Recurrent abdominal pain in children: psychiatric diagnoses and parental psychopathology

The course of mental health problems in children presenting with abdominal pain in general practice

OBJECTIVE

To investigate the course of mental health problems in children presenting to general practice with abdominal pain and to evaluate the extent to which abdominal pain characteristics during follow-up predict the presence of mental health problems at 12 months' follow-up.

DESIGN

A prospective cohort study with one-year follow-up.

SETTING

53 general practices in the Netherlands, between May 2004 and March 2006.

SUBJECTS

281 children aged 4-17 years.

MAIN OUTCOME MEASURES

The presence of a depressive problem, an anxiety problem, and multiple non-specific somatic symptoms at follow-up and odds ratios of duration, frequency, and severity of abdominal pain with these mental health problems at follow-up.

RESULTS

A depressive problem persisted in 24/74 children (32.9%; 95% CI 22.3-44.9%), an anxiety problem in 13/43 (30.2%; 95% CI 17.2-46.1%) and the presence of multiple non-specific somatic symptoms in 75/170 children (44.1%; 95% CI 36.7-51.6%). None of the abdominal pain characteristics predicted a depressive or an anxiety problem at 12 months' follow-up. More moments of moderate to severe abdominal pain predicted the presence of multiple non-specific somatic symptoms at follow-up.

CONCLUSIONS

In one-third of the children presenting to general practice for abdominal pain, anxiety and depressive problems persist during one year of follow-up. Characteristics of the abdominal pain during the follow-up period do not predict anxiety or depressive problems after one-year follow-up. We recommend following over time children seen in primary care with abdominal pain.

Annual research review: functional somatic symptoms and associated anxiety and depression--developmental psychopathology in pediatric practice

BACKGROUND

Medically unexplained physical symptoms, commonly referred to as functional somatic symptoms (FSS), are common in pediatric medical settings and associated with suffering, impairment, and medical help seeking. The association of pediatric FSS with anxiety and depressive symptoms and disorders across the life span is reviewed.

METHOD

Review and critique of controlled studies examining cross-sectional and longitudinal associations of FSS with anxiety and depressive symptoms and disorders in community-based and clinical samples of children and adolescents.

RESULTS

FSS are consistently associated cross-sectionally with anxiety and depressive symptoms and disorders in childhood and adolescence, and the likelihood of associated anxiety and depression increases with the number of reported FSS. The presence of one or more FSS early in life is associated with an increased likelihood of multiple FSS and anxiety and depressive symptoms and disorders later in life, and anxiety and depressive symptoms and disorders in childhood are associated with subsequent multiple FSS.

CONCLUSION

Strong associations between FSS, anxiety, and depression across the life span suggest the need to reconsider existing nosology and reconceptualize symptomatic relationships. Large, population-based longitudinal studies of FSS, anxiety, and depressive symptoms and disorders are needed to establish temporal relationships between the various symptoms and conditions.

Noncardiac chest pain in children and adolescents: a biopsychosocial conceptualization

Pediatric NCCP may be characterized by recurrent pain accompanied by emotional distress and functional impairment. This paper reviews and critiques literature on pediatric noncardiac chest pain (NCCP) and introduces a theoretical conceptualization to guide future study of NCCP in children and adolescents. A developmentally informed biopsychosocial conceptualization of NCCP etiology is proposed based on a synthesis of empirical evidence and clinical observations of pediatric NCCP within the context of relevant findings from the broader pediatric pain and anxiety literature. Multiple factors from biological, psychological, social, familial, and developmental domains are potentially relevant to the etiology of this ailment. This article concludes with directions for future research and clinical implications.

Anxiety, Depression, and Somatic Distress: Developing a Transdiagnostic Internalizing Toolbox for Pediatric Practice

Anxiety, depression, and somatic complaints are a common set of comorbid problems in children and adolescents. This "internalizing cluster" is highly prevalent, impairing during youth and into adulthood, and has substantial impacts on health-care systems. Fortunately, these problem areas may share several etiological factors and, thus, respond to similar interventions. In this paper, we present (a) the rationale for focusing on this cluster, (b) clinical theory on transdiagnostic processes uniting these problems, (c) description of core treatment techniques for this group, with a description of clinical outcomes for two sample cases, and (d) implications of this approach for new transdiagnostic treatment development and everyday clinical practice.

Somatic symptoms, severe mood dysregulation, and aggressiveness in preschool children

Many researchers have studied somatic symptoms in children. However, its association with severe mood dysregulation (SMD) is poorly known. The aim of this study is to detect the presence of SMD in preschool children and to know the prevalence of somatic symptoms and associations with psychopathology, SMD, and aggressiveness. The study population consists of children between 3 to 6 years of age enrolled in Barcelona's kindergarten schools (n = 319). Their parents completed questionnaires about the presence of somatic symptoms in children, absences from school and pediatric visits, child psychiatric symptoms, presence of symptoms of SMD, and aggressiveness. Teachers were also informed about SMD and aggressiveness. Children who complained frequent somatic symptoms (three or more in the last 2 weeks) were compared with those who did not. Two hundred five children (64.3%) reported at least one physical complaint in the 2 weeks preceding the study. One hundred participants (31.3%) reported frequent somatic complaints. Positive associations were found with anxiety symptomatology, separation anxiety, social phobia, pediatric visits, and school absences, but not with aggressiveness or SMD symptoms. Somatic symptoms are common in a sample of preschool children but do not show a positive association with the symptoms of SMD.

Physical symptoms and psychosocial correlates of somatization in pediatric primary care

A group of children, aged 8 to 13 years, presenting to their pediatricians with multiple medically unexplained physical symptoms (MUPS) were compared with a control group of children from the identical age range who were, according to their pediatricians, free of unexplained physical symptoms. The groups were compared on both self-reported and parented-rated scales assessing physical symptoms and psychosocial functioning. The multiple MUPS group, relative to controls, exhibited significantly higher levels of parent-reported emotional/behavioral symptoms and a trend toward higher patient-reported anxiety than controls. Parents' and child's reports of symptomatology were modestly correlated. Symptom patterns characteristic of pediatric somatization differed as a function of whether child or parent reports were analyzed. Methodological issues in research on pediatric somatization were addressed and some directions for future research emerged.

Familial risk factors for the development of somatoform symptoms and disorders in children and adolescents: a systematic review

The aim of this study was to examine whether familial risk factors for the development of somatoform symptoms and somatoform disorders in children and adolescents can be deduced from studies which investigated the intergenerational transmission of functional abdominal pain and somatoform disorders. A systematic review of articles published in English and German since 1990 was performed. Twenty-three relevant studies were found. The following putative familial risk factors for the development of somatoform symptoms and somatoform disorders were identified: somatization of parents, organic disease of a significant other, psychopathology of close family members, dysfunctional family climate, traumatic experiences in childhood and insecure attachment. Most of the putative familial risk factors are associated with many other psychiatric child disorders and are therefore mostly nonspecific. Further longitudinal studies, in which comorbidity and other putative risk factors are taken into account, are needed to identify specific familial risk factors for the development of somatoform symptoms and somatoform disorders.

