How (not) to interview children : interviews with young children in sexual abuse investigations in Finland

The present thesis had two main objectives: The first was to assess how child sexual abuse (CSA) interviews in Finland are conducted through analysing the interviewing techniques applied and the language used by the interviewers, as well as to suggest ways to improve interviews if they were found to have deficiencies. The second main aim was to contribute to the growing research corpus concerning CSA interviews, in particular, by addressing how interviewers follow up information provided by the child, by analysing whether child health care professionals would use childadapted language, and by studying the kind of modifications in the verbal behaviour of interviewers and children that were associated with a) repeated interviews, b) a support person’s presence at the interview, and c) the use of anatomically detailed dolls. Two complementary samples of CSA interviews were analysed. The first one was composed of child interviews with 3-12-year-old children (N = 27) that had been considered problematic by lawyers or other involved professionals (Studies I and IV). The second sample consisted of unselected interviews (N = 43) with children aged 3 to 8 years conducted in a number of hospitals in different parts of the country (Studies II and III). Study I: The verbal interaction between interviewer and child was analysed in a sample of interviews that had been considered to be problematic by involved professionals. Results showed that interviewers used inappropriate questioning techniques, relying on option-posing, specific suggestive and unspecific suggestive questions to a significant extent, these comprising around 50% of all interviewer utterances. The proportion of invitations, which the research community recommends interviewers to rely on, was strikingly low. Invitations and directive utterances were associated with an increase in informative responses by the child in terms of response type, number of new details reported, as well as length of response. The opposite was true for option-posing and suggestive utterances. Longer questions by the interviewer (in number of words) often rendered no reply from the child, whereas shorter questions were followed by descriptive answers. Even after the child had provided an informative answer, interviewers failed to follow up the information in an adequate way and instead continued to rely on focused and leading questions. Study II: Due to the possible bias of the sample analysed in Study I, the most important analyses were rerun with the unselected sample and reported separately. Results were quite similar between the two studies, indicating that the problems observed in Study I, with interviewers relying on option-posing and suggestive questions to a significant extent, are likely to be general and not specific for those interviews. Even if suggestive questions were slightly less and invitations slightly more common in this sample than in the previous study, almost half of the interviewer questions were still optionposing or suggestive, and also in this sample, interviewers failed to follow up information by the child in a facilitating manner. Differentiating between judicial and contextual details showed that while facilitators, invitations, and directive utterances elicited more contextual than judicial details, the opposite was true for specific suggestive utterances. These results might be explained by the reluctance of children to describe sexual details related to the abuse events. Alternatively, they may also be due to children describing incorrect sexual details as a result of suggestive interviewing techniques. Study III: This study examined features of the language used by the interviewers. Interviewer utterances included multiple questions, long statements, complicated grammar and concepts, as well as unclear references to persons and situations. More than a fifth of the interviewer utterances were coded as belonging to at least one of these categories. The results suggest that even professionals who are experienced in interacting with children may have difficulties in using a child-sensitive language, adding to the pool of studies showing similar problems to occur in legal hearings with children conducted by lawyers. As children rarely comment on, or even recognise, their lack of comprehension, the use of a language that is too complex can have detrimental consequences for the outcomes of investigative interviews. Interviewers used different approaches to introduce the topic of abuse. While 15% of the children spontaneously addressed the topic of abuse, probably indicating that they felt confident with the interviewer and the situation, in almost 50% of the cases, the interviewer introduced the topic of abuse in a way that can be considered leading. Interviews were characterised by a lack of structure, apparent in frequent rapid switches of topic by the interviewer. This manner was associated with a decrease in the number of new details provided by the children. Study IV: This study analysed possible changes in the interview dynamics associated with repeated interviewing, the presence of a support person (related to the child), and the use of anatomically detailed (AD) dolls. Repeated interviewing, in combination with suggestive questions, has previously been found to seriously contaminate children’s accounts. In the present material, interviewers used significantly more suggestive utterances in the repeated condition, thus endangering the reliability of the children’s reports. Few studies have investigated the effects of a support person’s presence at the interview. The results of the present study showed that interviewers talked more and children provided less information when a support person was present. Supporting some earlier findings regarding the use of AD dolls, the present results showed that using AD dolls was associated with longer interviewer utterances and shorter, less responsive, and less detailed child responses. Interviewers used up to five times more unspecific suggestive utterances when dolls were used, for instance through repeatedly asking the child to show “what really happened” with the dolls. Conclusion: The results indicate that CSA interviews in Finland are not conducted in a manner that follows best practice as defined by the research community and as stated in a number of guidelines. When comparing these questioning strategies with the recommendations, which have been predominant in the field for more than ten years now, it can be concluded that the interviews analysed were conducted in a manner that undermines the possibility to elicit an uncontaminated and accurate narrative from the children. A particularly worrying finding was the fact that interviewers did not follow up relevant information by the children in an adequate way. A number of clinical implications can be drawn from the results, particularly concerning the need for improvement in the quality of CSA interviews. There is convincing research regarding how to improve CSA interviews, notably through training forensic child interviewers to use a structured interviewing protocol, and providing them with continuous supervision and feedback. Allocating appropriate resources to improve the quality of forensic child interviews is a matter of protecting the rights of all persons involved in CSA investigations, in particular those of the children.

