Recurrent abdominal pain and headache--psychopathology, life events and family functioning

The association between parent mental health and pediatric chronic pain: a systematic review and meta-analysis

ABSTRACT

Mental health problems are common among parents of children with chronic pain and associated with worse outcomes for the child with chronic pain. However, the effect sizes of these associations between parent mental health and pediatric chronic pain vary widely across studies. The aim of this systematic review and meta-analysis was to generate pooled estimates of the (1) prevalence of mental health problems among parents of children with chronic pain and (2) associations between parent mental health and the (2a) presence of child chronic pain and (2b) functioning of children with chronic pain. Embase, MEDLINE, PsycINFO, Web of Science, and CINAHL were searched up to November 2022. Observational studies that examined symptoms or diagnoses of parent anxiety, depression, or general distress and the presence of child chronic pain and/or related functioning were included. From 32,848 records, 2 coders identified 49 studies to include in random-effects meta-analyses. The results revealed that mental health problems among parents of children with chronic pain were common (anxiety: 28.8% [95% CI 20.3-39.1]; depression: 20.0% [15.7-25.2]; general distress: 32.4% [22.7-44.0]). Poorer parent mental health was significantly associated with the presence of chronic pain (anxiety: OR = 1.91 [1.51-2.41]; depression: OR = 1.90 [1.51-2.38]; general distress: OR = 1.74 [1.47-2.05]) and worse related functioning (ie, pain intensity, physical functioning, anxiety and depression symptoms; r s = 0.10-0.25, all P s < 0.05) in children. Moderator analyses were generally nonsignificant or could not be conducted because of insufficient data. Findings support the importance of addressing parent mental health in the prevention and treatment of pediatric chronic pain.

Should pediatric cardiologists refer all patients with unexplained chest pain to a psychiatrist?

OBJECTIVE

The present study aimed to investigate the relationship between unexplained chest pain in children with parents' mental problems, parental attitudes, family functionality, and the child's mental problems.

MATERIAL AND METHOD

A total of 433 children (between 11 and 18 years of age) applied to the Pediatric Cardiology Outpatient Clinic due to chest pain in the last year. A clinical interview was conducted by a child psychiatrist with 43 patients and 33 controls included in the study due to unexplained chest pain.

RESULTS

Family history of physical illness was significantly higher in the chest pain group. When evaluated in terms of psychosocial risk factors, life events causing difficulties, derangement in the family, loss of a close person, and exposure to violence were statistically significantly higher in the group with chest pain. Mental disorders were observed in 67.4% of the children in the chest pain group as a result of the clinical interview. The total score of the DSM-5 somatic symptoms scale, which evaluates other somatic complaints in the chest pain group, was also significantly higher. When the family functions of both groups were evaluated, communication, emotional response, behaviour control, and general functions sub-dimensions were statistically significantly higher in families in the chest pain group.

CONCLUSION

We recommend that psychiatric evaluation be included in diagnostic research to prevent unnecessary medical diagnostic procedures in children describing unexplained chest pain, as well as to prevent the potential for diagnosing mental disorders in both children and adults.

How Perceptions of Parents' Parenting Behaviors Pave the Way to Somatic Symptoms: The Mediating Role of Emotion Regulation Among Adults

The purpose of this study was to investigate adult participants' reflections on their parents' parenting behaviors during childhood (parental overprotection and parental rejection), and their current emotion-regulation strategies and somatic symptoms. The study consisted of 627 participants and Somatization subscale of the Symptom Checklist-90-Revised, Difficulties in Emotion Regulation Scale and Short EMBU Children Form were given to the participants. Four different multiple mediation analyses were conducted to test mediator roles of emotion regulation difficulties between perceptions of the parenting behaviors (parental overprotection and rejection) and somatic symptoms among adults. Participants' lack of goals and lack of strategies while dealing with negative emotions mediated the relationship between mother/father rejection and somatic symptoms. However, only participants' lack of strategies while dealing with negative emotions mediated the relationship between mother/father overprotection and somatic symptoms. As a clinical implication, problem-focused coping strategies may assist adults with somatic symptoms. Also, mental health practitioners may focus on perceptions of overprotective and rejecting parental behaviors while formulizing somatic symptoms of the adult patients. Findings, strengths and limitations of this study were discussed in the light of the literature.

Family Functioning in Pediatric Functional Gastrointestinal Disorders: A Systematic Review

OBJECTIVE

Children with some chronic health conditions experience family functioning difficulties. However, research examining family functioning in youth with functional gastrointestinal disorders (FGIDs) has produced mixed results. Therefore, the current review critically synthesized the literature on family functioning among youth with FGIDs.

METHODS

A systematic search using pediatric, family functioning, and FGID search terms was conducted in PubMed, PsycInfo, and ProQuest. Out of the 586 articles initially identified, 17 studies met inclusion criteria. Studies were included if they presented original research in English, assessed family functioning, and the study sample consisted of children (0-18 years) diagnosed with a FGID. Quality assessment ratings were conducted for each included study based on a previously developed scientific merit 3-point rating system.

RESULTS

The majority of studies (n = 13) examined family functioning between youth with FGIDs and comparison groups. The remaining studies explored associations between family functioning and study variables (e.g., child psychosocial functioning and sociodemographic factors) and examined family functioning clusters among children with FGIDs. In general, children with FGIDs demonstrated poorer family functioning compared to healthy counterparts. Findings also suggested that child psychosocial functioning, disease characteristics, and sociodemographic factors were related to family functioning among youth with FGIDs. The average quality of studies was moderate (M = 2.3).