Childhood nonspecific abdominal pain in family practice: incidence, associated factors, and management

PURPOSE

Nonspecific abdominal pain (NSAP) is a common complaint in childhood. In specialist care, childhood NSAP is considered to be a complex and time-consuming problem, and parents are hard to reassure. Little is known about NSAP in family practice, but the impression is that family physicians consider it to be a benign syndrome needing little more than reassurance. This discrepancy calls for a better understanding of NSAP in family practice.

METHODS

Data were obtained from the Second Dutch National Survey of General Practice (2001). Using registration data of 91 family practices, we identified children aged 4 to 17 years with NSAP. We calculated the incidence, and we studied factors associated with childhood NSAP, referrals, and prescriptions.

RESULTS

The incidence of NSAP was 25.0 (95% confidence interval [CI], 23.7-26.3) per 1,000 person years. Most children (92.7%) with newly diagnosed NSAP (N = 1,480) consulted their doctor for this condition once or twice. Factors independently associated with NSAP were female sex (odds ratio [OR] = 1.4; 95% CI, 1.3-1.5), nongastrointestinal-nonspecific somatic symptoms (OR = 1.3; 95% CI, 1.1-1.5), and health care use (OR = 1.04; 95% CI, 1.03-1.05). When NSAP was diagnosed at the first visit, 3% of the patients were referred to specialist care, and 1% received additional testing. Family physicians prescribed medication in 21.3% of the visits for NSAP.

CONCLUSIONS

Childhood NSAP is a common problem in family practice. Most patients visit their doctor once or twice for this problem. Family physicians use little additional testing and make few referrals in their management of childhood NSAP. Despite the lack of evidence for effectiveness, family physicians commonly prescribe medication for NSAP.

Do Parents Maintain or Exacerbate Pediatric Functional Abdominal Pain? A Systematic Review and Meta-analysis

Parents may maintain or exacerbate functional abdominal pain (FAP) in children through modeling of physical symptoms and solicitous responses to the child’s complaints. This systematic review and meta-analysis aimed to examine these relationships. Parents of children with FAP reported more physical symptoms than parents of healthy children (effect size d = .36). As all studies were cross-sectional or retrospective, the causal direction was unclear. For parental responses to child complaints, not enough studies were available to perform a meta-analysis. We conclude that the present literature is unfit to establish whether parents maintain or exacerbate pediatric FAP through the processes investigated.

Children with co-morbid recurrent abdominal pain and anxiety disorders: results from a multiple-baseline intervention study

Recurrent Abdominal Pain (RAP), one of the most common complaints of childhood, is associated with many adverse outcomes. However, few treatment studies have been conducted, especially for children with co-morbid RAP and anxiety disorders. The primary aim of the present study was to explore the utility of a cognitive-behavioral treatment (CBT) and a treatment that combined both CBT and family-based approaches in a community sample of children with co-morbid anxiety and RAP. A multiple-baseline across participants design utilizing repeated measures of anxiety and pain was implemented (n = 8 families). An examination of the clinical significance of both treatment approaches is suggestive of their utility in the treatment of anxiety and pain symptoms in children with RAP. More research is warranted in RAP treatment outcome research, particularly with family-based approaches to treatment.

Functional abdominal pain and irritable bowel syndrome in children and adolescents

Functional abdominal pain (FAP) and irritable bowel syndrome (IBS) are both associated with recurrent abdominal pain and are among the most commonly diagnosed medical problems in pediatrics. The majority of patients with mild complaints improve with reassurance and time. For a distinct subset of patients with more severe and disabling illness, finding effective treatment for these disorders remains a challenge. Based on the biopsychosocial model of functional disease, the Rome III criteria have helped frame FAP and IBS in terms of being a positive diagnosis and not a diagnosis of exclusion. However, the lack of a single, proven intervention highlights the complex interplay of pathologic mechanisms likely involved in the development of childhood FAP and IBS and the need for a multidisciplinary, integrated approach. This article discusses the epidemiology, proposed mechanisms, clinical approach and therapeutic options for the management of FAP and IBS in children and adolescents.

Psychiatric disorders in children and adolescents presenting with unexplained chronic pain: what is the prevalence and clinical relevancy?

The prevalence of psychiatric disorders among children with unexplained chronic pain (UCP) is high in unselected populations and pain clinics, yet the clinical relevance of these disorders in children referred for unexplained pain is not known. This study assessed the prevalence of clinically relevant psychiatric disorders and their predictors in children referred to a children's hospital for UCP. Psychiatry morbidity was assessed in 134 children, aged 8-17 years, using the Diagnostic Interview Schedule for Children-parent version (DISC-P) and the Semi-structured Clinical Interview for Children and Adolescents (SCICA). Clinical relevance was determined using a maladjustment criterion of 61 or lower on the Children's Global Assessment Scale (CGAS). Pain parameters were measured with standardized questionnaires. Results were analysed by logistic regression. According to the DISC-P, 21% of the children had clinically relevant psychiatric disorders, predominantly anxiety disorders (18%). According to the SCICA, 28% of the children had clinically relevant psychiatric disorders, consisting of anxiety, affective, and disruptive disorders (12, 19, and 9%, respectively). Headache (compared to musculoskeletal pain) was an independent clinical predictor of psychiatric morbidity (OR = 3.10; 95% CI 1.07-8.92, p = 0.04/adjusted OR 2.99; 95% CI 1.02-8.74, p = 0.04). In conclusion, clinically relevant psychiatric disorders are common among children and adolescents referred for UCP. Adding a child psychiatrist assessment, treatable affective and disruptive disorders become identifiable. Children with an additional risk are those presenting with headache.

An investigation of health anxiety in families where children have recurrent abdominal pain

OBJECTIVES

To explore health anxiety in children with recurrent abdominal pain (RAP) using a symbolic play assessment.

METHODS

Children with RAP and two control groups (with asthma and well children) were recruited. Eighty-four families completed play and questionnaire assessments of health anxiety and psychological functioning.

RESULTS

Children with RAP demonstrated less use of psychological descriptions for feelings than control children, and were more likely to represent serious outcomes to health scenarios than well children, but not children with asthma. Mothers of children with RAP had higher levels of health anxiety, and rated their children as having more physical symptoms and anxiety.

