Pediatric inflammatory bowel disease

Acute cognitive and behavioral effects of systemic corticosteroids in children treated for inflammatory bowel disease

Systemic corticosteroids are a mainstay of treatment for many pediatric medical conditions. Although their impact on the central nervous system has been well-studied in animal models and adults, less is known about such effects in pediatric populations. The current study investigated acute effects of corticosteroids on memory, executive functions, emotion, and behavior in children and adolescents with inflammatory bowel disease (IBD). Patients 8-17 years with IBD (Crohn's disease, CD; ulcerative colitis, UC) on high-dose prednisone (n = 33) and IBD patients in remission off steroids (n = 33) completed standardized neuropsychological tests and behavior rating scales. In the IBD sample as a whole, few steroid effects were found for laboratory cognitive measures, but steroid-treated patients were rated as exhibiting more problems with emotional, and to a lesser extent with cognitive function in daily life. Steroid effects, assessed by laboratory measures and questionnaires, were more prevalent in CD than UC patients; UC patients on steroids sometimes performed better than controls. Sleep disruption also predicted some outcomes, diminishing somewhat the magnitude of the steroid effects. Corticosteroid therapy can have acute effects on cognition, emotion, and behavior in chronically ill children; the clinical and long-term significance of these effects require further investigation.

Qualitative development of the PROMIS(R) pediatric stress response item banks

OBJECTIVE

To describe the qualitative development of the Patient-Reported Outcome Measurement Information System (PROMIS®) Pediatric Stress Response item banks.

METHODS

Stress response concepts were specified through a literature review and interviews with content experts, children, and parents. A library comprising 2,677 items derived from 71 instruments was developed. Items were classified into conceptual categories; new items were written and redundant items were removed. Items were then revised based on cognitive interviews (n = 39 children), readability analyses, and translatability reviews.

RESULTS

2 pediatric Stress Response sub-domains were identified: somatic experiences (43 items) and psychological experiences (64 items). Final item pools cover the full range of children's stress experiences. Items are comprehensible among children aged ≥8 years and ready for translation.

CONCLUSIONS

Child- and parent-report versions of the item banks assess children's somatic and psychological states when demands tax their adaptive capabilities.

Increased risks of developing anxiety and depression in young patients with Crohn's disease

OBJECTIVES

Crohn's disease (CD) is associated with substantial psychosocial burden and increased risks for mental health disorders. This retrospective cohort study compared the risks of developing anxiety disorders and depression and incidences of psychotropic medication use between young CD patients and matched CD-free controls.

METHODS

Medical claims, prescription drug claims, enrollment, and demographic data for patients <18 years diagnosed with CD were obtained from the MarketScan database (1 January 2000-30 June 2006). Each CD patient was matched with five CD-free controls based on exact age, sex, and months of health plan enrollment. Incidence rates and risks of developing anxiety disorders and depression and psychotropic medication use in the 6 months after the index date were compared, as were risks of developing persistent anxiety or depression (receiving medical services related to a diagnosis of anxiety or depression or psychotropic therapy for >1 year).

RESULTS

After adjustment for patient characteristics, the risks of developing anxiety disorders (hazard ratio (HR) [95% confidence interval (CI);[equals;2.28 [1.65-3.17]) and depression (HR [95% CI;[equals;1.74 [1.35-2.25]) after CD diagnosis were significantly greater for the CD cohort (N=2,144) than for CD-free controls (N=10,720). Patients with CD also had greater risks of developing persistent anxiety and persistent depression (HR [95% CI;[equals;4.35 [2.22-8.50] and 2.75 [1.73-4.38], respectively).

CONCLUSIONS

Compared with matched CD-free controls, young patients with CD had significantly greater risks of developing anxiety disorders and depression, were more likely to receive psychotropic treatments, and had significantly greater risks of developing persistent anxiety and depression.

Quality of life and level of anxiety in youths with inflammatory bowel disease in Ireland

OBJECTIVE

Little is known of the psychological well-being of youths diagnosed as having inflammatory bowel diseases (IBDs). Much of the literature available focuses on adults with IBD and those that focus on youths tend to use generic measures of health-related quality of life (QOL). The primary aim of this research is to obtain a profile of the IBD-related QOL and levels of anxiety of youths of ages 9 to 17 years presenting with IBD to a national hospital. It is also intended to examine the clinical utility of the IMPACT-III questionnaire.

PATIENTS AND METHODS

A questionnaire battery containing the IMPACT-III questionnaire and the Spence Children's Anxiety Scale (SCAS) was posted to all of the patients on the database of the gastrointestinal clinic between the ages of 9 and 17 years (n = 215), resulting in an achieved sample size of 79 (response rate of 36.7%).