CONCLUSIONS

Maintaining healthy family functioning appears to be challenging for some families of children with FGIDs. Future research should explore the directionality of the relationship between family functioning and child physical and psychosocial outcomes to advance the understanding and treatment of pediatric FGIDs.

[The Coupling of Pain, Anxiety, and Stress]

The Coupling of Pain, Anxiety, and Stress Abstract. There is considerable neurobiological, clinical and epidemiological evidence that the systemic phenomena of anxiety and pain closely interact. Both perceptions trigger stress activation processes and are in turn modulated by long-term stress. This overview illustrates the coupling of pain, anxiety and stress with some clinical examples. The relations shown here should help us to gain a holistic view of the individual patient and his/her psychosocial reality, in which nociceptive, affective and vegetative symptoms are often interdependent and mutually reinforcing each other.

Lifestyle Modifications to Help Prevent Headache at a Developmental Age

Headache is the world's seventh most significant cause of disability-adjusted-life in people aged between 10 and 14 years. Therapeutic management is based on pharmacological approaches and lifestyle recommendations. Many studies show associations between each migraine-promoting lifestyle, behavioral triggers, frequency, and intensity of headaches. Nevertheless, the overall aspects of this topic lack any definitive evidence. Educational programs advise that pediatric patients who suffer from migraines follow a correct lifestyle and that this is of the utmost importance in childhood, as it will improve quality of life and assist adult patients in avoiding headache chronicity, increasing general well-being. These data are important due to the scarcity of scientific evidence on drug therapy for prophylaxis during the developmental age. The "lifestyle recommendations" described in the literature include a perfect balance between regular sleep and meal, adequate hydration, limited consumption of caffeine, tobacco, and alcohol, regular physical activity to avoid being overweight as well as any other elements causing stress. The ketogenic diet is a possible new therapeutic strategy for the control of headache in adults, however, the possible role of dietary factors requires more specific studies among children and adolescents. Educational programs advise that the improvement of lifestyle as a central element in the management of pediatric headache will be of particular importance in the future to improve the quality of life of these patients and reduce the severity of cephalalgic episodes and increase their well-being in adulthood. The present review highlights how changes in different aspects of daily life may determine significant improvements in the management of headaches in people of developmental age.

The Co-occurrence of Pediatric Chronic Pain and Anxiety: A Theoretical Review of a Developmentally Informed Shared Vulnerability Model

The development and maintenance of pediatric chronic pain and anxiety are complex, underscoring the need to better understand the interactive forces contributing to their co-occurrence. The shared vulnerability model (SVM) was developed to explain the co-occurrence of chronic pain and posttraumatic stress disorder in adults. Although many core tenets have been well supported by pediatric research, the SVM has yet to be extended to pediatric pain populations. We propose a developmentally informed pediatric SVM for advancing our understanding of the co-occurrence of pediatric chronic pain and anxiety disorders. The proposed SVM postulates that youth at increased risk for the development of chronic pain and/or anxiety share predisposing vulnerabilities, including anxiety sensitivity, and that these shared vulnerabilities give rise to negative emotional responses (child and parent) in the context of stressful events. Consequences of fear and anxiety, including avoidance behavior, further contribute to the development of chronic pain, anxiety, and their co-occurrence. The parental, school, and peer contexts in which these problems develop and are maintained in youth are pertinent to integrate into a SVM, as pediatric chronic pain and anxiety disorders share several social-contextual risk and maintenance factors. We also highlight new areas of inquiry.

The prevalence of headache in German pupils of different ages and school types

Background/objective

Headache in pupils is underestimated and has a negative impact on learning and life. The aim of this study was to investigate headache prevalence and its collateral effects, in pupils of different ages and school types in a German city.

Methods

Anonymized questionnaires were distributed to 5419 pupils attending primary and secondary schools. Demographics, headache frequency, analgesic use, school absence and, for secondary school children, data on lifestyle were collected.

Results

The questionnaire was returned by 2706 children (49%), 1362 (50.3%) girls, 1344 (49.7%) boys. Of these, 36.6% indicated a frequency of 1, and 31.5% a frequency of ≥ 2 headache days per month within the last 3 months. Headache prevalence increased with school grade, age and secondary school type: 63.6%, 67.2% and 79.5% for primary school children, pupils attending 8-year and pupils attending 6-year secondary schools, respectively. With secondary school level I certificates, pupils are prepared for general professional training in 6 years. Secondary school level II results, after 8 years of training, in university entrance level II certificates, which are the precondition for university studies. Girls reported significantly more headache than boys (73% vs. 63.1%). A significant relationship has been observed between headache frequency and school absence and between headache intensity and headache frequency. Of pupils with headache at least twice a month, 48.1% reported analgesic intake. Ibuprofen (49.1%) and paracetamol (32.8%) were the most frequently used analgesics. Of those pupils with headache ≥ 2 days/month, 68.3% did not have a specific headache diagnosis. Concomitant diseases and regular drug intake, analgesic intake for another reason than headache, caffeine consumption and lack of participation in sports were positively correlated with headache.