Cumulative Costs of Caries Prevention and Treatment in Children - with Special Reference to Work Division and Cohort Effect

Lapsen karieshoidon kustannuskertymän muutokset ja karieshoidon toimintakäytäntöjen yhteys kustannuksiin Tutkimuksen tavoitteena oli mitata terveyskeskuksessa hoidettavien lasten karieshoidon kumulatiivisia kustannuksia ja verrata niitä kahden erilaisen toimintatavan välillä. Lisäksi tarkasteltiin lasten hampaiden terveyttä. Tutkimus tehtiin julkisen palvelutuottajan näkökulmasta. Tutkimusaineisto kerättiin Kemin ja Tornion terveyskeskusten suun terveydenhuollon potilaskertomuksista. Kemin kohortit 1980, 1983 ja 1986 (n = 600) ja Tornion kohortit 1980 ja 1992 (n = 400) edustivat perinteistä ja Kemin kohortit 1989, 1992 ja 1995 (n = 600) uutta toimintatapaa työnjaon ja ehkäisyn ajoituksen suhteen. Kohortteja ja kaupunkeja verrattiin hampaiden terveyden (dmft/DMFT = 0 ja dmft ja DMFT keskiarvot 5 ja 12 vuoden iässä) ja voimavarojen käytön suhteen. Panoskäyttö johdettiin käyntimäärien avulla laskennallisen työajan kautta. Kustannuskertymät muodostettiin käyttämällä henkilöstömenoista laskettuja suorittajakohtaisia yksikkökustannuksia. Panoskäytön ja yksikkökustannusten kautta muodostettiin kustannuskertymät. Kustannusten ja terveysvaikutusten suhteita arvioitiin kustannus-vaikuttavuusanalyysissä. Suuhygienistien työpanosta hyödyntävällä varhaisen ehkäisyn toimintamallilla saavutettiin vähäisemmin kustannuksin alle kouluiässä parempi ja kouluiässä yhtä hyvä hammasterveys kuin perinteisellä, enemmän hammaslääkärien työpanokseen perustuvalla tavalla. Karieksen hoitoon liittyvien käyntien määrä oli nuorimmissa syntymävuosikohorteissa pienempi kuin vanhimmissa kohorteissa. Käynnit hammaslääkärissä vähenivät eniten. Toimintatavalla oli merkittävä vaikutus lapsen karieshoidon kokonaiskustannuksiin. Herkkyysanalyysin mukaan karieshoidon kustannukset olivat työnjakoa hyödyntämällä kolmanneksen pienemmät, kuin jos hoidon suorittajana olisi ollut ainoastaan hammaslääkäri-hoitaja työpari. Lasten karieshoidon kustannusvaikuttavuus kohentui molemmissa terveyskeskuksissa nuoremmissa kohorteissa vanhempiin verrattuna. Suun terveydenhuollon potilaskertomuksia olisi hyödynnettävä toiminnan kehittämisessä. Varhaisen ehkäisyn avulla voitaisiin kaikkien suun terveydenhuollon ammattihenkilöiden työpanos kohdentaa kustannustehokkaasti.

Natural history of celiac disease-associated antibodies and progression to overt disease in children at increased genetic risk

Background: Celiac disease is a lifelong, gluten-sensitive, autoimmune-mediated chronic enteropathy, tightly associated with risk alleles at the HLA class II genes. Aims: This study was carried out as a part of the population-based Type 1 Diabetes Prediction and Prevention (DIPP) Project. The first aim was to study the natural history of celiac disease-associated antibodies before the diagnosis of celiac disease was made. The second aim was to describe when and in which order celiac disease-associated and type 1 diabetes-associated antibodies appeared in children with genetic risk for both diseases. Subjects and Methods: Antibodies against tissue transglutaminase (TGA) and other celiac disease-associated antibodies were measured in serum samples collected at 3- to 12-month intervals of children at genetic risk for celiac disease who participated in the DIPP project. Celiac disease was confirmed by duodenal biopsy. Type 1 diabetes-associated antibodies were measured in all samples that had been collected. Overt disease was diagnosed according to World Health Organization criteria. Follow-up continued until a diagnosis of type 1 diabetes or until the end of a defined follow-up period. Results: TGA appeared in children at genetic risk for celiac disease only after the first year of life, but anti-gliadin antibodies often emerged significantly earlier, at age 6 months. The data show that spontaneous disappearance of celiac disease-associated antibodies, transient or persisting, is a common phenomenon, at least in prepubertal children. In children with genetic susceptibility to type 1 diabetes and celiac disease, celiac disease-associated antibodies usually develop earlier than the type 1 diabetes-associated antibodies. Conclusions: The transient nature of celiac disease-associated antibodies emphasizes the significance of establishing seropositivity repeatedly in screening detected celiac disease before gastroscopy and duodenal biopsy are considered and emphasized the importance of duodenal biopsy for diagnosing celiac disease.

