Recurrent pain, emotional distress, and health service use in childhood

Health-Related Quality of Life in Adolescents With Chronic Illness in Jamaica: Adolescent and Parent Reports

PURPOSE

The aim of this study is to assess the level of agreement between adolescents' self-assessment and parent-proxy reports on health-related quality of life (HRQOL) in Jamaican adolescents with chronic illness.

METHODS

A cross-sectional study was conducted, recruiting adolescents living with a chronic illness (ALCIs)-asthma, human immunodeficiency virus, insulin-dependent diabetes mellitus, or sickle cell disease and age/sex-matched healthy adolescents. Data were collected on HRQOL from adolescents and parents using the Pediatric Quality of Life Scale. Parent-adolescent agreement was determined at group level (Wilcoxon signed-rank test) and individual level (intraclass correlation coefficient).

RESULTS

Two hundred twenty-six (226) parent/adolescent pairs participated: 130 ALCIs and 96 healthy peers; mean age 14.9 ± 2.8 years; 58% females. Adolescents with and without chronic illness reported similar HRQOL; parent-proxies reported better HRQOL for healthy adolescents compared to ALCIs. Intraclass correlation demonstrated higher levels of parent-adolescent correlation for ALCIs than healthy adolescents (ALCIs: 0.11-0.34; healthy adolescents: 0.01-0.10). At group level, analyses demonstrated better parent-proxy rating of QOL in all of the scores with the exception of the general health score. Parent-proxies overestimated QOL for asthma and insulin-dependent diabetes mellitus but not for sickle cell disease and human immunodeficiency virus. Linear regression modeling revealed that female sex and living with chronic illness were significant predictors of agreement.

DISCUSSION

Parent-proxies overestimated adolescents' QOL compared to adolescents' report regardless of whether the adolescent was living with a chronic illness or not. As such, health care providers should elicit feedback from the adolescent wherever possible and proxy reports should be used as complementary information rather than primary source.

Promoting Racial/Ethnic Equity in Psychosocial Treatment Outcomes for Child and Adolescent Anxiety and Depression

Anxiety and depression are the most prevalent and least treated pediatric mental health problems. Racial/ethnic minority youths face greater risks for developing anxiety and depression and experience higher burden as they are less likely to receive adequate mental health services for these conditions or to have their needs met. Further, standard evidence‐based interventions for youth anxiety and depression may show diminished effects with racial/ethnic minority youths and with families of lower socioeconomic status. While community‐level interventions to combat structural racism and reduce population‐level risk are sorely needed, many youths will continue to require acute treatment services for anxiety and depression and interventionists must understand how to bring equity to the forefront of care. In this review, we adopt a health system framework to examine racial/ethnic disparities in system‐, intervention‐, provider‐, and patient‐level factors for psychosocial treatment of pediatric anxiety and depression. Current evidence on disparities in access and in efficacy of psychosocial intervention for anxious and depressed youths is summarized, and we use our work in primary care as a case example of adapting an intervention to mitigate disparities and increase equity. We conclude with recommendations for disparity action targets at each level of the health system framework and provide example strategies for intervening on these mechanisms to improve the outcomes of racial/ethnic minority youths.

Racial/ethnic minority youths face greater risks for developing anxiety and depression and experience higher burden from disorder as they are less likely to receive adequate mental health services for these conditions or to have their needs met.

Increasing access to services for anxiety and depression is of critical and immediate importance for racial/ethnic minority families. Issues of access may be associated with the physical location of services (e.g., primary care or telehealth) or with barriers of language, income, or financing.

Both service settings and research treatment protocols frequently require families of ethnic/racial minority youths to fit themselves to the demands of care, in ways that may not be culturally compatible (e.g., little parent involvement in treatment) or practically feasible (i.e., weekly sessions during parent working hours). Whenever possible, non‐essential aspects of intervention should be freed to match patient preferences and constraints, and interventions for anxiety and depression should be adopted that have broad impacts and options for personalization of goals.

Child-Focused Cognitive Behavioral Therapy for Pediatric Abdominal Pain Disorders Reduces Caregiver Anxiety in Randomized Clinical Trial

Pediatric functional abdominal pain disorders (FAPD) are associated with elevated anxiety in youth and their caregivers, both contributing to an adverse impact on functioning in youth with FAPD. While a CBT approach (ie, Aim to Decrease Anxiety and Pain Treatment [ADAPT]) is known to improve health outcomes for youth, it is unknown if child-focused treatment improves caregiver anxiety. This secondary analysis of a larger randomized clinical trial examined if child-focused CBT (ADAPT) for pain and anxiety also impacts caregiver anxiety and explored the relation between caregiver anxiety and child symptoms (ie, pain, disability, anxiety) after treatment. A total of 79 caregiver-child dyads were randomized to ADAPT plus treatment as usual (TAU) or TAU only. Caregiver anxiety and child outcomes (pain, disability, anxiety) were assessed at baseline and approximately 8 weeks later. Caregivers of children who completed ADAPT+TAU demonstrated lower anxiety compared to those who only received TAU. Moreover, regardless of treatment assignment, caregivers with greater anxiety had children who reported more pain and anxiety, but not functional disability at post-assessment. Results suggest a brief, child-focused intervention targeting pain and anxiety may also improve caregiver anxiety. As such, suggestions to improve future treatments are offered. PERSPECTIVE: Caregiver anxiety symptoms diminished after their child with functional abdominal pain completed a course of child-focused CBT targeting pain and anxiety. Further, caregiver anxiety was related to child-reported symptoms (pain and anxiety) after treatment. Therefore, improved caregiver mental health via a child-focused CBT may also improve pediatric outcomes.

"There's Nothing Wrong With You": Pain-Related Stigma in Adolescents With Chronic Pain

OBJECTIVE

Adolescents with chronic pain often experience symptom disbelief and social rejection by others secondary to "medically unexplained" symptoms. Although chronic pain is common in adolescents, limited research has conceptualized these social experiences as pain-related stigma in this population. The purpose of this study was to identify and describe pain-related stigma among adolescents with chronic pain and their parents using focus group methodology.

METHODS

Five adolescent focus groups (N = 18; Age M = 15.33 years, SD = 1.28) and three parent focus groups (N = 9) were conducted. Directed content analysis was used to analyze focus group transcripts. Stigma categories were developed a priori (Felt Stigma, Anticipated Stigma, Internalized Stigma, Concealment, and Controllability) and new categories emerged during analysis. Two coders reached 87.16% agreement for all groups (adolescent group: 90.34%; Parent group: 79.55%) and consensus was achieved for discordant codes.

RESULTS

Adolescents and their parents endorsed pain-related stigma across all social domains. Analyses revealed four main categories for both groups (a) Felt Stigma (subcategories: pain dismissal, faking or exaggerating, and mental health stigma), (b) Anticipated Stigma and Concealment, (c) Internalized Stigma, and (d) Sources of Pain-Related Stigma (subcategories: pain invisibility, lack of chronic pain knowledge, lack of understanding, and controllability).

CONCLUSIONS

Adolescents with chronic pain experience pain-related stigma from medical providers, school personnel, family members, and peers, which may have negative social and health implications. More research is needed to evaluate the link between pain-related stigma and health outcomes for adolescents with chronic pain. Clinical approaches targeting pain-related stigma are discussed.