Conclusions

The majority of pupils suffer from headache at least once a month. Since frequent headache results in educational and social limitations, pupils at risk should be identified and referred to headache education programs. Efforts are needed to improve the management of juvenile headache patients.

Seasonal Association of Pediatric Functional Abdominal Pain Disorders and Anxiety

OBJECTIVES

Abdominal pain-related pediatric functional gastrointestinal disorders (AP-FGIDs) are defined by abdominal discomfort or pain that may provide obstacles to everyday activities, such as school attendance. It has been reported that AP-FGID symptoms may be reduced in summer, but it is unclear what drives this seasonal variation. This pilot study aimed to explore whether the seasonal variation in AP-FGID symptoms could be explained by various psychological and behavioral factors.

METHODS

Parents of children with AP-FGID symptoms completed online questionnaires on symptoms, anxiety, parental responses to pain, sleep, diet, and physical activity once during spring months and again in the summer months.

RESULTS

In a sample of 34 participants who completed both questionnaires, 22 reported improvements during the summer months. These participants reported a significantly higher seasonal decrease in anxiety than participants whose children's symptoms did not improve from spring to summer (mean decrease 2.21 vs 0.08, P = 0.017). Both groups reported equal improvements in sleep and decreased stress from spring to summer. Neither group experienced statistically significant seasonal change in physical activity or fruit, vegetables, dairy, or caffeine consumption.

CONCLUSIONS

This study suggests that amelioration of gastrointestinal symptoms in pediatric patients with AP-FGID during summer months is associated with amelioration of anxiety in the same time period. It is not yet clear whether decreased anxiety is the cause or effect of decreased AP-FGID symptoms.

School Anxiety in Children and Adolescents with Chronic Pain

Anxiety is highly prevalent in pediatric chronic pain. This comorbidity has been explained by the presence of shared mechanisms underlying the development and maintenance of chronic pain and anxiety. Accumulating evidence demonstrates that school is a significant source of anxiety among youth with chronic pain and that anxiety contributes to school-related functional impairment in this population. This article reviews the cooccurrence of pediatric chronic pain and anxiety, identifies unique sources of heightened school anxiety among youth with chronic pain, and describes current approaches for assessing anxiety in pediatric pain settings. Highlighted by this review is the absence of a comprehensive evidence-based approach for assessing school anxiety in pediatric chronic pain. Given the psychometric limitations inherent to gathering data from a single source, recommendations for advancing measurement methods are provided. Novel approaches may be needed to shed more light on the way in which school anxiety is experienced in pediatric chronic pain.

Systematic review of childhood and adolescent risk and prognostic factors for persistent abdominal pain

This review aimed to identify childhood and adolescence risk and prognostic factors associated with onset and persistence of persistent abdominal pain and related disability and assess quality of the evidence. While findings suggest a possible role for negative emotional symptoms and parental mental health as risk and prognostic factors for onset and persistence of persistent abdominal pain, the evidence is of poor quality overall and nonexistent when it comes to prognostic factors associated with disability.

CONCLUSION

Further research is needed to increase confidence in existing evidence and to explore new factors. This research will inform prevention.

Screening for Psychosocial and Family Risk in Pediatric Gastrointestinal Disorders

OBJECTIVES

Screening for psychosocial comorbidity is recommended for pediatric patients presenting at an initial gastroenterology (GI) outpatient consultation. We developed and evaluated the psychometric properties of the GI Screener to address the need for a screening tool specific to pediatric GI patients.

METHODS

128 patients (8-18 years old, 63% female) and 126 parents completed age-specific versions of the GI Screener and 3 validated psychosocial comparison instruments (The Behavioral Assessment System for Children, The Functional Disability Inventory, The General Functioning scale of the Family Assessment Device) at their initial GI consultation. (30%) of families repeated the measures 2 weeks later. We identified GI Screener content domains and retained items using exploratory factor analysis. We evaluated internal consistency, construct validity, cross-informant reliability, and test-retest reliability of the trimmed measures.

RESULTS

Exploratory factor analysis identified 2 factors in both the parent and child scales: Symptom Impact and Emotional Functioning. Internal consistency estimates for the trimmed scales were good (Cronbach's alpha >0.75) for both Child and Parent scales. We found that the GI Screener for both patient and parents had good construct validity. Cross-informant reliability between Parent and Child scales at baseline had an estimated correlation of 0.56, while intra class correlation coefficients between baseline and 2-week scores showed high test-retest reliability (>0.7).

CONCLUSIONS

The GI Screener is a brief, valid and reliable measure that can aid in identifying families who are at high risk for psychosocial comorbidity facilitating the targeted delivery of psychosocial intervention and efficient use of health care resources.

Family functioning as a protective factor in treating adolescents with complex medico-psychosocial presentations

PURPOSE

Studies of adolescents with somatic symptoms with no identified organic cause make a clear connection between the health and wellbeing of the adolescent and the functioning of the family. There has been little systematic examination of the role of family functioning in treatment. We aim to determine whether there was an association between family functioning and treatment outcome in this 12 month prospective study.

METHODS

Fifty adolescents aged between 12 and 17 years (M=14.4, SD=1.32) and their parents were recruited. All adolescents presented with one or more physical symptoms as their primary complaint. Adolescent functioning and family relationships were measured at recruitment, 4 months into treatment and 12 months later. Generalised estimating equations (GEE) analyses were conducted to examine the relationships between the variables of interest.