Carbohydrate intake in children - associations with dietary intakes, growth, serum lipids,and dental health. The STRIP Project

This study is part of the STRIP study, which is a long-term, randomized controlled trial, designed to decrease the exposure of children in the intervention group (n=540) to known risk factors of atherosclerosis. The main focus of the intervention was the quality of dietary fat. The control group (n=522) did not receive any individualized counselling. Food consumption was evaluated with food records, and blood samples were drawn and growth was measured regularly for all participating children from 13 months to 9 years. A subsample of 66 children participated in a dental health survey. The number of studies on children’s carbohydrate intake, especially fibre intake, is insufficient. The current international recommendations for fibre intake in children are based on average assumptions and data extrapolated from intakes in adults and intake recommendations for adults. Finnish nutrition recommendations lack strict recommendations for dietary fibre in children. Due to fibre’s high bulk volume, excessive dietary fibre is considered to decrease energy density and hence it may have an adverse effect on growth. If fats are reduced from the diet, the low-fat diet may become high in sucrose. Therefore, especially in the STRIP study, it is important to determine the use of fibre and sucrose in children and possible associations with growth and nutrition as well as dental health. The results of the present study indicate that a high fibre intake does not displace energy or disturb growth in children and that children with high fibre intake have better quality of diet than those with low fibre intake. Additionally, dietary fibre intake associated inversely with serum cholesterol concentration. Other carbohydrates also affected serum lipid levels as well, since total carbohydrates, sucrose, and fructose increased serum triglyceride concentration. Total carbohydrate intake reduced HDL cholesterol concentration only in children with apoE3 or apoE4 phenotype. Over the period from the 1970s to the 1990s the dental health of children in Finland has substantially improved despite an increase in sucrose intake. The improvement was thought to be due to improved dental hygiene and the use of fluorine. However, during the past twenty years improvement in dental health has stopped. The present study showed that high long-term sugar intake increases risk of caries in children. High intake of sugar had also negative effects on the diet of children, because it worsens dietary quality by displacing essential nutrients. Furthermore, the quality of dietary fat was worse in children with high sucrose intake. In this study the children’s high sucrose intake was not associated with overweight, but interestingly, it associated inversely with growth.

The effectiveness of short-term literacy skills intervention on children at risk of reading and writing difficulties in Tanzania : a study of grade one children with dynamic assessment approach

The aim of the study was to create and evaluate an intervention programme for Tanzanian children from a low-income area who are at risk of reading and writing difficulties. The learning difficulties, including reading and writing difficulties, are likely to be behind many of the common school problems in Tanzania, but they are not well understood, and research is needed. The design of the study included an identification and intervention phase with follow-up. A group based dynamic assessment approach was used in identifying children at risk of difficulties in reading and writing. The same approach was used in the intervention. The study was a randomized experiment with one experimental and two control groups. For the experimental and the control groups, a total of 96 (46 girls and 50 boys) children from grade one were screened out of 301 children from two schools in a low income urban area of Dar-es-Salaam. One third of the children, the experimental group, participated in an intensive training programme in literacy skills for five weeks, six hours per week, aimed at promoting reading and writing ability, while the children in the control groups had a mathematics and art programme. Follow-up was performed five months after the intervention. The intervention programme and the tests were based on the Zambian BASAT (Basic Skill Assessment Tool, Ketonen & Mulenga, 2003), but the content was drawn from the Kiswahili school curriculum in Tanzania. The main components of the training and testing programme were the same, only differing in content. The training process was different from traditional training in Tanzanian schools in that principles of teaching and training in dynamic assessment were followed. Feedback was the cornerstone of the training and the focus was on supporting the children in exploring knowledge and strategies in performing the tasks. The experimental group improved significantly more (p = .000) than the control groups during the intervention from pre-test to follow-up (repeated measures ANOVA). No differences between the control groups were noticed. The effect was significant on all the measures: phonological awareness, reading skills, writing skills and overall literacy skills. A transfer effect on school marks in Kiswahili and English was found. Following a discussion of the results, suggestions for further research and adaptation of the programme are presented.