Pre-vaccination vulnerability and suspected adverse events following HPV vaccination. A case-control study nested in the Danish national birth cohort

Previous studies have indicated that girls experiencing suspected adverse events (AE) following HPV vaccination were more vulnerable prior to vaccination. However, no study has previously investigated differences in vulnerability using prospectively collected self-reported measures of vulnerability. The objective of this study therefore was to describe the distribution of biological and psychosocial indicators of vulnerability in girls referred to a hospital setting due to suspected adverse events and compare it with a sample of non-referred HPV vaccinated girls. The study was conducted as a case control study based within the Danish National Birth Cohort. Cases were defined as HPV vaccinated girls referred to a hospital setting between 2015 and 2017 due to suspected adverse events (n = 80), and 5 controls were randomly selected from the remaining source population, matched to cases on age at vaccination, region of residence and year of vaccination. The final study population consisted of 480 girls. Prior exposures were based on information gathered from an 11 year follow up of the DNBC and included information on self-rated health, frequent health complaints, medication use, bullying, stressful life events and physical activity. Conditional logistic regression analysis was used to estimate the association between each exposure and referral. The percentage of individuals in the exposed category of each exposure was generally higher for cases than controls. Particularly, the odds of being referred were higher for those with low self-rated health compared to high (OR [95%-CI] 2.43 [1.07-5.5]1), those being bullied (OR 3.19 [1.17-8.73]), and those who had taken medication (OR 2.22 [1.32-3.67]). Overall, these results indicated that girls experiencing suspected AE following HPV vaccination were more vulnerable prior to vaccination.

Pain Management in Children During the COVID-19 Pandemic

PURPOSE OF REVIEW

For many children, the SARS-CoV-2 pandemic has impacted the experience and treatment of their pain. This narrative review draws from the pain literature and emerging findings from COVID-19 research to highlight potentially meaningful directions for clinical consideration and empirical inquiry in the months and years to come.

RECENT FINDINGS

COVID-19 has been linked to diffuse acute pains as well as chronic pain sequelae. Contextual factors known to increase vulnerability for pain and associated functional disability have been exacerbated during the pandemic. Beyond these salient concerns has been the remarkable resilience demonstrated by patients and providers as healthcare systems have sought to harness creativity and innovative digital solutions to support optimal child wellbeing throughout this crisis.

SUMMARY

Ongoing research is needed to elucidate the short- and long-term effects of the pandemic on children's pain and to consider how the delivery of treatment via digital technology has impacted existing paradigms of pain management.

Self-reported symptoms of temporomandibular pain and jaw dysfunction in adolescents are associated with exposure to violence

BACKGROUND

Temporomandibular disorders (TMDs) are multifactorial, and high levels of stress seem to increase symptoms. The association with exposure to violence has not been explored in adolescent populations.

OBJECTIVE

To examine the association of self-reported symptoms of temporomandibular pain and jaw dysfunction with child physical abuse, intimate partner violence, forced sexual intercourse, and bullying victimisation.

METHODS

An epidemiological, cross-sectional, school-based study was conducted in Olinda, northeast Brazil. The sample comprised 2,431 adolescents aged 14-19 years. TMD-related symptoms and exposure to violence were assessed with questions from the 3Q/TMD screener and queries on exposure to different forms of violence. Multilevel logistic regressions were conducted to evaluate how 3Q screen-positive responses are associated with self-reported exposure to violence.

RESULTS

Self-reported TMD-related symptoms had a prevalence of 40.5%. Significantly more females than males screened positive to all 3Q/TMD questions (p < .001). Adolescents experiencing intimate partner violence (p = .012) and bullying (p < .001) had significantly higher odds of 3Q positive responses than those who reported no exposure to violence. Significant associations of TMD-related symptoms with forced sexual intercourse (p = .014) and with bullying (p = .007) were observed.

CONCLUSION

Adolescents with self-reported symptoms of temporomandibular pain and jaw dysfunction were significantly more often exposed to some type of violence. The number of adolescents reporting TMD-related symptoms increased in a dose-response manner with the number of violence forms the individual had experienced.

Cognitive Behavior Therapy Tailored to Anxiety Symptoms Improves Pediatric Functional Abdominal Pain Outcomes: A Randomized Clinical Trial

OBJECTIVES

To evaluate the feasibility of a stepped care model, and establish the effect of a tailored cognitive behavioral therapy, the Aim to Decrease Anxiety and Pain Treatment (ADAPT), compared with standard medical treatment as usual on pain-related outcomes and anxiety.

STUDY DESIGN

Eligible patients between the ages of 9 and 14 years with functional abdominal pain disorders (n = 139) received enhanced usual care during their medical visit to a gastroenterologist. Those that failed to respond to enhanced usual care were randomized to receive either a tailored cognitive behavioral therapy (ADAPT) plus medical treatment as usual, or medical treatment as usual only. ADAPT dose (4 sessions of pain management or 6 sessions of pain and anxiety management) was based on presence of clinically significant anxiety. Outcomes included feasibility, based on recruitment and retention rates. Response to ADAPT plus medical treatment as usual vs medical treatment as usual on pain-related outcomes and anxiety measures was also investigated using a structural equation modeling equivalent of a MANCOVA. Anxiety levels and ADAPT dose as moderators of treatment effects were also explored.

RESULTS

Based on recruitment and retention rates, stepped care was feasible. Enhanced usual care was effective for only 8% of youth. Participants randomized to ADAPT plus medical treatment as usual showed significantly greater improvements in pain-related disability, but not pain levels, and greater improvements in anxiety symptoms compared with those randomized to medical treatment as usual only. Anxiety and ADAPT treatment dose did not moderate the effect of treatment on disability nor pain.

CONCLUSIONS

Tailoring care based on patient need may be optimal for maximizing the use of limited psychotherapeutic resources while enhancing care.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03134950.

Agreement Between Child Self-report and Caregiver-Proxy Report for Symptoms and Functioning of Children Undergoing Cancer Treatment

IMPORTANCE

Adult patients are considered the best reporters of their own health-related quality of life (HRQOL). Self-report in pediatrics has been challenged by a limited array of valid measures. Caregiver report is therefore often used as a proxy for child report.

OBJECTIVES

To examine the degree of alignment between child and caregiver proxy report for Patient-Reported Outcomes Measurement Information System (PROMIS) HRQOL domains among children with cancer and to identify factors associated with better child and caregiver-proxy congruence.

DESIGN, SETTING, AND PARTICIPANTS

In this multicenter cohort study, children with a first cancer diagnosis and their caregivers completed surveys at 2 time points: within 72 hours preceding treatment initiation (T1) and during follow-up (T2), when symptom burden was expected to be higher (eg, 7-17 days later for chemotherapy). Data were collected from October 26, 2016, to October 5, 2018, at 9 pediatric oncology hospitals. Five hundred eighty children (aged 7-18 years) and their caregivers were approached; 482 child-caregiver dyads completed surveys at T1 (response rate 83%), and 403 completed surveys at T2 (84% of T1 participants). Data were analyzed from July 1, 2019, to April 22, 2020.

EXPOSURES

Participants received up-front cancer treatment, including chemotherapy and radiotherapy.

MAIN OUTCOMES AND MEASURES

Congruence between child self-report and caregiver-proxy report of PROMIS pediatric domains of mobility (physical functioning), pain interference, fatigue, depressive symptoms, anxiety, and psychological stress.

