Behavior Problems in Children and Adolescents With Chronic Physical Illness: A Meta-Analysis

Mental health clinical pathways for children and young people with long-term health conditions: A systematic review

RATIONALE

Clinical pathways (CPWs) are structured care plans that set out essential steps in the care of patients with a specific clinical problem. Amidst calls for the prioritisation of integrated mental and physical health care for young people, multidisciplinary CPWs have been proposed as a step towards closer integration. There is very limited evidence around CPWs for young people with mental and physical health needs, necessitating a review of the literature.

AIMS AND OBJECTIVES

The aim of this review is to understand how clinical pathways have been used to deliver mental health support to children and young people with long-term physical health conditions and their effectiveness across a range of outcomes.

METHODS

The databases MEDLINE, CENTRAL, PsycINFO and CINAHL were searched from inception to 6 September 2023. Keywords linked to children and young people, mental health, long-term physical health conditions and CPWs were used. Studies using either quantitative or qualitative research designs were included. All studies must have evaluated a CPW to provide mental health support to children and young people (up to 25 years old) with long-term health physical conditions. Both mental and physical health outcomes were considered. Pathways were grouped by integration 'model' as described in the wider literature.

RESULTS

The initial search returned 4082 studies after deduplication. A total of eight studies detailing six distinct care pathways (232 participants [170 children and young people; 50 caregivers; 12 healthcare professionals]) met eligibility criteria and were included in the analysis. Four pathways were conducted within an 'integrated model'; two were a combination of 'integrated' and 'colocated'; and none within a 'co-ordinated model'. Only pathways within an integrated model reported quantitative health outcomes, with improvements across a range of mental health measures. One negative physical health outcome was reported from an integrated diabetes pathway, but this should be interpreted with caution.

CONCLUSION

This review identified a range of CPW designs but most fell under an integrated model. The results suggest that calls for integrated mental health pathways in this population may be appropriate; however, conclusions are limited by a paucity of evidence.

Parent and Provider Differences in Ratings of Mental Health and Neurodevelopmental Concerns in Children with Neurologic Disorders

Children with neurologic disorders face increased risks for mental health and neurodevelopmental conditions, with information often limited to parent report. To better understand mental health and neurodevelopmental needs in this population, a retrospective chart review of a convenience sample of children with neurologic disorders referred for a neuropsychological evaluation was conducted in the present study to explore interrater agreement between care team members (referring providers, parents, pediatric neuropsychologist). Qualitative and quantitative data were collected from the evaluation reports of 129 youth (9:0-17:11 years old; 51.2% of female sex) with neurologic disorders (i.e., 38.0% traumatic brain injury, 27.1% epilepsy, 14.7% premature birth, 7.8% pediatric cancer, 3.9% prenatal substance exposure, and 14.7% other) who completed an evaluation in 2019. Over half the youth were flagged for unmet neurodevelopmental and mental health concerns and analyses revealed low interrater agreement for mental health concerns (κ = .324), better agreement for neurodevelopmental concerns (κ = .511), and low sensitivity of referring providers (Se = .326) and parents (Se = .366). One-way analyses of variance uncovered important factors (e.g., symptom severity, adaptive skills) that may account for missed concerns. Findings guide recommendations to strengthen methods for understanding mental health and/or neurodevelopmental concerns in children with neurologic disorders.

Mental health interventions for children and young people with long-term health conditions in Children and Young People's Mental Health Services in England

BACKGROUND

Almost a quarter of children and young people (CYP) in England have a long-term health condition (LTC), which increases the risk of developing mental health difficulties. There is a lack of understanding regarding the routine provision and efficacy of mental health interventions for CYP with LTCs within Children and Young People's Mental Health Services (CYPMHS).

METHODS

This study analysed national service-reported data in England from two secondary datasets. Data were submitted by services between 2011 and 2019. We evaluated data on the presence or absence of a serious physical health or neurological issue, and which interventions were offered.

RESULTS

A total of 789 CYP had serious physical health issues and 635 had neurological issues. The most common interventions delivered to CYP in either group have some evidence in the literature. Most CYP showed improvements across a range of outcomes.

CONCLUSIONS

This study found that prevalence rates and psychological intervention and outcome data were widely under-reported across both datasets, posing questions about their utility for this population. Such data would benefit from triangulation with data from other sources to understand pathways of care for these young people and the extent to which clinical datasets underreport the number of CYP with LTCs.

Love beyond gluten: self-esteem, illness identity, and social support in romantic rejection concerns among adolescents with celiac disease

Introduction

Fear of stigmatization, high perceived partner burden, or refraining from self-disclosure may manifest in romantic rejection concerns among adolescents with celiac disease (CD), potentially impacting their health-related quality of life (HRQOL). This study examined the prevalence, predictors, and consequences of romantic rejection concerns among adolescents and young adults with CD.

Methods

A cross-sectional online survey was conducted among 165 German adolescents and young adults (aged 14-22) with self-reported CD. Participants completed measures of romantic rejection concerns, illness identity, self-esteem, peer support, and CD-specific HRQOL.