Objective Evaluation of Nasal Dimensions in Children with Acoustic Rhinometry

Aims: This study was carried out to investigate the usefulness of acoustic rhinometry in the evaluation of intranasal dimensions in children. The aim was to define reference values for school children. In addition, the role of the VAS scale in the subjective evaluation of nasal obstruction in children was studied. Materials and methods: Measurements were done with Acoustic Rhinometry A1. The values of special interest were the minimal cross-sectional area (MCA) and the anterior volume of the nose (VOL). The data for reference values included 124 voluntary school children with no permanent nasal symptoms, aged between 7 and 14 years. Data were collected at baseline and after decongestion of the nose; the VAS scale was filled in before measurements. The subjects in the follow-up study (n=74, age between 1 and 12 years) were receiving intranasal spray of insulin or placebo. The nasal symptoms were recorded and acoustic rhinometry was measured at each control visit. Results: In school children, the mean total MCA was 0.752 cm2 (SD 0.165), and the mean total VOL was 4.00 cm3 (SD 0.63) at baseline. After decongestion, a significant increase in the mean TMCA and in the mean TVOL was found. A correlation was found between TMCA and age, and between TVOL and height of a child. There was no difference between boys and girls. A correlation was found between unilateral acoustic values and VAS at baseline, but not after decongestion. No difference wasfound in acoustic values or symptoms between the insulin and placebo group in the follow-up study of two years. Conclusions: Acoustic rhinometry is a suitable objective method to examine intranasal dimensions in children. It is easy to perform and well tolerated. Reference values for children between 7 and 14 years were established.

Burden of Influenza in Children

Background: Most children with influenza are treated as outpatients but, especially among young children, influenza-attributable illnesses often result in hospitalization. However, relatively scarce data exist on the clinical picture and the full disease burden of pediatric influenza. Prompt diagnosis of influenza could enable the institution of antiviral therapy and adequate cohorting of patients. Data are needed to help clinicians correctly suspect influenza at the time of hospital admission. Aims and methods: We conducted a prospective 2-year cohort study of respiratory infections in children aged ≤13 years to determine the incidence of influenza in outpatient children and to assess the clinical presentation of influenza in various age groups seen in primary care. We also determined the rates of different complications attributable to influenza and the absenteeism of the children and their parents due to the child’s influenza infection. We then conducted a further 16-year retrospective study of children ≤16 years of age, hospitalized with virologically confirmed influenza. We estimated the population-based rates of hospitalizations and determined the primary admission diagnoses of the hospitalized children in different age groups. Results: The average annual rate of influenza was highest (179 / 1000) among children <3 years old. In this age group, acute otitis media was diagnosed as a complication of influenza in 40% of children. High fever was the most prominent sign of influenza, and 20% of children <3 years of age had a fever ≥40oC. Most children had rhinitis already during the first days of the illness. The average annual incidence of influenzarelated hospitalization was highest (276 / 100,000) among infants <6 months of age, of whom 52% were primarily admitted due to sepsis-like illnesses. Respiratory symptoms accounted for 38% of the hospitalizations. Conclusions: Influenza causes a substantial burden of illness on outpatient children and their families. The clinical presentation of influenza is most severe in children <3 years of age. The high incidence of influenza-associated hospitalizations among infants aged <6 months calls for more effective ways to prevent influenza in this age group. The clinical manifestations of influenza vary widely in different age groups of children at the time of hospital admission. Awareness of this phenomenon is important for the early recognition of the illness and the potential initiation of effective antiviral treatment of these patients.

Violations of children's rights in armed conflicts : international treaties, observations by peacekeepers and crisis management training in Finland

Ninety-nine Finnish peacekeepers, who had been serving in 15 different operations around the world, participated in the study (8 women, 27-52 years old, m = 37.4, SD = 8.9; and 91 men, 21-69 years old, m = 41.4, SD = 10.2). Three military crisis management trainers from the Finnish Defence Forces International Centre also participated in the study. The data was collected with two webbased questionnaires. In addition two interviews were made with specialists of civilian crisis management in Finland. The study also provides an overview of international treaties concerning children’s rights in armed conflict. The results show that 48.7 % of dangers for children in conflicts reported by the peacekeepers were related to physical injury (e.g. landmines and traffic), and 27.4 % were related to social problems (e.g. poverty, child soldiers, and trafficking). 24.1 % of the peacekeepers had made observations of children’s rights violations either often or very often during peacekeeping operations. 49.6 % of the observations were related to social problems (e.g. child labour or being forced to beg), and 33.0 % were related to physical injury (e.g. assault). Frequency of observation of children’s rights violations was not associated with either sex or military degree of the peacekeepers; instead it was significantly correlated with the peacekeepers’ degree of knowledge of EU’s child protection guidelines. On the basis of the results, it is recommended that knowledge about children’s rights and protection should be included in the training of Finnish crisis management personnel to a much higher degree than at the present.