RESULTS

It was found that 63% (n = 50) of participants had total IMPACT-III scores below the cutoff of 143, previously established for remission. In addition, 5 participants reported being unhappy with their lives. Thirty-nine percent (n = 31) of participants had elevated anxiety symptoms on ≥ 1 of the SCAS subscales. Anxiety level was found to be a significant predictor of QOL (β = -0.616, P = 0.001). Qualitative feedback highlighted the variability of physical and psychological symptoms participants experience, feelings of anger or embarrassment around the condition, and posed numerous questions, indicating that there is a lack of knowledge among patients around IBD.

CONCLUSIONS

These findings support the utility of screening patients with IBD for psychological difficulties and estimates of QOL. Further research and group interventions are recommended.

Cognitive-behavioral therapy for adolescents with inflammatory bowel disease and subsyndromal depression

OBJECTIVE

To examine the feasibility and efficacy of a manual-based cognitive-behavioral therapy (CBT) in reducing depressive symptomatology in adolescents with inflammatory bowel disease (IBD). Primary and Secondary Control Enhancement Therapy-Physical Illness (PASCET-PI) modified for youths with IBD was compared to treatment as usual (TAU), plus an information sheet about depression, without therapist contact using assessable patient analysis.

METHOD

Following assessment, participants 11 to 17 years old with IBD and mild to moderate subsyndromal depression were randomly assigned to PASCET-PI (n = 22) or comparison treatment (n = 19). Primary outcome measures at baseline (T1) and 12 to 14 weeks posttreatment (T2) were Children's Depression Inventory (child/parent report), Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), Children's Global Assessment Scale, and Perceived Control Scale for Children.

RESULTS

The PASCET-PI group showed significantly greater improvement in Children's Depression Inventory (child/parent report), Children's Global Assessment Scale, and Perceived Control Scale for Children posttreatment than the comparison group.

CONCLUSIONS

Screening and treatment of depressive symptoms in pediatric settings is feasible. PASCET-PI may be an efficacious intervention for subsyndromal depression in adolescents with IBD, although comparison with a more active treatment is necessary to attribute the improvement to PASCET-PI.

CLINICAL TRIAL REGISTRATION INFORMATION

URL: http://clinicaltrials.gov. Unique identifier: NCT00446238.

The adolescent with a chronic illness

The primary care clinician can play an important role in enhancing the quality of life for the adolescent with chronic illness through developmentally appropriate, individualized and compassionate coordination of care (Sidebar 2). Special attention to the process of adolescence, family, and psychological issues are required for successful management. Transition of care to adult services should be planned carefully with a multidisciplinary team.

Depressive symptoms and inflammatory bowel disease in children and adolescents: a cross-sectional study

OBJECTIVES

This study assessed the rates of depressive symptoms in older children and adolescents with inflammatory bowel disease (IBD) and the associations between depressive symptoms and IBD disease characteristics.

METHODS

One hundred and two youths (aged 11-17 years) with IBD seen consecutively in a gastroenterology clinic were screened for depressive symptoms using the Children's Depression Inventory (CDI). Subjects with CDI scores > or = 12 were evaluated for current psychiatric diagnoses using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). Disease characteristics examined included IBD type, duration, current severity, course, age at diagnosis and steroid treatment.

RESULTS

Of the total sample, 25 (24.5%) had a CDI score > or = 12, consistent with clinically significant depressive symptoms. Nineteen of 25 qualified subjects participated in the K-SADS-PL semi-structured interview and 16 of 19 met criteria for major or minor depressive disorder. Mean CDI scores positively correlated with age at IBD diagnosis but not with IBD type, duration or course. Youths with moderate/severe current IBD-related symptoms had significantly higher mean CDI scores than those with inactive disease activity. Anhedonia, fatigue and decreased appetite were selectively correlated with IBD disease severity. Subjects on steroids were more likely to have CDI scores > or = 12, and those with such scores were on higher doses of steroids than subjects without clinically significant depressive symptoms (both P values < 0.05).

CONCLUSIONS

These findings support the recommendation that adolescents with IBD in outpatient medical care settings, particularly older adolescents and those on steroids, should be screened for depression.

Inflammatory bowel diseases in pediatric and adolescent patients: clinical, therapeutic, and psychosocial considerations

Inflammatory bowel diseases (Crohn's disease and ulcerative colitis) primarily affect young adults, but in 15%-25% of cases, the initial disease starts in childhood. Many aspects of inflammatory bowel disease, including initial evaluation, nutritional support, medical and surgical intervention, and the direction of future research, are encountered in both adult and pediatric patients. However, it is important to delineate issues specific to pediatric patients, especially growth velocity impairment, derangements in and treatment of abnormal bone mineralization, and transitional care issues; the lack of extensive randomized, controlled pediatric therapeutic trials is also a concern. This article reviews the epidemiology of pediatric inflammatory bowel disease incidence and prevalence worldwide, clinical issues (including impairments of growth velocity and bone density), diagnostic and therapeutic interventions, and psychosocial issues unique to pediatric patients. Future research directions defined by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and opportunities provided by existing pediatric research databases are highlighted.