CONCLUSIONS

The symbolic play paradigm provided discriminating insights into health anxiety in children. The findings suggest that childhood RAP may be associated with higher levels of parental health anxiety. These aspects of family functioning might usefully be explored in families where a child has RAP.

Self-reported and laboratory-based responses to stress in children with recurrent pain and anxiety

OBJECTIVE

To examine heart rate (HR) responses to and coping with stress in children with recurrent abdominal pain (RAP), anxiety, and healthy controls.

METHODS

A clinical sample (children with RAP and children with anxiety) was compared to control children on self-reported and HR responses to stress and a laboratory test of pain tolerance and intensity (cold pressor).

RESULTS

Children in the clinical sample had elevated HRs compared to healthy controls before, during, and after laboratory tasks. Self-reported stress reactivity to social stress was positively correlated with HR at all study time intervals. Secondary control coping with social stress was negatively correlated with HR at most study time intervals. Internalizing symptoms were positively correlated with HR and self-reported stress reactivity.

CONCLUSIONS

Stress reactivity, as reflected in both self-reported and HR responses to laboratory stressors, is related to the presence of both RAP and anxiety in children.

Childhood predictors of recurrent abdominal pain in adolescence: A 13-year population-based prospective study

OBJECTIVE

To investigate maternal and child emotional symptoms, physical health problems, and negative life events measured at children's age 18 months and 12 years as potential predictors for self-reported recurrent abdominal pain (RAP) in adolescents (14 years).

METHODS

A population-based prospective study conducted at child health clinics (preventive health care) in Norway followed a cohort of 916 mothers with children from children's age 18 months until adolescence. Child self-report was obtained from 12 years of age. Outcome measure was adolescent self-reported RAP.

RESULTS

Of 456 adolescents, 58 (13%) reported RAP. Of these, 36 (62%) were girls. By multivariate analyses, the following maternal factors predicted RAP in adolescence: psychological distress at children's age 18 months (OR, 2.5; 95% CI, 1.3-4.8) and a maternal history of psychological distress at children's age 12 years (OR, 3.2; 95% CI, 1.7-6.2). The following child factors measured at age 12 years predicted RAP in adolescence: abdominal (OR, 2.5; 95% CI, 1.3-4.9) and extraintestinal pain (OR, 2.3; 95% CI, 1.2-4.4) by maternal report, self-reported frequent extraintestinal pain (OR, 2.9; 95% CI, 1.4-5.9), and self-reported depressive symptoms (OR, 2.4; 95% CI, 1.1-5.1). Negative life events and physical health in mothers and toddlers did not predict RAP.

CONCLUSIONS

This is the first cohort study that finds maternal psychological distress in early childhood to predict RAP in their offspring 13 years later. Our results support that maternal psychological distress and preadolescent children's depressive and somatic symptoms may play a role in the development of RAP.

Child and family psychiatric and psychological factors associated with child physical health problems: results from the Boricua youth study

To examine associations among Puerto Rican children's physical health problems and children's internalizing disorders, parental psychopathology and acculturative stress, and family factors. A population-based probability sample of 2491 Puerto Rican children, aged between 5 and 13 years, and caregivers from the South Bronx and the U.S. Commonwealth of Puerto Rico participated in this study. The parent version of the Diagnostic Interview Schedule for Children-IV was used to assess children's internalizing disorders. Children's anxiety disorders, parental psychopathology, and acculturative stress were associated with childhood asthma, abdominal pain, and headaches. Children's depressive disorders, maternal acceptance, and family functioning were associated with abdominal pain and headaches. Parents of children living in Puerto Rico were more likely to report physical health problems in their children than in the Bronx. Children's internalizing disorders, parental psychopathology, and acculturative stress may be important areas to target among Puerto Rican children with physical health problems.

Hypoalgesia related to elevated resting blood pressure is absent in adolescents and young adults with a history of functional abdominal pain

Elevated resting blood pressure (BP) is hypoalgesic in healthy individuals, but this effect is absent in adults with chronic somatic pain. This study tested whether BP-related hypoalgesia is similarly altered in individuals with a history of chronic visceral pain in childhood. Resting BP was assessed in 94 adolescents and young adults with a known history of childhood functional abdominal pain (FAP) and 55 comparable healthy controls. Responses to an acute heat pain stimulus were then evaluated following exposure to two laboratory stressors. A significant participant type x systolic BP (SBP) interaction (p<.005) revealed that elevated resting SBP was associated with significantly higher heat pain threshold (p<.001) in healthy controls, but was unrelated to pain threshold in the FAP group. A similar pattern was observed for heat pain tolerance, with elevated SBP linked to significantly higher pain tolerance (p<.05) in healthy controls, but unrelated to tolerance in the FAP group. Dysfunction in BP-related hypoalgesia associated with FAP was evident regardless of whether childhood FAP had resolved or still persisted at the time of laboratory testing. Subgroup analyses indicated that BP-related hypoalgesia (in healthy controls) and FAP-linked absence of this hypoalgesia was observed only among females. Result suggest that childhood visceral chronic pain may be associated with relatively long-lasting dysfunction in overlapping systems modulating pain and BP that persists even after FAP resolves. Potential implications for later hypertension risk are discussed.

Anxiety sensitivity and catastrophizing: associations with pain and somatization in non-clinical children

This study examined the relationships among anxiety sensitivity (AS), catastrophizing, somatization and pain in 240 non-clinical children (121 girls; mean age = 12.7 years). Children with pain problems (n = 81; 33.8%) reported greater AS and catastrophizing (ps < .01) relative to children without pain problems. AS but not catastrophizing was significantly associated with current pain. However, both AS and catastrophizing were significantly associated with somatization. AS and catastrophizing represent related but partially distinct cognitive constructs that may be targeted by interventions aimed at alleviating pain and somatization in children.

Pediatric psychogenic nonepileptic seizures: a study of assessment tools

The goal of this study was to identify assessment tools and associated behavioral domains that differentiate children with psychogenic nonepileptic seizures (PNES) from those with epilepsy. A sample of 24 children with PNES (mean age 14.0 years, 14 female), 24 children with epilepsy (mean age 13.6 years, 13 female), and their parents were recruited from five epilepsy centers in the United States. Participants completed a battery of behavioral questionnaires including somatization, anxiety, and functional disability symptoms. Children with PNES had significantly higher scores on the Childhood Somatization and Functional Disability Inventories, and their parents reported more somatic problems on the Child Behavior Checklist (CBCL). Depression, anxiety, and alexithymia instruments did not differentiate the groups. Measures of somatization and functional disability may be promising tools for differentiating the behavioral profile of PNES from that of epilepsy. Increased somatic awareness and perceived disability emphasize the similarity of PNES to other pediatric somatoform disorders.