Temporomandibular Disorders and Headache in Adolescents

13-16-vuotiaiden purentaelimistön toimintahäiriöt ja päänsärky Tutkimuksen tarkoituksena oli selvittää purentaelimistön toimintahäiriöihin (TMD) liittyvien oireiden ja kliinisten löydösten esiintyvyyttä ja muutosta kolmen vuoden seurannan aikana päänsärystä kärsivillä nuorilla ja heidän verrokeillaan, TMD-löydösten yhteyttä eri tyyppisiin päänsärkyihin ja päänsärkyyn liittyviin tekijöihin, TMD-löydöksiä ennustavia tekijöitä sekä perhetaustan osuutta TMD-löydösten esiintyvyyteen. Tutkimus perustui kahteen laajaan koululaismateriaaliin Turun seudulla. Ensimmäinen 13-vuotiaiden nuorten ryhmä (n = 311) osallistui myös 16-vuotiaana seuranta-tutkimukseen. Toisen 13-vuotiaiden nuorten ryhmän (n = 154) äidit (n = 154) osallistuivat myös tutkimukseen, jossa selvitettiin tapaus-verrokkiasetelmassa TMD-löydösten ja päänsärkyjen esiintyvyyttä kahdessa sukupolvessa. Nuoret jaettiin päänsärkyryhmiin ja terveisiin kontrolleihin IHS (1988) päänsärky-kriteerien mukaisesti kyselykaavakkeen ja lääkärin suorittaman haastattelun ja kliinisen tutkimuksen antamien tietojen perusteella. Lääkäri määritteli äitien päänsärkydiagnoosin kyselykaavakkeen tietojen perusteella. Kaikki nuoret ja heidän äitinsä haastateltiin ja heille tehtiin kliininen purentafysiologinen tutkimus sokkoutetusti. Tutkimuksen tulokset osoittivat, että tytöillä esiintyi TMD-löydöksiä selvästi enemmän kuin pojilla sekä ennen puberteettia että sen jälkeen. Tutkimuksessa havaittiin selkeä yhteys TMD-löydösten ja molempien päänsärkytyyppien, migreenin ja episodisen tensiotyyppisen päänsäryn, välillä. Kolmen vuoden seurannan aikana TMD-löydöksissä havaittiin runsasta muutosta ja iän myötä vähenemistä, mutta TMD-oireiden kohdalla ei vastaavaa muutosta todettu. TMD-löydösten ja niska-hartiaseudun lihaskipujen välillä havaittiin yhteys 13-vuotiailla nuorilla. Mikään päänsärkyyn liittyvistä tekijöistä 13-vuotiailla ei osoittautunut ennustavaksi taustatekijäksi myöhemmille TMD-löydöksille. TMD-löydösten suhteen ei todettu perheyhteyttä. Päänsäryistä kärsivillä nuorilla on enemmän myös muita kiputiloja, kuten purentaelimistön toimintahäiriöitä ja niska-hartiaseudun kipuja, kuin heidän terveillä verrokeillaan. 1316 vuoden iässä nämä löydökset ovat valtaosaltaan lieviä ja vaihtelevia.

Families in the Shadow of Cancer

The aims of this study were 1) to clarify the factors associated with family functioning in cancer patient’s families with dependant children, 2) to examine children’ mental health when they are exposed to parental cancer, 3) to explore the subjective experience of having cancer during pregnancy, and finally, 4) to describe the implementation of a childcentred family intervention for cancer patients’ families with dependant children in an adult oncology setting. The study groups were collected between May 1st 2002 and April 30th 2004. They consisted of one European group collected from six different countries (N = 381) and two Finnish clinical groups (N = 85 and N = 2). The first Finnish clinical group of 85 cancer patient families with dependant children included a sub-sample of 54 families with children aged 11-17 years. The second Finnish clinical group consisted of two pregnant cancer patients. Additionally, a control group (N = 59) consisting of a sub-sample of 49 families with children aged 11-17 years was used. Quantitative methods (FAD, BDI, YSR, SOC, SF-8) and qualitative methods (observation, interviews, diaries, videotapes) were used exclusively and/or in combination. The results can be summarised as follows: 1) cancer “per se “ did not impair family functioning, children’s mental health, early interaction between ill mothers and their infant, 2) maternal depression or the ill parent’s depression were significantly associated with impairment in family functioning, 3) the individual’s good sense of coherence was associated with improvement in family functioning, and 4) a child-centred family intervention, which aims to give space for elaborating on cancer in the family, validates the sense of coherence and children’s feelings, and promotes open communication was welcomed. It is important to note that in the European study group, the prevalence of depression was 35 % (BDI > 16) among ill mothers, and 28% among healthy mothers, 28% among ill fathers, and 13% among healthy fathers. Early screening and effective treatment of depression in cancer patients and their partners is of paramount importance for the mental health of children and the well-being of the family. Pregnant cancer patients are in need of psychosocial support.

