Parental Reports of Health Care Practices for Adolescents with Down Syndrome Thesis Nurs. 1997 W323p c.2 Wasson, Deborah A. by Deborah A. Wasson Parental reports of health care practices 1997. Submitted in Partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Approved by: Alice Conway, RN, Pitt). Committee Chairperson of Edinboro University of Pennsylvania Date /j Judith Schilling,tRNP, Ph.D. 7 y Committee Member of Edinboro University of Pennsylvania Date /) T fcynthia Legin-'Bucell, PhD. Committee Member of Edinboro University of Pennsylvania Apn Date ,r r Parental Reports of Health Care Practices for Adolescents with Down Syndrome by Deborah A. Wasson Submitted in Partial Fulfillment of the Requirements For the Master of Science in Nursing Degree Abstract Parental Reports of Health Care Practices for Adolescents with Down Syndrome Literature indicates that the majority of primary care providers are not meeting the health care needs of their adolescent patients. A survey of parents of adolescents with Down syndrome was conducted to determine the parents’ perception of the extent to which primary care providers are addressing the unique needs of their adolescent patients with Down syndrome. The tool utilized was a researcherdeveloped survey that assessed the frequency of performance of multiple health care screenings and education as recommended by Guidelines for Adolescent Preventative Services, the American Academy of Pediatrics, and the Down Syndrome Medical Interest Group. The sample consisted of the parents of seven female and six male adolescents with a mean age of 15.77 years. The results from this study indicated that primary care providers were not addressing the unique health care needs of their adolescent patients with Down syndrome. ii Acknowledgements I would like to take this opportunity to express my sincere appreciation to all those people who helped to make this thesis possible. I would like to thank the members of my thesis committee: Dr. Alice Conway, Dr. Judy Schilling, and Dr. Cynthia Legin-Bucell for their time, energy, and direction. I would like to thank Dr. Len Leshin, MD, FAAP, for his expert advice on my survey. I would also like to thank the members of the northwestern Pennsylvania Association of Retarded Citizens (ARC) parent support group who helped to pilot my survey. And last, but not least, I would like to thank my children, Samantha, Jessica, Megan, Charles, and Cassandra, for their unending support, patience, and inspiration throughout this long process. My deepest appreciation to each and every one of you. iii Table of Contents Title Page Abstract ii Acknowledgements 111 List of Tables vm List of Figures ix Chapter I - Introduction 1 Background of the Problem 1 Research Question 2 Theoretical Framework 2 Statement of the Problem 4 Statement of Purpose 4 Assumptions 5 Limitations 5 Definition of Terms 5 Summary 6 8 Chapter II - Review of Literature Risks in Adolescence 8 Substance Use 8 Sexual Activity 9 Health-Risk Issues 9 10 Current Health Care iv Title Page 11 Down syndrome Routine Health Care 13 Cardiac 14 Respiratory 15 Growth 15 Endocrine 16 Atlantoaxial Instability 16 Depression 17 Hearing 18 Eye/Vision 18 Dental 19 Reproductive 19 Primary Care 21 Summary 22 26 Chapter III - Methodology Research Design 26 Instrumentation 26 28 Pilot Study Sample, Setting, and Procedure 28 Protection of Human Rights 29 Data Analysis 29 v Title Page Summary 30 Chapter IV - Results 31 Sample 31 Demographics 32 Location and Frequency of Health Care 36 Routine Screening 37 Down Syndrome Complications 39 Adolescent Issues 41 Safety Issues 44 Sexual Issues 45 Social/School Issues 46 Additional Comments 48 Summary 49 V. Summary, Conclusions, and Recommendations Summary of Research and Discussion 50 50 Demographics 50 Routine Screening 51 Down Syndrome Complications 52 Adolescent Issues 53 Safety Issues 54 Sexual Issues 54 vi Title Page Social/School Issues 55 Overall Satisfaction 55 Conclusions 56 Recommendations 56 Summary 57 References 58 Appendixes 63 A. Selection of Guidelines for Adolescent Preventive Services (GAPS) 64 Recommendations B. Survey for Parents of Adolescents with Down Syndrome 67 C. Introduction Letter to Down Syndrome Parent Support Group 76 D. Introduction Letter to Down Syndrome Listserver 77 E. Edinboro University IRB Exempt Review 78 F. Survey Data 79 vii List of Tables Page Table 1. Parents’ Ages 32 2. Parents Educational Levels 33 3. Annual Household Income 34 4. Ages of Adolescents with Down Syndrome 35 5. Mean Household Demographics 36 viii List of Figures Figure Page 1. Routine Screening 37 2. Down Syndrome Complications 39 3. Adolescent Issues 42 4. Safety Issues 44 5. Sexual Issues 46 6. Social/School Issues 47 ix 1 Chapter I Introduction This chapter provides a brief overview of adolescence and Down syndrome and the need for primary care during this period. Dorothea Orem's (1995) self-care deficit theory of nursing is utilized as the theoretical framework for this study and is described. Assumptions, limitations, and definition of terms are also provided. Background of the Problem Adolescence is a time of rapid growth and development. This period is difficult and often complicated by current trends in society, especially the trend toward fewer opportunities for adolescents to have contact with supportive adults (Millstein, Nightingale, Petersen, Mortimer, & Hamburg, 1993). These, coupled with unhealthy behaviors such as sedentary life-style and poor nutritional habits along with availability of harmful activities or substances—alcohol, drugs, weapons, unsafe vehicle use, and unsafe sexual practices—place the adolescent at risk for morbidity and mortality (Igra & Millstein, 1993). During adolescence, the addition of a developmental disability such as Down syndrome creates increased challenges that need to be met (Newacheck, 1989). Down syndrome is the most common identifiable cause of mental retardation and accounts for almost one-third of all cases (Trumble, 1993). The adolescent with Down syndrome must deal with numerous medical conditions in addition to all the typical problems of adolescence. Primary care directed at risk behaviors can reduce morbidity and mortality 2 during adolescence (Igra & Millstein, 1993). Primary care providers are in a unique position to direct the primary and secondary prevention services needed for today’s adolescents (Millstein et al., 1993). However, although over 70% of adolescents are seen by a physician yearly, their unique health care needs are not always being addressed (Igra & Millstein, 1993). Research Question Review of the literature suggests that the health care needs of adolescents are not being fully met by primary care providers. This study seeks to determine the extent to which primary care providers are addressing the health care needs of adolescents with Down syndrome as perceived by the adolescents’ parents. Theoretical Framework Dorothea Orem has outlined her self-care deficit theory of nursing in Nursing: Concepts of Practice (1995). Orem describes her theory as based on the belief that adult persons have developed the capabilities necessary to meet their own needs (self- care) and the needs of their dependents (dependent-care) for functioning and development. The ability to engage in self-care and dependent-care is termed self- care agency and dependent-care agency. The total requirement for regulation of functioning and development is termed therapeutic self-care demand. It is the difference between the therapeutic self-care demand and the self-care or dependent­ care agency that concerns the primary care provider. This is the area in which the patient requires assistance to fulfill his/her needs for support and promotion of normal functioning, maintenance of normal growth and development, prevention or cure of 3 potentially disabling processes, prevention or compensation for resulting disability, and promotion of well-being. The primary care provider assists the person in meeting his/her self-care requisites in one or more of several ways: 1. Acting for or doing for another. 