RESULTS

Of the 482 dyads included in the analysis, 262 children (54%) were male (mean [SD] age, 12.9 [3.4] years), 80 (17%) were Black, and 71 (15%) were Hispanic. Intraclass correlations between child self-report and caregiver proxy report showed moderate agreement for mobility (0.57 [95% CI, 0.50-0.63]) and poor agreement for symptoms (range, 0.32 [95% CI, 0.24-0.41] for fatigue to 0.42 [95% CI, 0.34-0.50] for psychological stress). Children reported lower symptom burden and higher mobility than caregivers reported. In a multivariable model adjusted for child and parent sociodemographic factors and the caregiver's own self-reported HRQOL, caregivers reported the child's mobility score 6.00 points worse than the child's self-report at T2 (95% CI, -7.45 to -4.51), exceeding the PROMIS minimally important difference of 3 points. Caregivers overestimated the child's self-reported symptom levels, ranging from 5.79 (95% CI, 3.99-7.60) points for psychological stress to 13.69 (95% CI, 11.60-15.78) points for fatigue. The caregiver's own self-reported HRQOL was associated with the magnitude of difference between child and caregiver scores for all domains except mobility; for example, for fatigue, the magnitude of difference between child and caregiver-proxy scores increased by 0.21 (95% CI, 0.13-0.30) points for each 1-point increase in the caregiver's own fatigue score.

CONCLUSIONS AND RELEVANCE

This study found that caregivers consistently overestimated symptoms and underestimated mobility relative to the children themselves. These results suggest that elicitation of the child's own report should be pursued whenever possible.

Standardizing Pediatric Somatic Symptom and Related Disorders Care: Clinical Pathway Reduces Health Care Cost and Use

BACKGROUND

Pediatric somatic symptom and related disorders (SSRDs) are common with high health care costs and use because of lack of standardized, evidence-based practice. Our hospital implemented a clinical pathway (CP) for SSRD evaluation and management. Our study objective was to evaluate health care cost and use associated with the organization's SSRD CP in the emergency department (ED) and inpatient settings hypothesizing lower cost and use in the CP group relative to controls.

METHODS

We conducted a retrospective analysis of costs and use before and after implementation of the SSRD CP. Data were collected from the hospital's electronic health record and the Pediatric Health Information System database. Participants included pediatric patients on the CP ("P" group) and control groups with an SSRD diagnosis and mental health consultation either the year before the CP ("C" group) or during the CP study period ("T" group). Primary outcomes included costs, length of stay, diagnostic testing, imaging, subspecialty consultation, and readmission rates.

RESULTS

The ED P group had more lower-cost imaging, whereas the inpatient T group greater higher-cost imaging than other groups. The inpatient P group had significantly shorter length of stay, fewer subspecialty consults, and lower costs. There were no significant group differences in readmission rates. The CP reduced median total costs per patient encounter by $51 433 for the inpatient group and $6075 for the ED group.

CONCLUSIONS

The CP group showed significant reductions in health care cost and use after implementation of a CP for SSRD care. In future work, researchers should explore patient and practitioner experience with the SSRD CP and long-term outcomes.

Non-specific Health complaints and self-rated health in pre-adolescents; impact on primary health care use

The objective of the present study was to explore past and future primary health care use in preadolescents reporting frequent non-specific health complaints or a low self-rated health compared to that of preadolescents with no frequent health complaints or with good self-rated health. The study was conducted as a cohort study based within the Danish National Birth Cohort (1996–2002). Information on non-specific health complaints and self-rated health was obtained by an 11-year follow-up questionnaire. Information about number of general practitioner (GP) contacts was obtained from the Health Insurance Service Register. A total of 44,877 pre-adolescents gave complete exposure information. Pre-adolescents who reported frequent non-specific health complaints had a higher use of GP compared to pre-adolescents without complaints across the five years following the index date (somatic complaints: IRR = (1.46 [1.38; 1.55], mental complaints: IRR = 1.16 [1.12; 1.19], both complaints: IRR = 1.58 [1.47; 1.69]). The same pattern was found for the association between low self-rated health and number of GP contacts (IRR = 1.41 (1.36; 1.46)). Non-specific health complaints and a poor self-rated health in pre-adolescents was associated with a higher past and future use of GP, indicating a need for development of early interventions with help for symptom management.

The Influence of Caregiver Distress and Child Anxiety in Predicting Child Somatization in Youth with Functional Abdominal Pain Disorders

Pediatric functional abdominal pain disorders (FAPD) are associated with adverse outcomes including increased somatization (e.g., heightened physiological sensations that include gastroenterological and non-gastroenterological symptoms) and increased functional disability. Caregiver distress and child anxiety are separately associated with the adverse outcomes of pediatric FAPD. However, the cumulative role of caregiver (i.e., stress, anxiety, and depression) and child psychological functioning (anxiety) in relation to adverse outcomes associated with FAPD, and particularly somatization, is unclear. Thus, the present investigation sought to examine the role of caregiver distress and child anxiety in relation to pain-related functioning (i.e., somatization, pain intensity, functional disability) in youth with FAPD. Data were gathered as part of a larger study examining a psychological treatment for youth with FAPD. Participants (ages 9–14) with FAPD completed measures of child anxiety, pain, and pain-related functioning. Caregivers completed a measure of caregiver distress (e.g., stress, anxiety, depressive symptoms). Pearson correlations revealed significant positive associations between child anxiety and child functional disability. Additionally, caregiver anxiety, child anxiety, and child somatization were all significantly and positively correlated with one another. Therefore, we assessed whether child anxiety may potentially mediate the relationship between caregiver anxiety and child somatization in this cross-sectional study. The indirect association between caregiver anxiety and child somatization via child anxiety was not significant. Future research including longitudinal designs to further understand the relationship between caregiver anxiety, child anxiety, and child pain-related functioning, would enhance understanding of how these potentially modifiable psychological factors may impact adverse outcomes of FAPD.

Recurrent Pain and Academic Achievement in School-Aged Children: A Systematic Review

Recurrent pain and school failures are common problems in children visiting the school nurses office. The overall aim of the current study was to investigate the relationship between recurrent pain and academic achievement in school-aged children. Literature was searched in seven electronic databases and in relevant bibliographies. Study selection, data extraction, and study and evidence quality assessments were performed systematically with standardized tools. Twenty-one studies met the inclusion criteria and 13 verified an association between recurrent pain (headache, stomachache, and musculoskeletal pain) and negative academic achievement. Two longitudinal studies indicated a likely causal effect of pain on academic achievement. All studies had substantial methodological drawbacks and the overall quality of the evidence for the identified associations was low. Thus, children’s lack of success in school may be partly attributed to recurrent pain problems. However, more high-quality studies are needed, including on the direction of the association and its moderators and mediators.

Parent Attributions of Ambiguous Symptoms in Their Children: A Preliminary Measure Validation in Parents of Children with Chronic Pain

How parents attribute cause to their child’s physical symptoms is likely important in understanding how the parent responds to the child, as well as the child’s health outcomes, especially within the context of chronic illness. Here, we adapt the Symptom Interpretation Questionnaire for parent report (SIQ-PR) and provide preliminary validation in a sample of parents of children with chronic pain (N = 311). Confirmatory factor analysis revealed that the SIQ-PR structure is consistent with the original measure, with three distinct attribution types: psychological (emotional/affective), somatic (illness/disease), and environmental (situational/transient) causes. All three subscales demonstrated satisfactory to good internal consistency, and temporal stability. Parents typically endorsed more than one attribution for each symptom, indicating that parents of children with chronic pain have a multidimensional interpretation of physical symptoms in their children. Further, parent psychological and somatic attributions, but not environmental attributions, were significantly associated with (i) parent protective responses towards their child, and (ii) the child’s self-reported somatic and psychological symptoms, indicating convergent and divergent validity. The SIQ-PR may be a useful measure for future studies investigating intergenerational and interpersonal models of pediatric chronic pain, and more broadly, to examine parent attributions of children’s ambiguous symptoms within the context of childhood chronic illness.