RESULTS

Results suggested significant improvements in adolescent outcomes between baseline and 4 months (all p<0.01), which were sustained to 12 months (all p<0.01). Adolescents from healthier families at initial presentation had significantly improved psychosocial functioning over the course of the study (all p<0.001).

CONCLUSION

Our findings highlight the importance of taking a family approach to the treatment of adolescents with medically unexplained symptoms.

Headache and Recurrent Abdominal Pain: A Controlled Study by the Means Of The Child Behaviour Checklist (CBCL)

Headache and recurrent abdominal pain (RAP) are common disorders in children and adolescents, frequently referred to paediatricians. Both disorders show similarities in trigger and comorbid factors, their burden on family and individual life, and a paroxysmal trend with risks of chronicization over time. However, very few studies have compared directly headache and RAP. The main aim of this study was to compare the psychological profile of headache and RAP patients vs. healthy controls. A total of 210 children and adolescents [99 boys, 111 girls; age range 4-18 years; mean age (m.a.) = 11.04, SD 4.05] were assessed: 70 headache patients (m.a. 12.4 years; SD 2.9; F = 35, M = 35), 70 RAP patients (m.a. 9 years; SD 3.6; F = 30, M = 40) and 70 controls (m.a. 11.7 years; SD 4.6; F = 46, M = 24). The diagnoses had been made according to international systems of classification both for headache (ICHD-II criteria) and RAP (Rome II criteria). The psychological profile had been made according to the Child Behaviour Checklist 4-18 (CBCL). ANOVA one-way analysis was used to compare CBCL scales and subscales between groups. Headache and RAP showed a very similar trend vs. control for the main scales of the CBCL, with a statistically significant tendency to show problems in the Internalizing scale (anxiety, mood and somatic complaints) and no problems in the Externalizing (behavioural) scale. Only for the Attention Problems subscale migraineurs showed a significant difference compared with RAP. In conclusion, headache and RAP show a very similar psychological profile that should be considered not only for diagnostic and therapeutic purposes, but also from the aetiological aspect.

Developmental trajectories of paediatric headache - sex-specific analyses and predictors

BACKGROUND

Headache is the most common pain disorder in children and adolescents and is associated with diverse dysfunctions and psychological symptoms. Several studies evidenced sex-specific differences in headache frequency. Until now no study exists that examined sex-specific patterns of change in paediatric headache across time and included pain-related somatic and (socio-)psychological predictors.

METHOD

Latent Class Growth Analysis (LCGA) was used in order to identify different trajectory classes of headache across four annual time points in a population-based sample (n = 3 227; mean age 11.34 years; 51.2 % girls). In multinomial logistic regression analyses the influence of several predictors on the class membership was examined.

RESULTS

For girls, a four-class model was identified as the best fitting model. While the majority of girls reported no (30.5 %) or moderate headache frequencies (32.5 %) across time, one class with a high level of headache days (20.8 %) and a class with an increasing headache frequency across time (16.2 %) were identified. For boys a two class model with a 'no headache class' (48.6 %) and 'moderate headache class' (51.4 %) showed the best model fit. Regarding logistic regression analyses, migraine and parental headache proved to be stable predictors across sexes. Depression/anxiety was a significant predictor for all pain classes in girls. Life events, dysfunctional stress coping and school burden were also able to differentiate at least between some classes in both sexes.

CONCLUSIONS

The identified trajectories reflect sex-specific differences in paediatric headache, as seen in the number and type of classes extracted. The documented risk factors can deliver ideas for preventive actions and considerations for treatment programmes.

The buffering effect of family functioning on the psychological consequences of headache

The current study aimed to examine whether high family functioning mitigates the association between headache intensity and distress. The sample consisted of 124 patients with chronic or recurrent headache. Patients completed validated questionnaires about headache intensity, family functioning, and distress. Hierarchical regression analyses were performed to examine the interaction between headache intensity and family functioning on distress. Headache intensity was positively associated with distress (r = .28, p = .002). As hypothesized, family functioning moderated this association (B = -.01, p = .023). More specifically, the positive association between headache intensity and distress was significant only among patients with lower family functioning (B = .01, p < .001) and not among patients with higher levels of family functioning (B = .006, p = .075). Functional families appear to buffer the distress level in patients; they showed relatively low levels of distress regardless of the severity of their headache. In contrast, patients with dysfunctional families who experienced more pain reported more distress, presumably because they did not receive adequate help and support from these families. This study underlines the importance of a broader perspective on family dynamics in coping with pain.

Comorbid Psychological Conditions in Pediatric Headache

Children and adolescents with chronic daily headaches (CDH) often have comorbid psychological conditions, though their prevalence is unclear. Pediatric patients with CDH may have higher rates of disorders such as anxiety and depression. However, some researchers have found that scores on depression and anxiety screening measures for pediatric patients with migraine are within reference range. Barriers to identify patients with psychiatric disorders have included limited validated screening tools and lack of available mental health resources. Several validated screening tools have recently been used in studies of pediatric patients with CDH. Once identified, treatment of comorbid psychological conditions may lead to improved functioning and headache outcomes.

Alexithymic characteristics in pediatric patients with primary headache: a comparison between migraine and tension-type headache

Background

Alexithymia is a personality construct characterized by difficulties in verbal emotional expression and a limited ability to use one’s imagination. Evidence of alexithymic characteristics was found in adults suffering from headache, while little is known about children. The aim of this study was to establish the prevalence of alexithymia in two different subgroups of children and adolescents suffering from primary headache. We also looked for correlation between alexithymia in children and in their mothers.