Results

Participants reported moderate levels of concerns about the impact of CD on their romantic relationships, with no significant gender differences. Participants involved in romantic relationships expressed lower concerns of rejection, but similar preference for a "gluten-free partner." Hierarchical regression analysis revealed that higher illness acceptance and peer support predicted lower rejection concerns. Significant interactions emerged between self-esteem and illness acceptance, and between self-esteem and peer support. Higher illness acceptance predicted fewer rejection worries only among those with high self-esteem, while peer support played a mitigating role only for those with low self-esteem. Romantic rejection concerns significantly predicted lower CD-specific HRQOL across all domains.

Discussion

Anxieties about CD's impact on romantic relationships are prevalent among adolescents and may hinder their HRQOL. The findings highlight the complex interplay between self-esteem, illness identity, and social support in shaping romantic concerns. Targeted interventions focusing on peer support and fostering positive illness identity are recommended to alleviate rejection fears and improve HRQOL among youth with CD.

The moderating role of psychological capital in the relationship between school-related stress and outcomes of academic achievement and behavior problems among students with health impairments

Numerous researches have examined the relationship between school-related stress and outcomes of academic achievement and behavior problems; however, a very few studies were conducted to assess the moderating role of psychological capital in this relat.ionship, especially focusing on students with health impairments. The current study was carried out to investigate the association of school-related stress and psychological capital with academic achievement and behavior problems in students with health impairments, as well as the possible moderating influence of psychological capital in the school-related stress and outcomes relationships. The study involved 233 students with health impairments in Addis Ababa. Instruments used for the study include the Demographic Questionnaire, Perceived School-Related Stress Scale, Psychological Capital Questionnaire, Strengths and Difficulties Questionnaire, and school record reviews. Descriptive statistics, structural equation modeling, and multi-group structural equation modeling were utilized to analyze the data. Results revealed that school-related stress was significantly and negatively associated with academic achievement and positively with behavior problems. Psychological capital was significantly and positively associated with academic achievement and negatively with behavior problems. Higher levels of psychological capital had a significant moderating role in the relationships between school-related stress and both outcomes of academic achievement and behavior problems. The finding suggests that PsyCap is a positive resource to counteract the detrimental impacts of school-related stress on the academic achievement and behavior problems of students with health impairments.

Clinical effectiveness of drop-in mental health services at paediatric hospitals: A non-randomised multi-site study for children and young people and their families - study protocol

BACKGROUND

Despite the high prevalence of mental health difficulties in children and young people with long-term health conditions (LTCs), these difficulties and experiences are often overlooked and untreated. Previous research demonstrated the effectiveness of psychological support provided via a drop-in mental health centre located in a paediatric hospital. The aim of this prospective non-randomised single-arm multi-centre interventional study is to determine the clinical effectiveness of drop-in mental health services when implemented at paediatric hospitals in England.

METHODS

It is hypothesised that families who receive psychological interventions through the drop-in services will show improved emotional and behavioural symptoms. Outcomes will be measured at baseline and at 6-month follow-up. The primary outcome is the difference in the total difficulties score on the Strengths and Difficulties Questionnaire (SDQ) reported by parent or child at 6 months. Secondary outcomes include self and parent reported Paediatric Quality of Life Inventory (PedsQL), self-reported depression (PHQ-9) and anxiety measures (GAD-7) and family satisfaction (CSQ-8).

DISCUSSION

This trial aims to determine the clinical effectiveness of providing psychological support in the context of LTCs through drop-in mental health services at paediatric hospitals in England. These findings will contribute to policies and practice addressing mental health needs in children and young people with other long-term health conditions.

TRIAL REGISTRATION

ISRCTN15063954, Registered on 9 December 2022.

Risk perception, well-being, depression and anxiety in children and adolescents with rheumatic diseases during the COVID-19 pandemic - results from the prospective multicenter KICK-COVID study in Germany

OBJECTIVE

To investigate the psychosocial burden in children and adolescents with juvenile rheumatic diseases during the COVID-19 pandemic.

METHODS

As part of the multicentre observational KICK-COVID study linked to the National Pediatric Rheumatology Database, adolescents < 21 years and parents of children < 12 years with rheumatic diseases answered questions on perceptions of health risk (PHR) due to SARS-CoV2, stress, well-being (WHO-5) and symptoms of depression (PHQ-9) and anxiety (GAD-7). Data were collected at routine visits from June to December 2021 and assessed for association with demographic and clinical parameters, treatment and patient-reported outcomes by multivariable regression analyses.

RESULTS

Data from 1356 individuals (69% female, 50% adolescents) were included. Median PHR on a numeric rating scale (NRS, 0-10) was 4 (IQR 2-6), median perceived stress was 3 (IQR 1-6). Adolescents reported a worse well-being with a significantly lower median WHO-5-score (60, IQR 40-76) than parents reported for their children < 12 years (80, IQR 68-84). Moderate to severe symptoms of depression and anxiety were reported by 14.3% and 12.3% of the adolescents, respectively. PHR was significantly higher in patients with systemic lupus erythematosus, methotrexate or biologic disease-modifying anti-rheumatic drug therapy than in patients without these characteristics, whereas lower WHO-5 or higher PHQ-9 or GAD-7 scores were only associated with poorer patient-reported health status and physical functioning.

CONCLUSION

The perception of health risk due to SARS-CoV2 infection was not paralleled by an impairment of mental health, which were, however, significantly correlated with self-rated health status and functional capacity, highlighting the importance of patient-reported outcome assessment.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), no. DRKS00027974. Registered on 27th of January 2022.