Connecting the Mind-Body Split: Understanding the Relationship between Symptoms and Emotional Well-Being in Chronic Pain and Functional Gastrointestinal Disorders

Paediatric chronic conditions, e.g., chronic pain and functional gastrointestinal disorders, are commonly diagnosed, with fatigue, pain and abdominal discomfort the most frequently reported symptoms across conditions. Regardless of whether symptoms are connected to an underlying medical diagnosis or not, they are often associated with an increased experience of psychological distress by both the ill child and their parents. While pain and embarrassing symptoms can induce increased distress, evidence is also accumulating in support of a reciprocal relationship between pain and distress. This reciprocal relationship is nicely illustrated in the fear avoidance model of pain, which has recently been found to be applicable to childhood pain experiences. The purpose of this article is to illustrate how mind (i.e., emotions) and body (i.e., physical symptoms) interact using chronic pain and gastrointestinal disorders as key examples. Despite the evidence for the connection between mind and body, the mind-body split is still a dominant position for families and health care systems, as evidenced by the artificial split between physical and mental health care. In a mission to overcome this gap, this article will conclude by providing tools on how the highlighted evidence can help to close this gap between mind and body.

Impact of functional somatic symptoms on 5-7-year-olds' healthcare use and costs

OBJECTIVE

Knowledge about childhood functional somatic symptoms (FSS) and healthcare costs is scarce. This study aims to assess whether FSS in children aged 5-7 years are associated with increased future primary healthcare.

DESIGN

At baseline of the observational cohort study, between years 2005 and 2007, 1327 children from the Copenhagen Child Cohort were assessed at ages 5-7 years for FSS and chronic physical diseases using the Soma Assessment Interview. Information on primary healthcare use was obtained from the National Health Insurance Service Register, and measured as the price of all medical services outside the hospital during a 4.5-year follow-up period from the day of assessment. Regression with bootstrap bias-corrected and accelerated CIs were performed.

RESULTS

1018 (76.8%) children had no FSS with primary healthcare use adjusted for other child health problems, maternal education and family changes of €448.2, 388.2-523.8 and number of face-to-face contacts: 11.90, 10.71-13.25; 250 (18.9%) had FSS with healthcare use €441.0, 355.0-550.3 and face-to-face contacts: 11.22, 9.60-12.91, and 58 (4.4%) had impairing FSS with healthcare use: €625.9, 447.9-867.8 and face-to-face contacts: 14.65, 11.20-19.00. In unadjusted regression analysis, impairing FSS were associated with increased healthcare use (increased costs: €246.0, 67.6-494.3). The adjusted association was slightly attenuated (increased costs: €177.8, 1.3-417.0).

CONCLUSIONS

Impairing FSS in children aged 5-7 years is a predictor for the child's future primary healthcare use. More research on complex predictive models is needed to further explore the clinical significance of these results, and to contribute to the underpinning of early interventions towards impairing FSS in children.

Chronic Abdominal Pain in Children and Adolescents: Parental Threat Perception Plays a Major Role in Seeking Medical Consultations

Background. Pain symptoms, associated impairment, and parental perception of threat are reported to be predictors of health care utilization (HCU) in childhood chronic abdominal pain (CAP). However, mediating variables and their interrelations have not yet been systematically studied. Objectives. This study aims to identify mediating pathways of influence between child's abdominal pain and the number of pain-related medical visits. Methods. In a multicenter study, we recruited N = 151 parent-child dyads with children aged 6-17 years suffering from CAP. A composite measure of pain symptoms was defined as predictor and the number of pain-related medical visits as outcome variable. This relation was analyzed by serial mediation, including child- and parent-reported impairment and parental threat perception as mediators. Results. Only parental threat perception significantly linked child's pain symptoms to the number of medical visits. Measures of impairment did not have a significant effect. Conclusions. Parental pain-related threat perception is strongly related to health care seeking in childhood CAP. Addressing threat perception might be a fruitful parent-centered approach in clinical practice.

Laparoscopic antireflux surgery increases health-related quality of life in children with GERD

INTRODUCTION

Improving health-related quality of life (HRQoL) is increasingly recognized as an essential part of patient care outcome. Little is known about the effect of laparoscopic antireflux surgery (LARS) on the HRQoL in the pediatric patients. The aims of this study were to evaluate the effect of LARS on HRQoL in children with gastroesophageal reflux disease (GERD) and to identify predictors that influence HRQoL outcome after LARS.

METHODS

Between 2011 and 2013, 25 patients with therapy-resistant GERD [median age 6 (2-18) years] were included prospectively. Caregivers and children with normal neurodevelopment (>4 years) were asked to fill out the validated PedsQL 4.0 Generic Core Scales before and 3-4 months after LARS.

RESULTS

The PedsQL was completed by all caregivers (n = 25) and 12 children. HRQoL total score improved significantly after LARS, both from a parental (p = 0.009) and child's perspective (p = 0.018). The psychosocial health summary and physical health summary scores also improved significantly after LARS. HRQoL before and after LARS was significantly lower in children with impaired neurodevelopment (p < 0.001). However, neurodevelopment did not influence the effect of LARS on HRQoL. The only significant predictor for improvement in HRQoL after LARS was age at the time of operation (p = 0.001).

CONCLUSIONS

HRQoL significantly improves after LARS. Although children with impaired neurodevelopment had lower overall HRQoL, neurodevelopment by itself does not predict inferior improvement in HRQoL after LARS. Older children have a more favorable HRQoL outcome after LARS compared to younger children. This may suggest caution when considering LARS in younger GERD patients.

When somatization is not the only thing you suffer from: Examining comorbid syndromes using latent profile analysis, parenting practices and adolescent functioning

Understanding somatization presents a challenge to clinicians because it is often associated with other syndromes. We addressed somatization's comorbidity with other internalizing syndromes (anxiety, depression, withdrawal) using latent profile analysis. A representative sample of 3496 Israeli middle and high-school youths reported their internalizing symptoms, perceived parenting practices, psychosocial functioning, and health behaviors. Four profiles, similar across age and gender, were identified: overall-low (65.4%), moderately-high anxiety/depression/withdrawal (24.4%), high somatization (4.8%), and overall-high (5.4%). MANOVAs and follow-up ANOVAs revealed that for the most part the overall-high profile evinced the worst parenting, psychosocial functioning, and health behaviors (smoking and drinking), while the overall-low group evinced the best. For most variables the high somatization and moderately high profiles displayed midway results. However, the moderately-high profile reported higher levels of harsh parenting than the high somatization profile. The high somatization profile reported similar or higher levels of smoking, risk taking, vandalism, and rule violation than the overall-high group. High somatization, either alone or alongside anxiety, depression, and withdrawal, was associated with disruptive and risk-taking behaviors. This link might reflect problems in emotion and anger regulation and become stronger in adolescence because of dysregulation processes characterizing this period. Implications for practice are discussed.

The PSC-17: Subscale Scores, Reliability, and Factor Structure in a New National Sample

BACKGROUND

The Pediatric Symptom Checklist-17 (PSC-17) is a widely used, briefer version of the PSC-35, a parent-completed measure of children's psychosocial functioning. Despite the extensive use of the PSC-17 over the past 15 years there has not been a large-scale replication of the original derivation study.

OBJECTIVE

To examine the prevalence of positive screens, reliability, and factor structure of PSC-17 scores in a new national sample and compare them with the derivation sample.