Occlusal and dentofacial characteristics of the deciduous dentition and treatment effects of the eruption guidance appliance in the early mixed dentition

The aim of this investigation was to analyze the dental occlusion in the deciduous dentition, and the effects of orthodontic treatment carried out in the early mixed dentition with the eruption guidance appliance. The deciduous occlusion and craniofacial morphology of 486 children (244 girls and 242 boys) were investigated at the onset of the mixed dentition period (mean age 5.1 years, range 4.0-7.8 years). Treatment in the treatment group and follow-up in the control group were started when the first deciduous incisor was exfoliated (T1) and ended when all permanent incisors and first molars were fully erupted (T2). The mean age of the children was 5.1 years (SD 0.5) at T1 and 8.4 years (SD 0.5) at T2. Treatment was carried out with the eruption guidance appliance. Occlusal changes that took place in 167 children were compared with those of 104 untreated control children. Pre- and post-treatment cephalometric radiographs were taken, and the craniofacial morphology of 115 consecutively treated children was compared with that of 104 control children. The prevalence of malocclusion in the deciduous dentition was 68% or 93% depending on how the cut-off value between the acceptable and non-acceptable occlusal characteristic was defined. The early dentofacial features of children with distal occlusion, large overjet and deepbite differed from those with normal occlusion. However, the skeletal pattern of these three malocclusions showed considerable similarity each being characterized by a retrusive mandible, small maxillo-mandibular difference, convex profile, retrusive lower incisors, and large interincisal angle. In the treatment group, overjet and overbite decreased significantly from T1 to T2. Following treatment, a tooth-to-tooth contact was found in 99% of the treated children but only in 24% of the controls. A Class I molar relationship was observed in 90% of the children in the treatment group, and in 48% in the control group. Good alignment of the incisors was observed in 98% of the treated children, whereas upper crowding was found in 32% and lower crowding in 47% of the controls. A significant difference between the groups was found in the mandibular length, midfacial length and maxillo-mandibular differential. The occlusal correction, brought about by the eruption guidance appliance, was achieved mainly through changes in the dentoalveolar region of the mandible. In addition, the appliance seemed to enhance the growth of the mandible. Treatment in the early mixed dentition using the eruption guidance appliance is an effective method to normalize occlusion and reduce further need of orthodontic treatment. Only few spontaneous corrective changes can be expected without active intervention.

Counselling on limited preoperative fasting in paediatric ambulatory tonsillectomy

