Noncardiac chest pain and psychopathology in children and adolescents

Fifteen-minute consultation on excluding cardiac causes of chest pain

Chest pain can be an extremely worrying symptom for children and parents, but is typically benign and rarely cardiac in origin. It can become problematic for paediatricians in acute care balancing parental expectations and not missing sinister causes. In addition, ordering unnecessary tests can be expensive, can lead to a prolonged hospital stay and unnecessary referrals to clinics. The aim of this review is to give an overview of the common causes of chest pain in children and how to identify cardiac causes using case vignettes.

Effect of cognitive-behavior therapy for children with functional abdominal pain: a meta-analysis

BACKGROUND

Cognitive-Behavior Therapy (CBT) is the validated non-pharmacological treatment for chronic pain in pediatric patients. While some suggested CBT were comparable to the usual care in reducing children's functional abdominal pain. This meta-analysis was designed to systematically review the literature for RCTs that investigated the efficacy of CBT in children with functional abdominal pain (FAP).

METHODS

PubMed, Embase, and the Cochrane library were searched for papers published up to October 2022. Studies applying different CBT delivery methods (in-person, web-based, phone-based) were included in this meta-analysis to evaluate the comprehensive effectiveness of CBT compared with usual care. Weighted and standardized mean difference with the 95% confidence intervals were used for the synthesis of the results. Primary outcome was the decrease of functional disability inventory (FDI) and the secondary outcomes were the decrease of severity in pain intensity, depression, anxiety, gastrointestinal symptoms, and improvement in physical quality of life (QoL).

RESULTS

A total of 10 RCTs with 1187 children were included in the final analysis. The results showed that CBT resulted in better effect in reducing functional disability inventory (SMD=-2.282, 95%CI: -4.537 to -0.027, P = 0.047), pain intensity (SMD=-0.594, 95%CI: -1.147 to -0.040, P = 0.036), and improving QoL (SMD = 14.097, 95%CI: 0.901 to 27.292, P = 0.036) compared with the control groups. Comparable effects were observed in the severity of depression (SMD=-0.493, 95%CI: -1.594 to 0.608, P = 0.380), anxiety (SMD=-0.062, 95%CI: -0.640 to 0.517, P = 0.835), and gastrointestinal symptoms (SMD=-1.096 95%CI: -2.243 to 0.050, P = 0.061) between CBT and usual treatment.

CONCLUSIONS

We observed the differences in post-treatment FAP and pain intensity for children receiving CBT compared with children receiving treatment as usual. CBT in the setting of FAP demonstrates promising developments and highlights the need for future research.

Comorbidity of behavioral problems and parental acceptance-rejection in children diagnosed with chest discomfort, palpitations, vasovagal syncope, and underlying heart disease: a multiple case-control study

BACKGROUND

Children who experience chest discomfort, palpitations, vasovagal syncope, and underlying heart disease often present a complex clinical picture. Not only are they dealing with potential cardiac issues, but they may also exhibit behavioral problems that can complicate the diagnostic and treatment process. Moreover, parental acceptance or rejection can significantly influence the child's well-being and medical outcomes in such cases. This study aims to explore the comorbidity of behavioral problems and parental acceptance-rejection in children diagnosed with these cardiac symptoms and underlying heart disease.

METHODS

In a case-control study, the Parental Acceptance - Rejection Questionnaire and Parental version of Strengths and Difficulties Questionnaire (SDQ) was filled by parents of 314 patients from pediatric cardiology clinic.

RESULTS

The control group scored substantially lower overall according to SDQ. The vasovagal syncope subgroup was found to have considerably lower scores on the subscale. The group with chest discomfort scored highly in hostility and aggression in the PARQ. In comparison to the other groups, the vasovagal syncope and chest pain group demonstrated higher scores in undifferentiated rejection and total score.

CONCLUSION

This study showed a correlation between children's behavioral and emotional problems and cardiac symptoms. This states that children's relationship with their parents has an impact on their symptoms. It will be necessary to conduct further studies to determine a causal association and devise preventative measures.

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.

Successful completion of treadmill testing provides relief and reassurance for children with non-specific chest pain

OBJECTIVE

Non-specific chest pain is one of the leading causes of admissions in paediatric cardiology outpatient clinics, and its management usually consists of extensive reassurance of patients and their families. As we have often observed that successful completion of treadmill testing during diagnostic work-up provides relief and reassurance in these patients and their families, we planned this study to quantitatively assess anxiety levels and perception of illness among children with non-specific chest pain before and after treadmill testing.