2. Guiding and directing. 3. Providing physical or psychological support. 4. Providing and maintaining an environment that supports development. 5. Teaching. For the adolescent with Down syndrome, the primary care provider is required to adjust and adapt the health care orientation (Orem, 1995). In this case, the goal of health care is to create an environment that will "support life, facilitate integrated functioning, and contribute to present and future normalcy in daily living" (Orem, 1995, p. 139). The primary care provider needs to address several health care requirements: 1. Continuous health care to achieve the adjustments and adaptations the patient needs for support of life processes and integrated functioning. 2. Continuous health evaluation to determine the effects of the genetic defect on general health, growth and development, and functioning. 3. Continuous diagnosis to determine the effects of the genetic defect on medical conditions. 4. Specific protection against complications or extension of present impairments into more disabling limitations. 4 5. Health maintenance and promotion as well as specific protection from actual or possible effects of the genetic defect on general health, growth and development, and functioning. 6. Assistance to the patient and family in assuming appropriate roles in continuing health care, including self-care. 7. Assisting the patient in meeting universal and developmental components of self- care adjusted to this stage of development. Statement of the Problem Adolescent patients' unique health care needs are not being met by health care providers (Igra & Millstein, 1993). This stage of life is a trying time for the adolescent and caregiver under the best of circumstances. Adding a developmental disability creates increased challenges that need to be met. The adolescent with Down syndrome must deal with all the typical problems of adolescence, work to establish a personal identity, find some private space, and pursue his/her own interests (Trumble, 1993). The role of the primary care provider should be to assist the adolescent and caregiver in meeting the universal and developmental components of self-care, while at the same time considering the potential or actual health deviations of the individual (Orem, 1995). Unfortunately, review of literature suggests the majority of primary care providers are not providing this type of holistic care for their adolescent patients at this time (Igra & Millstein, 1993). Statement of Purpose The purpose of this research study was to determine the extent to which 5 primary care providers were addressing the unique needs of their adolescent patients with Down syndrome. This was determined through a survey of parents of adolescents with Down syndrome. Assumptions The assumptions of this study were: 1 Adolescents with Down syndrome have unique care needs due to both their stage of life and their medical diagnosis. 2. Parents of adolescents with Down syndrome are aware of the health care needs of their children. 3. Parents are aware of health care provided by primary care providers for their adolescents with Down syndrome. Limitations The limitations of this study were: 1. Convenience sampling method was utilized which may effect the generalizability of this study. 2. Sample for study was obtained from an Internet Listserver and a single Down syndrome parent support group and may effect the generalizability of this study. 3. No previous study was found on the extent of health care provided to adolescents with Down syndrome. Definition of Terms The terms utilized in this study were: 1. Adolescence is the period of life between 11 and 21 years of age (Sifuentes, 1996). 6 2. Down syndrome is a genetic disorder caused by trisomy 21 and characterized by mild-to-severe mental retardation (Thomas, 1989). 3 Primary care is the comprehensive health care that patients receive from the same health care provider over a longitudinal period of time (Noble, 1996). 4. Primary care provider is a health care professional (physician, nurse practitioner, or physician assistant) providing primary care to patients. Summary Adolescents have unique developmental needs that need to be addressed by the primary care provider in order to decrease morbidity and mortality in this population. Currently, many primary care providers are not meeting the needs of their adolescent patients (Igra & Millstein, 1993). Down syndrome is a common congenital condition that results in varying degrees of mental retardation and increased risk for various medical conditions. The primary care provider needs to adjust care to account for the degree of retardation of the individual patient, as well as for any concurrent medical conditions. Dorothea Orem's self-care deficit theory of nursing was utilized as the framework for this study. Orem states that the primary care provider should adjust and adapt the health care orientation to meet the needs of the adolescent with Down syndrome. The primary care provider also needs to adjust the universal and developmental components of self-care. It was the purpose of this study to determine the extent to which primary care providers were addressing the unique needs of their adolescent patients with Down 7 syndrome, as perceived by the adolescents1 parents. This information was determined through a survey of parents of adolescents with Down syndrome. Assumptions, limitations, and terms utilized in this study have been provided. 8 Chapter II Review of Literature This chapter provides a review of current literature on adolescence and Down syndrome. The purpose of this chapter is to provide the reader with a selective overview of the population to be studied and some of their specific health care issues. Risks in Adolescence Adolescence is a stage of life between the ages of 11 and 21 and is characterized by rapid growth and development (Sifuentes, 1996). The individual begins this period as a child and ends it as an adult. According to Igra and Millstein (1993), adolescence is a high-risk period. Studies by Richert, Jay, and Gottlieb (1990) and Key, Marsh, and Darden (1995) have found that adolescents represent a medically underserved portion of the population, and over the last 30 years are the only group who have not experienced improvement in their overall health. Adolescents today face many risks including substance abuse, early sexual activity, sexually transmitted diseases (STDs), early parenthood, injuries, homicide, depression, and suicide (Key et al., 1995). These factors lead to increased morbidity and mortality in this population. It is the purpose of this section to explore some of these factors. Substance Use. Richert et