Gaining consensus on emotional wellbeing themes and preferences for digital intervention type and content to support the mental health of young people with long-term health conditions: A Delphi study

BACKGROUND

Young people (YP) with long-term conditions (LTCs) are at greater risk of psychological distress than those without LTCs. Despite this, there is a scarcity of quality digital interventions designed to help improve mental wellbeing in this population. The aim of this study was to determine what YP, parents and health professionals preferred for future interventions.

METHODS

Twenty-six YP with asthma, diabetes and/or epilepsy (the three most common LTCs in YP), 23 parents of YP with LTCs and 10 health professionals mainly in paediatric specialisms (total n = 59) took part in an online Delphi study to gain consensus (set at 75% agreement) on four questions across three rounds. Participants ordered psychological themes that may be experienced by YP with LTCs by importance and ranked digital intervention types and delivery modes by importance or usefulness. The most common results were reported if no consensus was reached by round 3.

RESULTS

Participants preferred a mobile phone app (73% agreement) and a mixture of one-on-one and group support for an intervention (75% agreement). The two highest ranked psychological themes were anxiety (44%) and wanting to appear 'normal' (38%), and the top intervention type was 'general counselling' (54% agreement).

CONCLUSION

There was a clear desire for an app to help with the psychological aspects of living with LTCs and for a combination of one-to-one and group intervention elements. Anxiety and wanting to appear 'normal' might be two closely linked psychological challenges that could be addressed by a single intervention.

IMPLICATIONS

The results will be important to consider for a future intervention, although further consultation will be needed for app development.

PATIENT OR PUBLIC CONTRIBUTION

Two YP with a LTC provided feedback on the study protocol including the aims and procedures of the project. Another six YP with LTCs were consulted on an early draft of the study questionnaire (the four questions), which was subsequently revised. Once the project began, a patient and public involvement group consisting of two YP with LTCs and one parent of a YP with an LTC gave feedback on the research process, lay report of the results and dissemination plan.

Novel insight into GLUT1 deficiency syndrome: screening for emotional and behavioral problems in youths following ketogenic diet

BACKGROUND

Glucose transporter type 1 deficiency syndrome (GLUT1DS) is a rare disorder with a broad spectrum of neurological manifestations. The ketogenic diet (KD) is, to date, the gold standard treatment. Behavioral problems, well recognized in patients with chronic conditions, have not been, so far, deeply investigated in GLUT1DS patients. We performed an exploratory study to assess the risk of emotional and behavioral problems and investigated the potential role of influencing factors related to the pathology itself or KD treatment.

METHODS

This was a mono-center retrospective study involving youths with GLUT1Ds treated with KD and a group of migraine patients age- and gender-matched. Patients were included if the main caregiver completed the Child Behavior Check List 6-18 (CBCL). Descriptive statistics for demographic and clinical data and questionnaire scores were computed. Correlational analyses were used to assess the potential associations of clinical variables and age and time from KD introduction with CBCL scores in GLUT1DS patients.

RESULTS

We enrolled nine youths with GLUT1DS and 9 with migraine. In the GLUT1DS group, none of the mean scores of the CBCL items fell within the borderline/clinical range, except for social problems located in the borderline range. Investigation for influencing factors revealed the patient's age related to withdrawn/depressive (r=0.709, P=0.032) and social problems (r=.684, P=0.042). Time from the introduction of KD was related to social problems (r=.827, P=0.006). From the comparison with the scores obtained from migraine patients, significantly higher scores emerged in the latter group in internalizing problems (Z=-2.48, P=0.01), externalizing problems (Z=-3.49, P<0.001), anxious/depressed subscale (Z=-2.37, P=0.014), somatic complaints subscale (Z=-2.624, P=0.008), aggressive behavior subscale (Z=-2.539, P=0.011).

CONCLUSIONS

Although highly exploratory in its nature, this study provides a novel insight into GLUT1DS. Our data suggested that the risk for internalizing problems in GLUT1DS youths was related to higher age and higher time elapsed from KD introduction. They occurred at a sub-clinical level, making them difficult to detect, if not expressly and systematically investigated.

Autism traits, social withdrawal, and behavioral and emotional problems in a Norwegian cohort of adolescents with rare genetic disorders

BACKGROUND

Adolescents with rare genetic disorders represent a population that can be at risk in psychosocial terms. Despite its importance, the association of autism traits and social withdrawal in behavioral and emotional problems in adolescents with rare genetic disorders remains understudied.

AIM

The study aimed to empirically examine the clinical characteristics of adolescents with rare genetic disorders with a behavior theory-driven approach.

METHOD

We investigated the behavioral and emotional problems and current and lifetime autistic traits in a sample of 93 Norwegian adolescents (Mage = 13.2 years, SDage = 2.4, rangeage 10-17, 62.4% females, 37.6% males) with various rare genetic disorders. The adolescents were investigated cross-sectionally utilizing standardized psychometric questionnaires rated by their parents.

RESULTS

More current and lifetime autistic traits and social withdrawal were all associated with more internalizing problems. Further analyses demonstrated that social withdrawal partially mediated the positive association between current autistic traits and internalizing problems. In contrast, social withdrawal fully mediated the positive association between lifetime autistic traits and internalizing problems.