METHOD

We studied 50 children (aged 11.8 ± 3.0 years, range 7-17 years; 24 females, 26 males) with a chief complaint of non-specific chest pain and negative history and echocardiography. They were asked to fill the Revised Children's Anxiety and Depression Scale before the treadmill testing and 1-10 days after successful completion of treadmill testing.

RESULTS

Average total anxiety scores (36.38 ± 19.09 versus 33.36 ± 19.09, respectively) and average of total anxiety + depression scores (44.3 ± 24.92 versus 40.8 ± 26.97, respectively) of the children were found to be significantly lower after negative treadmill testing as compared to scores before testing (p < 0.05). Alterations in separation anxiety, panic, social phobia, obsession-compulsion scores were not statistically significant (p > 0.05).

CONCLUSION

Children with non-specific chest pain feel relieved and reassured after successful completion of treadmill testing. To the best of our knowledge, our study is the first in the literature to show this relationship quantitatively.

Uncommon Causes of Chest Pain in Children: An Experience From a Tertiary Care Hospital

Background Chest pain is one of the common complaints for emergency and outpatient department (OPD) visits in children and adolescents. Chest pain accounts for 0.6% of pediatric emergency visits and 2.5% of pediatric outpatient consultations. The prevalence of chest pain and the etiological factors associated with children in India is unclear. The primary objective of this study was to evaluate the etiology of chest pain in children and adolescents. The secondary objective was to describe the demographic characteristics and associated symptoms with chest pain and the outcomes of children after the intervention. Methodology A retrospective analysis of case records of 55 children aged between 5 and 15 years who attended the emergency or OPD of the hospital with the primary complaint of chest pain from July 1, 2019, to June 30, 2021, was done. Results The mean age of patients in our study was 10.75 ± 2.47 years. Of 55 children, 26 were males, and 26 were females (male-to-female ratio = 0.9). In total, 43 (78.2%) patients had screen time of more than two hours. Palpitation was recorded in 11 (20.4%) patients, whereas only four (7.3%) children had breathing difficulties. Of 55 children, 46 (83.6%) had psychogenic causes, six (10.9%) had organic reasons, and three had no identifiable cause of chest pain. Anxiety disorder (40%) and depression (21.8%) were the leading psychogenic causes of chest pain. Overall, 13 (23.6%) children had associated smartphone and internet addiction disorder. Of 55 children, 36 (63.6%) improved following an appropriate intervention. Five children had some or no improvement in chest symptoms. Finally, 15 (27.3%) children were lost to follow-up. Conclusions Chest pain is one of the common complaints in the pediatric age group needing referral to a pediatric cardiologist. The most common etiology associated with chest pain is often non-cardiac and psychogenic. Good patient history taking, clinical examination, and fundamental investigations are sufficient to unravel the etiology in most cases.

Anxiety, depressive, and somatoform disorders in children and adolescents referred to paediatric cardiology with somatic symptoms

INTRODUCTION

Chest pain, palpitations, and syncope are among the most common referrals to paediatric cardiology. These symptoms generally have a non-cardiac aetiology in children and adolescents. The aim of this study was to investigate the rate of common psychiatric disorders in children and adolescents referred to the paediatric cardiology clinic with chest pain, palpitations, and syncope and the relationship between cardiological symptoms and psychiatric disorders.

METHODS

Children and adolescents aged 8-16 years who presented at the paediatric cardiology clinic with primary complaints of chest pain, palpitation, or syncope were included in the study. After a detailed cardiology examination, psychiatric disorders were assessed using the DSM IV-TR diagnostic criteria and a semi-structured interview scale (KSADS-PL). The Child Depression Inventory and Spielberger's State-Trait Anxiety Inventory for Children were also applied to assess the severity of anxiety and depression.

RESULTS

The study participants comprised 73 (68.90%) girls and 33 (31.10%) boys with a mean age of 12.5 ± 2.4 years. Psychiatric disorders were determined in a total of 48 (45.3%) participants; 24 (38.7%) in the chest pain group, 12 (48.0%) in the palpitation group, and 12 (63.2%) in the syncope group. Cardiological disease was detected in 17% of the cases, and the total frequencies of psychiatric disorders (p = 0.045) were higher in patients with cardiological disease.

