Pediatric
Pediatr Nephrol (1992) 6:405-406 9 IPNA 1992
Nephroaogy
Letters to the editors Psychosocial adjustment to end-stage renal failure Sirs,
We read with interest the paper by Brownbridge and Fielding [1] on psychosocial adjustment of children with endstage renal failure. In so far as the study compares children on hospital haemodialysis with children after transplantation it addresses an area we have also covered in our study of children undergoing treatment in Manchester, United Kingdom [2]. The findings of Brownbridge and Fielding [1] are Comparable to ours, in showing a better psychosocial adjustment of children after transplantation than on dialysis, in line with the more favourable physical status of transplant patients. However, the results of the author' s comparison of children on continuous ambulatory peritoneal dialysis (CAPD)/home haemodialysis and on hospital haemodialysis are more open to question. Firstly, the use of the Rutter A scale to assess child behaviour is not appropriate for pre-school age children, and six of the seven children under 7 years were in the CAPD group; this may have biased the scores in this group. Secondly, the authors consider the possibility that the results could have been affected by the fact that assignment to different groups was not random. Support for this possibility is given by the parental anxiety and depressive scores in the CAPD/home dialysis group. These were considerably below the dividing line between sick and healthy populations. Moreover, the children's scores on the depressive scale in this group were also well below the mean for healthy children in other surveys. In addition, it is possible that, had the young children been excluded from the analysis of Rutter scores, the mean score would have been lower and therefore indicative of less psychopathology. Taken together, all of these findings suggest that the CAPD/home dialysis group was exceptionally healthy psychologically. It seems likely that this would contribute to the decision to allocate children to this type of
treatment, since it makes considerable demands on parental and child co-operation. Thirdly, as the authors point out, treatment type and dialysis centres are closely related. They set out reasons for belfeving that this has not influenced the results, but this possibility cannot be excluded. The question of whether CAPD leads to better psychosocial adjustment than hospital haemodialysis would still seem to be open. The goal of "proving" one treatment better than another may be elusive, but beyond this, psychosocial studies are invaluable in identifying problems and directing the provision of psychosocial support in paediatric end-stage renal failure programmes, as suggested by the authors in their introduction. These problems probably change in any one child with time, depending on numerous factors including staff, patients, and type and duration of treatment. R. J. Postlethwaite1, M. E. Garralda3, J. M. Reynolds1, and M. Morton 2 Departments of 1Paediatrics and 2Psychiatry Royal Manchester Children's Hospital Pendlebury Near Manchester M27 1HA, UK 2Department of Psychiatry St. Mary's Hospital Medical School Paddington London, UK
References 1. Brownbridge G, Fielding D (1991) Psychosocial adjustment to endstage renal failure. Pediatr Nephrol 5:612-616 2. Reynolds JM, Garralda ME, Postlethwaite RJ, Goh D (1991) Changes in psychosocial adjustment after renal transplantation. Arch Dis Child 66:508-513
Reply Sirs, We would like to comment upon the letter from Postlethwaite et al. regarding our paper "Psychosocial adjustment to end-stage renal failure: comparing haemodialysis, continuous ambulatory peritoneal dialysis and transplantation [1]. As notedin their letter, the results of our multicentre United Kingdom study (Leeds, Liverpool, Nottingham and Glasgow) do indeed support the findings of their recently published Manchester-based study [2], in concluding that
the psychosocial adjustment of children after transplantation is better than that of children on dialysis. However, Postlethwaite et al. question the results of our comparison of children on chronic ambulatory peritoneal dialysis (CAPD) with children on haemodialysis, and our finding of improved psychosocial status of children and parents in the CAPD group. Firstly, they correctly note that, in our sample, six of the seven children under the age of 7 years were receiving
406