CONCLUSION AND IMPLICATIONS

Our results demonstrate important characteristics of adolescents with rare genetic disorders that may guide clinicians and future interventions. Social withdrawal may be prodromal to internalizing problems such as anxiety and depression. Thus, clinically addressing social withdrawal can represent a means to prevent internalizing problems in adolescents with rare genetic disorders and autistic traits.

UK guideline on the transition and management of childhood liver diseases in adulthood

INTRODUCTION

Improved outcomes of liver disease in childhood and young adulthood have resulted in an increasing number of young adults (YA) entering adult liver services. The adult hepatologist therefore requires a working knowledge in diseases that arise almost exclusively in children and their complications in adulthood.

AIMS

To provide adult hepatologists with succinct guidelines on aspects of transitional care in YA relevant to key disease aetiologies encountered in clinical practice.

METHODS

A systematic literature search was undertaken using the Pubmed, Medline, Web of Knowledge and Cochrane database from 1980 to 2023. MeSH search terms relating to liver diseases ('cholestatic liver diseases', 'biliary atresia', 'metabolic', 'paediatric liver diseases', 'autoimmune liver diseases'), transition to adult care ('transition services', 'young adult services') and adolescent care were used. The quality of evidence and the grading of recommendations were appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

These guidelines deal with the transition of YA and address key aetiologies for the adult hepatologist under the following headings: (1) Models and provision of care; (2) screening and management of mental health disorders; (3) aetiologies; (4) timing and role of liver transplantation; and (5) sexual health and fertility.

CONCLUSIONS

These are the first nationally developed guidelines on the transition and management of childhood liver diseases in adulthood. They provide a framework upon which to base clinical care, which we envisage will lead to improved outcomes for YA with chronic liver disease.

Clinical effectiveness of the psychological therapy Mental Health Intervention for Children with Epilepsy in addition to usual care compared with assessment-enhanced usual care alone: a multicentre, randomised controlled clinical trial in the UK

BACKGROUND

Mental health difficulties are common in children and young people with chronic health conditions, but many of those in need do not access evidence-based psychological treatments. The study aim was to evaluate the clinical effectiveness of integrated mental health treatment for children and young people with epilepsy, a common chronic health condition known to be associated with a particularly high rate of co-occurring mental health difficulties.

METHODS

We conducted a parallel group, multicentre, open-label, randomised controlled trial of participants aged 3-18 years, attending epilepsy clinics across England and Northern Ireland who met diagnostic criteria for a common mental health disorder. Participants were randomised (1:1; using an independent web-based system) to receive the Mental Health Intervention for Children with Epilepsy (MICE) in addition to usual care, or assessment-enhanced usual care alone (control). Children and young people in both groups received a full diagnostic mental health assessment. MICE was a modular psychological intervention designed to treat common mental health conditions in children and young people using evidence-based approaches such as cognitive behaviour therapy and behavioural parenting strategies. Usual care for mental health disorders varied by site but typically included referral to appropriate services. Participants, along with their caregivers, and clinicians were not masked to treatment allocation but statisticians were masked until the point of analysis. The primary outcome, analysed by modified intention-to-treat, was the parent-report Strengths and Difficulties Questionnaire (SDQ) at 6 months post-randomisation. The study is complete and registered with ISRCTN (57823197).

FINDINGS

1401 young people were potentially deemed eligible for study inclusion. Following the exclusion of 531 young people, 870 participants were assessed for eligibility and completed the SDQ, and 480 caregivers provided consent for study inclusion between May 20, 2019, and Jan 31, 2022. Between Aug 28, 2019, and Feb 21, 2022, 334 participants (mean ages 10·5 years [SD 3·6] in the MICE group vs 10·3 [4·0] in control group at baseline) were randomly assigned to an intervention using minimisation balanced by age, primary mental health disorder, diagnosis of intellectual disability, and autistic spectrum disorder at baseline. 168 (50%) of the participants were female and 166 (50%) were male. 166 participants were randomly assigned to the MICE group and 168 were randomly assigned to the control group. At 6 months, the mean SDQ difficulties for the 148 participants in the MICE group was 17·6 (SD 6·3) and 19·6 (6·1) for the 148 participants in the control group. The adjusted effect of MICE was -1·7 (95% CI -2·8 to -0·5; p=0·0040; Cohen's d, 0·3). 14 (8%) patients in the MICE group experienced at least one serious adverse event compared with 24 (14%) in the control group. 68% percent of serious adverse events (50 events) were admission due to seizures.

INTERPRETATION

MICE was superior to assessment-enhanced usual care in improving symptoms of emotional and behavioural difficulties in young people with epilepsy and common mental health disorders. The trial therefore shows that mental health comorbidities can be effectively and safely treated by a variety of clinicians, utilising an integrated intervention across ages and in the context of intellectual disability and autism. The evidence from this trial suggests that such a model should be fully embedded in epilepsy services and serves as a model for other chronic health conditions in young people.

FUNDING

UK National Institute for Health Research Programme Grants for Applied Research programme and Epilepsy Research UK Endeavour Project Grant.