CONCLUSION

It is clinically important to know that the frequency of psychiatric disorders is high in patients presenting at paediatric cardiology with chest pain, palpitations, and syncope. Physicians should be aware of patients' psychiatric problems and take a biopsychosocial approach in the evaluation of somatic symptoms.

Chest pain in a pediatric emergency department: clinical assessment and management reality in a third-level Portuguese hospital

Chest pain in children and adolescents is a common complaint in the emergency department (ED), being mostly benign. A thorough patient history and physical examination should be enough in most cases for its proper management. Regarding non-cardiac chest pain, anxiety plays an important role.

Are Maternal Personality Traits an Etiological Factor in Adolescents with Functional Chest Pain?

BACKGROUND

In the etiology of functional chest pain (FCP), parental personality traits are worth considering in the context of the biopsychosocial model. The αlpha factor sub-dimension of the five-factor personality model (5FPM) includes agreeableness, conscientiousness, and neuroticism. There is increasing evidence that this dimension may be related to psychosomatic diseases. It was aimed to investigate how maternal personality traits affect adolescents with FCP. The hypothesis was determined that adolescents diagnosed with FCP can have lower quality of life and be more depressive/anxious and their mothers can have factor-α personality traits and be more depressive/anxious.

METHODS

The sample of this single-center, cross-sectional, case-control study consisted of 25 adolescents with FCP and their parents. The control group consisted of 35 age and sex matched healthy adolescents and their parents. Psychopathology was screened using the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL) and psychiatric comorbidities were excluded. The Child Depression Inventory (CDI), the Spielberger State-Trait Anxiety Inventory (STAI), and KINDL forms were completed by the adolescents. The Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Five-Factor Personality Inventory short form (FFPI) were completed by the parents.

RESULTS

Mothers of adolescents with FCP scored significantly higher compared with mothers of healthy controls in agreeableness and conscientiousness and scored significantly lower in neuroticism. Higher levels of mothers' neuroticism scores were associated with higher CDI and STAI-1 scores in FCP group. Agreeableness (Exp (B) = 10.097; p = .004; confidence interval [CI] = 2.049-49.745) and conscientiousness (Exp (B) = 16.414; p = .011; CI = 1.902-141.682) were statiscally significant in regression model.

CONCLUSIONS

This study showed for the first time that mother's alpha factor personality traits may be one of the factors that contribute to the presence of FCP.

Relationship between non-cardiac chest pain and internalizing problems in pre-school aged children

OBJECTIVE

Non-cardiac chest pain is a common and persistent problem for children; yet, typically, there is no clear medical cause. To date, no behavioural and/or psychological factors have been studied to explain chest pain in a pre-school paediatric sample. We hypothesized that pre-school children with medically unexplained chest pain would have higher rates of behavioural problems compared to healthy controls.

METHODS

We assessed 41 pre-school children with non-cardiac chest pain and 68 age matched children with benign heart murmurs as the control group using the Child Behaviour Check List-1 1/2-5 to evaluate emotional and behavioural problems.

RESULTS

Internalizing problem scores comprising emotionally reactive, anxiety/depression, and somatic complaints were higher in children with non-cardiac chest pain than in the control group. Among the possible factors, the factor that is related to behaviour problem scores, in univariate analysis, was a significant and inverse correlation between maternal education and behaviour problem scores. Also, maternal employment status was associated with behavioural problems. Children with a housewife mother were more susceptible to having such behavioural problems. Based on multiple regression analyses, being in the non-cardiac chest pain group was found to be significantly related to internalizing problems in our total sample.

CONCLUSIONS

These results suggest that pre-school children with non-cardiac chest pain may experience increased levels of certain behavioural comorbidities. Systematic behavioural screening could increase the detection of behavioural problems and improve care for this population. Future studies of non-cardiac chest pain in pre-school children should include larger samples and comprehensive diagnostic assessments as well as long-term follow-up evaluations.