CAPD. They suggest that an inappropriate use of the Rutter scale with these children may have biased our results. In fact, the Rutter A scale was not used for these children. Although this is not explicitly stated in the paper we do note "The figures in parentheses in Table 2 indicate variations in the sample size used in the analysis. This occurred for three main reasons [1] due to limitations of the children's a g e . . . " (pp 615-616). Postlethwaite et al. also argue that our results would tend to support the notion that the CAPD group were "exceptionally healthy psychologically" and that this "would contribute to the decision to allocate the children to this type of treatment". Specifically they cite as supporting evidence for their views (1) "parental anxiety and depression scores" which were "considerably below the dividing line between sick and healthy populations, and (2) "children's scores on the depression scale which were also well below the mean for healthy populations". We believe that Postlethwaite et al. are misguided in their analysis. Normative data on the Leeds scale show that for depression 62% of a normal healthy sample scored less than 2 on the scale, whilst for anxiety 74% of the normal sample scored less than 4 [3]. Accordingly our CAPD parent group with mean scores for depression and anxiety of 3.70 and 4.87, respectively could not be considered "exceptionally healthy" by these standards. Turning to depression scores of youngsters on CAPD, here the mean score for our sample of children was 6.26 which is slightly higher than the mean depression score (5.92) of an unselected group of diabetic children cited by the authors in their standardization of the
test (M. Kovacs, personal communication, 1983). We therefore do not consider our CAPD children or families to be "exceptional" in the sense raised by Postlethwaite et al. In our discussion we considered several rival hypotheses for our findings, including the confounding of treatment type with age, dialysis centre and the possible preselection of type of treatment on psychosocial criteria (pp 615-616). Whilst we would agree that our data are not conclusive, we are compelled by the interpretation that, in general, treatment by CAPD and home haemodialysis seemed to be more compatible with children's and parents' psychosocial adjustment than w a s treatment by hospital haemodialysis. Dorothy Fielding and Garry Brownbridge Departments of Clinical Psychology, and Paediatrics and Child Health St. James's University Hospital Leeds LS9 7TF, UK
References 1. Brownbridge G, Fielding D (1991) Psychosocial adjustment to endstage renal failure. Pediatr Nephrol 5:612-616 2. Reynolds JM, Garralda ME, Postlethwaite RJ, Goh D (1991) Changes in psychosocial adjustment after renal transplantation. Arch Dis Child 66:508-513 3. Snaith RP, Bridge GWK, Hamilton M (1977) The Leeds scales for the self-assessment of anxiety and depression, manual. Psychological Test Publications, Barnstaple
Literature abstract Am J Med (1991) 91:345 -353
Morbidity of systemic lupus erythematosus: role of race and socioeconomic status M. Petri, S. Perez.Gutthann, J. C. Longenecker, and M. Hochberg Objective: To determine if differences in morbidity of systemic lupus erythematosus (SLE) as measured by (1) important renal disease, (2) number of hospitalizations, and (3) neuroligic disease can be explained by race, socioeconomic status (SES), or measures of compliance. Design: The interrelationship of black race, SES, and the physician's assessment of compliance as risk factors for morbidity was examined in a cohort of 198 patients with SLE (179 female, 115 black). SES was measured with Nam-Powers scores for education (years), income, and job status, and source of insurance; compliance was assessed by physician global assessment and percent of protocol visits kept. Morbidity outcomes were important renal disease (creatinine level 1.5 mg/dL or greater, renal faialure, nephrotic syndrome), neurologic involvement, and number of hospitalizations. Setting: The Johns Hopkins Rheumatology Faculty Practice, in which both private and clinic patients are seen. Results: Black patients had significantly lower SES on all measures (p 0.0001) and were also less compliant by physician global assessment (odds ratio [OR] = 0.39, p = 0.002). Univariate analyses showed that blacks had a higher frequency of important renal disease (OR = 2.07, 95% confidence interval [CI] 1.05 to 4.11) and hypertension (OR = 1.80,
95% CI 1.01 to 3.23). Important renal disease was associated with the physician global assessment of compliance (p = 0.009) and hypertension (p