Effects of comorbid asthma and eczema on child and family quality of life

Paediatric chronic health conditions are associated with poorer psychological wellbeing and quality of life for children and families. This study investigated differences in child and parent/family quality of life between families of children with asthma only, eczema only, or both asthma and eczema, and tested predictors of child and parent/family quality of life. A convenience sample of 106 families completed parent-report measures of child and parent/family quality of life, child emotional and behavioural difficulties, parent adjustment and parenting practices. Between-groups ANOVAs indicated no differences for child quality of life, whereas parent/family quality of life was worse for those with eczema only compared to asthma only. Multiple linear regression revealed that child emotional difficulties predicted worse child quality of life, whereas worse parent adjustment, child emotional difficulties and eczema only (compared to both asthma and eczema) predicted worse parent quality of life. Results suggest that families of children with eczema may be at particular risk for impaired parent/family quality of life. Interventions that take a family-centred approach to improving child and parent adjustment should be investigated as an adjunct to medical treatment to reduce the impact of chronic health conditions on quality of life for children and families.

Risk of new onset and persistent psychopathology in children with long-term physical health conditions: a population-based cohort study

Children and young people (CYP) with long-term physical health conditions (pLTCs) have increased risk of psychopathology compared to physically healthier peers. We explored risk factors for new onset and persistent psychiatric disorders in CYP with pLTCs compared to CYP without pLTCs. This 3-year follow-up study involved a UK representative sample of CYP from the British Child and Adolescent Mental Health Surveys (N = 7804). We examined potential baseline predictors of new onset and persistent psychiatric disorders at follow-up in four groups of children based on the presence of any physical and/or any psychiatric conditions at baseline. Psychiatric disorders were assessed using standardised multi-informant diagnostic assessment. Separate multivariable binary logistic regressions were conducted for each group. In CYP with pLTCs, rented housing (aOR = 1.42, 95% CI  1.01 to 1.99), non-traditional family structure (aOR = 2.08, 95% CI  1.42 to 3.05), increased parental distress (aOR = 1.09, 95% CI  1.04 to 1.14), and greater peer relationship difficulties (aOR = 1.29, 95% CI  1.19 to 1.39) predicted future psychiatric disorder. Only peer relationship difficulties predicted persistent disorder (aOR = 1.27, 95% CI  1.17 to 1.38) in this group. A greater number of factors predicted the onset of psychiatric disorder in CYP with pLTCs compared to physically healthier peers and similarly, a higher number of factors predicted persistent disorder in CYP without pLTCs. CYP with pLTCs might comprise a group with different vulnerabilities, some of which are potentially tractable and may be useful indicators of patients who require preventable or management interventions.

Testing a model of benefit-finding and growth in youths with chronic health conditions

BACKGROUND

The experience of benefit-finding and growth (BFG), defined as perceiving positive life changes resulting from adversity, is increasingly studied among youths with chronic health conditions (CCs). However, empirical evidence is scarce for explaining individual differences in BFG. The study aimed to test a model of BFG, including an interplay of personal and environmental factors and coping processes.

METHODS

A sample of N = 498 youths (12-21 years) recruited from three German patient registries for CCs (type 1 diabetes: n = 388, juvenile idiopathic arthritis: n = 82, cystic fibrosis: n = 28) completed a questionnaire including self-reported optimism, social support from parents and peers, coping strategies, and BFG. The model was created to reflect the theoretical assumptions of the Life Crisis and Personal Growth model and current empirical evidence. Structural equation modeling was conducted to evaluate the incremental explanatory power of optimism, peer group integration, parental support, acceptance, cognitive reappraisal, and seeking social support over and above sociodemographic and disease-related characteristics.

RESULTS

The model (CFI = 0.93; RMSEA = 0.04; SRMR = 0.05) explained 32% of the variance in BFG. Controlling for sociodemographic and disease-related characteristics, acceptance, cognitive reappraisal, and seeking social support were directly and positively linked to BFG. All tested coping strategies significantly mediated the association between optimism and BFG, whereas seeking social support significantly mediated the relation between peer group integration and BFG.

DISCUSSION

The study stresses the prominent role of emotion-focused coping strategies and peer group integration in enhancing BFG in youths with CCs.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), no. DRKS00025125. Registered on May 17, 2021.

The use of youth healthcare services and its association with health-related quality of life, physical and mental health and over-the-counter analgesics use in 13-19-year-old adolescents: a cross-sectional study

BACKGROUND

Youth healthcare services in Norway include a public health nurse (PHN) at school and local youth health centres (YHCs). They provide health services for all adolescents free of charge, focusing on health promotion and disease prevention. The present study aimed to assess possible associations between health-related quality of life (HRQoL), physical and mental health, over-the-counter analgesics (OTCA) use and use of youth healthcare services among 13-19-year-old adolescents.

METHODS

This study was based on national, cross-sectional data from the Ungdata Survey conducted in 2022. The sample was comprised of 16 482 adolescents. Multiple logistic regression was used to analyse the associations between HRQoL, headaches, selected physical symptoms, psychological distress, use of OTCA, PHN availability, sociodemographic variables, and use of the PHN at school or at a YHC. The KIDSCREEN-10 was used to measure HRQoL, and the Hopkins Symptoms Checklist 10 was used to measure symptoms of psychological distress.