Etiology and treatment of chest pain in children and adolescents

Chest pain is a very common symptom in pediatric patients. Although children with chest pain are relatively unlikely to be suffering from significant cardiac diseases, it is important not to overlook life-threatening diseases. Complete history taking and physical examination––which involves identifying the duration of pain, onset, character, associated symptoms, and aggravating factors––are extremely important. The most common causes of pediatric chest pain are idiopathic and musculoskeletal, while less than 3% of cases are of cardiac origin. Recent studies indicate that chest pain resulted from psychosomatic disorders increases in non-cardiac chest pain in children and adolescents. The reassurance of the benign nature of chest pain is enough in most cases of non-cardiac chest pain in children and adolescents. When echocardiography is performed on patients with exertional chest pain, it is important to confirm the origin of coronary artery to exclude any coronary anomaly. Exertional chest pain, combined syncope, and symptoms of myocardial ischemia should raise the suspicion of significant cardiac diseases. When the chest pain is accompanied by red flag signs, physicians must refer the patients to a pediatric cardiologist.

A preliminary study of the child abuse and central sensitization in adolescent patients with chronic non-organic chest pain and an overlooked condition: juvenile fibromyalgia syndrome

BACKGROUND

Only a small percentage of pediatric chest pain is of cardiac origin and the most common detected cause is musculoskeletal. Among musculoskeletal causes, acute chest pain is better described, with the causes of chronic pain not being adequately investigated in the literature. The aim of studuy is to evaluate the musculoskeletal causes of non-cardiac chest pain and investigate the relationship of chest pain with child abuse and central sensitization.

METHODS

Patients aged 12 to 18 years presenting with chest pain for at least 3 months were evaluated by a pediatric cardiologist and those without an organic pathology were referred to the physical medicine and rehabilitation clinic. In addition to detailed history and physical examination, juvenile fibromyalgia was questioned according to the 2016 revised diagnostic criteria of the American College of Rheumatology. The visual analog scale (to measure intensity of chest pain), the Central Sensitization Inventory (to evaluate the presence of central sensitization), the Hospital Anxiety Depression Scale (to determine depression and anxiety), the Childhood Trauma Questionnaire (to assess the presence of child abuse) were administered.

RESULTS

The study was completed with 64 patients. Twenty-six percent of patient (n = 17) were diagnosed with juvenile fibromyalgia, and central sensitization was detected in 34.4% (n = 22). Pain intensity, anxiety, depression and abuse scores were higher in patients with juvenile fibromyalgia than those without juvenile fibromyalgia and in patients with central sensitization compared to those without central sensitization (p < 0.001 for both). Higher scores of pain were related with child abuse [beta = 0.763, p < 0.001, (%95 CI, 4.397; 8.841)] and central sensitization of pain [beta = 0.382, p = 0.008 (95% CI: (0.986;6.231)] in regression analyses.

CONCLUSION

In this study, juvenile fibromyalgia was detected as a cause of non-cardiac chest pain. Juvenile fibromyalgia or central sensitization may also indicate childhood abuse.

Anxiety, depression, and behavioural rating scales in children with non-cardiac chest pain

INTRODUCTION

Chest pain is the second most common reason for referral to paediatric cardiologists after benign heart murmurs. Aetiology frequently depends on non-cardiac reasons. In addition, individuals may experience non-cardiac chest pain which is idiopathic or of unknown origin. The aim of this study is to examine psychological symptoms in children and adolescents with medically unexplained chest pain.

METHODS

A total of 76 patients (ages 8-18 years) were included in the study, who were referred to the paediatric cardiology department with the complaint of chest pain but did not have any detected cardiac aetiology or any other organic causes of chest pain. The control group was composed of 51 healthy volunteers. Self-evaluation scales were given to both groups which included Beck Anxiety Inventory and Children's Depression Inventory. Also parents of both groups completed the Conner's Parent Rating Scale for assessment of Attention-deficit/hyperactivity disorder.

RESULTS

Anxiety scores of the non-cardiac chest pain group were significantly higher compared to controls. No significant differences were found between patients and controls in terms of attention-deficit/hyperactivity disorder and depression scores. In patient group, patterns were similar for boys and girls and for children and adolescents; except girls scored significantly higher than boys in children's depression inventory.

CONCLUSIONS

In children and adolescents, non-cardiac chest pain is associated with increased levels of anxiety. These results show the importance of psychiatric evaluation in non-cardiac chest pain patients. Larger controlled studies are needed to determine the prevalence and impact of attention-deficit/hyperactivity disorder and depression in children and adolescents with non-cardiac chest pain.

The Importance of Esophageal and Gastric Diseases as Causes of Chest Pain

PURPOSE

Pediatric chest pain is considered to be idiopathic or caused by benign diseases. This study was to find out how much upper gastrointestinal (UGI) diseases are major causes of chest pain in pediatric patients.