METHODS

Data were collected on 80 680 pediatric outpatients, ages 4 to 15 years, whose parents filled out the PSC-17 from 2006 to 2015 via the Child Health and Development Interactive System, an electronic system that presents and scores clinical measures.

RESULTS

The rates of positive screening on the overall PSC-17 (11.6%) and on the internalizing (10.4%) and attention (9.1%) subscales were comparable to rates found in the original sample, although the rate of externalizing problems (10.2%) was lower than in the derivation study. Reliability was high (internal consistency 0.89; test-retest 0.85), and a confirmatory factor analysis provided support for the original 3-factor model.

CONCLUSIONS

Fifteen years after the PSC-17 was derived in a large nationally representative outpatient pediatric sample, a new and larger national sample found rates of positive screening, reliability, and factor structure that were comparable. Findings from this study support the continued use of the PSC-17 clinically as a screening tool in pediatric settings and in research.

Child and Family Antecedents of Pain During the Transition to Adolescence: A Longitudinal Population-Based Study

Pediatric persistent pain is associated with poorer physical and psychosocial functioning in children, as well as immediate and long-term societal costs. Onset typically occurs in early adolescence, suggesting that late childhood is a key window for identifying potential intervention targets before pain symptoms become entrenched. This study used population-based data from the Longitudinal Study of Australian Children (n = 3,812) and adopted a biopsychosocial and ecological systems approach to investigate child, family, and sociodemographic factors associated with pain problems in children transitioning to adolescence. The prevalence of at least weekly parent-reported pain in the study sample was approximately 5% at 10 to 11 years of age, and pain continued at 12 to 13 years of age for 40% of these children. Key factors at 10 to 11 years that uniquely predicted parent-reported pain problems at 12 to 13 years were frequency of previous pain (1-3 times weekly: odds ratio [OR] = 7.49; 95% confidence interval [CI], 4.3-13.0; 4-7 times weekly: OR = 17.8; 95% CI, 8.7-36.5) and sleep difficulties (OR = 1.86; 95% CI, 1.16-2.97). This study highlights the importance of early intervention for persistent pain in childhood, because pain complaints in late childhood tend to persist into early adolescence.

PERSPECTIVE

This article used a biopsychosocial and ecological systems approach to understanding predictors of pain problems during the transition to adolescence within a nationally representative community-based cohort. Sleep difficulties at 10 to 11 years uniquely predicted pain at ages 12 to 13 years, suggesting that early intervention using sleep interventions may be a promising direction for future research.

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.

Health-related Quality of Life in Infants With Chronic Liver Disease

OBJECTIVE

The objective of the present study was to report on the health-related quality of life (HRQOL) of infants with chronic liver disease using the PedsQL (Pediatric Quality of Life Inventory) Infant Scales.

METHODS

The 36-item (ages 1-12 months) and 45-item (ages 13-24 months) PedsQL Infant Scales (physical functioning, physical symptoms, emotional functioning, social functioning, cognitive functioning) were completed by 50 parents of infants with chronic liver disease.

RESULTS

Infants ages 1 to 12 months had significantly lower HRQOL scores compared with a matched healthy sample. Infants 13 to 24 months trended to lower physical HRQOL scores that did not reach statistical significance. Recent hospitalizations had an impact on the majority of HRQOL subscales, as did ascites, and failure to thrive.

CONCLUSIONS

Infants ages 1 to 12 months with chronic liver disease demonstrate lower HRQOL compared with healthy children with physical subscales being most severely affected. The PedsQL Infant Scales allow the definition of HRQOL during a critical period of an infants' development that has been heretofore difficult to measure.

Anxiety Adversely Impacts Response to Cognitive Behavioral Therapy in Children with Chronic Pain

OBJECTIVE

To evaluate whether clinical anxiety in children presenting to a pediatric pain management center is associated with a poorer treatment response for those who completed pain-focused cognitive behavioral therapy (CBT).

STUDY DESIGN

The total sample consisted of 175 children, 40 of whom completed CBT for chronic pain. The Screen for Child Anxiety Related Emotional Disorders was completed at initial evaluation and outcome measures (average pain intensity and the Functional Disability Inventory) were collected during the initial evaluation and at the end of CBT. Group differences in outcomes were examined following CBT. The role of anxiety in CBT initiation and completion was also explored.

RESULTS

Presence of clinical anxiety was associated with greater initiation and/or completion of pain-focused CBT but also a poorer treatment response. Specifically, the group with subclinical anxiety exhibited a substantial reduction in pain intensity, and the group with clinical anxiety exhibited a more limited response to treatment (F [1, 36] = 13.68 P < .01). A similar effect was observed for Functional Disability Inventory, such that the group with clinical anxiety had a significantly smaller response to treatment (F [1, 38] = 4.33 P < .05). The difference in pain and disability between groups following CBT suggest moderate effects (Cohen d = 0.77 and 0.78, respectively).

CONCLUSIONS

Although youths with clinical anxiety are more likely to start and/or complete pain-focused CBT, anxiety has an adverse impact on CBT treatment response in children with chronic pain. Identification of patients with anxiety and use of tailored behavioral interventions may improve clinical outcomes.

Quality of Life in Survivors of Pediatric Cancer and Their Siblings: The Consensus Between Parent-Proxy and Self-Reports

OBJECTIVES

To examine the discrepancy between survivor-parent and sibling-parent reports of health-related quality of life (HRQL) and the level of agreement (i.e., correlation) between child reports (i.e., survivor and sibling) and parent-proxy reports of HRQL.

METHODS

Fifty-one families participated. Pediatric cancer survivors (49% male; 6-18 years of age) and one sibling (47% male; 9-18 years of age) completed a measure of their HRQL. As well, one parent (14% male; 27-65 years of age) from each family completed a proxy report of their children's (i.e., survivor and sibling) HRQL. Consensus was determined through discrepancy and agreement scores, between parent-proxy and children's (i.e., survivors and siblings) self-reports of total HRQL, and physical, emotional, social, and school functioning subscales.

RESULTS

Repeated-measures analysis of variance (ANOVA) revealed significant group differences for total HRQL (F = 6.79, P ≤ 0.01). Repeated-measure ANOVAs of subscale discrepancy scores revealed significant group differences for physical functioning scores (F = 6.39, P < 0.01). A significant interaction was also found for social functioning when age at diagnosis was considered as a covariate (F = 10.30, P < 0.01). Zero-order and intraclass correlation coefficients revealed different levels of agreement between parent and child reports. Specifically, there was poorer agreement between parent-proxy and sibling's self-reports, particularly on social and emotional subscales.

CONCLUSIONS

Discrepancy and agreement are both important indices to consider when examining consensus between parent-proxy and child self-reports. The findings from this study have important implications for future research and suggest that the impact of cancer on siblings should be further investigated.

Annual Costs of Care for Pediatric Irritable Bowel Syndrome, Functional Abdominal Pain, and Functional Abdominal Pain Syndrome

OBJECTIVES

To estimate annual medical and nonmedical costs of care for children diagnosed with irritable bowel syndrome (IBS) or functional abdominal pain (syndrome; FAP/FAPS).

STUDY DESIGN

Baseline data from children with IBS or FAP/FAPS who were included in a multicenter trial (NTR2725) in The Netherlands were analyzed. Patients' parents completed a questionnaire concerning usage of healthcare resources, travel costs, out-of-pocket expenses, productivity loss of parents, and supportive measures at school. Use of abdominal pain related prescription medication was derived from case reports forms. Total annual costs per patient were calculated as the sum of direct and indirect medical and nonmedical costs. Costs of initial diagnostic investigations were not included.