Medical evaluation of children with chronic abdominal pain: impact of diagnosis, physician practice orientation, and maternal trait anxiety on mothers' responses to the evaluation

This study examined the effects of diagnosis (functional versus organic), physician practice orientation (biomedical versus biopsychosocial), and maternal trait anxiety (high versus low) on mothers' responses to a child's medical evaluation for chronic abdominal pain. Mothers selected for high (n=80) and low (n=80) trait anxiety imagined that they were the mother of a child with chronic abdominal pain described in a vignette. They completed questionnaires assessing their negative affect and pain catastrophizing. Next, mothers were randomly assigned to view one of four video vignettes of a physician-actor reporting results of the child's medical evaluation. Vignettes varied by diagnosis (functional versus organic) and physician practice orientation (biomedical versus biopsychosocial). Following presentation of the vignettes, baseline questionnaires were re-administered and mothers rated their satisfaction with the physician. Results indicated that mothers in all conditions reported reduced distress pre- to post-vignette; however, the degree of the reduction differed as a function of diagnosis, presentation, and anxiety. Mothers reported more post-vignette negative affect, pain catastrophizing, and dissatisfaction with the physician when the physician presented a functional rather than an organic diagnosis. These effects were significantly greater for mothers with high trait anxiety who received a functional diagnosis presented by a physician with a biomedical orientation than for mothers in any other condition. Anxious mothers of children evaluated for chronic abdominal pain may be less distressed and more satisfied when a functional diagnosis is delivered by a physician with a biopsychosocial rather than a biomedical orientation.

Determinants of somatic complaints in 18-month-old children: the generation R study

OBJECTIVE

To investigate the effect of child temperament, maternal psychologic symptoms, maternal chronic pain, and parenting stress on children's somatic complaints.

METHODS

The study was embedded in the Generation R Study, a population-based cohort study. Child somatic complaints were assessed via mother-report in 5,171 children of 18 months of age. Questionnaires assessed maternal somatic symptoms, symptoms of depression, anxiety during pregnancy and 2 months after delivery, maternal chronic pain during pregnancy, parenting stress 18 months after birth, and mother-reported child temperament 6 months after birth, as the determinants.

RESULTS

Fearful temperament, temperamental falling reactivity, maternal somatic symptoms, anxiety symptoms, and parenting stress each independently and prospectively increased the likelihood of children's somatic complaints at 18 months of age.

CONCLUSIONS

In toddlers, temperament, maternal stress, and maternal somatic symptoms seem particularly important for the development of somatic complaints, but long-term research is needed to establish causality and predictive value of these factors.

Irritable bowel syndrome in childhood: visceral hypersensitivity and psychosocial aspects

Visceral hypersensitivity is often considered to play a major etiologic role in the pathophysiology of irritable bowel syndrome in adults, and some authors argue that this increased sensitivity is mainly due to psychological factors. In contrast, there are no data in children with irritable bowel syndrome which confirm this relationship. The aim of the study was to evaluate the relationship between psychosocial aspects and sensorymotor function in children affected by irritable bowel syndrome. Ten children fulfilling the Rome II criteria for irritable bowel syndrome and seven healthy controls were enrolled. We studied the thresholds and the perception of visceral stimuli in the rectum by means of an electronic barostat (isobaric phasic distentions, 3 mmHg/1 min, interval 1 min) and a validated questionnaire. Personality features were evaluated by means of the Big Five Questionnaire for Children. Sleep, mood disturbance, anxiety and individual performance (missed school days, school results and social activities) were also evaluated. Children with irritable bowel syndrome showed significantly lower thresholds for discomfort (14.8 +/- 3.5 vs 22.3 +/- 6.9 mmHg, P = 0.010) and a higher cumulative perception score (28.2 +/- 11.1 vs 12.3 +/- 8.0, P = 0.005) compared with healthy controls. A higher emotional instability (57.8 +/- 7.0 vs 48.7 +/- 10.1, P = 0.047), sleep disturbance (7.2 +/- 1.0 vs 9.3 +/- 0.5, P = 0.004) and anxiety (6.3 +/- 2.0 vs 2.3 +/- 1.7, P = 0.009) were observed in irritable bowel syndrome patients. Moreover, in a multivariate analysis, the cumulative perception score was significantly related to emotional instability (P = 0.042). In conclusion children with irritable bowel syndrome exhibit visceral hypersensitivity and psychosocial impairment. Emotional instability, as a personality feature in these children, seems to modulate the perception response to visceral stimulations.

Autonomic activity and somatic symptoms in response to success vs. failure on a cognitive task: a comparison of chronic abdominal pain patients and well children

OBJECTIVES

To compare autonomic nervous system (ANS) activity and somatic symptoms in chronic abdominal pain (CAP) patients and well children during (a) resting baseline, (b) training in a cognitive task, and (c) random assignment to success vs. failure on the task.

METHODS

The ECG was continuously recorded with a dual lead system (Biopac) in 45 CAP patients and 22 well children, ages 9-16 years (mean age=12.3). Heart rate variability (HRV) was analyzed during the 5-min resting baseline, training, and success/failure on the task. Performance expectations were assessed before the task. Gastrointestinal (GI) and non-GI somatic symptoms were assessed before and after the task.

RESULTS

Compared to well children, CAP patients reported lower expectations for their task performance and higher GI symptoms (P's<.05). During success, CAP patients exhibited significant increases in both sympathetic (P<.05) and parasympathetic (P<.05) activity, whereas well children exhibited no change in ANS activity. During failure, CAP patients exhibited significant increases in somatic symptoms (<.05) but no change in ANS activity.

CONCLUSIONS

The lower performance expectations of CAP patients compared to well children may have influenced their experience of success and contributed to differences in their autonomic activity.

Functional gastrointestinal disorders: past and present

BACKGROUND

Chronic abdominal pain is a common complaint in childhood and adolescence. Despite decades of clinical observations and research, it still poses a challenge to pediatric health care professionals. The aim of this review is to highlight the epidemiology of pediatric chronic abdominal pain and to describe the pathogenesis of this disorder, its clinical manifestations, evaluation and therapeutic options.

DATA SOURCES

Articles on chronic abdominal pain in the recent years from PubMed, MEDLINE, and reference textbooks were reviewed.

RESULTS

Chronic abdominal pain, a functional gastrointestinal disorder (FGID), is a multifactorial condition that results from a complex interaction between psychosocial and physiologic factors via the brain-gut axis. A thorough history coupled with a complete physical examination and normal screening studies rule out an organic cause in 95% of the cases. It is highly important for the physician to establish a trusting relationship with the child and parents because successful treatment including modification of physical and psychological stress factors, dietary changes, and drug therapy depends greatly on education, reassurance and active psychological support.