al. (1990) found that the susceptibility to substance use and abuse occurs more frequently in those adolescents who demonstrate low self- esteem, feelings of alienation, high need for social approval and immediate gratification, family distress, and inadequate coping and communication skills. They 9 further found that alcohol is the most frequently used substance, with many adolescents reporting serious pressures to drink by age 15 years. Sexual Activity. Adolescent sexual activity is considered a social morbidity of the 1990s and, to reduce the impact of early sexual activity, this issue needs to be brought up in early adolescence and discussed frequently after that (Spencer, Fife, & Rabinovich, 1995). Richert et al. (1990) found that over 12 million adolescents are currently sexually active with the average age of first coitus being 16 years. This sexual activity may lead to STDs or pregnancy. According to Richert et al., adolescents account for almost one-third of all abortions performed. They also stated that sexually transmitted chlamydia infection affects 3 to 4 million individuals annually and is most common in the 15 to 19 year old population. The recommendation from Richert et al. was for adolescents to understand that the only absolute preventive method for pregnancy or STDs is sexual abstinence. Spencer et al. (1995) found that it is unlikely that once an adolescent is sexually active he/she will stop having sex. However, they believe the primary care provider can provide discrete guidance from a respected authority figure to encourage responsible sexual behavior. Richert et al. noted that if the adolescent will not abstain, he/she should be provided with preventive methods of protection. Health-Risk Issues. According to Richert et al. (1990), the primary care provider should assess the risk status of the adolescent in a nonjudgmental fashion and encourage the adolescent in health promotion. Key et al. (1995) wrote that health assessment and screening for adolescents should include addressing health-risk issues 10 such as depression, suicide, homicide, and injuries. Richert et al. (1990) encouraged the primary care provider to help adolescent patients avoid risk-taking behaviors. To accomplish this, Richert et al. recommended avoiding fear tactics that may inadvertently challenge the adolescent to try the behavior. They felt a more effective strategy is to build self-esteem, which helps to minimize peer influence. Current Health Care. Adolescents represent a medically under-served portion of the population and over the last 30 years are the only group who have not experienced improvement in their overall health (Richert et al., 1990; Key et al., 1995). According to Igra and Millstein (1993), much of adolescent morbidity and mortality can be attributed to preventable risk factors including sedentary life-style, poor nutritional habits, substance abuse, early sexual activity, STDs, early parenthood, injuries, homicide, depression, and suicide. According to Wasson et al. (1995), early detection and anticipatory guidance is critical to reduce adolescent morbidity and mortality. Igra and Millstein (1993) wrote that while over 70% of adolescents are seen by a physician yearly, their unique health care needs were not being addressed. They found that two-thirds of visits by adolescents to physicians included no counseling advice of any type. They recommended this be corrected because adolescents view health care providers as credible and important sources of health education and failure to provide health education could be interpreted by the adolescent as silent approval for potentially health-damaging behaviors. 11 To counteract adolescent morbidity and mortality, Elster and Kuznets (1994) recommended a greater number of services directed to the primary and secondary prevention of major health threats facing today's adolescents. They developed Guidelines for Adolescent Preventive Services (GAPS) designed to provide a framework for health assessment and screening for adolescents. Igra and Millstein (1993) have found the use of reminder systems for primary care providers, such as age-specific preventive services checklists attached to patient charts, to be an effective means to facilitate adherence to prevention guidelines. GAPS is one such reminder system and has been developed to direct primary care providers in how to provide preventive services to their adolescent patients (Elster & Kuznets, 1994). Through GAPS, Elster and Kuznets recommended adolescents have yearly contact with their primary care provider. This allows the opportunity to reinforce health promotion, identify early stages of health risk behaviors, provide immunizations, and develop a good working relationship with the adolescent. Although the GAPS recommendation was for annual visits, unless a problem is detected complete physical examinations are only recommended once during each stage of adolescence or three times during this period. Several of the GAPS recommendations are provided in Appendix A. Down syndrome Down syndrome is a congenital condition marked by a collection of commonly recognized characteristics and was first described in 1865 by Dr. John Langdon Down (Cooley & Graham, 1991). Down syndrome is found in all cultures, 12 ethnic groups, socioeconomic levels, and geographic regions. It occurs when there is extra chromosome 21 material, and despite prenatal testing the incidence of Down syndrome has not decreased significantly (Trumble, 1993). According to Magill (1989), although Down syndrome is associated with some degree of mental retardation, it is now accepted that infants and children with Down syndrome follow the normal stages of development but at a slower pace. Several recent developments have improved the prospects for a healthy, productive life for individuals bom with Down syndrome (Cooley & Graham, 1991). First and foremost, almost all babies bom with Down syndrome today are being raised within a family. As recently as the 1970s, institutional placement at birth was commonly recommended. Cooley and Graham noted that access to quality health care has also improved dramatically with the federal Child Abuse Amendments of 1984 having a major impact. These amendments require that disabled infants under all circumstances must be provided with nutrition, hydration, medication, and any medically indicated treatment. Thus health care cannot be withheld simply because the individual has Down syndrome. The improved medical care received has led to an increased life expectancy for the estimated 7,000 to 12,000 individuals with Down syndrome bom in the United States each year (Caputo, Wagner, Reynolds, Guo, & Goel, 1989). In 1929 according to Magill (1989), the life expectancy of an infant with Down syndrome was 9 years; by 1947, it had increased to 15 years. A recent study by Baird and Saadovnick (1987) found that more than 70% of individuals bom with Down syndrome survive to age 30 years. 