Methods

This study involved 89 participants: 47 (11 males, 36 females, aged 8 to 17 years) suffering from tension-type headache (TTH), and 42 (18 males, 24 females, aged 8 to 17 years) suffering from migraine (M), based on the International Classification of Headache Disorders (ICHD 2013). A control group of 32 headache-free subjects (26 females and 6 males, aged 8 to17 years) was also considered. Two questionnaires were administered to measure alexithymia: the Alexithymia Questionnaire for Children to young patients and controls, and the Toronto Alexithymia Scale (TAS-20) to the mothers.

Results

Higher rates of alexithymia emerged in the TTH group compared to the M group. In particular, TTH sufferers had difficulty identifying their feelings. The mothers of children with headaches didn’t score higher in alexithymia compared to other mothers. In the M and in the control group, there was a significant correlation between the rates of alexithymia in young people and in their mothers.

Conclusions

To date no other study has investigated alexithymia in subgroups of primary headaches in developmental age. Our results suggest that patients suffering from TTH are more alexithymic than M patients. This pave the way to etiopathogenetic and clinical considerations, calling for a comprehensive and multidisciplinary approach to tackle the problem of headache.

ADHD and functional somatic symptoms: structural equations of a conceptual model

AIMS

To examine the effect of anxiety and parental overprotection on functional somatic symptoms (FSS) in children with attention deficit hyperactivity disorder (ADHD).

METHOD

Seventy-six children and adolescents (aged 6-17) with ADHD and their parents completed a clinical interview about psychiatric and somatic symptoms. Parents also reported about parenting styles. Structural equation modeling (SEM) was used.

RESULTS

The generalized anxiety, overprotection, and specific phobia variables each had a direct effect on FSS.

CONCLUSIONS

Anxiety symptoms and parental overprotection may play a role in the development of FSS in children with ADHD. Further research is necessary to corroborate our findings.

Selected family characteristics are associated with adolescents' subjective health complaints

AIM

This national study of schoolchildren in Greece investigated the association between adolescents' subjective health complaints (SHC) and a number of family characteristics.

METHODS

Questionnaires were completed by a random, school-based sample of children from 12 to 18 years of age, and one of their parents (76.6% mothers), in 2003. Data from 1041 adolescent-parent pairs were analysed. Multiple linear regression analysis was used to assess the associations between the adolescent's SHC and the following characteristics: parent's marital status, parent's physical and mental health status, parent's worries about their child's SHC, the parent-child relationship, family cohesion, family socio-economic status and the adolescent's sex and age.

RESULTS

The analysis showed that the adolescents' SHC were independently and significantly correlated with poor parental subjective mental health status, poor quality parent-child relationships and parental worry. There were also associations between levels of SHC and female and older adolescents.

CONCLUSION

Certain family features can be seen as potential contributing factors to SHC in adolescence and should therefore constitute complementary targets for prevention and treatment planning.

Adolescents' multiple, recurrent subjective health complaints: investigating associations with emotional/behavioural difficulties in a cross-sectional, school-based study

BACKGROUND

Adolescence has been documented as the peak age of onset for mental health perturbations, clinical disorders and unsubstantiated health complaints. The present study attempted to investigate associations between multiple, recurrent subjective health complaints (SHC) with emotional/behavioural difficulties, as measured by the Strengths and Difficulties Questionnaire scale (SDQ), among Greek adolescents.

METHODS

Questionnaires were administered in a large, nation-wide, random, school-based sample of Greek adolescents, aged 12-18 years. Data from 1170 participants were analyzed. Adolescents with multiple, recurrent SHC were compared in terms of their emotional/behavioural difficulties to their peers with lower levels of health complaints. SDQ scales were separately investigated for their associations with multiple, recurrent SHC, after adjustment for gender, age and socioeconomic status (ses). Further analysis included multiple logistic regression models with multiple, recurrent SHC as the dependent variable and gender, age, ses and SDQ Total difficulties score as independent factors. Potential gender and age interactions were also explored.

RESULTS

Almost half of the study participants reported multiple, recurrent SHC. Adolescents with multiple, recurrent SHC had higher scores on all SDQ scales, except from the Prosocial behavior scale, compared to their peers with lower levels of health complaints. Emotional Symptoms, Conduct Problems, Hyperactivity/Inattention and Peer Problems were associated with greater likelihood of having multiple, recurrent SHC, after adjustment for gender, age and ses. The multiple logistic regression models revealed that older adolescents and girls, as well as those with increased Total difficulties score had an increased risk for multiple, recurrent SHC reporting. No significant interaction between SDQ scales and gender or age was found.

CONCLUSIONS

Our study highlights the magnitude of psychological burden among adolescents experiencing multiple, recurrent SHC. Professionals in school and clinical settings should be cautious for impaired emotional/behavioural functioning when assessing adolescents with multiple, recurrent SHC, so as early identification of at-risk individuals and timely, appropriate referrals are facilitated.

Screening for psychiatric comorbidity in children with recurrent headache or recurrent abdominal pain

BACKGROUND

Recurrent pain symptoms in children are associated with psychiatric comorbidities that could complicate treatment. We investigated the prevalence of psychiatric comorbidity in children with recurrent headache or recurrent abdominal pain and evaluated the screening potential of the Strength and Difficulties Questionnaire compared with the Development and Well-Being Assessment (DAWBA).

