CBT in paediatric and adolescent health settings: A review of practice-based evidence

A qualitative evaluation of DAFNE-HART: A psychoeducational programme to restore hypoglycaemia awareness

AIMS

Impaired awareness of hypoglycaemia (IAH) in people with type 1 diabetes is a dangerous condition that is associated with a six-fold greater risk of severe hypoglycaemia than for people with awareness. A new psychoeducational programme, DAFNE-HART, has been specifically designed to address persistent IAH. The initial pilot showed promising outcomes including fewer hypoglycaemic episodes and improved hypoglycaemia awareness. This aim of this paper is to report the development and qualitative evaluation of DAFNE-HART from participant interviews.

METHODS

DAFNE-HART incorporates diabetes education with two psychological approaches that have demonstrated efficacy in long-term health conditions: motivational interviewing and cognitive behaviour therapy. The course, delivered across two UK locations included both group and individual support over a 6-week period facilitated by DAFNE educators, trained and supervised by a clinical psychologist. Semi-structured interviews were conducted with 19 participants immediately after their courses and the interviews were analysed using grounded theory.

RESULTS

Five main themes emerged which describe the behavioural changes people made to their diabetes management, the development of new attitudes and beliefs, their experiences of regaining hypoglycaemia cues, reactions to the course format and the significance of the relationship with their care provider. Participants provide insights into how the course changed their view of IAH and led to practical changes in minimising hypoglycaemia.

CONCLUSIONS

Integration of psychological techniques into diabetes education can address the cognitive and motivational barriers to restoring awareness and optimal diabetes management. It is suggested that further research is needed to evaluate this programme in a larger sample, over a longer time frame.

Psychosocial interventions for the diabetic patient

Diabetes usually requires substantial life-long self-management by the patient. Psychological factors and the patient's health beliefs are important determinants of self-care behavior. Education has a modest influence on generating better self-care, but psychologically based interventions are clearly more effective. This review gives an overview of these interventions with some discussion of their basis in psychological theory. Some labels such as cognitive behavioral therapy and family therapy include a wide range of approaches. Randomized trials have generally produced improvement in measures of psychological well-being, but improved glycemic control has been more elusive. The influence on behavior can be very dependent on the individual therapist. Only a few trials have managed to sustain improvement in glycosylated hemoglobin beyond a year. Not all patients are prepared to engage and accept these forms of therapeutic intervention. We are still some way from moving psychological management from the trial situation into the diabetic clinic.

A randomized controlled trial of cognitive behaviour therapy to improve glycaemic control and psychosocial wellbeing in adolescents with type 1 diabetes

We evaluated a cognitive behaviour therapy–based programme to improve glycaemic control and psychosocial wellbeing in adolescents with type 1 diabetes. A total of 147 adolescents aged 13–16 years were randomized to the intervention ( n = 73) or standard care ( n = 74). The primary outcome was glycaemic control at 3 and 12 months post randomization, and secondary measures were stress, self-efficacy and quality of life. Mixed-effects regression models were used to assess differences in means between groups at each time point. There was little evidence of differences in glycaemic control between groups. However, psychosocial wellbeing improved in the intervention group compared to the control group. Recommendations for future programmes are discussed. The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12608000368336).

'Sometimes it feels as if the world goes on without me': adolescents' experiences of living with chronic fatigue syndrome

AIMS AND OBJECTIVES

To explore the experience of being an adolescent with chronic fatigue syndrome.

BACKGROUND

Despite ample research, chronic fatigue syndrome is still poorly understood, and there are still controversies related to the illness. Adolescents with chronic fatigue syndrome are often unable to attend school and lose social relations with friends. The challenges they face will affect their quality of life.

DESIGN

A qualitative, phenomenological hermeneutical design.

METHOD

Six boys and twelve girls, aged 12-18, were interviewed, emphasising their own experiences living with chronic fatigue syndrome. Analyses were performed using a phenomenological hermeneutical method.

RESULTS

The core theme, 'Sometimes it feels as if the world goes on without me', encompasses the feelings an adolescent living with chronic fatigue syndrome might have about life. The core theme was supported by four subthemes: 'On the side of life--locked in and shut out'; 'the body, the illness and me'; 'if the illness is not visible to others, does it exist?'; and 'handling life while hoping for a better future'. The subthemes reflect the experience of social isolation, their own and others' understanding of the illness and hope for the future.

CONCLUSIONS

Not being able to be with friends, or attend school, made the adolescents feel different and forgotten. They felt alienated in their own bodies and were struggling to be visible to themselves and to their surroundings. Spending less time with friends and more time with their parents constituted a threat to independence and development. Yet they managed to envision a better future despite all the difficulties.

RELEVANCE FOR CLINICAL PRACTICE

To provide effective support and constructive relations to adolescents with chronic fatigue syndrome, all health professions involved need insight from the persons who are themselves ill. Health centres could function as resource centres for patients and healthcare professionals.

Psychosocial perspectives in the treatment of pediatric chronic pain

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

The Role of the Mental Health Practitioner in the Assessment and Treatment of Child and Adolescent Chronic Pain

Chronic and recurrent benign pain complaints are common among children and adolescents. Although many young persons with chronic pain adapt well, a small, but significant, proportion experience marked functional deficits. Pain can produce life disruptions, e.g. impeding activities and maturation, and interferes with family functioning. Conventional medically-based approaches have been inadequate in addressing chronic pain and its sequelae. Instead, effective management requires an interdisciplinary approach involving paediatricians and mental health practitioners working collaboratively to treat psychiatric comorbidities, enhance the patient's functional adaptation, restore the child or adolescent's maturational and social capabilities and reduce family disruptions.