CONCLUSIONS

FGIDs are a cause of great anxiety, distress and morbidity in children as well as adults. As our understanding of these conditions improves, our therapeutic interventions will progress not only to overcome them but also to intervene early in the disease course so as to limit long-term impact.

Psychosocial predictors of somatic symptoms in adolescents of parents with HIV: a six-year longitudinal study

The objective of this study was to identify salient parent and adolescent psychosocial factors related to somatic symptoms in adolescents. As part of a larger intervention study conducted in New York, 409 adolescents were recruited from 269 parents with HIV. A longitudinal model predicted adolescent somatization scores six years after baseline assessment. Adolescent somatic symptoms were assessed at baseline and at 3-month intervals for the first two years and then at 6-month intervals using the Brief Symptom Inventory. Baseline data from adolescents and parents were used to predict adolescent somatic symptoms. Variables related to increased adolescent somatic symptoms over six years included being younger and female; an increased number of adolescent medical hospitalizations; more stressful life events; adolescent perception of a highly rejecting parenting style; more parent-youth conflict; no experience of parental death; and parental distress over their own pain symptoms. Our findings extend the literature by virtue of the longitudinal design; inclusion of both parent and child variables in one statistical model; identification of study participants by their potentially stressful living condition rather than by disease or somatic symptom status; and inclusion of serious parental illness and death in the study.

Psychiatric disorders and family functioning in children and adolescents with functional abdominal pain syndrome

BACKGROUND AND AIM

Functional abdominal pain syndrome (FAPS) is a functional gastrointestinal disorder. There is a heightened risk when conducting potentially dangerous and unnecessary medical investigations and procedures in children with FAPS. The aim of this study was to survey the rate of the psychiatric disorders and family functioning in children and adolescents with FAPS.

METHODS

The subjects were a consecutive new sample of 45 children and adolescents with FAPS, 45 with an organic abdominal pain, and 45 pain-free comparison subjects aged 5-18 years that were interviewed using the Farsi version of K-SADS. Family functioning and the severity of pain were also studied.

RESULTS

About 51.1% of patients with FAPS suffered from at least one psychiatric disorder. Psychiatric disorders in the FAPS patients studied included general anxiety disorder (8.9%), obsessive-compulsive disorder (11.1%), attention deficit hyperactivity disorder (15.6%), separation anxiety disorder (24.4%), and major depressive disorder (15.6%). Except for generalized anxiety disorder and tic disorder, the other disorders were significantly more common in the FAPS group than in the two other control groups. Family functioning scores were not significantly different between groups.

DISCUSSION

There is a high rate of psychiatric disorders in children and adolescents with FAPS in Iran, but our study found fewer incidences of disorders than previous reports have indicated. Family dysfunction difficulties in FAPS children are not more common than those in the control groups.

Anxiety and somatic complaints in children with recurrent abdominal pain and anxiety disorders

OBJECTIVE

To compare anxiety symptoms and disorders in children and adolescents with recurrent abdominal pain (RAP), anxiety disorders, and healthy control children.

METHODS

Twenty-one children with RAP (nine males, mean age = 11.05) were compared to 21 children with anxiety disorders (11 males, mean age = 12.29), and 21 children without pain or anxiety (nine males, mean age = 11.57) using diagnostic interviews and continuous measures of anxiety and other internalizing symptoms.

RESULTS

Sixty-seven percent of children with RAP met criteria for an anxiety disorder. Children with RAP were higher than well children but not significantly different from children with anxiety on total internalizing and anxiety symptoms.

CONCLUSIONS

RAP and anxiety are closely related. Further understanding between these disorders is essential to understanding the development and progression of RAP, and to inform the prevention and treatment of the disorder.

Pain Catastrophizing Scale for Francophone Adolescents: a preliminary validation

BACKGROUND

In adults, it is well known that high levels of pain catastrophizing are related to increased pain and disability as well as to heightened anxiety and depression. However, due to the lack of a measure of pain catastrophizing adapted for francophone adolescents, little is known about the role of catastrophizing in this population.

OBJECTIVES

To adapt the French version of the Pain Catastrophizing Scale (PCS) and to examine the psychometric properties and factorial structure of the PCS for Francophone Adolescents (PCS-Ado).

METHODS

The French version of the PCS was modified by a group of experts. The format of the questions was modified to be appropriate for adolescents aged between 12 and 18 years. To assess the psychometric properties of the PCS-Ado, 345 adolescents completed the PCS-Ado and questionnaires measuring depression, anxiety and intensity of pain. Twelve to 16 weeks later, participants completed the questionnaires again to examine the test-retest reliability of the PCS-Ado.

RESULTS

Results revealed a three-factor solution similar to the original PCS. In addition, results revealed that PCS-Ado had good internal consistency (PCS-Ado total: 0.85; rumination: 0.72; magnification: 0.66; helplessness: 0.74), and high test-retest reliability (r=0.73). Finally, significant correlations among catastrophizing, depression, anxiety and pain intensity support the construct validity of the PCS-Ado.

CONCLUSIONS

The results suggest that the PCS-Ado is valid and reliable with francophone adolescents. Further research is required to assess the validity of the PCS-Ado in clinical settings.

Seasonal variation in the presentation of abdominal pain

BACKGROUND

Anxiety and depression, conditions frequently associated with childhood chronic abdominal pain (AP), are characterized by seasonal exacerbations. A seasonal pattern characterized by a higher frequency of consultations for AP during winter has been suspected but has never, to our knowledge, been demonstrated. We hypothesize the presence of a seasonal variation in AP consultations with a winter predominance.

AIMS

To determine the seasonal distribution of AP consultations among centers across time and geographic latitude.

PATIENTS AND METHODS

This was a retrospective cohort study. The number of outpatient consultations from primary care clinics and every pediatric specialty clinic that resulted in a diagnosis of AP and the total number of outpatient consultations (2001-2004) from 6 tertiary care institutions (Chicago, Pittsburgh, Wilmington, Pensacola, Orlando, Jacksonville) was determined. Rates of consultations were compared across time and between cities. Four time periods of interest, with 2- and 3-month definitions, were arbitrarily selected. Seasonal rates across time were compared separately for each of the 2-month (January-February vs June-July) and 3-month periods (January-March vs June-August). Logistic regression models for each city were used to determine variations in the rate of outpatient AP cases by season or by year.

RESULTS

A total of 3,929,522 outpatient consultations and 73,591 AP consultations were analyzed. The rates of AP consultations were consistently higher in the winter months at all of the sites. The results differed between sites at northern and southern latitudes.