13 Individuals with Down syndrome have increased risk for numerous conditions, which can have an adverse impact on their health and development (Cooley & Graham, 1991). Most of these conditions can be treated and complications minimized if diagnosed early. The American Academy of Pediatrics Committee on Genetics (1994) recommended these conditions be addressed when providing health care to this population. They advise that primary care providers must be aware of the Down syndrome associated conditions so as to be aggressive in their identification and treatment. Routine Health Care. Several individuals and groups have developed guidelines for caring for individuals with Down syndrome (Cooley & Graham, 1991; Trumble, 1993; American Academy of Pediatrics Committee on Genetics, 1994; Cohen, 1996). These guidelines aim to assist primary care practitioners in providing quality medical care to individuals with Down syndrome and are designed to cover health care from birth to death. It is generally accepted that an individual with Down syndrome requires the same preventive health care and screenings as any other individual (Cooley & Graham, 1991; Cohen, 1996). In addition, Cooley and Graham (1991) feel the primary care provider must assist the family and individual with Down syndrome to deal with issues of aging, medical problems associated with Down syndrome, problems of reproductive health, living arrangements, employment, guardianship or estate-planning, as well as routine health screening and promotion. According to the American Academy of Pediatrics Committee on Genetics (1994), in addition to 14 assessing and treating the medical conditions associated with Down syndrome, the primary care provider needs to provide anticipatory guidance for the adolescent and caregiver for: 1. Issues related to transition into adulthood. 2. Appropriateness of school placement with emphasis on adequate vocational training. 3. Sexuality and socialization, including the need for and degree of supervision, as well as the need for contraception. 4. Group homes, workshop settings, and other community-supported employment. 5. Intrafamilial relationships, financial planning, and guardianship. 6. Transfer to adult medical care, if appropriate or desired. Cardiac. Congenital heart disease affects 50% of children with Down syndrome (American Academy of Pediatrics Committee on Genetics, 1994). Recent studies have sought to determine cardiac anomalies among older individuals with Down syndrome. Goldhaber, Brown, and Sutton (1987) utilized Doppler echocardiography to study asymptomatic non-institutionalized adults with Down syndrome who had an average age of 26 years. Among this population, 57% were found to have mitral valve prolapse and 11% were found to have aortic regurgitation. This study concluded that mitral valve prolapse and aortic regurgitation seem to occur in adulthood rather than childhood. Another study by Geggel, O’Brien, and Feingold (1993) looked at 35 patients with Down syndrome, aged 12 years or older, who had no congenital heart disease 15 based on previous physical examinations. For patients aged 12 to 18, they found no incidence of aortic regurgitation. They did, however, find that 58% had mitral valve prolapse. The Down Syndrome Medical Interest Group recommends assessment for mitral valve prolapse and aortic regurgitation with an echocardiogram for individuals without congenital heart disease once at 18 years of age (Cohen, 1996). Respiratory. Cooley and Graham (1991) noted that children with Down syndrome have an increased susceptibility to respiratory tract infections, acute and chronic airway obstructions, sleep apnea, and cor pulmonale. According to Marcus, Keens, Bautista, von Pechmann, and Ward (1991), obstructive sleep apnea syndrome (OSAS) consists of complete and partial sleep apnea, hypoventilation, and arterial oxygen desaturation, and is a common manifestation in children with Down syndrome. Their study of children with Down syndrome found that when assessed overnight, 63% had obstructive sleep apnea, 81% had hypoventilation, and 56% had arterial oxygen desaturation. This compared with only 13% of control subjects having obstructive sleep apnea and none having hypoventilation or arterial oxygen desaturation when assessed overnight. The Down Syndrome Medical Interest Group recommends review of respiratory system by history and physical exam at each yearly exam (Cohen, 1996). Snoring, unusual sleeping positions, fatigability during the day, reappearance of napping in an older child, or behavior change could indicate an obstructive airway problem and require further investigation. Growth. Cooley and Graham (1991) reported that individuals with Down syndrome are consistently shorter than their peers at any age are and are expected to 16 follow a modified growth curve. Therefore, the Down Syndrome Medical Interest Group recommends primary care providers utilize specially constructed growth charts for their patients with Down syndrome (Cohen, 1996). Cronk et al. (1988) found evidence suggesting that the growth rate is less severely reduced during the 3 to 10 year age range than in infancy and adolescence. They also found that the adolescent growth spurt occurs in children with Down syndrome, but may be less than that of other children. Cronk et al. (1988) found that children with Down syndrome also have a tendency to be overweight beginning in early childhood. They have constructed growth charts for children with Down syndrome from age 1 month to 18 years. These charts are based on 4,650 observations of 730 children and provide a clearer analysis of the growth pattern of the child with Down syndrome. They recommend these charts to be used in conjunction with those from the National Center for Health Statistics to provide better assessment of the child’s growth pattern. Endocrine. Hypothyroidism is more common in children with Down syndrome with a prevalence of about 15% (Cooley & Graham, 1991). According to Trumble (1993), most cases of hypothyroidism in Down syndrome develop during adolescence and may be difficult to screen for because many of the signs and symptoms—dry skin, constipation, developmental delay, and hypotonia-are similar to the inherent features of Down syndrome. Therefore, it is recommended to obtain annual T3, T4, and TSH levels (Cohen, 1996; Cooley & Graham, 1991). Atlantoaxial Instability. According to Cooley and Graham (1991), individuals with Down syndrome generally have low muscle tone and ligamentous laxity, which 17 increases the risk of joint subluxations and dislocations. The most serious manifestation of ligamentous laxity involves the cervical spine and is termed atlantoaxial instability. Atlantoaxial instability is the increased mobility of the articulation of the first and second cervical vertebrae (American Academy of Pediatrics Committee on Sports Medicine and Fitness, 1995). It affects approximately 15% of adolescents with Down syndrome and is generally asymptomatic. The instability is generally due to excess laxity of the transverse ligaments that hold the odontoid process close to the anterior arch of the atlas (Pueschel, Scola, & Pezzullo, 1992). Instability has been noted to vary over time with either an increased or decreased laxity, so Pueschel, Scola, and Pezzullo (1992) recommend repeat radiographs every 5 years. The Down Syndrome Medical Interest Group recommends periodic reevaluation at 12 years, 18 years and once in adulthood for those individuals with normal findings (Cohen, 1996). They recommend that children with borderline or abnormal findings should be reevaluated after one year with further evaluation for any significant neurological changes. Depression. Individuals with Down syndrome frequently suffer from depression, but it often goes undiagnosed due to the difficulty in assessing individuals with mental retardation (Cohen, 1996). According to the Down Syndrome Medical Interest Group, typical signs of depression in individuals with Down syndrome are skill and memory losses, significant activity slow downs, hallucinatory-like self talk, and more extreme withdrawal (Cohen, 1996). 