METHODS

The records of 75 children (42 boys and 33 girls, aged 3-17 years old) who have presented with mainly chest pain from January 1995 to March 2015 were retrospectively reviewed. Chest X-ray and electrocardiography (ECG) were performed in all aptients. Further cardiologic and gastrointestinal (GI) evaluations were performed in indicated patients.

RESULTS

Chest pain was most common in the children of 6 and 9 to 14 years old. Esopha-gogastric diseases were unexpectedly the most common direct causes of the chest pain, the next are idiopathic, cardiac diseases, chest trauma, respiratory disease, and psychosomatic disease. Even though 21 showed abnormal ECG findings and 7 showed abnormalities on echocardiography, cardiac diseases were determined to be the direct causes only in 9. UGI endoscopy was performed in 57 cases, and esophago-gastric diseases which thereafter were thought to be causative diseases were 48 cases. The mean age of the children with esophago-gastric diseases were different with marginal significance from that of the other children with chest pain not related with esophago-gastric diseases. All the 48 children diagnosed with treated with GI medicines based on the diagnosis, and 37 cases (77.1%) subsequently showed clinical improvement.

CONCLUSION

Diagnostic approaches to find out esophageal and gastric diseases in children with chest pain are important as well as cardiac and respiratory investigations.

Panic disorder in children and adolescents with noncardiac chest pain

Adults with panic disorder (PD) often present to medical settings with noncardiac chest pain (NCCP), but less is known about children and adolescents with this complaint. We sought to characterize PD in youth with NCCP and compare features with PD in youth in psychiatric outpatient settings. Using a semi-structured diagnostic interview we evaluated 132 youth (ages 8-17) with NCCP recruited from two medical settings. Twenty-seven (20.5 %) met full DSM-IV criteria for PD, eleven of which were children (<13 years). Most frequent panic symptoms were somatic complaints, although cognitive symptoms were also common. Only 14.8 % had clinically significant agoraphobia. Comorbid anxiety disorders and major depression were common. Overall, clinical features of PD among youth with NCCP are similar to PD in psychiatric settings. Interventions for PD may benefit youth who present initially with NCCP. Systematic psychiatric screening could increase detection of PD and improve care for this population.

Screening for adolescent anxiety disorders in a pediatric emergency department

OBJECTIVES

Adolescence is a time of increasing risk for some anxiety disorders. Scant data exist on adolescent anxiety in emergency department (ED) settings. We sought to characterize select clinical characteristics and health care use associated with anxiety disorders in a pediatric ED.

METHODS

We screened a convenience sample of 100 adolescent-parent dyads presenting to the ED for the presence of child anxiety disorders using the 5-item Screen for Child Anxiety Related Emotional Disorders, parent (SCARED-P) and child (SCARED-C) versions. Additional demographic and clinical data were also collected.

RESULTS

The SCARED-P and SCARED-C screens identified probable anxiety disorder(s) in 26% to 33% of adolescent participants, respectively. Correlates of positive SCARED-C screens were female sex, asthma, presenting complaint involving headache or migraine, and school absenteeism due to physical problems. Correlates of positive SCARED-P screens were lower parental educational level, presenting complaint involving headache or migraine, and more medical specialty and total medical visits. Few anxious adolescents had received mental health services in the past 6 months. In multivariate models, female sex was independently associated with SCARED-C total score, and presenting complaint involving headache or migraine was independently associated with SCARED-P total score.

CONCLUSIONS

The current pilot data suggest that anxiety disorders are more prevalent among adolescent ED patients than among the general population but largely untreated. Several demographic and clinical variables may help to identify occult anxiety disorders. Greater awareness of anxiety disorders in this population may assist in redirecting a pattern of low use of mental health services but higher overall health care use.

Anxiety and impairment in a large sample of children and adolescents with chronic pain

BACKGROUND

Anxiety is the most common psychiatric condition in children and adolescents, and is linked to significant disruptions across domains of function. Due to the avoidant nature of anxiety and pain-related disability, studying anxiety symptoms in children with chronic and recurrent pain conditions is important.

OBJECTIVES

To examine anxiety symptoms in a large cohort of children and adolescents evaluated for complex chronic and recurrent pain conditions.

METHODS

Through retrospective chart review, data on anxiety, pain and functional disability were collected from 655 children evaluated at a multidisciplinary pain clinic over a three-year period.