Pediatr Nephrol (1992) 6:405-406 9 IPNA 1992
Nephroaogy
Letters to the editors Psychosocial adjustment to end-stage renal failure Sirs,
We read with interest the paper by Brownbridge and Fielding [1] on psychosocial adjustment of children with endstage renal failure. In so far as the study compares children on hospital haemodialysis with children after transplantation it addresses an area we have also covered in our study of children undergoing treatment in Manchester, United Kingdom [2]. The findings of Brownbridge and Fielding [1] are Comparable to ours, in showing a better psychosocial adjustment of children after transplantation than on dialysis, in line with the more favourable physical status of transplant patients. However, the results of the author' s comparison of children on continuous ambulatory peritoneal dialysis (CAPD)/home haemodialysis and on hospital haemodialysis are more open to question. Firstly, the use of the Rutter A scale to assess child behaviour is not appropriate for pre-school age children, and six of the seven children under 7 years were in the CAPD group; this may have biased the scores in this group. Secondly, the authors consider the possibility that the results could have been affected by the fact that assignment to different groups was not random. Support for this possibility is given by the parental anxiety and depressive scores in the CAPD/home dialysis group. These were considerably below the dividing line between sick and healthy populations. Moreover, the children's scores on the depressive scale in this group were also well below the mean for healthy children in other surveys. In addition, it is possible that, had the young children been excluded from the analysis of Rutter scores, the mean score would have been lower and therefore indicative of less psychopathology. Taken together, all of these findings suggest that the CAPD/home dialysis group was exceptionally healthy psychologically. It seems likely that this would contribute to the decision to allocate children to this type of
treatment, since it makes considerable demands on parental and child co-operation. Thirdly, as the authors point out, treatment type and dialysis centres are closely related. They set out reasons for belfeving that this has not influenced the results, but this possibility cannot be excluded. The question of whether CAPD leads to better psychosocial adjustment than hospital haemodialysis would still seem to be open. The goal of "proving" one treatment better than another may be elusive, but beyond this, psychosocial studies are invaluable in identifying problems and directing the provision of psychosocial support in paediatric end-stage renal failure programmes, as suggested by the authors in their introduction. These problems probably change in any one child with time, depending on numerous factors including staff, patients, and type and duration of treatment. R. J. Postlethwaite1, M. E. Garralda3, J. M. Reynolds1, and M. Morton 2 Departments of 1Paediatrics and 2Psychiatry Royal Manchester Children's Hospital Pendlebury Near Manchester M27 1HA, UK 2Department of Psychiatry St. Mary's Hospital Medical School Paddington London, UK
References 1. Brownbridge G, Fielding D (1991) Psychosocial adjustment to endstage renal failure. Pediatr Nephrol 5:612-616 2. Reynolds JM, Garralda ME, Postlethwaite RJ, Goh D (1991) Changes in psychosocial adjustment after renal transplantation. Arch Dis Child 66:508-513
Reply Sirs, We would like to comment upon the letter from Postlethwaite et al. regarding our paper "Psychosocial adjustment to end-stage renal failure: comparing haemodialysis, continuous ambulatory peritoneal dialysis and transplantation [1]. As notedin their letter, the results of our multicentre United Kingdom study (Leeds, Liverpool, Nottingham and Glasgow) do indeed support the findings of their recently published Manchester-based study [2], in concluding that
the psychosocial adjustment of children after transplantation is better than that of children on dialysis. However, Postlethwaite et al. question the results of our comparison of children on chronic ambulatory peritoneal dialysis (CAPD) with children on haemodialysis, and our finding of improved psychosocial status of children and parents in the CAPD group. Firstly, they correctly note that, in our sample, six of the seven children under the age of 7 years were receiving
406
