Paediatrics (RCH) - Theses

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    Investigation of the short- and long-term complications of anorexia nervosa/atypical anorexia nervosa and the impact of the coronavirus pandemic
    Springall, Gabriella Anne Cornell ( 2022-10)
    Anorexia nervosa (AN) is an increasingly prevalent psychiatric disorder in which restricted energy intake leads to significantly low weight, a fear of weight gain, and a distorted perception of one’s body image. Individuals with this condition experience complications which affect the heart, muscles and bones, hormones, and mental health. The long-term prognosis for AN is difficult to predict; whilst many complications resolve with refeeding and weight gain, some damage may be permanent and disordered cognitions may persist. Furthermore, the impact of the coronavirus (COVID-19) pandemic on mental health and eating disorders is increasingly evident. However, reasons for declining mental health and the onset of disordered behaviours, as well as how the treatment of individuals is affected, remains unclear. The aim of this project was to (1) assess long-term cardiovascular and mental health following recovery from AN, and (2) determine the impact of the COVID-19 pandemic on both current and former AN patients. To achieve this, four separate but interrelated studies were conducted. The first study involved a four-year retrospective chart review of all patients presenting to the Royal Children’s Hospital Eating Disorder Service between 2017-2020. To assess the impact of the COVID-19 pandemic, the number and severity of presentations was compared between years via analyses of variance. The second study investigated long-term psychological outcomes and predictors of recovery and prognosis by administering online questionnaires to former AN patients from the Royal Children’s Hospital and Monash Children’s Hospital. The questionnaires assessed eating and exercising behaviours, mood, and COVID-19 impact. The third study involved non-invasive physical testing of the former patients to assess long-term cardiovascular health post AN recovery. Finally, further interrogation of carotid ultrasound images using wave analysis techniques provided valuable insight into the biomechanical interactions between the heart and vascular network. All outcome measures were compared to healthy controls and/or normal thresholds. Results revealed there was a surge in new AN cases under COVID-19 restrictions in 2020. Changes to routines, and feelings of isolation and loneliness were recognised as triggers for disordered behaviours. Mixed responses to telehealth and online learning were also reported. Former patient questionnaire responses indicated that psychological recovery from AN can be sustained long-term when individuals receive early and intense treatment. However, elevated levels of stress were exhibited by the former AN patients. This may reflect inherent personality features, such as perfectionism, which have been closely correlated with the condition. Despite increased stress and a history of an eating disorder, the former AN patients did not appear more susceptible to the impacts of the COVID-19 pandemic and faired comparably to controls. Cardiovascular assessments indicated that an increased propensity for cardiovascular disease may be associated with AN even after recovery. Regional changes in arterial stiffness, endothelial dysfunction, and abnormal autonomic regulation were identified in early adulthood. Overall, as the first research study to report on long-term cardiovascular and mental health following AN recovery, and the impact of the COVID-19 pandemic on an adolescent population within Melbourne (the most locked down city in the world), this thesis fills a critical gap in eating disorders literature. It identifies factors that contribute to patient course and outcome, reveals persisting cardiovascular adaptations, and informs of specific issues faced by both current and former AN patients during the pandemic. These findings have the potential to guide disease surveillance strategies and optimise clinical interventions.
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    Using simulation-based education to teach hospital staff how to manage behavioural emergencies in children with autism
    Mitchell, Marijke Jane ( 2020)
    Behavioural emergencies due to high-risk behaviours are increasing globally in paediatric health care settings and place the child, their family, other inpatients and staff at high-risk of harm. High-risk behaviours have been reported in up to two thirds of children with autism spectrum disorder (ASD) and intellectual disability (ID). Admission to hospital can trigger high-risk behaviours in children, especially those with ASD or ID, and increase their intensity or frequency. Patient and staff safety can be compromised if staff are not confident or competent in managing aggressive outbursts. As well as the safety risks, these behaviours result in delayed treatment, prolonged procedure times, increased health care costs and poorer health outcomes. Having a critical mass of well-trained staff who are confident in preventing and managing behavioural emergencies is important. However, these skills may be beyond the usual scope of practice of the acute paediatric health care provider. Paediatric acute health care is a complex specialty encompassing children with a wide range of developmental levels who operate within an array of unique family-centred care systems. Staff need many and varied skills and strategies that can be adapted to effectively interact with the spectrum of ages, developmental stages, neurodiversity and parental/carer involvement experienced in the acute paediatric setting. Simulation-based education (SBE) has been found to be superior to traditional clinical medical education for clinical skill acquisition and is gaining acceptance as a training method for teaching skills in managing clinical aggression. Simulation training allows practice of skills without patient risk and may be more effective than traditional teaching formats for aggression management. The aim of this thesis is to better understand the cause of behavioural emergencies caused by children in hospital and to use this knowledge to develop, implement and evaluate a simulation-based training program for acute care paediatric staff on managing aggression in children with ASD or ID. The program of research was established with four objectives linked to four independent studies, each informing the next. First, we conducted a systematic review to assess the effectiveness of simulation-based training for increasing de-escalation knowledge, skills and behaviour of staff working in the acute care setting. Second, we conducted a one-year retrospective study of behavioural emergencies that triggered an emergency response team attendance in a quaternary paediatric hospital to understand their frequency, type, context and management. Third, we designed a simulation-based education session about prevention and management of aggression in a neurotypical adolescent. We used a proof-of-concept study design to evaluate the acceptability of this training and to gain an understanding of the impact on participants’ self-perceived confidence levels in managing clinical aggression. Fourth, we designed a more specific simulation training program about management of aggression and high-risk behaviours in adolescents with ASD and ID in the hospital setting. Our final study was a pilot and feasibility cluster randomised controlled trial (RCT) of this simulation-based education, with mixed method design. Understanding aggression and high-risk behaviours in paediatric health care settings is an emerging area of research. The findings of these four studies have increased our understanding of the prevention and management of aggression and high-risk behaviours in acute care paediatric settings. Simulation-based education could become an important part of a multi-faceted strategy that is now needed to reduce the prevalence of high-risk behaviours in acute care settings and paediatric hospitals, and to improve outcomes if behavioural emergencies occur. Further evaluation of this training format for managing high-risk behaviours (including aggression), in children with ASD and ID is required. As well as simulation education, features of provider and patient systems need to be considered when formulating solutions to this complex issue in the paediatric acute care setting.