CONCLUSIONS

There seems to be a seasonal variation in consultation patterns for AP at the tertiary care level. A possible role of daylight hours, climate, latitude, and stress is proposed.

Recurrent abdominal pain in school children: effect of obesity and diet

AIMS

To study the epidemiology and some of the risk factors of childhood recurrent abdominal pain (RAP) in school age children.

METHODS

We used a questionnaire concerning socioeconomic parameters, intensity, frequency, duration, nature of RAP and anthropometric measures. We used several criteria to identify RAP and the Wong-Baker FACES scale for pain intensity and calculated the gender/age-specific body mass index (BMI) Z-score using NCHS standards. Obesity was defined as a BMI>or=95th percentile for age and gender.

RESULTS

A total of 925 children mean age of 9.5 years completed and returned the questionnaires. The prevalence of RAP was 24%; 22% among boys versus 26% among girls (p=0.28) and reached its peak among children aged 7-9 (29%) years. Children with BMI>or=95% percentile reported more RAP compared to those not obese (33.3% vs. 22.5%) (OR=1.8, p=0.01). There was an inverse correlation between fruit consumption and RAP prevalence with 20% among children reporting more than three serving of fruit per week compared to 40% of those who did not consume any fruits (p<0.002). Logistic regression analysis confirmed BMI>or=95th percentile and low consumption of fruits are significant risk factors for RAP.

CONCLUSIONS

There is a significant association between RAP and obesity and both conditions are prevalent among children in this population. Understanding more about the co-morbidity between RAP and obesity could have important implications on RAP management and treatment.

Relationships among anxious symptomatology, anxiety sensitivity and laboratory pain responsivity in children

Existing laboratory-based research in adult samples has suggested that anxiety sensitivity (AS) increases an individual's propensity to experience pain-related anxiety, which in turn enhances pain responsivity. Such relationships have not been examined in younger populations. Thus, the present study used structural equation modeling (SEM) to test a conceptual model in which AS would evidence an indirect relationship with pain intensity via its contribution to state-specific anticipatory anxiety in relation to a variety of laboratory pain tasks (cold pressor, thermal heat, and pressure pain) in 234 healthy children (116 girls; mean age = 12.6 years, range = 8-18 years). The model further hypothesized that existing anxious symptomatology would demonstrate a direct relationship with pain intensity. Results of the SEM supported the proposed conceptual model with the total indirect effect of AS accounting for 29% of the variance in laboratory pain intensity via its effects on pain-related anticipatory anxiety. AS did not however, evidence a direct relationship with pain intensity. Anxious symptomatology on the other hand, demonstrated a significant direct effect on pain intensity, accounting for 15% of variance. The combined effects of AS, anxiety symptoms, and anticipatory anxiety together explained 62% of the variance in pain intensity. These relationships did not differ for boys and girls, indicating no moderating effect of sex in the proposed model. The present results support the potential benefit of assessing both AS and anxiety symptoms in children prior to undergoing painful stimulation.

A Review of Psychological Models and Interventions for Medically Unexplained Somatic Symptoms in Children

The aim of this review is to outline the various psychological models of medically unexplained somatic symptoms in children and the interventions derived from these. The interventions that have been evaluated in randomised controlled trials are reviewed, and the implications of the findings for the models are described.

Multiple somatic symptoms linked to positive screen for depression in pediatric patients with chronic abdominal pain

OBJECTIVES

Abdominal pain is a frequent childhood complaint, comprising 2% to 4% of all reasons for pediatric office visits. Patients referred for evaluation of chronic abdominal pain (CAP) frequently present with comorbid nonspecific somatic symptoms that may complicate the medical evaluation and lead to unnecessary diagnostic tests and procedures. We tested the hypothesis that multiple nongastrointestinal (GI) symptoms in children presenting with CAP is a marker for clinically significant levels of depressive symptoms.

METHODS

Participants were 400 consecutive new patients (ages 8-17 years; 63% female) referred to the pediatric gastroenterology clinic for evaluation of abdominal pain of > 3 months' duration. Patients reported how frequently they experienced 7 non-GI symptoms. Patients were screened for depression with the Children's Depression Inventory.

RESULTS

On the basis of their Children's Depression Inventory scores, 58 (15%) patients had a positive screen for clinically significant depressive symptoms. Patients with a positive versus negative depression screen did not differ by sex, pain duration or laboratory evidence of organic disease. Patient report of > or = 3 non-GI symptoms maximized sensitivity (71%) and specificity (75%) in prediction of depression screening results. With each addition of a non-GI symptom, the odds of a positive screen for depression doubled.

CONCLUSIONS

For patients with and without organic disease findings associated with CAP, the presence of > or = 3 non-GI symptoms should signal the practitioner to evaluate for depression and may be used as an indicator of the likelihood of depression in the absence of specific inquiry into emotional symptoms.

'Needs expressed' and 'offers of care': an observational study of mothers with somatisation disorder and their children

BACKGROUND

The abnormal illness behaviours characterising somatisation disorder may be learnt responses acquired through exposure to parental illness and health anxiety in childhood. In this observational STUDY WE EXPLORE THIS HYPOTHESIS BY EXAMINING PATTERNS OF INTERACTION IN MOTHERS AND THEIR SCHOOL AGE CHILDREN.

METHOD

A sample of 136 mother and child pairs in 3 groups (42 mothers with somatisation disorder, 44 organically ill mothers and 50 healthy mothers) completed a battery of self-report and interview measures. Their interaction in semi-structured play tasks and a meal was videotaped and later analysed for the presence of 'needs' and 'offers of care' by researchers who were blind to maternal group membership.

RESULTS

During play, a greater proportion of the children of somatising mothers expressed 'health and safety' needs than did children of other mothers. In contrast, during a meal, these children expressed fewer needs of all types. Children of somatising mothers were more likely than other children to ignore their mothers' offers of care. The somatising mothers expressed more health and safety needs during the meal than did other mothers and were generally less responsive to all needs expressed by their children.

CONCLUSIONS

Our study suggests that mothers with somatisation disorder and their children interact differently than other mother-child pairs. This finding supports the theory for environmental influences in the development of this disorder.

Evaluation of guided imagery as treatment for recurrent abdominal pain in children: a randomized controlled trial

Background

Because of the paucity of effective evidence-based therapies for children with recurrent abdominal pain, we evaluated the therapeutic effect of guided imagery, a well-studied self-regulation technique.

Methods

22 children, aged 5 – 18 years, were randomized to learn either breathing exercises alone or guided imagery with progressive muscle relaxation. Both groups had 4-weekly sessions with a therapist. Children reported the numbers of days with pain, the pain intensity, and missed activities due to abdominal pain using a daily pain diary collected at baseline and during the intervention. Monthly phone calls to the children reported the number of days with pain and the number of days of missed activities experienced during the month of and month following the intervention. Children with ≤ 4 days of pain/month and no missed activities due to pain were defined as being healed. Depression, anxiety, and somatization were measured in both children and parents at baseline.