RESULTS

A total of 258 children, mean age 13.4 years (±5.5), were included, and 183 (70.9%) were female. Total annual costs per patient were estimated to be €2512.31. Inpatient and outpatient healthcare use were major cost drivers, accounting for 22.5% and 35.2% of total annual costs, respectively. Parental productivity loss accounted for 22.2% of total annual costs. No difference was found in total costs between children with IBS or FAP/FAPS.

CONCLUSIONS

Pediatric abdominal pain related functional gastrointestinal disorders impose a large economic burden on patients' families and healthcare systems. More than one-half of total annual costs of IBS and FAP/FAPS consist of inpatient and outpatient healthcare use.

TRIAL REGISTRATION

Netherlands Trial Registry: NTR2725.

Item-level informant discrepancies between children and their parents on the PROMIS(®) pediatric scales

OBJECTIVE

The study objective was to describe the individual item-level discrepancies between children ages 8-17 years and their parents for the PROMIS(®) pediatric scales. Contextual effects on item-level informant discrepancies for the pediatric pain interference items were further analyzed conditional on whether the child, the parent, or anyone else in the household experienced chronic pain.

METHODS

Parallel pediatric self-report and parent proxy-report items were completed by approximately 300 parent-child dyads depending on form assignment and individual nonresponse. Agreement between parent and child responses to individual items was measured using the polychoric correlation coefficient and weighted κ. The Chi-square test of symmetry was utilized for a comparison of the pattern of parent-child item discrepancies on the response scales, and the differences between the child and parent responses on the 1-5 item response scale are summarized .

RESULTS

A continuum of higher item-level parent-child discrepancies was demonstrated starting with peer relationships, anger, anxiety, and depressive symptoms, followed by progressively lower parent-child discrepancies for energy, fatigue, asthma impact, pain interference, upper extremity, and mobility items. Parent-child discrepancies for pain interference items were lower in the context of chronic pain either in the child or in the parent.

CONCLUSIONS

Parent-child item-level discrepancies were lower for more objective or visible items than for items measuring internal states or less observable items measuring latent variables such as peer relationships and fatigue. Future research should focus on the child and parent characteristics that influence domain-specific item-level discrepancies, and under what conditions item-level parent-child discrepancies predict child health outcomes.

The relation between parenting stress and adolescents' somatisation trajectories: a growth mixture analysis

OBJECTIVE

The impact of somatisation in adolescence is substantial. Knowledge on (predictors of) individual-level development of somatisation is necessary to develop tailored treatment. The current study assessed individual-level development of somatisation by means of latent mixed modelling. Parenting stress was included as a predictor of somatisation trajectory membership and within-trajectory variation.

METHODS

A total of 1499 adolescents and one of their parents (mostly the mother) agreed to participate. Questionnaires were administered when the adolescents were respectively 12-13 (T1), 13-14 (T2), and 14-15 (T3) years old. Adolescents reported on their somatisation, parents on their parenting stress.

RESULTS

Four individual somatisation trajectories were found: increased, long-term low, long-term high, and decreased. Higher early parenting stress (T1) significantly predicted less favourable trajectory membership (increased and long-term high). The relation between later parenting stress (T2 and T3) and somatisation depended on trajectory membership. For adolescents in the long-term high and decreased somatisation trajectories, lower T2 and T3 parenting stress was related to higher somatisation, while for adolescents in the long-term low and increased trajectories, higher T2 and T3 parenting stress was related to higher somatisation.

CONCLUSIONS

The results support a general recommendation to prevent the onset of high levels of parenting stress. In addition, for families in which high levels of parenting stress already exist, clinicians should be aware of natural fluctuations in parenting stress, its associated features (e.g., aspects of overall care, like looking for professional help) and of the consequences this might have for the adolescent.

Nonspecific abdominal pain is a safe diagnosis

AIM

The aim of this study is to assess if a clinical diagnosis of nonspecific abdominal pain (NSAP) is safe and if patients with this initial diagnosis are likely to require further investigation or surgical intervention.

METHODS

3323 patients admitted with NSAP from July 1990 to September 2012 utilizing a prospective database of all surgical admissions were included. Readmission over the period of the study and specifically within 30 days of their initial presentation was identified together with any invasive investigation or surgical intervention.

MAIN RESULTS

319 children (9.6%) were subsequently readmitted with abdominal pain at some point during the study period. Of these, 78 (2.3%) were readmitted within 30 days. 118 (3.5%) children subsequently had an operation or invasive investigation some point following their initial admission. Of these 33 (0.6%) had the procedure within 3 months of the initial admission. 13 patients had an appendicectomy within 3 months of the initial presentation. Of these histology confirmed appendicitis in 8 patients. This gives an overall incidence of "missed" appendicitis of 0.2 % (8/3323).

CONCLUSION

This study confirms that a clinical diagnosis of nonspecific abdominal pain (NSAP) is safe in a pediatric population and the risk of "missing" appendicitis is only 0.2%. Patients and/or parents can be confidently reassured that the risk of missing organic pathology is very low.

Enxaqueca e Estresse em Mulheres no Contexto da Atenção Primária

O presente estudo teve por objetivo verificar a associação entre enxaqueca e estresse em mulheres, assim como examinar o melhor modelo de predição da enxaqueca, considerando variáveis pessoais e do contexto ambiental. A enxaqueca foi identificada pelo Teste de Cefaleia em 75 mulheres sem antecedentes psiquiátricos. O estresse foi avaliado por meio do Inventário de Sintomas de Stress para adultos. Paralelamente, foram avaliados: eventos vitais, nível socioeconômico e características da amostra. Verificou-se que 55% das mulheres apresentaram enxaqueca e 59% sintomas de estresse. O modelo de predição identificou que o estresse foi o único preditor da enxaqueca em mulheres. Os achados mostram associação entre enxaqueca e estresse, a qual precisa ser levada em conta na assistência à saúde da mulher.

Biliary dyskinesia and symptomatic gallstone disease in children: two sides of the same coin?

BACKGROUND

Despite lack of consensus criteria, biliary dyskinesia (BD) is an increasingly accepted pediatric diagnosis.

AIMS

We compared patient characteristics, outcomes, and resource utilization (before and after surgery) between children with BD and symptomatic cholecystolithiasis (LITH).

METHODS

Data from the electronic medical record were abstracted for children diagnosed with BD or LITH between December 1, 2002, and November 30, 2012, at Children's Hospital of Pittsburgh.

RESULTS

Four hundred and ten patients were identified (BD: 213 patients, LITH: 197 patients). Patients with BD had significantly lower BMI, longer symptom duration, more dyspeptic symptoms, and were more likely to present with other symptoms. Forty-one patients (13.8%) with BD underwent cholecystectomy despite a normal gallbladder ejection fraction (GB-EF). In 32 of these, sincalide triggered pain compared to 75 of the 155 patients with low GB-EF. After surgery, patients with BD more commonly visited gastroenterology clinics and had more GI-related hospitalizations, while emergency room visits decreased in both groups. Only the nature of biliary disease independently predicted continuing pain after surgery, which in turn was the best predictor for higher resource utilization after cholecystectomy.

CONCLUSIONS

A large percentage of children with BD did not meet the adult diagnostic standards. Compared to those with LITH, children with BD have more widespread symptoms and continue to use more clinical resources after surgery. These findings suggest that despite its benign prognosis, BD is increasingly treated like other potentially acute gallbladder diseases, although it has the typical phenotype of FGIDs and should be treated using approaches used in such disorders.