RESULTS

Approximately 11% of children and adolescents reported clinically elevated anxiety symptoms, with elevated levels across dimensions of anxiety ranging from 14% (social anxiety, worry) to 27% (physiological). In addition, a notable 31% of the sample potentially minimized their anxiety by responding in a socially desirable manner. Anxiety was linearly associated with greater pain-related functional disability, but was not directly correlated with pain. Moderation analyses revealed that at low levels of worry, higher levels of pain were associated with greater functional disability, whereas at high levels of worry, pain no longer predicted the level of functional disability.

CONCLUSIONS

These findings document the prevalence of anxiety in children and adolescents with chronic pain, and also extend recent studies examining the complex relationships among pain, anxiety and pain-related disability.

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.

Psychiatric disorders in youth with medically unexplained chest pain versus innocent heart murmur

OBJECTIVE

To examine the prevalence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychiatric disorders in youth with chest pain compared with a control sample with innocent heart murmur.

STUDY DESIGN

We assessed youth ages 8 to 17 years who were examined in cardiology settings for medically unexplained chest pain (n=100) or innocent heart murmur (n=80). We conducted semi-structured interviews and assessed medical history, quality of life, and disability.

RESULTS

Youth with chest pain had a higher prevalence of psychiatric disorders compared with youth with murmur (74% versus 47%, χ(2)=13.3; P<.001). Anxiety disorders predominated, although major depression was also more common in the chest pain group (9% versus 0%; Fisher exact tests; P<.01). Onset of psychiatric disorders generally preceded chest pain. Patterns were similar for boys and girls and for children and adolescents. Chest pain was associated with poorer quality of life and with pain-related disability for youth with co-morbid psychiatric disorder.

CONCLUSIONS

In childhood and adolescence, medically unexplained chest pain is associated with a high prevalence of psychiatric disorders. Systematic mental health screening may improve detection and enhance treatment of these patients.

Behavioral and emotional problems among children aged 6-14 years on highly active antiretroviral therapy in Addis Ababa: a cross-sectional study

Children infected with human immunodeficiency virus (HIV) are at particular risk for psychological disturbance. Little is known about the mental health status of children on highly active antiretroviral therapy (HAART). A hospital-based cross-sectional study of 318 children aged 6-14 on HAART in Addis Ababa was conducted. Behavioral and emotional problem was assessed using the child behavior check list (CBCL/6-18). Logistic regression analysis was done to select the best subset of predictor variables and determine their association with behavioral and emotional problems. Of the 318 caregivers of children aged 6-14 on HAART, 39.3% of the children had behavioral and emotional problems. Low family monthly income (AOR, 3.44, 95% CI, 1.89-6.25), older age (AOR, 2.27, 95% CI, 1.34-3.83), and parental loss (AOR, 1.89, 95% CI, 1.10-3.25) were found to be determinants of behavioral and emotional problems in the multivariate logistic regression. There is high prevalence of behavioral and emotional problems in children on HAART in Addis Ababa. More support is needed to children from families of low income and those who lost their parents. Further research should be carried out to enhance better understanding and appropriate response to behavioral and emotional problems.

A Unified, Transdiagnostic Treatment for Adolescents With Chronic Pain and Comorbid Anxiety and Depression

Chronic pain disorders represent a significant public health concern, particularly for children and adolescents. High rates of comorbid anxiety and unipolar mood disorders often complicate psychological interventions for chronic pain. Unified treatment approaches, based on emotion regulation skills, are applicable to a broad range of emotional disorders and suggest the possibility of extending these interventions to chronic pain and pain-related dysfunction. This case report describes the use of a unified protocol for treatment of an adolescent boy with chronic daily headache and social anxiety and an adolescent girl with whole body pain and depression. Following weekly, 50-minute individual treatment sessions, the boy demonstrated notable improvement in emotional symptoms, emotion regulation skills, somatization, and functional disability. The girl showed some improvement on measures of anxiety and depression, although there appeared to be a worsening of pain symptoms and somatization. However, both patients demonstrated improvement over follow-up. This case study illustrates the potential utility of a unified treatment approach targeting pain and emotional symptoms from an emotion regulation perspective in an adolescent population.

Cognitive-behavioral treatment of persistent functional somatic complaints and pediatric anxiety: an initial controlled trial

BACKGROUND

Children and adolescents who seek medical treatment for persistent physical distress often suffer from co-occurring anxiety disorders. Treatment options for this impaired population are limited. This study tests the feasibility and potential efficacy of a cognitive-behavioral intervention targeting pain and anxiety for youth with impairing functional physical symptoms and anxiety disorders presenting to pediatricians for medical care.