18 Hearing. A study of patients with Down syndrome by Balkany, Downs, Jafek, and Krajicek (1979) found 78% of patients examined had significant hearing loss. Of these, 83 /o were conductive, usually related to middle ear effusions, and 17% were sensorineural. Of all subjects tested, 64% had binaural hearing loss. According to the American Academy of Pediatrics Committee on Genetics (1994), hearing loss may begin to develop during the second decade in individuals with Down syndrome; therefore, they recommend an annual audiology evaluation. Eye/Vision. Individuals with Down syndrome are noted to have numerous eye disorders at a higher rate than the general population. Caputo et al. (1989) conducted a review of the ocular features of Down syndrome in a non-institutionalized population of patients referred to an ophthalmic clinic. They found refractive problems to be common with astigmatism in 22% of the patients, myopia in 22%, and hyperopia in 21% of the patients. Fifty-seven percent of the patients had strabismus, and 29% had nystagmus. Other findings included excessive tearing in 15%, spoke wheel optic nerve in 12%, cataracts in 11%, and glaucoma in 5%. Roizen, Mets and Biondis (1994) looked at a general population of individuals with Down syndrome. They also found increased incidence of optic disorders, but often at a lower level. Roizen et al. found strabismus in 27% of the patients, myopia in 22%, hyperopia in 13%, nystagmus in 20%, cataracts in 5%, and glaucoma in 1% of the patients. Because the development of significant visual loss from these causes can be avoided if treated early, early evaluation for ophthalmic disorders and annual or biennial follow-ups are recommended (Roizen et al., 1994; American Academy of Pediatrics 19 Committee on Genetics, 1994; Cohen, 1996). Dental Children with Down syndrome are predisposed to dental abnormalities (Cooley & Graham, 1991). Cooley and Graham (1991) noted an increased frequency of delays and alterations in the sequence of tooth eruption, and missing teeth occurring in about 50% of individuals. Barnett, Press, Friedman, and Sonnenberg (1986) found that patients with Down syndrome have an increased susceptibility and earlier onset of periodontal diseases which affects the supporting structures of the teeth. Their study found that 92% of Down syndrome subjects over the age of 16 had some bone loss. The bone loss was first seen at about age 16. Barnett et al. also noted a lower overall prevalence of dental caries in patients with Down syndrome when compared to a control group. The Down Syndrome Medical Interest Group recommends twice yearly dental examinations (Cohen, 1996). Reproductive. Sexual maturation and development in adolescents with Down syndrome follows the same pattern as their peers (Cooley & Graham, 1991). Williams (1983) found that the onset of puberty, with its potential for sexual activity and reproduction, can be especially difficult for parents of the child with Down syndrome. Mims (1996) recommended that the primary care provider, who is less emotionally involved with the adolescent than the parents, provide support and guidance in this area. Williams recommended all sex education be individualized to fit the child’s developmental level, physical maturation, and level of social skills. Although males with Down syndrome usually have normal secondary sexual characteristic development, the penis and scrotum may be small and the testes may be 20 histologically abnormal with markedly decreased spermatogenesis (Cooley & Graham, 1991; Sheridan et al., 1989). Since attainment of a full erection is often difficult and ejaculation is not always possible, many males with Down syndrome are infertile (Trumble, 1993). However, Sheridan et al. reported one documented case of a child being fathered by a man with Down syndrome. The father was a 29-year-old man with trisomy 21. Paternity was confirmed through DNA analysis from chorionic villi sampling of the fetus and blood sampling of the parents. Therefore, fertility must be assumed in all males with Down syndrome unless proven otherwise. Females with Down syndrome experience menarche and menses very much like their peers (Cooley & Graham, 1991). Evaluation of women with Down syndrome have found that ovulation occurs in 40-70% of menstrual cycles (Cooley & Graham, 1991) and fertility should be presumed (Trumble, 1993). Pregnancy has been documented in females with Down syndrome in at least 30 cases (Cooley & Graham, 1991). According to Bovicelli, Orsini, Rizzo, Montacuti, and Bacchetta (1982) the progress of the pregnancy is generally uneventful and maternal complications are rare. However, they note labor and delivery are generally difficult due to malpresentation, abnormalities in the shape and size of the pelvis, and lack of cooperation. Obstetric operations are often required, and of 21 reported deliveries, 7 were cesarean sections, 2 were breech extractions, and 1 was a forceps delivery. Bovicelli et al. also reported that the infants are at increased risk for mental retardation. Of the known 30 cases of Down syndrome pregnancies, 11 (35%) resulted in a normal child, 10 (35%) resulted in a child with Down syndrome, 6 21 (20%) resulted in a child with a malformation and/or mental retardation, and 3 (10%) resulted in abortion or stillbirth. The high incidence of mental retardation may be explained by either the child developing in a genetically unbalanced maternal environment or the transmission of abnormal genotypes. Of the 30 known cases of pregnancies to females with Down syndrome, 15 cases have unknown paternity. In 7 cases the father was closely related to the mother, and in the remaining 8 cases, the father was also mentally retarded. Primary Care Little information is available on utilization of primary care services by adolescents with disabilities. An analysis of data from the 1984 National Health Interview Survey found that disabled adolescents utilize health care services three times as much as their non-disabled peers (Newacheck, 1989). While their disability leads to increased contact with health care providers, little information is available on the quality or content of care provided (Newacheck, 1989; Hedberg, Byrd, Klein, Auinger, & Weitzman, 1996). Lack of health insurance is associated with reduced use of health care services (Newacheck, 1989). Hedberg et al. (1996) reported an attempt to counteract poor access to primary care due to lack of health insurance by the introduction of community health centers. They noted that the availability of high-quality and comprehensive health care in the community increases availability and utilization of primary health care by adolescents. Chicoine, McGuire, Hebein, and Gilly (1995) believed that the health care of 22 adolescents with Down syndrome is also better served by community-oriented primary care centers specifically designed to meet their needs. They described one such center, the Lutheran General Adult Down Syndrome Clinic in Chicago, opened in January of 1992. The center was designed to provide comprehensive medical care with