A psychometric evaluation of the panic disorder severity scale for children and adolescents

The Panic Disorder Severity Scale (PDSS; Shear et al., 1997) is a well-validated measure that assesses symptoms of panic disorder with or without agoraphobia (PDA) in adults. The Panic Disorder Severity Scale for Children (PDSS-C) is an adaptation of the PDSS for youth ages 11-17. The current study evaluated the psychometric properties of the PDSS-C. Participants included 60 adolescents from a randomized controlled trial investigating the efficacy of an intensive cognitive behavioral treatment (CBT) for adolescent PDA. Convergent and discriminant validity of PDSS-C scores were evaluated via observed associations between the PDSS-C and the Childhood Anxiety Sensitivity Index (CASI; Silverman, Fleisig, Rabian, & Peterson, 1991), Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Conners, 1997), and Children's Depression Inventory (CDI; Kovacs, 2003). Baseline and posttreatment data afforded the opportunity to evaluate the measure's sensitivity to treatment-related change. PDSS-C scores demonstrated acceptable internal consistency (α = .82) and adequate 1-day test-retest reliability (r = .79). Convergent and discriminant validity of the PDSS-C scores were supported through significant associations with the CASI and the MASC, and nonsignificant associations with the CDI, respectively. Linear regression analysis demonstrated sensitivity to treatment-related changes-that is, greater PDSS-C change scores were significantly associated with assignment to CBT vs. waitlist condition. Clinical utility was further established through significant associations between PDSS-C change scores and MASC and CASI change scores, and through nonsignificant associations with CDI change scores. Results support the use of PDSS-C scores as reliable, valid, and clinically useful for the assessment of youth panic disorder in research and clinical settings.

The association between parenting behavior and somatization in adolescents explained by physiological responses in adolescents

INTRODUCTION

This study adds to the knowledge on somatization in adolescents by exploring its relation with parenting behavior and the mediating/moderating role of physiological responses in adolescents to parenting behavior.

METHOD

Eighteen adolescents with high and 18 adolescents with low somatization scores and their mothers completed a discussion task, from which observed parenting behavior scores were derived. Skin conductance in adolescents was measured before and during the discussion.

RESULTS

For adolescents with high levels of physiological responses, unadaptive parenting was related to a higher chance of high somatization scores. For low physiologically responsive adolescents, the relation between parenting behavior and somatization was not significant.

CONCLUSION

Parenting behavior is not univocally related to somatization in adolescents, but the association depends on physiological responses in adolescents.

Parenting stress and dimensions of parenting behavior: cross-sectional and longitudinal links with adolescents' somatization

OBJECTIVE

This study explored direct and indirect associations between adolescents' somatization, parenting stress, and three parenting dimensions (warmth, psychological control, and harsh punishment). First, the associations were explored cross-sectionally. Second, significant cross-sectional links were further examined longitudinally in order to decide upon temporality.

METHOD

A total of 1499 adolescents and one of their parents (mostly the mother) agreed to participate. Questionnaires were administered when the child was respectively 12-13 (T1), 13-14 (T2), and 14-15 (T3) years old. Adolescents reported on their somatization, parents on their parenting behavior and parenting stress.

RESULTS

Cross-sectionally, indirect links were found between all parenting dimensions and adolescents' somatization, through parenting stress. Longitudinal examination revealed two key aspects. First, parenting stress significantly predicted somatization. Higher T1 parenting stress was predictive for higher T2 and T3 somatization. When controlled for T1 parenting stress, higher T2 parenting stress (or in other words increased parenting stress at T2) was predictive for lower T3 somatization. Second, parenting stress was found to significantly predict parenting behaviors. Higher T1 parenting stress was predictive for higher T2 and T3 harsh punishment but increased parenting stress at T2 was predictive for lower harsh punishment one year later. Higher T1 parenting stress significantly predicted higher T2 psychological control.

CONCLUSIONS

Clinicians should be aware that parenting stress may be a risk factor for the development of somatization in early adolescence. However, in later adolescence, increased parenting stress might be protective.

Comparison of 4 Pediatric Health-Related Quality-of-Life Instruments: A Study on a Medicaid Population

BACKGROUND

Few studies have compared multiple health-related quality-of-life (HRQOL) instruments simultaneously for pediatric populations. This study aimed to test psychometric properties of 4 legacy pediatric HRQOL instruments: the Child Health and Illness Profile (CHIP), the KIDSCREEN-52, the KINDL, and the Pediatric Quality of Life Inventory (PedsQL).

METHODS

This study used data from 908 parents whose children (ages 2-19 years) were enrolled in Florida Medicaid. Parents were asked via telephone interview to complete each instrument appropriate to the age of their children. Structural, convergent/discriminant, and known-group validities were investigated. We examined structural validity using confirmatory factor analyses. We examined convergent/discriminant validity by comparing Spearman rank correlation coefficients of homogeneous (physical functioning and physical well-being) versus heterogeneous (physical and psychological functioning) domains of the instruments. We assessed known-groups validity by examining the extent to which HRQOL differed by the status of children with special health needs (CSHCN).

RESULTS

Domain scores of the 4 instruments were not normally distributed, and ceiling effects were significant in most domains. The KIDSCREEN-52 demonstrates the best structural validity, followed by the CHIP, KINDL, and PedsQL. The PedsQL and the KIDSCREEN-52 show better convergent/discriminant validity than the other instruments. Known-groups validity in discriminating CSHCN versus no needs was the best for the PedsQL, followed by the KIDSCREEN-52, the CHIP, and the KINDL.

CONCLUSION

No one instrument was fully satisfactory in all psychometric properties. Strategies are recommended for future comparison of item content and measurement properties across different HRQOL instruments for research and clinical use.

Associations between health-related quality of life and the decision to perform surgery for childhood intermittent exotropia

OBJECTIVE

To assess associations between health-related quality of life (HRQOL) and the decision to perform strabismus surgery for children with intermittent exotropia.

DESIGN

Retrospective chart review.

PARTICIPANTS

Children with intermittent exotropia.

METHODS

Included subjects, identified in a clinical practice, had assessment of HRQOL using the intermittent exotropia questionnaire (IXTQ), comprising child, proxy, and parent components (parent domains: function, psychosocial, and surgery). The IXTQ scores were evaluated for association with surgery, along with standard clinical measures: prism and alternate cover test (PACT), stereoacuity, and control score (mean of the 3 most recent scores). Included data were from preoperative examination (surgical cohort) or from most recent follow-up examination (nonsurgical cohort). Univariate and multivariate logistic regression analyses were performed, and relative risk (RR) ratios were calculated. Spearman rank correlations were calculated to identify highly correlated items.

MAIN OUTCOME MEASURES

Association of individual factors with the decision to perform surgery, calculated using RR ratios.

RESULTS

One hundred six children with intermittent exotropia (median age, 6 years; range, 2-16 years) were eligible for inclusion. Nineteen (18%) of 106 underwent surgery. Using all available data, the IXTQ proxy score, IXTQ parent function score, IXTQ parent psychosocial score, distance control score, near control score, near PACT, and Randot Preschool stereoacuity (Stereoptical Co, Inc, Chicago, IL) were associated with undergoing surgery (P<0.1). Sixty-nine of 106 patients had complete data on all factors identified in univariate analysis and were included in multivariate analyses. Fourteen (20%) of these 69 patients underwent surgery. In multivariate analyses, poor distance control score (RR, 1.83; 95% confidence interval [CI], 1.25-2.68) and reduced IXTQ parent function score (RR, 0.96; 95% CI, 0.92-0.99) were associated with surgical intervention. Repeat multivariate analyses retaining only 1 of the highly correlated items showed IXTQ proxy, IXTQ parent psychosocial, larger near PACT, and worse near control were also associated with surgery.