Results

At baseline the children who received guided imagery had more days of pain during the preceding month (23 vs. 14 days, P = 0.04). There were no differences in the intensity of painful episodes or any baseline psychological factors between the two groups. Children who learned guided imagery with progressive muscle relaxation had significantly greater decrease in the number of days with pain than those learning breathing exercises alone after one (67% vs. 21%, P = 0.05), and two (82% vs. 45%, P < 0.01) months and significantly greater decrease in days with missed activities at one (85% vs. 15%, P = 0.02) and two (95% vs. 77%. P = 0.05) months. During the two months of follow-up, more children who had learned guided imagery met the threshold of ≤ 4 day of pain each month and no missed activities (RR = 7.3, 95%CI [1.1,48.6]) than children who learned only the breathing exercises.

Conclusion

The therapeutic efficacy of guided imagery with progressive muscle relaxation found in this study is consistent with our present understanding of the pathophysiology of recurrent abdominal pain in children. Although unfamiliar to many pediatricians, guided imagery is a simple, noninvasive therapy with potential benefit for treating children with RAP.

Pain in Adolescent Psychiatric Patients

BACKGROUND

  Little is known about the extent of pain among adolescent psychiatric patients, and the relationships with psychosocial factors and psychiatric symptoms.

METHOD

  A representative sample of 129 adolescent patients were assessed with measures including the Youth Self-Report, the Mood and Feelings Questionnaire, and instruments assessing self-perceptions, coping styles, stresses, sociodemographic factors, and childhood abuse.

RESULTS

  More than half of the adolescents (54%) reported to be bothered currently by frequent pain. Frequent pain correlated with depression, self-harm, suicide attempt, and with ruminative and emotion oriented coping. Adolescents suffering from frequent pain had more often experienced childhood abuse/neglect. A stepwise multiple regression analysis revealed that depression, alcohol intoxication and childhood neglect were the strongest concurrent predictors of frequent pain.

CONCLUSIONS

  Clinicians should ask child and adolescent psychiatric patients about pain, and be aware of possible connections with abuse/neglect, depression and suicidality.

Functional Symptoms and Somatoform Disorders in Children and Adolescents: The Role of Standardised Measures in Assessment

Functional or unexplained medical symptoms (physical symptoms that are not adequately explained by organic factors and where a major role for psychological factors is assumed) are common amongst children in the general population but can also be an expression of somatisation and somatoform disorders. Co-morbid psychopathology is common. We describe measures mostly used in research into problems related to somatisation in children and adolescents that may be helpful to clinical researchers. Some address the nature and severity of physical symptoms, others document illness attitudes, beliefs and functional impairment, and a third group assesses emotional symptoms. Questionnaires can be helpful for clinicians in quantifying (i) the nature and severity of somatic symptoms and associated functional impairment, (ii) contributory health attitudes and illness beliefs and (iii) co-morbid or primary anxiety and depressive disorders. Together with pain and activity diaries and careful documentation of school attendance, these measures may also be helpful in monitoring treatment response.

Psychiatric, somatic, and gastrointestinal disorders, and Helicobacter pylori infection in children with recurrent abdominal pain

AIMS

To examine the utility of the Rome II criteria in children with recurrent abdominal pain (RAP) and compare them to those who met Apley's criteria and those who met neither criteria.

METHODS

Prospective study in general paediatric clinics in Komagane, Japan. Children with abdominal pain were classified into those who met Rome II criteria, those who met Apley's criteria, and those who met neither.

RESULTS

A total of 182 children with RAP participated; 45 children met Rome II criteria, 55 met Apley's criteria, and 82 met neither. Children who met Rome II criteria had a significantly higher prevalence of psychiatric and somatic disorders compared to the group met neither (36% v 6%, 22% v 10%, respectively). The overall prevalence of H pylori was 7%; prevalence increased with age from 3% at age < or = 10 to 10% for children >10 years. Children who met Rome II criteria had a significantly higher prevalence of H pylori infection than the reference group (18% v 4%). In a logistic regression model, all the study variables were included in the model specifying first the Rome II criteria group as the independent variable; psychiatric disorders, H pylori infection, and older age group were independent risk factors.

CONCLUSIONS

More than half the children suffering from recurrent abdominal pain met neither Apley's nor Rome II criteria. Children who meet Rome II criteria should be evaluated for psychiatric disorders and should be tested for H pylori infection. Despite the overall trend for a fall in the prevalence of H pylori infection among children in Japan, there are subpopulations of sick children where the prevalence of the infection is relatively high.

Diurnal salivary cortisol concentration in school-aged children: increased morning cortisol concentration and total cortisol concentration negatively correlated to body mass index in children with recurrent abdominal pain of psychosomatic origin

INTRODUCTION

The sampling method for salivary cortisol is sensitive, specific and pain-free. Our knowledge about cortisol concentration in saliva and plasma in school-aged children is sparse and contradictory.

AIM

To estimate diurnal variation in salivary cortisol concentration in children with and without psychosomatic recurrent abdominal pain (RAP), and to compare groups and relate the concentrations to age, sex, puberty, body mass index (BMI), allergy, headache and ethnicity. CHILDREN AND METHOD: Saliva was collected in 'Salivette' tubes from 159 healthy girls and 147 healthy boys, aged 5-15 years, and from 25 girls and 6 boys, aged 6-18 years, with RAP of psychosomatic origin, at 08.00 h, 13.00 h and 20.00 h. Saliva was analysed using a commercial RIA-cortisol kit.

RESULTS

The median concentrations in healthy girls and boys were 8.8/8.3 nmol/l at 08.00 h, 5.5/5.3 nmol/l at 13.00 h, and 2.1/2.3 nmol/l at 20.00 h, respectively. Cortisol concentrations differed between 6-7 year-old and 9 year-old children (higher in the former). Age-matched post-menarcheal girls had higher cortisol concentrations in the evening, 2.2 vs 1.7 nmol/l (p = 0.03). The results were independent of BMI, headache and allergy. In the RAP group, diurnal cortisol concentrations in girls/boys at the different time-points were 14.8/12.9, 5.2/5.8, and 2.4/2.7 nmol/l, respectively, and were negatively correlated to BMI. Total secretion of cortisol was higher than in healthy children. Cortisol concentration was independent of allergy, headache and ethnicity,

CONCLUSION

In healthy children, salivary cortisol concentration was dependent on time, age and menarche. In children with RAP of psychosomatic origin, morning and total secretion of cortisol were significantly higher than in healthy children and negatively correlated to BMI.