METHODS

Eighty-three outpatients aged 5-17 years attending a tertiary medical center for a primary diagnosis of migraine (n = 32), tension-type headache (n = 32), or recurrent abdominal pain (n = 19), and 33 healthy matched controls completed the brief self-reporting Strength and Difficulties Questionnaire followed by the Development and Well-Being Assessment. Findings were compared among groups and between instruments.

RESULTS

The pain groups were characterized by a significantly higher number of Development and Well-Being Assessment diagnoses (range 0-11) than controls and a significantly greater prevalence (by category) of Development and Well-Being Assessment diagnoses (P < 0.001 for both). Anxiety and depression were the most prevalent Development and Well-Being Assessment diagnoses. Comorbidities were more severe in the headache groups than the controls (P < 0.001). In general, any diagnosis by the Development and Well-Being Assessment was associated with a significantly higher Strength and Difficulties Questionnaire score (P < 0.001). Abnormal scores on the emotional, conduct, and hyperactivity Strength and Difficulties Questionnaire scales were significantly predictive of a Development and Well-Being Assessment diagnosis (P < 0.003).

CONCLUSION

Children referred to specialized outpatient pediatric units for evaluation of recurrent pain are at high risk of psychopathology. The Strength and Difficulties Questionnaire may serve as a rapid cost-effective tool for initial screening of these patients.

Brief hypnotherapeutic-behavioral intervention for functional abdominal pain and irritable bowel syndrome in childhood: a randomized controlled trial

Functional abdominal pain and irritable bowel syndrome are two prevalent disorders in childhood which are associated with recurrent or chronic abdominal pain, disabilities in daily functioning, and reduced quality of life. This study aimed to evaluate a brief hypnotherapeutic-behavioral intervention program in a prospective randomized controlled design. Thirty-eight children, 6 to 12 years of age, and their parents were randomly assigned to a standardized hypnotherapeutic-behavioral treatment (n = 20) or to a waiting list condition (n = 18). Both groups were reassessed 3 months after beginning. Primary outcome variables were child-completed pain measures and pain-related disability. Secondary outcome variables were parent-completed measures of their children's pain and pain-related disability. Health-related quality of life from both perspectives also served as a secondary outcome. In the treatment group, 11 of 20 children (55.0%) showed clinical remission (>80% improvement), whereas only one child (5.6%) in the waiting list condition was classified as responder. Children in the treatment group reported a significantly greater reduction of pain scores and pain-related disability than children of the waiting list condition. Parental ratings also showed a greater reduction of children's abdominal pain and pain-related disability. Health-related quality of life did not increase significantly.

CONCLUSIONS

Hypnotherapeutic and behavioral interventions are effective in treating children with long-standing AP. Treatment success of this brief program should be further evaluated against active interventions with a longer follow-up.

Prevalence of child sexual abuse in pediatric patients with chronic abdominal pain

BACKGROUND AND OBJECTIVES

A history of sexual abuse is to be found in approximately 40% of all adult patients with gastrointestinal complaints. Data on the prevalence of child sexual abuse (CSA) in children with chronic abdominal pain (CAP) are lacking. The objective of this systematic review is to determine the prevalence of CSA in pediatric patients with CAP.

METHODS

We conducted a systematic literature search in the electronic databases MEDLINE, EMBASE, PsychInfo, and ERIC. Reference lists of relevant articles were scanned for additional citations. We selected case-control, cohort and cross-sectional studies investigating the prevalence of CSA in children with CAP, ages 0 to 18 years. Data were extracted from relevant studies, which were assessed for methodological quality by 2 independent reviewers. Prevalence of CSA was the main outcome measure.

RESULTS

The literature search yielded a total of 269 articles. Only 2 studies met our inclusion criteria, reporting CSA in 2.1% and 8.0% of children (age range 4-21 years) with CAP. Both studies were conducted in small groups (n = 48 and n = 50) without control group(s) and did not use standardized or validated instruments for diagnosing CSA.

CONCLUSIONS

According to existing data, the prevalence of a history of CSA in pediatric patients with CAP is lower than in adult patients; however, no well-designed studies have been conducted in children. Future research is required to determine a reliable prevalence of CSA in children with CAP.

Functional gastrointestinal symptoms in children with anxiety disorders

This study examined the incidence and correlates of functional gastrointestinal symptoms in children with anxiety disorders. Participants were 6-13 year old children diagnosed with one or more anxiety disorders (n = 54) and non-clinical control children (n = 51). Telephone diagnostic interviews were performed with parents to determine the presence and absence of anxiety disorders in children. Parents completed a questionnaire that elicited information about their child's gastrointestinal symptoms associated with functional gastrointestinal disorders in children, as specified by the paediatric Rome criteria (Caplan et al., Journal of Pediatric Gastroenterology & Nutrition, 41, 296-304, 2005a). Parents and children also completed a symptom severity measure of anxiety. As expected, children with anxiety disorders were significantly more likely to have symptoms of functional gastrointestinal disorders (FGID), compared to children without anxiety disorders. That is, 40.7 % of anxious children had symptoms of a FGID compared to 5.9 % of non-anxious control children. Children with anxiety disorders were significantly more likely to have symptoms of functional constipation, and showed a trend for a higher incidence of irritable bowel syndrome symptoms compared to non-anxious control children. Furthermore, higher anxiety symptom severity was characteristic of anxious children with symptoms of FGID, compared to anxious children without FGID symptoms and non-anxious control children. Also, children with anxiety disorders, regardless of FGID symptoms, were more likely to have a biological family member, particularly a parent or grandparent, with a gastrointestinal problem, compared to non-anxious control children. The high incidence of FGID symptoms in children with anxiety disorders warrants further research on whether gastrointestinal symptoms reduce following psychological treatments for childhood anxiety disorders, such as cognitive behavioural therapy.