Rajoitetun preoperatiivisen paaston ohjaus lasten päiväkirurgisessa nielurisaleikkauksessa Tutkimuksen tarkoituksena oli selvittää, onko sairaanhoitajan toteuttama, vanhempien interaktiivinen preoperatiivinen ohjaus lapsen rajoitettuun preoperatiiviseen paastoon ja aktiiviseen nesteyttämiseen turvallista, kuinka vanhemmat omaksuvat kyseistä tietoa ja edistääkö se turvallisesti lapsen postoperatiivista toipumista päiväkirurgisen nielurisaleikkauksen jälkeen. Aineisto koostui sadastakuudestatoista perheestä, joiden lapsi, iältään 4 – 10 vuotta, oli kutsuttu päiväkirurgiseen nielurisaleikkaukseen. Koeryhmä (n= 58) ohjattiin interaktiivisesti lapsen preoperatiiviseen paastoon ja aktiiviseen preoperatiiviseen nesteyttämiseen. Lapsen suositellut preoperatiiviset paastoajat olivat: 4t syömättä ja 2t juomatta. Leikkauspäivän aamuna vanhemmat rohkaisivat lapsia juomaan annokset kirkkaita nesteitä kahteen otteeseen; jälkimmäinen annos 2t ennen leikkausta. Kontrolliryhmä (n= 58) sai preoperatiivisen ohjauksen kirjallisena ilman interaktiivista ohjausta; paastoajat olivat samat kuin koeryhmässä: 4t syömättä ja 2t juomatta. Vanhempien tiedontasoa lapsen leikkaukseen liittyvästä paastosta mitattiin tietotestillä, joka sisälsi myös preoperatiivista tiedontarvetta ja ahdistusta mittaavan mittarin (The Amsterdam Preoperative Anxiety and Information scale, APAIS). Mittaukset suoritettiin ennen preoperatiivista ohjausta tai kirjallisten ohjeiden lähettämistä sekä lapsen leikkausta seuraavana päivänä. Lapsen leikkauksen jälkeen vanhemmat arvioivat myös heille välitetyn informaation tasoa. Lapsen postoperatiivista kipua, pahoinvointia, janoa ja nälkää lapset itse arvioivat VAS- asteikolla (10cm), ja vanhemmat ja sairaanhoitajat numeerisella 0 – 10 asteikolla. Mittaukset suoritettiin 2t, 4t, 8t, ja 24t lapsen leikkauksen jälkeen. Vanhemmat pitivät päiväkirjaa lapsen ravinnosta ja kipulääkityksestä. Aineisto analysoitiin sekä tilastollisesti että sisällön analyysilla. Vanhempien tiedontaso lapsen leikkauksen jälkeen oli molemmissa ryhmissä merkitsevästi parantunut, mutta kontrolliryhmän vanhempien ahdistus ei ollut helpottanut verrattuna heidän ahdistukseensa ennen lapsen leikkausta. Mitä korkeammat pisteet vanhemmat saivat tietotestistä lapsen leikkauksen jälkeen sitä vähemmän he tunsivat tiedontarvetta ja ahdistusta. Merkitsevästi alhaisemmat pisteet tietotestistä oli vanhemmilla, joilla oli alempi peruskoulutus. Kontrolliryhmän lapset paastosivat preoperatiivisesti merkitsevästi pitempään kuin koeryhmän lapset. Perioperatiivisesti lapset paastosivat kiinteästä ruuasta yhtä kauan, mutta nesteistä kontrolliryhmä merkitsevästi pitempään. Postoperatiivisen toipumisen alussa koeryhmän lapset olivat merkitsevästi kivuttomampia. Molemmissa ryhmissä lapset olivat kipeimpiä kahdeksan tuntia leikkauksesta ja pahoinvointisimpia neljä tuntia leikkauksesta. Ensimmäisen kahdeksan tunnin aikana leikkauksen jälkeen lapset eivät olleet janoisia tai nälkäisiä, mutta VAS- arvot koeryhmässä jäivät alhaisemmalle tasolle kuin kontrolliryhmässä 24 postoperatiivisen tunnin ajan. Leikkausta seuraavana aamuna kontrolliryhmän lapset olivat merkitsevästi janoisempia ja nälkäisempiä kuin interventioryhmän lapset. Sairaanhoitajan toteuttama vanhempien interaktiivinen preoperatiivinen ohjaus lapsen rajoitettuun preoperatiiviseen paastoon lisää vanhempien tiedontasoa ja vähentää preoperatiivista tiedontarvettaan ja ahdistusta, ja turvallisesti parantaa lapsen kokemusta leikkausprosessin ja postoperatiivisen toipumisen aikana nielurisaleikkauksen jälkeen. Kaikkien leikkaukseen tulevien lasten nesteyttäminen kaksi tuntia ennen päivän ensimmäistä leikkausta voi olla ratkaisu lasten kohtuuttomien perioperatiivisten paastoaikojen estämiseksi. Aina ei kuitenkaan ole mahdollisuuksia vanhempien henkilökohtaiseen kohtaamiseen, mikä haastaa hoitotieteellisen tutkimuksen kartoittamaan muita mahdollisuuksia vanhempien interaktiiviseen ohjaukseen.

Dental Health in Primary Teeth after Prevention of Mother-Child Transmission of Mutans Streptococci. A Historical Cohort Study on Restorative Visits and Maternal Prevention Costs

