is born sick or prematurely find themselves adapting to this stressful and often unexpected event whilst also trying to establish their role as a new parent. With no current large British studies, this study explores the experiences of both mothers and fathers in the NICU in relation to adaptation and parental role development and how their experience changes over time. In total 76 parents were interviewed using semi structured interviews 7-10 days following the birth to capture their early experiences of the NICU and then again beyond 28 days to explore any changes in their views and feelings over time. Interviews were tape recorded, transcribed verbatim into the written word and imported into WINMAX PRO. Data analysis revealed nine major sections. These are preparation prior to birth, labour and delivery, first sight of infant, support from the partner, family, friends and other parents, support from and communication with staff, adaptation to the NICU experience, development of the parental role, changes with time and the experiences of fathers. Findings show differences in what mothers and fathers find stressful about their NICU experience, how they adapt to the birth of a sick or premature infant and in their development of the parental role. With the passage of time the events surrounding the birth became less significant as parents start to look to the future. Their role as a parent continued to develop with feelings that their baby needed and recognised them, but many parents felt that they were unable to influence what happened to their baby in the NICU. Recommendations are made for further research and for changes to NICU practice.

Background: Reactive attachment disorder (RAD) has been described as one of the least researched and most poorly understood psychiatric disorders (Chaffin et al., 2006). Despite this, given what is known about maltreatment and attachment, it is likely that RAD has profound consequences for child development. Very little is known about the prevalence and stability of RAD symptoms over time. Until recently it has been difficult to investigate the presence of RAD due to limited measures for informing a diagnosis. However this study utilised a new observational tool Method: A cross sectional study design with a one-year follow-up explored RAD symptoms in maltreated infants in Scotland (n=55, age range= 16-62 months) and associated mental health and cognitive functioning. The study utilised the Rating of Inhibited Attachment Behavior Scale (Corval, et al., unpublished 2014) that has recently been developed by experts in the field along side The Disturbances of Attachment Interview (Smyke & Zeanah, 1999). Children were recruited as part of the BeST trial, whereby all infants who came in to the care of the local authority in Glasgow due to child protection concerns were invited to participate. The study sample was representative of the larger pool of data in terms of age, gender, mental health and cognitive functioning. Results: The sample was found to be representative of the population of maltreated children from which it was derived. Prevalence of RAD was found to be 7.3% (n=3, 95% CI [0.43 – 14.17]) at T1, when children are first placed in to foster care. At T2, following one year in improved care conditions, 4.3% (n=2, 95% CI [below 0 – 10.16]) met a borderline RAD diagnosis. Levels of observed RAD symptoms decreased significantly at T2 in comparison to T1 but carer reported symptoms of RAD did not. Children whose RAD symptoms did not improve were found to be significantly older and showed less prosocial behaviour. RAD was associated with some mental health and cognitive difficulties. Lower Verbal IQ and unexpectedly, prosocial behaviour were found to predict RAD symptoms. Conclusions: The preliminary findings have added to the developing understanding of RAD symptoms and associated difficulties however further exploration of RAD in larger samples would be invaluable.

This thesis aimed to examine service contact among children and young people with mental health problems, and has three complementary parts. The first is a secondary analysis of data from the British Child and Adolescent Mental Health Survey (BCAMHS) 2004, which explored mental health related service contact in relation to psychopathology over three years. The second and third parts focussed on young people with ADHD in transition from child services, which is a particularly challenging time. This involved a qualitative interview study of young peoples’ experiences, and an analysis of primary care prescribing of ADHD medication over the transition period using a cohort from the Clinical Practice Research Datalink from 2005-2013. Less than a third of children with a psychiatric disorder in BCAMHS reported contact with child mental health services. Instead, teachers were the most frequently used service, with two-thirds reporting mental health related contact. Interviews with young people with ADHD highlighted themes including concerns around medication management post transition and need for information. The prescribing analysis found that the majority of adolescents on ADHD medication at age 16 stopped during the transition period. This continuing disparity between estimates of symptom persistence and medication persistence suggests that many may be stopping medication from which they could still benefit; as various barriers have been identified to ongoing prescribing. In summary, the findings of these three linked studies suggest common themes in terms of unmet needs and gaps between policy and practice in mental health services for children and young people. One of the chief implications is the need for oversight and policy levers to ensure the implementation of best practice, accompanied by complementary efforts to better understand and overcome other barriers to providing optimal care, including research into knowledge and attitudes of different groups and the provision of targeted training.