Trajectories of symptoms and impairment for pediatric patients with functional abdominal pain: a 5-year longitudinal study

OBJECTIVE

This prospective study characterizes trajectories of symptoms and impairment in pediatric patients with abdominal pain not associated with identifiable organic disease.

METHOD

The Children's Somatization Inventory and the Functional Disability Inventory were administered four times over 5 years to 132 patients (6-18 years old) seen in a pediatric gastroenterology clinic. Individual trajectories were empirically grouped and correlates of trajectory group membership at baseline were evaluated.

RESULTS

A model with three unique trajectories was found to adequately fit both symptom and impairment data. Two trajectories indicated relatively long-term improvement and one indicated continued high levels of symptoms and impairment. At baseline, the long-term risk group did not have the most severe pain but had significantly more anxiety, depression, lower perceived self-worth, and more negative life events.

CONCLUSIONS

These results indicate that several distinct trajectories of relatively long-term outcomes may exist in children with functional abdominal pain. One trajectory indicated long-term risk for a high level of symptoms and impairment. Psychosocial correlates of long-term risk for physical symptoms and impairment, such as child-reported stress and internalizing symptoms, may be useful for treatment planning.

Early parental and child predictors of recurrent abdominal pain at school age: results of a large population-based study

OBJECTIVE

To assess whether parental psychological and physical factors and child factors measured in the first year of life were associated with recurrent abdominal pain (RAP) in children at age 6(3/4) years.

METHOD

A longitudinal cohort study (the Avon Longitudinal Study of Parents and Children), followed 8,272 children from pregnancy to age 6(3/4) years. Parental reports of child and parent functioning were gathered. Associations between parental and child functioning assessed at 6 to 8 months postpartum, and RAP measured at age 6(3/4) years were investigated.

RESULTS

The prevalence of RAP in this sample was 11.8%. Both maternal anxiety (adjusted odds ratio = 1.53; 95% confidence interval 1.24-1.89) and paternal anxiety (adjusted odds ratio = 1.38; 95% confidence interval 1.12-1.71) in the first year of a child's life were associated with later childhood RAP. Parent reports of child temperament features such as irregular feeding and sleeping were also associated with later RAP.

CONCLUSIONS

This is the first evidence from a prospective study that anxiety in both mothers and fathers and child temperament features predate the occurrence of RAP in children. These findings highlight the potential importance of addressing parental anxiety in families in which children present with RAP, although some caution should be exercised in their interpretation because of possible reporting bias.

Nonepileptic seizures treatment workshop summary

In May 2005, an international, interdisciplinary group of researchers gathered in Bethesda, MD, USA, for a workshop to discuss the development of treatments for patients with nonepileptic seizures (NES). Specific subgroup topics that were covered included: pediatric NES; presenting the diagnosis of NES, outcome measures for NES trials; classification of NES subtypes; and pharmacological treatment approaches and psychotherapies. The intent was to develop specific research strategies that can be expanded to involve a large segment of the epilepsy and psychiatric treatment communities. Various projects have resulted from the workshop, including the initial development of a prospective randomized clinical trial for NES.

Psychological correlates of depression in children with recurrent abdominal pain

OBJECTIVE

To examine the associations between coping style, social support, self-efficacy, locus of control, maternal adjustment, and depressive symptoms in children with recurrent abdominal pain (RAP) of childhood.

METHODS

Fifty children with RAP (8-18 years) and their mothers were recruited from a gastroenterology clinic (GI) and community medical practices. Participants completed questionnaires that assessed coping style, social support, self-efficacy, locus of control, maternal adjustment, and psychological adjustment.

RESULTS

Passive coping strategies such as isolating oneself from others, catastrophizing, and behavioral disengagement were associated with more child-reported depressive symptoms. Higher levels of self-efficacy and greater social support from teachers and classmates were associated with fewer child-reported depressive symptoms. Higher levels of maternal adjustment problems, higher social support from parents, and lower social support from classmates were associated with maternal reports of more child internalizing symptoms.

CONCLUSIONS

These findings suggest that coping style, self-efficacy, social support, and maternal adjustment are correlates of depressive symptoms in children with RAP.

[Risk factors for back pain in children and adolescents]

Factors that have led to the increasing prevalence of back pain amongst children and adolescents living in industrialized nations are mostly unknown. The following literature review was aimed at determining the risk factors for back pain amongst children and adolescents. We searched both PUBMED and MEDLINE between the years 1985 and 2003 for the keywords "children or adolescents" and "back pain". Only data published in original articles were used. The risk for suffering back pain is influenced by physical, behavioural, emotional and social factors. The effects of physical activity, sitting, muscle status, weight of schoolbags, exercise, television and computer use, as well as age and gender on the development of back pain in children and adolescents were examined. Associations between continuous or recurring back pain and psychosocial factors (lifestyle, emotional factors, social relationships) could be demonstrated. There was no relationship between changes of the spine seen by radiological tests and the development of chronic back pain. Longitudinal epidemiological studies are urgently needed to delineate the risk factors for the development as well as the natural history of chronic back pain in the young.

Quality of life for children with functional abdominal pain: a comparison study of patients' and parents' perceptions

OBJECTIVE

Children with chronic abdominal pain of nonorganic origin, termed functional abdominal pain (FAP), experience school absences and social withdrawal and report impaired physical ability. The aim of this study was to assess patients' and parents' perceptions of health-related quality of life (QoL) for children with FAP.

METHODS

Between October 2002 and November 2003, 209 children (including 125 girls; age: 11.2 +/- 3.5 years) and 209 parents were recruited from a pediatric referral center. At the time of their initial evaluations, participants completed a validated, health-related QoL instrument (Pediatric Quality of Life Inventory), which was scored on a scale of 0 (poor) through 100 (best). Children with FAP (n = 65) and their families were compared with control groups of healthy children (n = 46) and children with histologically proven inflammatory bowel disease (IBD) (n = 42) or gastroesophageal reflux disease (GERD) (n = 56).

RESULTS

Children with FAP had self-reported QoL scores (score: 78) that were similar to those for children with GERD (score: 80) or IBD (score: 84). Children with FAP had lower QoL scores than did healthy children (score: 88). Parents of children with FAP reported lower QoL scores, compared with their children's scores (scores: 70 vs 78).

CONCLUSIONS

Children with FAP reported lower QoL, compared with their healthy peers, and had the same QoL scores as did children with IBD or GERD. Parents' perceptions of QoL for children with FAP were lower than their children's self-reported scores. These findings highlight the clinical significance of FAP and may provide insight into one facet of the disease's biopsychosocial etiology.