an emphasis on prevention to adults and adolescents with Down syndrome aged 11 and older. The center provided complete primary care with specialty referrals as required. Chicoine et al. reported that the impact of the center has been positive in improving the quality of life for the patients seen. The greatest improvement was shown in analysis of 48 patients who presented with diminishing intellectual, functional, and/or social capabilities. Alzheimer's disease, which has a high incidence in the Down syndrome population, was suspected as the cause. Further examination by primary care providers trained to care for individuals with Down syndrome indicated that 46 of the 48 patients had a reversible disease such as depression or hypothyroidism. Appropriate treatment resulted in significant improvement of symptoms and quality of life for the patients and families or caregivers. Summary This chapter has provided a review of the literature for adolescence and Down syndrome. Adolescence is a period with several factors leading to morbidity and mortality. Adolescents currently are medically underserved and, over the last 30 years, are the only group who have not experienced improvement in their overall health. Early detection and anticipatory guidance by primary care providers is critical to reduce adolescent morbidity and mortality. 23 Several areas constitute high risk for morbidity and mortality during adolescence. Sexual activity is a major area of concern. Issues about sexuality need to be brought up in early adolescence and discussed frequently after that. Substance use and abuse is another high-risk area. Alcohol is currently the most frequently used substance by adolescents. The use of reminder systems has been found to be an effective way to facilitate adherence to prevention guidelines. GAPS has been developed to direct primary care providers in how to provide preventive services to their adolescent patients and makes several recommendations (Elster & Kuznets, 1994). These recommendations include yearly contact between adolescents and their primary care provider. Down syndrome is a congenital condition caused by extra chromosome 21 material and marked by a collection of commonly recognized physical features and numerous medical conditions. Prenatal testing to detect Down syndrome is increasing but has not reduced the birth incidence. Down syndrome is always associated with some degree of mental retardation but it is now accepted that infants and children with Down syndrome follow the normal stages of development, but at a slower pace. Several recent developments such as family living arrangements and improved health care have brightened the prospects for a healthy, productive life for individuals bom with Down syndrome. Several groups have developed medical care guidelines for individuals with Down syndrome. Those with Down syndrome require the same preventive health care and screenings as any other individual. In addition, 24 the primary care provider must address the numerous medical conditions that affect individuals with Down syndrome. Congenital heart disease affects 50% of children with Down syndrome. There is also evidence of mitral valve prolapse and aortic regurgitation developing in adolescence and adulthood. Children with Down syndrome have an increased susceptibility to respiratory tract infections, acute and chronic airway obstructions, sleep apnea, and cor pulmonale. Individuals with Down syndrome are consistently shorter and heavier than their peers and are expected to follow a modified growth curve. There are specially constructed growth charts for children with Down syndrome, which should be utilized to monitor the patient’s growth. Acquired hypothyroidism is more common in children with Down syndrome with most cases developing during adolescence. Individuals with Down syndrome generally have low muscle tone and ligamentous laxity that increases the risk of joint subluxations and dislocations; the most serious of which involves the cervical spine and is termed atlantoaxial instability. Individuals with Down syndrome often suffer from depression, have a high prevalence of hearing loss, numerous eye disorders, and dental abnormalities. Sexual maturation and development in adolescents with Down syndrome follow the same pattern as their peers and sexuality issues must be addressed in this population. Sex education needs to be individualized to fit the child's developmental level, physical maturation, and level of social skills. Primary care is designed to help reduce the impact of the major health threats facing today's adolescents. Adolescents with Down syndrome require the same care 25 in addition to health care directed towards their various medical problems. Little information is available concerning primary care of adolescents with disabilities. The information that is available indicates health care services are being utilized, but does not indicate the quality or content of services provided. 26 Chapter III Methodology This chapter describes the methodology utilized to determine the extent to which primary care providers are providing the recommended health care for their adolescent patients with Down syndrome. Included in this chapter are the research design, sample and setting, and procedure utilized for this study. Research Design This study utilized a non-experimental survey research design. The goal of this study was to gather information regarding the health care provided to adolescents with Down syndrome as reported by their parents. Instrumentation A survey was utilized as the research tool (see Appendix B). Due to lack of previous research in this area, the tool was researcher-designed. The survey consisted of three sections. The first section contained a letter from the researcher describing the purpose of the study and instructions on completing the survey (see Appendix C and Appendix D). The second section elicited demographic information concerning the respondent’s relationship to the adolescent with Down syndrome, number of parents living in the household, mother's and father s ages, mother s and father s education levels, household income range, and state or country of residence as well as the child’s age and sex. Also included in this section were two questions concerning the frequency and location of the child's routine health care visits. Question 1 concerned the location where the child received his/her primary care with the 27 availability of responses of: 1. Does Not Receive Health Care. 2. Community Health Clinic. 3. Group Practice. 4. Private Health Care Practitioner Practice. 5. Down Syndrome Clinic. 6. Other. Question number 2 utilized a scale for frequency of visits, allowing responses of: 1. No Routine Visits. 2. Visits Every Three Months. 3. Visits Every Six Months. 4. Visits Every One Year. 5. Visits Every Two Years. The final section of the survey contained 29 questions. Of these, 25 questions concerned health care services as recommended by Guidelines for Adolescent Preventative Services (GAPS), the American Academy of Pediatrics, and the Down Syndrome Medical Interest Group. The frequency these services had been performed were determined and compared to recommended frequencies. These 25 questions utilized a five point Likert-type scale and allowed for responses of: 1. Has Never Mentioned It. 2. Never Between The Ages Of 11 And 21 Years. . 