CAPD. They suggest that an inappropriate use of the Rutter scale with these children may have biased our results. In fact, the Rutter A scale was not used for these children. Although this is not explicitly stated in the paper we do note "The figures in parentheses in Table 2 indicate variations in the sample size used in the analysis. This occurred for three main reasons [1] due to limitations of the children's a g e . . . " (pp 615-616). Postlethwaite et al. also argue that our results would tend to support the notion that the CAPD group were "exceptionally healthy psychologically" and that this "would contribute to the decision to allocate the children to this type of treatment". Specifically they cite as supporting evidence for their views (1) "parental anxiety and depression scores" which were "considerably below the dividing line between sick and healthy populations, and (2) "children's scores on the depression scale which were also well below the mean for healthy populations". We believe that Postlethwaite et al. are misguided in their analysis. Normative data on the Leeds scale show that for depression 62% of a normal healthy sample scored less than 2 on the scale, whilst for anxiety 74% of the normal sample scored less than 4 [3]. Accordingly our CAPD parent group with mean scores for depression and anxiety of 3.70 and 4.87, respectively could not be considered "exceptionally healthy" by these standards. Turning to depression scores of youngsters on CAPD, here the mean score for our sample of children was 6.26 which is slightly higher than the mean depression score (5.92) of an unselected group of diabetic children cited by the authors in their standardization of the
test (M. Kovacs, personal communication, 1983). We therefore do not consider our CAPD children or families to be "exceptional" in the sense raised by Postlethwaite et al. In our discussion we considered several rival hypotheses for our findings, including the confounding of treatment type with age, dialysis centre and the possible preselection of type of treatment on psychosocial criteria (pp 615-616). Whilst we would agree that our data are not conclusive, we are compelled by the interpretation that, in general, treatment by CAPD and home haemodialysis seemed to be more compatible with children's and parents' psychosocial adjustment than w a s treatment by hospital haemodialysis. Dorothy Fielding and Garry Brownbridge Departments of Clinical Psychology, and Paediatrics and Child Health St. James's University Hospital Leeds LS9 7TF, UK
References 1. Brownbridge G, Fielding D (1991) Psychosocial adjustment to endstage renal failure. Pediatr Nephrol 5:612-616 2. Reynolds JM, Garralda ME, Postlethwaite RJ, Goh D (1991) Changes in psychosocial adjustment after renal transplantation. Arch Dis Child 66:508-513 3. Snaith RP, Bridge GWK, Hamilton M (1977) The Leeds scales for the self-assessment of anxiety and depression, manual. Psychological Test Publications, Barnstaple
Literature abstract Am J Med (1991) 91:345 -353
Morbidity of systemic lupus erythematosus: role of race and socioeconomic status M. Petri, S. Perez.Gutthann, J. C. Longenecker, and M. Hochberg Objective: To determine if differences in morbidity of systemic lupus erythematosus (SLE) as measured by (1) important renal disease, (2) number of hospitalizations, and (3) neuroligic disease can be explained by race, socioeconomic status (SES), or measures of compliance. Design: The interrelationship of black race, SES, and the physician's assessment of compliance as risk factors for morbidity was examined in a cohort of 198 patients with SLE (179 female, 115 black). SES was measured with Nam-Powers scores for education (years), income, and job status, and source of insurance; compliance was assessed by physician global assessment and percent of protocol visits kept. Morbidity outcomes were important renal disease (creatinine level 1.5 mg/dL or greater, renal faialure, nephrotic syndrome), neurologic involvement, and number of hospitalizations. Setting: The Johns Hopkins Rheumatology Faculty Practice, in which both private and clinic patients are seen. Results: Black patients had significantly lower SES on all measures (p 0.0001) and were also less compliant by physician global assessment (odds ratio [OR] = 0.39, p = 0.002). Univariate analyses showed that blacks had a higher frequency of important renal disease (OR = 2.07, 95% confidence interval [CI] 1.05 to 4.11) and hypertension (OR = 1.80,
95% CI 1.01 to 3.23). Important renal disease was associated with the physician global assessment of compliance (p = 0.009) and hypertension (p