Myofascial pain in the adolescent

PURPOSE OF REVIEW

Whereas in the recent past pain in the child and adolescent was directed to cancer management, there is increasing interest in pain in children and adolescents in relation to nonmalignant conditions. Additionally, there is an emerging literature related to disorders of myofascial function as a cause of pain.

RECENT FINDINGS

Pain associated with myofascial dysfunction is common in the adolescent female. Pain in this group of women has been shown to extend into adulthood. Although there has been attention directed to the management of endometriosis through laparoscopic surgical approaches, these are seen as limiting. Myofascial dysfunction is now regarded as an important factor in the evaluation of adolescent pain. One of the most important approaches to the reduction of severe pain in the adolescent is the complete menstrual suppression through use of continuous oral contraceptives or contraceptive rings. Operative laparoscopy has been heavily utilized but there are increasing concerns about the overutilization of this procedure

SUMMARY

Alternative approaches to myofascial pain include multidisciplinary care with a rehabilitative perspective.

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

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

Feasibility and impact of a school-based intervention for families of urban adolescents with asthma: results from a randomized pilot trial

The purpose of this study was to test the feasibility and short-term outcomes of Asthma: It's a Family Affair!, a school-based intervention for adolescents with asthma and their caregivers. Twenty-four ethnic minority families with a middle school student with asthma were randomized to immediate intervention or no-treatment control. Intervention students received six group sessions on prevention and management of asthma. Caregivers received five group sessions teaching child-rearing skills to support the youth's autonomy and asthma self-management. All students attended all sessions; caregivers attended an average of three. Two months post-intervention, relative to controls, intervention caregivers reported better problem-solving with children. Intervention students were more responsible for carrying medication, took more prevention steps, and woke fewer nights from asthma. The intervention resulted in positive short-term changes in family relations, asthma management by students, and health status.

Predictors of good adherence of adolescents with diabetes (insulin-dependent diabetes mellitus)

OBJECTIVES

The purpose of this study was to identify the factors that predict good adherence to health regimens by adolescents with diabetes (insulin-dependent diabetes mellitus).

METHODS

Altogether, 300 individuals aged 13-17 years were randomly selected from the Finnish Social Insurance Institution's register. Ninety-seven per cent (N=289) of the selected adolescents returned the questionnaire. The data were analysed using the SPSS (Statistical Package for Social Sciences) for Windows software package. Logistic regression was used to find the factors that predict good adherence to health regimens.

RESULTS

About one-fifth (19%) of the respondents with diabetes felt that they complied fully with the health regimens, while 75% placed themselves in the category of satisfactory adherence, and the remaining 6% reported poor adherence. The most powerful predictor was the threat to mental wellbeing. The likelihood that adolescents who felt the disease to be a threat to their mental wellbeing would comply with health regimens was 7.68-fold as compared to those who did not regard the disease as a threat to their mental wellbeing. The next most powerful predictor was support from physician. The support from nurses, and the motivation, energy and willpower to take care of themselves and the threat to physical wellbeing, also predicted good adherence. The logistic regression model explained 82% of the variance, and the model predicted correctly 88% of the adolescents with good adherence.

DISCUSSION

This paper shows that adolescents with diabetes show quite good adherence. It also indicates the factors that predict good adherence to health regimens. To improve adherence, these factors should be given special attention in the care of adolescents.

Recent developments in the pharmacological management of pain in children

PURPOSE OF REVIEW

This review explores progress in developmental pharmacokinetics, pharmacogenomics and formulations of analgesic agents, and discusses potential implications for pain therapy.

RECENT FINDINGS

Characterization of the developmental pharmacokinetics of morphine, tramadol, paracetamol and nonsteroidal anti-inflammatory drugs has improved dosing in children. Oral sugar solutions have replaced the brandy/sugar pacifier and are effective for single painful events in neonates. Intravenous paracetamol offers increased dosing accuracy, and avoids absorption and bioavailability variability. New nitric-oxide-releasing versions of paracetamol and nonsteroidal anti-inflammatory drugs offer safer alternatives to their parent drugs with enhanced potency. Ketamine has come under a cloud for its possible effects on the neonatal developing brain, but it is being used increasingly in children to supplement opioids for pain after major surgery. Hopes that morphine analgesia may improve neurological outcome in premature babies have not materialized. Reports concerning chronic pain are generally case series and controlled trials are rare and nearly nonexistent in children.

SUMMARY

Unlicensed drug use in the very young will increase as familiarity increases. Pharmacogenomic studies have the potential to tailor drug therapy to the individual and decrease between-patient variability. Unfortunately, the pharmacodynamic knowledge in children of analgesic agents remains neglected and is usually extrapolated from adult data.

Principles of management of musculoskeletal conditions in children and young people

Musculoskeletal symptoms and rheumatic conditions are common throughout childhood and adolescence. Age- and development-appropriate care and management of children and young people with such conditions is vital, acknowledging that they are NOT small adults! The major aspect of both paediatric and adolescent rheumatology care which differentiates it from adult care is the fact that children and young people are still growing, in contrast to the ageing and senescence which characterizes adult rheumatology. Growth must be considered in the global sense, incorporating cognitive and psychosocial growth as well as physical growth. Likewise, the reciprocal influences of growth and a chronic rheumatic condition should be considered when caring for young people with childhood-onset rheumatic disease. This chapter will detail the general principles of management of such symptomatology with primary reference to chronic conditions.