RESULTS

Girls used the youth healthcare services more frequently than boys. Better HRQoL was significantly associated with fewer visits to the PHN at school. Girls reported lower HRQoL and mental health, and more pain and frequent OTCA use than boys. When having symptoms of psychological distress, boys had greater odds of visiting the PHN at school than girls. For girls in senior high school, headaches and OTCA use were strongly associated with visiting the PHN at school and the YHC. In senior high school, boys with an immigration background had greater odds of visiting the YHC than native Norwegian boys, while girls with an immigration background were less likely to visit the YHC than native Norwegian girls.

CONCLUSIONS

Our results show that more girls than boys use youth healthcare services. When adolescents experience pain, have mental problems, use OTCA, or report low levels of HRQoL, they have greater odds of using youth healthcare services. Youth healthcare services offer excellent opportunities to support and follow up with adolescents. The findings provide important insights into youth healthcare services used by adolescents for various stakeholders, including PHNs and policy makers, with potential implications for future public health efforts.

Attachment style and children and young people with chronic dermatological conditions

BACKGROUND

Dermatological conditions are common in childhood and, in their more severe forms, can cause pain, disability and social marginalisation. Despite attachment being a known factor contributing to psychological and physiological development in childhood and several adult studies showing associations between attachment and dermatology outcomes (Tomas-Aragones, 2018), attachment in young dermatology patients has not been investigated.

OBJECTIVES

This study examined if (1) 8-16-year-olds with chronic dermatological conditions were more likely to show attachment insecurity than general population peers; (2) attachment style was linked to psychological functioning; and (3) facial involvement was associated with attachment insecurity.

METHOD

One hundred and twenty-two 8-16-year-olds attending a specialist paediatric dermatological service were compared on the Child Attachment Interview (CAI) to general population data. The Strengths and Difficulties Questionnaire (SDQ) was used to measure psychosocial functioning.

RESULTS

The dermatology group was significantly more likely to be insecurely attached than their general population peers (χ2 [1] = 4.76, p < .05). The secure group self-reported significantly better psychological functioning on all indices compared with the insecure group (Total Difficulties: F[1,89] = 15.30, p < .001). There were no significant differences between secure and insecure groups on parent-reported psychological measures (Total Difficulties: F[1,94] = 0.67, p = .42). Children with facial involvement were not significantly more likely to be insecurely attached.

CONCLUSIONS

Increased risk of attachment insecurity, particularly in the anxious pre-occupied category, as well as an association between attachment and psychosocial functioning resonated with adult studies suggesting that further research about the role of attachment with young dermatology patients is warranted.

Facing Pediatric Rheumatic Diseases: The Role of Disease Activity and Parental Emotion Regulation Strategy in Parents' and Children's Psychological Adjustment

BACKGROUND

Pediatric rheumatic diseases (PRDs) are a group of chronic disorders that start in childhood and are characterized by periodic exacerbations and remissions of symptoms, with limitations in family, school, and social activities. The aim of this study was to detect differences in parents' psychological adjustment and emotion regulation strategies, and parent-reported children's adjustments in families of children with active and inactive PRDs.

METHODS

Fifty-four parents (38 mothers and 16 fathers) of children with PRD were recruited from a pediatric unit. Disease activity was evaluated by their pediatric rheumatologist, while parents' depressive and anxiety symptoms, emotion regulation strategies, and children's emotional difficulties and hyperactivity-inattention symptoms were assessed through a web-based survey.

RESULTS

Parents of children with active PRDs reported higher levels of their child's emotional difficulties and hyperactivity-inattention symptoms. Linear regression analysis demonstrated that having a child in the active phases of PRD and lower use of cognitive reappraisal lead to higher children's emotional symptoms, while active disease, low use of cognitive reappraisal, and greater expressive suppression were associated with higher hyperactivity-inattention symptoms. Our study highlights that children with PRDs and their parents may be at increased risk for psychological problems, especially during the active disease phase, highlighting the importance of a multidisciplinary approach.

The effectiveness of play therapy in children with leukemia: A systematic review

PROBLEM

Leukemia is the most common form of childhood cancer worldwide. Children living with leukemia experience various problems because of the disease's progression, harmful effects of treatment, and prolonged hospitalization process. To increase their well-being and alleviate their problems, these children require ongoing support. One solution that both parents and professionals can use is play therapy. This systematic review aimed to identify the type and effectiveness of play therapy in children living with leukemia.

ELIGIBILITY CRITERIA

We searched PubMed, Scopus, ScienceDirect, and ProQuest databases. Additionally, we performed manual searches on Google Scholar, Google Web, and grey literature. Inclusion criteria comprised: 1) Studies that implemented play therapy on leukemia children, 2) Full-text articles available in English or Indonesian languages from January 2000 to December 2021 and updated until July 2023, and 3) Intervention studies employing quasi-experimental or randomized controlled trial (RCT) designs.

SAMPLE

From 1099 articles, 16 studies were selected. Several forms of play therapy were found, including pretend, music, art, and sand play therapy.

RESULTS

Of the sixteen studies in this systematic review, fifteen demonstrated beneficial effects on psychological issues, particularly anxiety, despair, stress, and physical problems (fatigue and pain).

CONCLUSION

Play therapy effectively alleviates some physical and psychosocial problems in children living with leukemia.

IMPLICATION

Nurses can utilize play therapy as an intervention for children living with leukemia. Additionally, comparative research is recommended with a similar research strategy concerning studies with the same design.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022318549.