Individual and additive effects of mothers' and fathers' chronic pain on health outcomes in young adults with a childhood history of functional abdominal pain

OBJECTIVE

To evaluate effects of mothers' and fathers' chronic pain on health outcomes in adult sons and daughters with a childhood history of functional abdominal pain (FAP).

METHOD

Adults (n = 319; Mean age = 22.09 years) with a childhood history of FAP reported parental history of chronic pain and their own current health (chronic pain, somatic symptoms, disability, use of medication and health care, illness-related job loss).

RESULTS

Positive histories of maternal and paternal chronic pain were each associated with poorer health in sons and daughters, regardless of child or parent gender. Having 2 parents with chronic pain was associated with significantly poorer health than having 1 or neither parent with chronic pain.

CONCLUSIONS

Chronic pain in both mothers and fathers is associated with poor health and elevated health service use in young adults with a childhood history of FAP. Having both parents with chronic pain increases risk for adverse outcomes.

[Functional somatic symptoms in a Spanish sample: psychopathology and educational styles]

INTRODUCTION

Although there are many studies on functional somatic symptoms (FSS), there are few conducted with Spanish samples. The aim of this study was to assess the prevalence of frequent functional somatic symptoms in a Spanish sample, and to look for relationships with psychopathology and parenting styles.

PATIENTS AND METHODS

The sample consisted of 672 participants from 6 to 8 years-old attending primary school in the region of Osona (Catalonia, Spain). The parents reported on the presence of FSS in children, school absence, paediatric visits; psychiatric symptoms, and parenting styles. Children who complained of frequent somatic symptoms (four or more in the previous fortnight) were compared with children who did not complain.

RESULTS

A total of 429 of the 672 (63.8%) children had at least one physical complaint during the two weeks prior to the study. Almost one quarter (162, 24.1%) of the participants had frequent FSS. Significant relationships were found with, separation anxiety, social phobia, and visits to the paediatrician. A small effect of overprotection/control parenting style on FSS was observed.

CONCLUSIONS

Functional somatic symptoms are common in a Spanish sample of children between 6 to 8 years-old. These children may be considered a risk group for future emotional distress. It is also important for future research to clarify the nature of the relationship between overprotection and FSS.

Headache disorders in children and adolescents: their association with psychological, behavioral, and socio-environmental factors

OBJECTIVE

This cross-sectional study on a randomly drawn population sample of children and adolescents (n = 3399; aged 9 to 15) aimed at the assessment of patterns of associations between psychosocial variables and primary headache disorders like migraine (MIG) or tension-type headache. A headache-free group served as a control.

METHODS

Data on headache and psychological trait variables (eg, internalizing symptoms), behavioral factors (eg, physical activities), and socio-environmental factors (eg, life events) were gathered by questionnaire. Logistic regression analyses were conducted with headache types (MIG, tension-type, and non-classifiable headache) as dependent variables.

RESULTS

The pattern of correlations was largely congruent between the headache disorders. Associations were closest regarding maladaptive psychological traits (in particular internalizing symptoms with an odds ratio > 4 regarding MIG) compared with socio-environmental factors and particularly the behavioral factors. Unfavorable psychological traits and socio-environmental strains demonstrated distinctly stronger associations with MIG than tension-type headache and explained more variance in the occurrence of pediatric headache disorders than parental headache. Sex-specific analyses showed similarities as well as differences regarding the correlations, and in general, the associations were stronger in girls than boys.

CONCLUSIONS

A common path model as posited by several researchers in the field may explain the parallelism in biopsychosocial vulnerability regarding the different headache disorders.

Psychosocial perspectives in the treatment of pediatric chronic pain

Chronic pain in children and adolescents is associated with major disruption to developmental experiences crucial to personal adjustment, quality of life, academic, vocational and social success. Caring for these patients involves understanding cognitive, affective, social and family dynamic factors associated with persistent pain syndromes. Evaluation and treatment necessitate a comprehensive multimodal approach including psychological and behavioral interventions that maximize return to more developmentally appropriate physical, academic and social activities. This article will provide an overview of major psychosocial factors impacting on pediatric pain and disability, propose an explanatory model for conceptualizing the development and maintenance of pain and functional disability in medically difficult-to-explain pain syndromes, and review representative evidence-based cognitive behavioral and systemic treatment approaches for improving functioning in this pediatric population.

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.