METHODS

Children and adolescents (aged 8-16) experiencing somatic complaints, without an explanatory medical disorder (i.e., functional), were recruited from primary care and specialty (gastroenterologists and cardiologists) pediatricians. Forty children, primarily with gastrointestinal symptoms, who met criteria for a co-occurring anxiety disorder, were randomly assigned to a cognitive-behavioral treatment addressing pain and anxiety, Treatment of Anxiety and Physical Symptoms (TAPS), or to a waiting list control.

RESULTS

TAPS was found to be an acceptable treatment for this population and was superior to the waiting list condition. Eighty percent of children in TAPS were rated as treatment responders by independent evaluators compared with none of the controls. Overall, self- and parent ratings indicated reductions in children's somatic discomfort and anxiety following intervention. TAPS participants maintained clinical gains 3 months following treatment.

CONCLUSIONS

The study supports the feasibility and preliminary efficacy of a cognitive-behavioral intervention targeting co-occurring physical distress and anxiety in youth presenting for medical treatment. Such an approach has the potential to exert broad impact on children's dysfunction and to minimize exposure to invasive, ineffective, and costly medical procedures and treatments.

Epidemiology and risk factors of pediatric chest pain: a systematic review

The epidemiology and associated risk factors of pediatric chest pain are not well described. Several studies report the prevalence of chest pain types among children and adolescents; however, detailed prospective studies that aim to determine continued morbidity, mortality, health-care seeking behaviors, continued medication use, and quality of life are lacking. A greater understanding of pediatric chest pain epidemiology and risk factors is required.

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.

Musculoskeletal causes of pediatric chest pain

Musculoskeletal chest pain is the most common identifiable cause of chest pain in children and adolescents. A lesion or irritation of any layer of the anterior chest wall may lead to pain. Causes range from the common, such as costochondritis, to the rare, such as chronic recurrent multifocal osteomyelitis. Regardless of the cause, chest pain raises concern of cardiac abnormalities, and may rapidly lead to significant anxiety and lifestyle alterations. Thus, efficient and accurate identification of the cause of pediatric chest pain by a thorough history and physical examination is important to minimize the disruption it may cause.

Psychopathology and disability in children with unexplained chest pain presenting to the pediatric emergency department

OBJECTIVE

Chest pain is a common presentation in the pediatric emergency department (PED). In the majority of cases, no clear medical cause is found. Among adults with noncardiac chest pain, psychopathology including panic disorder is common. We assessed the likelihood and type of psychopathology as well as the health status of children and adolescents with unexplained chest pain who presented to the PED.

METHODS

We performed a semistructured diagnostic interview of children 8 to 17 years old who presented to an urban, tertiary-care PED with a primary complaint of chest pain for which no medical cause was found. We used Diagnostic Statistical Manual of Mental Disorders, Fourth Edition criteria to diagnose psychopathology. We also assessed pain severity, extent of other somatic complaints, quality of life, and functional disability using standard, validated instruments.

RESULTS

We enrolled 32 children with a mean age of 12.8 (SD, 2.9) years (range, 8-17 years); 47% were female. Twenty-six (81%) were diagnosed with a Diagnostic Statistical Manual of Mental Disorders, Fourth Edition anxiety disorder; 9 (28%) had full-criteria panic disorder. Quality of life was compromised in multiple domains, and children reported a range of functional disabilities due to chest pain. Other somatic symptoms, including other pain complaints, were commonly reported in this sample.

CONCLUSION

Unexplained chest pain in the PED is frequently associated with potentially treatable anxiety disorders. Emergency physicians should consider the possibility of anxiety disorders in patients with medically unexplained chest pain.

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.

Evaluation of chest pain in the pediatric patient

Chest pain is common in children seen in emergency departments, ambulatory clinics, and cardiology clinics. Although most children have a benign cause of their pain, some have serious and life-threatening conditions. The symptom must be carefully evaluated before reassurance and supportive care are offered. Because serious causes of chest pain are uncommon and not many prospective studies are available, it is difficult to develop evidence-based guidelines for evaluation. The clinician evaluating a child with chest pain should keep in mind the broad differential diagnosis and pursue further investigation when the history and physical examination suggest the possibility of serious causes.