Suicidal Risk Behaviors in Adolescents With Rare Neurodevelopmental Disorders: The Role of Sex, Autistic Traits, and Mental Health Difficulties

OBJECTIVE

Autistic traits are associated with mental health difficulties and risk of suicidal risk behaviors among adolescents. Little is known about how autistic traits affect the mental health of adolescents with rare neurodevelopmental disorders (RNDs). The aim of this study was to investigate the relationship between autistic traits, mental health difficulties, and suicidal risk behaviors in adolescents with RNDs.

METHODS

Parents (N = 93) completed the Child Behavior Checklist, Social Communication Questionnaire, and Social Responsiveness Scale about their adolescent (Mage = 13.1, SD = 2.3, 62.4% females) with an RND (e.g., sex chromosome aneuploidies, Fragile X syndrome, 22q11.2 deletion syndrome). The data were analyzed with hierarchical logistic regression analysis.

RESULTS

The prevalence of suicidal risk behaviors (16.1%) was similar to that reported among autistic youth and was higher among boys than girls. More autistic traits were associated with suicidal risk behaviors in bivariate analysis. In multivariate analysis, more anxiety/depressive symptoms were associated with more suicidal risk behaviors and externalizing problems associated with suicidal risk behaviors beyond autistic traits and anxiety/depressive symptoms.

CONCLUSION

Adolescents with RNDs are at risk of suicidal risk behaviors, especially those with higher levels of autistic traits, anxiety/depressive symptoms, and externalizing problems. Assessment of autistic traits, mental health difficulties, and suicide risk may be indicated for adolescents with RNDs to determine if corresponding intervention is needed.

The impact of childhood glaucoma on psychosocial functioning and quality of life: a review of the literature

We present a novel comprehensive literature review of studies of the psychosocial functioning (PF) and quality of life (QoL) of patients with childhood glaucoma and their caregivers. Our findings demonstrate variable study quality and approach, as well as inconsistent results relating to the association of glaucoma-specific factors and sociodemographic variables with measured PF and QoL. Future studies should focus on the development of culturally cognizant and standardized assessment tools, execution of multi-center longitudinal studies with global representation, evaluation of PF and QoL among siblings and childhood glaucoma providers, and implementation of interventions to improve patient and caregiver PF and QoL.

Extracurricular Activities, Child and Caregiver Mental Health, and Parental Aggravation-A National Cross-Sectional Study

OBJECTIVE

Expanding access to extracurricular activities (EA) may help address the growing mental health needs of children and caregivers. Evidence supports that EA may benefit child mental health, but few studies explore whether this association is influenced by child and EA factors. Further, the impact of EA on caregivers remains unknown.

METHODS

We conducted a secondary analysis of the 2019 National Survey of Children's Health (NSCH), a nationally representative sample of children and their caregivers. We used responses from caregivers of children aged 6 to 17. Weighted logistic regressions tested associations between EA and 1) child anxiety and/or depression diagnosis, 2) caregiver mental health, and 3) parental aggravation, controlling for child, family, and neighborhood-level covariates. Interaction terms tested whether associations were moderated by child age, sex, and presence of physical, developmental, or behavioral condition. Subanalyses explored whether results varied by EA number and type.

RESULTS

Weighted sample included 21,259 children. There were disparities in which children were engaged in EA. EA participation was associated with lower odds of a 1) child being diagnosed with anxiety and/or depression; 2) caregiver reporting "fair/poor" mental health, and 3) caregiver reporting "usually/always" experiencing parental aggravation. Child age, sex, EA number and type, but not health condition, influenced the relationship between EA and child anxiety and/or depression diagnosis.

CONCLUSIONS

Access to EA is associated with child mental health and family functioning. Further studies should assess causality and specific mechanisms of action.

Maternal adverse childhood experiences and behavioral problems in preschool offspring: the mediation role of parenting styles

BACKGROUND

Maternal history of adverse childhood experiences (ACEs) has been found to be associated with children's health outcomes. However, the underlying mechanisms were unclear. This study aimed to examine the association between maternal ACEs and behavioral problems in their preschool offspring and to explore the potential mediating role of maternal parenting styles in the association.

METHODS

A cross-sectional study was conducted involving 4243 mother-child dyads in Chengdu, China. Mothers completed the Adverse Childhood Experiences-International Questionnaire (ACE-IQ) to assess their history of ACEs (i.e., physical abuse, emotional abuse, physical neglect, emotional neglect, witnessing domestic violence, household substance abuse, household mental illness, incarcerated household member, parental separation or divorce, parental death, bullying, and community violence), the short Egna Minnen Beträffande Uppfostran Parent Form (S-EMBU-P) to evaluate their parenting styles (i.e., emotional warmth, rejection, and overprotection), and the 48-item Conners' Parent Rating Scale (CPRS-48) to measure behavioral problems in their children. Logistic regression models were established to examine the association between cumulative number of maternal ACEs and children's behavioral problems. The mediating role of parenting styles in this association was explored by generalized structural equation models (GSEM).

RESULTS

Of the participating mothers, 85.8% (n = 3641) reported having experienced at least one type of ACE. Children of mothers with ≥2 ACEs showed a significantly increased risk of behavioral problems across all dimensions, including conduct problems, learning problems, psychosomatic problems, impulsive-hyperactive, anxiety, and hyperactivity index, in both crude and adjusted models (all p-values < 0.05). Dose-response patterns were also observed between the cumulative number of maternal ACEs and children's behavioral problems. In addition, maternal parenting styles of rejection emerged as a significant mediator, accounting for approximately 8.4-15.0% of the associations.