28 3. Once Between The Ages Of 11 And 21 Years. 4. More Than Once Between The Ages Of 11 and 21 Years But Less Than Once A Year. 5. Once A Year Between The Ages Of 11 And 21 Years. 6. More Than Once A Year Between The Ages Of 11 And 21 Years. Question 28 determined the level of satisfaction with the primary care provider with five possible responses from Very Satisfied to Very Dissatisfied. The final 3 questions were open-ended questions to elicit any additional information the respondents wished to add. The survey was reviewed by a Fellow of the American Academy of Pediatrics for content validity and a representative of the English Department at Edinboro University for readability. Pilot Study. The survey was piloted by four members of a northwestern Pennsylvania Association of Retarded Citizens (ARC) parent support group. Two questions were clarified after the pilot study. Options of Mom, Dad, Step-mom, and Step-dad were added to elicit parents residing in the household. Question number 2 was clarified with the addition of the phrase physicals, not sick visits to define Routine Visits. All participants in the pilot study completed the questionnaire in less than 15 minutes. Sample, Setting, and Procedure The targeted convenience sample was parents of children with Down syndrome between the ages of 11 and 21 residing in the United States who read English. This study utilized two groups for convenience sampling. The developed 29 survey was placed on an Internet Listserver designed for parents of children with Down syndrome. The survey was placed on the Internet Listserver on three separate occasions over the course of seven days. The setting was in whatever location the parents had access to the Internet. The second sample was obtained through a Down syndrome parent support group located in northwestern Pennsylvania. A representative from this group was given copies of the survey to distribute to members of the group who met study criteria. This sample was given approximately three weeks to complete the survey. The surveys were returned to the researcher in self-addressed, stamped envelopes provided by the researcher. The setting for this group was in whatever location they chose to complete the survey. Protection of Human Rights An introduction accompanied the survey to allow the parents to know the purpose of the survey. The completion and return of the survey to the researcher was deemed as informed consent. All data remained confidential and anonymous. The researcher kept the returned surveys in a locked safe, no names were required, identifying information on responses returned via e-mail was removed and destroyed, and the data was reported as aggregate data. The study was reviewed by the Edinboro University Internal Review Board (IRB) and given an exempt review prior to being instituted (see Appendix E). Data Analysis The study consisted of 13 surveys returned by March 31, 1997 from the target sample that met the research criteria. Data on the frequency each specific health care 30 need were addressed by the primary care provider was compared to recommended frequencies. These data were analyzed through descriptive analysis with description of the parents perception of the frequency primary care providers addressed individual health care issues. This information was compared to recommended frequencies as put forth by GAPS, the American Academy of Pediatrics, and the Down Syndrome Medical Interest Group. Summary The goal of this study was to determine the degree to which primary care providers are meeting the needs of their adolescent patients with Down syndrome. Analysis of data obtained through survey of parents of adolescents with Down syndrome was utilized to determine the frequency targeted health care is being addressed by primary care providers as reported by the parents. 31 Chapter IV Results This chapter presents the results obtained from a survey of parents of adolescents with Down syndrome (see Appendix F). The results were analyzed with descriptive analysis and were utilized to determine the extent to which primary care providers are providing recommended health care for their adolescent patients with Down syndrome. Sample This study utilized two samples; one obtained from an Internet Listserver designed for parents of children with Down syndrome, and the other from a Down syndrome parent support group located in northwestern Pennsylvania. The survey was placed on the Internet Listserver on three separate occasions: March 2, 1997, March 6, 1997, and March 9, 1997. On March 2, 1997, this Listserver had 557 subscribers in 22 countries. Of the 557 subscribers, 458 were from the United States. Eight surveys were returned via e-mail. Of these eight, two were unable to be included in analysis due to not meeting the criteria for this sample. One of the surveys not included was from the parent of a 24 year-old with Down syndrome. The other survey not included was from a Canadian parent of a 6 year-old with Down syndrome. Twenty copies of the survey were delivered to a representative of a northwestern Pennsylvania Down syndrome parent support group on March 5, 1997. Seven completed surveys were returned and were included in the analysis. Thus a 32 total of 13 surveys were utilized in the analysis. Demographics Of the 13 returned surveys, 11 (84.6%) were completed by mothers and 2 (15.4%) were completed by fathers. There were 12 (92.3%) mothers, 10 (76.9%) fathers, and 1 (7.7%) stepfather residing in the households. One (7.7%) survey did not indicate which parents were residing in the household. Mothers’ ages ranged from 30-59 years. Fathers’ ages ranged from 30-60 and over years. See Table 1 for reported parents’ ages. Table 1 Parents’ Ages Mother Father Range IL na 30-39 years 2 3 40-49 years 7 4 50-59 years 3 4 60 years and over 0 1 ■£ = 13 surveys were relumed; one survey did nor indicate age of mother or father 33 Mothers’ reported years of education ranged from 12-18 years. Fathers’ reported years of education ranged from 10-19 years. Respondents’ reports of parents’ educational levels are provided in Table 2. Table 2 Parents’ Educational Levels Mother Father n! na 10 0 1 12 3 5 13 1 1 14 2 2 15 3 0 16 2 1 18 1 1 19 0 Highest Grade Completed 1 ,t indicate educational level of IL - 13 surveys were returned; one survey did no Mother or father 34 Household annual income ranged from under $20,000 to the $80,000-$99,000 range. The complete breakdown of respondents’ reported household incomes is provided in Table 3. Table 3 Annual Household Income na Range na under $20,000 1 $20,000-$34,000 1 $35,000-$49,000 3 $50,000-$64,000 3 $65,000-$79,000 2 $80,000-$99,000 3 13 surveys were returned The adolescents with Down syndrome had an age range of 13-19 years (see Table 4). Table 5 contains the mean household demographics of the respondents in regard to mother’s age, father’s age, mother’s educational level, father’s educational 35 level, household annual income, and age of the adolescent with Down syndrome. Table 4 Ages of Adolescents with Down Syndrome Age na 13 3 14 2 15 1 16 2 17 1 18 2 19 2 nl = 13 surveys were returned The surveys came from various locations throughout the continental United States, with one (7.7%) survey each from California, Florida, Michigan, New Jersey, and Washington. Pennsylvania had most of the representation with eight (61.5%) of the returned surveys. 