CONCLUSIONS

After accounting for poorer exodeviation control at distance, reduced parent and proxy HRQOL were associated with undergoing strabismus surgery for childhood intermittent exotropia. Recognizing reduced parental HRQOL may be important, with a possible role for educational or counselling interventions.

In search of risk factors for chronic pain in adolescents: a case-control study of childhood and parental associations

Objectives

This study was designed to investigate whether an individual and parental history of functional pain syndromes (FPS) is found more often in adolescents suffering from chronic pain than in their pain-free peers.

Methods

Our case–control study involved 101 adolescents aged 10–18 years. Cases were 45 patients of the Chronic Pain Clinic at Sydney Children’s Hospital with diverse chronic pain disorders. Controls consisted of 56 adolescent volunteers who did not have chronic pain. Adolescents and their parents filled out questionnaires assessing demographic data as well as known and potential risk factors for chronic pain. A history of FPS was assessed by questionnaire, including restless legs syndrome (RLS). Chi-squared tests and t-tests were used to investigate univariate associations between chronic pain in adolescents and lifetime prevalence of FPS. Logistic regression was used to test multivariate associations, while controlling for possible confounders.

Results

Migraine, non-migraine headaches, recurrent abdominal pain (RAP), and RLS were reported significantly more frequently in cases than controls (P-values of 0.01, <0.001, 0.01, and 0.03, respectively). Parental migraine, RAP, and RLS were also significantly associated with adolescent chronic pain in the multivariate analyses. Individual history of migraine, non-migraine headaches, and RAP, along with parental history of RAP and depression significantly accounted for 36%–49% of variance in chronic pain. Other associations with chronic pain were generally in accordance with previous reports.

Discussion

It may be helpful when assessing a child who has chronic pain or is at risk of chronic pain, to enquire about these associations. Based on the current findings, an individual history of migraine, non-migraine headaches, and RAP, as well as parental migraine, RAP, and RLS are symptoms that are of particular relevance to assess.

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.

Neurological and biological foundations of children's social and emotional development: an integrated literature review

This article provides an integrated review of the expert literature on developmental processes that combine social, biological, and neurological pathways, and the mechanisms through which these pathways may influence school success and health. It begins with a historical overview of the current understanding of how attachment relationships and social environments influence brain development and plasticity and are, therefore, central to the physical and mental health of individuals and populations. It then expands on the effect of plasticity in relation to behavior and learning at school. This article concludes with a discussion of the role the school nurse may play in supporting health and learning by recognizing signs of relational stress and by advocating for prevention strategies.

Chronic pain and pain-related disability across psychiatric disorders in a clinical adolescent sample

BACKGROUND

People who suffer from psychiatric disorders are burdened with a high prevalence of chronic illnesses and pain, but evidence on pain prevalence among adolescents with psychiatric disorders is scarce. The aim of this study was to investigate the frequency and location of self-reported chronic pain and pain-related disability in adolescent psychiatric patients.

METHODS

This study was part of the larger Health Survey administered at the Department of Child and Adolescent Psychiatry (CAP) at St. Olav's University Hospital, in Trondheim, Norway. All patients aged 13-18 years who visited the CAP clinic at least once between February 15, 2009 and February 15, 2011 were invited to participate. A total of 717 (43.5% of eligible/invited patients) participated; of these, 566 were diagnosed with one or more psychiatric disorders. The adolescents completed a questionnaire, which included questions about pain and pain-related disability. Clinical diagnoses were classified by a clinician according to International Statistical Classification of Diseases and Related Health Problems, 10th revision criteria.

RESULTS

In adolescents with psychiatric disorders, 70.4% reported chronic pain, and 37.3% experienced chronic pain in three or more locations (multisite pain). Chronic musculoskeletal pain was the most prevalent type of pain (57.7%). Pain-related disability was found in 22.2% of the sample. The frequency of chronic pain and multisite pain increased with age, and girls reported a higher frequency of chronic pain, multisite pain and pain-related disability than boys did. There was an increased risk of chronic pain among adolescents with mood or anxiety disorders versus those with hyperkinetic disorders, yet this was not present after adjusting for sex. Comorbidity between hyperkinetic and mood or anxiety disorders involved an increased risk of pain-related disability.

CONCLUSIONS

In this study, seven out of 10 adolescents with psychiatric disorders reported chronic pain. These findings indicate the importance of early detection of chronic pain in adolescents with psychiatric disorders, to provide targeted treatment and reduce poor long-term outcomes.

Parent-proxy perception of overweight adolescents' health-related quality of life is different according to adolescent gender and age and parent gender

This study assessed health-related quality of life (HRQoL) reported by overweight adolescents and compared to their parent-proxy perception of HRQoL, according to adolescent gender, adolescent age, and parent gender. Patients and a total of 179 adolescents aged 10 to 18 years with excess weight were evaluated for perceived HRQoL prior to beginning a weight-loss intervention, using the Pediatric Quality of Life Inventory (PedsQL 4.0) questionnaire, estimating quality of life in the physical, emotional, social, and school domains, as well as index measures of psychosocial and overall quality of life. Parents completed the same questionnaire estimating his or her child's HRQoL. Compared to their child's self-report, parents underestimated all the domains of HRQoL except the school domain. Parents underestimated all the domains of HRQoL among boys; however, they only underestimated the physical domain among girls. Comparisons between parent-proxy perception and self-report of the adolescent according to adolescent's age revealed that parents underestimated their children's HRQoL in the younger adolescents (10 to 13 years) for all except for the school domain and underestimated only the physical domain in older adolescents (14 to 18 years). The same comparison between parent-proxy perception and their child's self-report of HRQoL according to parent gender showed that mothers underestimated HRQoL in all domains except for the school domain, while fathers only underestimated the school domain.

CONCLUSION

The differences between self-report of overweight adolescent and perceptions of their parents about the HRQoL of their children are influenced by adolescent gender and age and parent gender.

Inpatient characteristics of the child admitted with chronic pain

OBJECTIVE

To define the demographic, diagnostic, procedural, and episode of care characteristics for children admitted with chronic pain.

METHODS

We used the Pediatric Health Information System database to obtain data on demographic characteristics, length of stay, readmission rates, diagnoses, and procedures for children admitted with chronic pain. Patients with sickle cell disease, cancer, burns, cerebral palsy, transplants, and ventilator-dependent children were excluded.

RESULTS

A total of 3752 patients with chronic pain were identified from 2004 through 2010. Admissions increased by 831% over this time period. The mean age of these patients was 13.5 years, the most common race was white (79%), and female subjects outnumbered male subjects by 2.41 to 1. The most common admission and principal discharge diagnosis was abdominal pain; comorbid diagnoses were common, with a mean of 10 diagnoses per patient. In total, 65% of patients had a comorbid gastrointestinal diagnosis and 44% had a psychiatric diagnosis. The mean length of stay was 7.32 days, with an expected length of stay of 4.24 days; 12.5% were readmitted at least once within 1 year. They underwent a mean of 3.18 procedures per patient.

CONCLUSIONS

The average child admitted with chronic pain is a teenaged female with a wide variety of comorbid conditions, many of which are gastrointestinal and psychiatric in nature. Admissions for chronic pain are rising and account for substantial resource utilization. Future studies should further characterize this population, with the overall objective of improving outcomes and optimizing cost-effective care.