Emotional/behavioural, social correlates and one-year predictors of frequent pains among early adolescents: Influences of pain characteristics

In a one-year longitudinal study, emotional/behavioural correlates and predictors of four common pain complaints (headaches, stomach, back and limb pain), were examined in a representative school sample of 2360 adolescents aged 12- to 15-years. At first assessment, 18.3% reported being bothered by a frequent pain (at least once a week) and 40% of the pain sufferers had two or more pain locations, more commonly reported by girls. Subjects having any of the four frequent pains reported having fewer friends and were more often absent from school. Frequency and number of reported pains among adolescents were positively related to levels of internalising and externalising problems. These latter problems were consistently and significantly higher among adolescents with frequent back and limb pains, however, when coexistence of another frequent pain was controlled, differences were small. Number of pains at the one-year follow-up was significantly predicted by frequent back pain and headache, depressive symptoms scores, somatic complaints (other than pain), number of friends and reduced leisure time activities during the follow-up period. Frequent back pain and depressive symptoms also predicted multiple frequent pains (vs single frequent pain) at the follow-up as did recent parental divorce. It is concluded that various emotional and behavioural problems, and which are commonly regarded as being specifically related to pain type or location among adolescents, depend rather on frequency and coexistence of multiple frequent pains. Assessment of adolescents with frequent and multiple pains should, therefore, include broad screening of internalising as well as externalising problems as well as various aspects of impairment.

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.

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.

Systematic review of family functioning in families of children and adolescents with chronic pain

Disturbances in family functioning have been identified in youth with chronic pain and are associated with worse child physical and psychological functioning. Assessment measures of family functioning used in research and clinical settings vary. This systematic review summarizes studies investigating relationships among family functioning, pain, and pain-related disability in youth with chronic pain. Sixteen articles were reviewed. All studies were cross-sectional; 7 utilized between-group comparisons (chronic pain versus healthy/control) and 12 examined within-group associations among family functioning, pain, and/or pain-related disability. Studies represented youth with various pain conditions (eg, headache, abdominal pain, fibromyalgia) ages 6 to 20 years. Findings revealed group differences in family functioning between children with chronic pain and healthy control subjects in 5 of 7 studies. Significant associations emerged among family variables and pain-related disability in 6 of 9 studies with worse family functioning associated with greater child disability; relationships between family functioning and children's pain were less consistent. Different patterns of results emerged depending on family functioning measure used. Overall, findings showed that families of children with chronic pain generally have poorer family functioning than healthy populations and that pain-related disability is more consistently related to family functioning than pain intensity.

PERSPECTIVE

This review highlights the importance of family factors in pain-related disability in youth with chronic pain. Results suggest that family-level variables may be an important target for intervention. Family functioning measures showed significant variation, and researchers should take this into account when selecting instruments for use in research and clinical settings.

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.

Assessment and treatment of psychological factors in pediatric chest pain

Chest pain is regularly encountered in pediatric medical settings and may be associated with many organic diagnoses that vary widely in morbidity and mortality. Patients with chest pain with and without organic disease may also suffer from comorbid, exacerbating, or causal psychopathology. This article provides practical general guidelines for psychological diagnosis and alleviation of emotional and behavioral difficulties. Specific medical conditions that may benefit from psychological consultation are highlighted. Pediatric chest pain, including an analysis of medically unexplained chest pain, is examined from a psychological perspective that includes a critical review of relevant literature and suggestions for the clinical management of this condition.

Burden of anxiety disorders in pediatric medical settings: prevalence, phenomenology, and a research agenda

The current review describes the phenomenology of several common anxiety disorders in children and adolescents as they present in medical settings. Anxiety disorders and associated features in children are described, along with epidemiology, functional impairment, common somatic complaints, medical comorbidity, health care utilization, and presentation in general and in specialty pediatric medical settings. Recommendations for clinical management in pediatric settings are presented, and evidence-based interventions and emerging treatments for pediatric anxiety disorders are described. The review concludes with a discussion of future research directions that may lead to increased recognition and improved management of anxiety disorders in pediatric medical settings.

Abdominal pain in Dutch schoolchildren: relations with physical and psychological comorbid complaints in children and their parents

OBJECTIVES

Children with functional abdominal pain (FAP) frequently report comorbid complaints such as anxiety and activity limitations. Their parents often experience heightened levels of anxiety, depression, and somatization. The aim of the present study was to investigate whether these comorbid complaints in children and their parents are specific for FAP or can also be found in a community sample.

PATIENTS AND METHODS

Six hundred sixty-five schoolchildren (ages 7-18 years) filled out questionnaires concerning AP, activity limitations, somatic complaints, quality of life, and symptoms of anxiety and depression. A total of 391 of their parents filled out questionnaires concerning parental anxiety, depression, and somatization. Pearson correlations and multiple regression analyses were performed.

RESULTS

A total of 56.5% of the children reported AP at least once in a 2-week period. Univariate relations with AP were found for activity limitations (r = 0.392), somatic complaints (r = 0.408), 3 of 5 domains of quality of life (r ranging from -0.120 to -0.209), and symptoms of anxiety and depression (r, respectively, 0.329 and 0.361). Multivariate analyses showed only significant relations for female sex (β = 0.230), younger age (β = -0.077), activity limitations (β = 0.247), somatic complaints (β = 0.170), and depressive symptoms (β = 0.093).

CONCLUSIONS

Activity limitations, somatic complaints, and depressive symptoms are related to AP in the general population, whereas a reduced quality of life, anxiety, and parental internalizing problems seem specific comorbid complaints for FAP. Future research on parental internalizing problems, quality of life, and anxiety as risk factors for FAP is warranted.

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.