36 Table 5 Mean Household Demographics M na Mother’s Age 40-49 years 12 Father’s Age 40-49 years 12 Mother's Education 14.33 years 13 Father's Education 13.67 years 13 Annual Income $50,000-564,000 13 Child's Age 15.77 years 13 na = 13 surveys were returned; one survey did not indicate age of mother or father Location and Frequency of Health Care Five (38.5%) of the adolescents were reported as receiving their care from group medical practices and eight (61.5%) from private medical practices. Routine visits were recommended once a year during adolescence. Three (23.1 /o) of the adolescents had no routine visits with their primary care provider, two (15.4%) had routine visits every six months, and eight (61.5%) had routine visits once a year. The percentage of adolescents receiving routine health care at less than the recommended frequency is provided in Figure 1. Routine Screening 100.00% £ c o o 80.00% -S 60.00% S E 40.00% EO 8 S E o 8o> CL *- 80.00% □ diet 60.00% -- 40.00% -20.00% -0.00% ■BZ □ weight control □ exercise □ physical changes Ilf Figure 3. Percentage of adolescents with Down syndrome receiving anticipatory guidance for adolescent issues below the recommended frequency. Discussion of healthy weight control was recommended at each yearly visit. Healthy weight control was never discussed with seven (53 8%) adolescents. Healthy weight control was discussed once between the ages of 11 years and 21 years with one (12.5%) adolescent. Healthy weight control was discussed more than once 43 . between the ages of 11 years and 21 years, but less than once a year with three (23.1%) adolescents. Healthy weight control was discussed once a year between the ages of 11 years and 21 years with two (15.4%) adolescents. (See Figure 3). Discussion of exercise was recommended at each yearly visit. Primary care providers never mentioned exercise to six (46.2%) adolescents. Exercise was mentioned once between the ages of 11 years and 21 years to one (7.7%) adolescent. Exercise was mentioned more than once between the ages of 11 years and 21 years, but less than once a year to three (23.1%) adolescents. Exercise was mentioned once a year between the ages of 11 years and 21 years to three (23.1%) adolescents. (See Figure 3). Discussion of expected physical changes during adolescence is recommended at each yearly visit. Primary care providers never mentioned expected physical changes during adolescence to six (46.2%) of the respondents. Expected physical changes during adolescence were discussed once between the ages of 11 years and 21 years with one (7.7%) respondent. Expected physical changes during adolescence were discussed more than once between the ages of 11 years and 21 years, but less than once a year with three (23.1%) respondents. Expected physical changes during adolescence were discussed once a year between the ages of 11 years and 21 years with one (7.7%) respondent. Expected physical changes during adolescence were discussed more than once a year between the ages of 11 years and 21 years with two (15.4%) respondents. (See Figure 3) 44 Safety Issues Discussion of safety issues was recommended at each yearly visit. Primary care providers were reported as never discussing safety issues with 11 (84.6%) adolescents. Safety issues were discussed more than once between the ages of 11 years and 21 years, but less than once a year with one (7.7%) adolescent. Safety issues were discussed once a year between the ages of 11 years and 21 years with one (7.7%) adolescent. (See Figure 4). Safety Issues 100.00% $ c o o 80.00% X, « &5 60.00% ?I 40.00% -- s (V3 20.00% — Q. *- 0.00% 1_ : -li □ seatbelts, helmets, guns □ alcohol, tobacco, drugs □ abuse prevention ----------------------------------------------------------- ■ I: ■- „ Figure 4. Percentage of adolescents with Down syndrome receiving anticipatory guidance for safety issues below the recommended frequency. Discussion of (he use oftobacco, alcohol, and drugs was recommended at each yearly visit. Primary care providers had never mentioned the use of tobacco, alcohol, and drugs to 12 (92,3%) ofthe adolescents. The use of tobacco, alcohol, and 45 drugs was discussed once between the ages of 11 years and 21 years with one (7.7%) adolescent. (See Figure 4). Discussion regarding prevention of emotional, physical, and sexual abuse was recommended at each yearly visit. Prevention of emotional, physical, and sexual abuse discussions by primary care providers were never mentioned to 12 (92.3%) of the respondents. Prevention of emotional, physical, and sexual abuse was mentioned more than once between the ages of 11 years and 21 years, but less than once a year to one (7.7%) respondent. (See Figure 4.) Sexual Issues Discussion of sexual issues was recommended at each yearly visit. Primary care providers did not mention expected sexual interest to 12 (92.3%) of the adolescents. Expected sexual interest was discussed more than once a year between the ages of 11 years and 21 years for one (7.7%) adolescent. (See Figure 5). Discussion of sexual behavior was recommended at each yearly visit. Primary care providers never mentioned sexual behavior with 11 (84.6%) of the adolescents. Sexual behavior was discussed once between the ages of 11 years and 21 years with one (7.7%) adolescent. Sexual behavior was discussed more than once a year between the ages of 11 years and 21 years with one (7.7%) adolescent. (See Figure 5). Discussion of birth control was recommended at each yearly visit. Primary care providers never mentioned birth control to 10 (76.9%) of the respondents. Birth control was discussed once between the ages of 11 years and 21 years with one (7.7%) respondent. Birth control was discussed more than once between the ages of 46 11 years and 21 years, but less than once a year with two (15.4%) respondents. Primary care providers have never discussed sexually transmitted diseases with any (100%) of the respondents. (See Figure 5). Sexual Issues 100.00% $ c o o 80.00% 0J 5 g> 5 5o £o 2 E v. Q. U 0) □ sexual interest 60.00% -H 40.00% -H □ sexual behavior □ birth control □ STDs 20.00% -H 0.00% Figure 5, Percentage of adolescents with Down syndrome receiving anticipatory guidance for sexual issues below the recommended frequency. Social/School Issues Assessment for depression was recommended yearly. Assessment for depression by primary care providers with questioning about signs and symptoms has never occurred for 10 (76.9%) adolescents. Assessment for depression had occurred once between the ages of 11 years and 21 years for two (12.5%) adolescents. Assessment for depression had occurred more than once between the ages of 11 years and 21 years, but less than once a year for one (7.7%) adolescent. (See Figure 6). Discussion of expected social development was recommended at each yearly 47 visit. Expected social development discussion by primary care providers had never occurred for !0 (76.9%) respondents. Expected social development was mentioned once between the ages of 11 years and 21 years to one (7.7%) respondent. Expected social development was mentioned more than once between the ages of 11 years and 21 years, but less than once a year to one (7.7%) respondent. Expected social development was mentioned more than once a year between the ages of 11 years and 21 years to one (7.7%) respondent. (See Figure 6). Social/School Issues 100.00% £ c o o 80.00% -- n 60.00% -- fI O> c (J V