Mutansstreptokokkitartunnan ehkäisemisen pitkäaikaisvaikutukset maitohampaiden terveyteen. Kohorttitutkimus korjaavan hoidon määrästä ja kariesehkäisyn kustannuksista. Tutkimuksen tarkoituksena oli selvittää varhaisen mutansstreptokokki (MS)-kolonisaation ehkäisyn pitkäaikaisvaikutuksia korkean kariesriskin omaavien lasten maitohampaistossa sekä tarkastella MS-tartunnan estämisen kustannuksia. Tiedot lasten hampaiden terveydestä ja hammashoitotoimenpiteistä syntymästä 10-vuotiaaksi sekä äiteihin kohdistuneen kariesehkäisyn kustannuksista kerättiin Ylivieskan terveyskeskuksen asiakirjoista. Tutkimuksessa oli mukana yhteensä 507 lasta, heistä 148 oli osallistunut aikaisempaan Ylivieskan äiti-lapsitutkimukseen, jossa verrattiin äitien käyttämän ksylitolipurukumin ja äidille tehtyjen fluori- tai klooriheksidiinilakkausten vaikutusta pikkulasten hampaiden terveyteen. Maitohammaskariesta esiintyi 10-vuotiaaksi asti merkitsevästi vähemmän lapsilla, jotka eivät olleet saaneet MS-tartuntaa alle 2-vuotiaana, heidän maitohampaansa säilyivät 3,4 vuotta kauemmin täysin ehjinä (p<0.001) ja he tarvitsivat vähemmän maitohampaiden korjaavaa hoitoa (p=0.005) kuin lapset, joiden hampaisto oli kolonisoitunut MS-bakteerilla jo 2-vuotiaana. Koska ksylitoliryhmän lasten MS-kolonisaatio oli vähäisintä, heidän maitohampaissaan oli vähemmän kariesta ja korjaavan hoidon tarvetta kuin kahden muun korkeariskisen ryhmän lapsilla. Äitien käyttämän ksylitolipurukumin kustannukset olivat yhteensä 116 euroa ja lapsen maitohampaiden säilyminen täysin ehjinä vuoden pidempään maksoi 37 euroa. Kun MS-tartunta oli saatu estettyä, korkean kariesriskin omaavien lasten hampaiden terveys oli samalla tasolla kuin keskimäärin koko ikäkohortilla. Lapsen maitohampaat säilyvät terveinä pidempään ja korjaavan hoidon tarve vähenee, kun MS-kolonisaatio alle 2-vuotiaana saadaan estettyä. Lapsen MS-kolonisaatio vähenee merkitsevästi, kun äiti käyttää ksylitolipurukumia lapsen ollessa 0-2 vuoden ikäinen, siten pikkulapsen äidin säännöllinen ksylitolipurukumin käyttö saattaa olla julkisen tereydenhuollon kannalta tarkoituksenmukainenterveyttä edistävä menetelmä.

Identifying first graders at risk of reading and writing difficulties : creating a group-based screening tool in kiswahili in Tanzania

Early identification of beginning readers at risk of developing reading and writing difficulties plays an important role in the prevention and provision of appropriate intervention. In Tanzania, as in other countries, there are children in schools who are at risk of developing reading and writing difficulties. Many of these children complete school without being identified and without proper and relevant support. The main language in Tanzania is Kiswahili, a transparent language. Contextually relevant, reliable and valid instruments of identification are needed in Tanzanian schools. This study aimed at the construction and validation of a group-based screening instrument in the Kiswahili language for identifying beginning readers at risk of reading and writing difficulties. In studying the function of the test there was special interest in analyzing the explanatory power of certain contextual factors related to the home and school. Halfway through grade one, 337 children from four purposively selected primary schools in Morogoro municipality were screened with a group test consisting of 7 subscales measuring phonological awareness, word and letter knowledge and spelling. A questionnaire about background factors and the home and school environments related to literacy was also used. The schools were chosen based on performance status (i.e. high, good, average and low performing schools) in order to include variation. For validation, 64 children were chosen from the original sample to take an individual test measuring nonsense word reading, word reading, actual text reading, one-minute reading and writing. School marks from grade one and a follow-up test half way through grade two were also used for validation. The correlations between the results from the group test and the three measures used for validation were very high (.83-.95). Content validity of the group test was established by using items drawn from authorized text books for reading in grade one. Construct validity was analyzed through item analysis and principal component analysis. The difficulty level of most items in both the group test and the follow-up test was good. The items also discriminated well. Principal component analysis revealed one powerful latent dimension (initial literacy factor), accounting for 93% of the variance. This implies that it could be possible to use any set of the subtests of the group test for screening and prediction. The K-Means cluster analysis revealed four clusters: at-risk children, strugglers, readers and good readers. The main concern in this study was with the groups of at-risk children (24%) and strugglers (22%), who need the most assistance. The predictive validity of the group test was analyzed by correlating the measures from the two school years and by cross tabulating grade one and grade two clusters. All the correlations were positive and very high, and 94% of the at-risk children in grade two were already identified in the group test in grade one. The explanatory power of some of the home and school factors was very strong. The number of books at home accounted for 38% of the variance in reading and writing ability measured by the group test. Parents´ reading ability and the support children received at home for schoolwork were also influential factors. Among the studied school factors school attendance had the strongest explanatory power, accounting for 21% of the variance in reading and writing ability. Having been in nursery school was also of importance. Based on the findings in the study a short version of the group test was created. It is suggested for use in the screening processes in grade one aiming at identifying children at risk of reading and writing difficulties in the Tanzanian context. Suggestions for further research as well as for actions for improving the literacy skills of Tanzanian children are presented.