CONCLUSIONS

Our findings indicated an intergenerational association of maternal ACEs with behavioral problems in preschool offspring, which was mediated by maternal parenting styles of rejection. Early screening and targeted intervention strategies are critical to mitigate the downstream consequences of maternal ACEs on young children's outcomes. Providing support and resources to improve parenting skills may prove beneficial.

Self-reported emotional and behavioral problems among school-going adolescents in Nepal-A cross-sectional study

BACKGROUND

Studies on self-reported emotional and behavioral problems (EBPs) among adolescents are still sparse in many low- and middle-income countries. In Nepal, no such studies have been performed on a larger scale, and little is known about self-reported EBPs in the adolescent population.

METHODS

This cross-sectional, school-based study on EBPs included 1904 adolescents aged 11-18 years, enrolled in government and private schools located in 16 districts in Nepal. The Nepali version of the Youth Self Report form was used to assess self-reported EBPs, and the Teacher Report Form was used to assess academic performance. Analysis of variance (ANOVA) was used for gender comparisons on adolescents' EBPs and on academic competence. Multiple regression analysis was done to explore correlates of self-reported EBPs.

RESULTS

The overall prevalence of self-reported EBPs was 14.2%; 15.6% in boys and 12.9% in girls. The mean Total Problems score was 39.27 (standard deviation = 24.16); no gender differences were observed. Boys scored higher on Externalizing Problems and girls scored higher on Internalizing Problems. The effect sizes for gender comparisons were small with Hedges' g ranging from -0.29 to 0.28. Physical illness and negative/traumatic life events were positively correlated with self-reported EBPs, whereas academic performance was negatively correlated. However, the effect sizes were small (η2 < 0.02).

CONCLUSION

This study helps to narrow the knowledge gap on the prevalence, magnitude, and types of self-reported EBPs in Nepali adolescents. It demonstrated an association between self-reported EBPs and academic performance and linked self-reported EBPs to other factors such as negative/traumatic life events and physical illness. The findings might assist health authorities in the planning of mental health services and may also provide valuable background information to clinicians dealing with adolescent mental health problems.

Pediatric health professionals' perceptions of social health inequalities and proportionate universalism in a French academic hospital: a qualitative study

To describe healthcare professionals' perceptions of social health inequalities in the context of pediatric chronic disease and their insights regarding proportionate universalism as a potential solution to reduce them. Semi-directive interviews were conducted with healthcare professionals from different pediatric chronic disease departments of a single French academic hospital. This qualitative study was based on an inductive thematic analysis; an interview topic guide was used for the interviews and the analysis. In this study, we highlighted three main themes: the healthcare professionals' perceptions of social health inequalities in their practices, their beliefs regarding the causality of those inequalities, and potential solutions proposed by healthcare professionals to reduce them. Healthcare professionals very often associated inequalities with socio-economic precariousness or geographical disparities but were not familiar with the notion of a social gradient. Paradoxically, while they claimed not to differentiate among patients in their practice, they did report adapting care, depending on the social situation. For healthcare professionals, inequalities were the result of misunderstood problems, a lack of family support, a failure of the prevention system, and a lack of financial resources.

CONCLUSION

We still need to develop solutions to tackle those inequalities at every level of the healthcare system, and healthcare professionals must be more actively involved in this effort. One approach is to adapt public health principles such as proportionate universalism to individual care.

WHAT IS KNOWN

• Social health inequalities exist in pediatric care and a social gradient has been shown in many clinical situations. • Exploring health professionals' perceptions of social health inequalities can lead to solutions to tackle them.

WHAT IS NEW

• Pediatricians and pediatric nurses were not fully aware of the social gradient of health. • Although they claimed not to differentiate between patients in their practice, healthcare professionals did adapt care when complicated social situations arose.

Socioemotional and behavioural difficulties in children with chronic physical conditions: analysis of the Longitudinal Study of Australian Children

OBJECTIVES

To examine the prevalence of socioemotional and behavioural difficulties (SEBDs) in children with chronic physical conditions (CPCs) and to analyse how this prevalence varied with the type and number of CPCs and the age of the child.

DESIGN

Cross-sectional study of a secondary data analysis of the Longitudinal Study of Australian Children.

SETTING

An Australian nationally representative sample of general population of children.

PARTICIPANTS

15 610 children-waves aged 6-14 years.

INTERVENTION/EXPOSURE

Children reported to have at least 1 of the 21 CPCs by their parents.

MAIN OUTCOME MEASURES

Clinically relevant SEBDs were defined using standardised cut-offs of the parent-administered Strengths and Difficulties Questionnaire.

RESULTS

Children with a CPC have significantly increased odds of total, internalising and externalising SEBDs than those without (total SEBDs, adjusted odds rartio or OR 3.13, 95% CI 2.52 to 3.89), controlling for sex, age, socioeconomic status and parental mental health status. The highest prevalence of total SEBDs was found in children with chronic fatigue (43.8%), epilepsy (33.8%) and day wetting (31.6%). An increasing number of comorbid CPCs was associated with a rising prevalence of SEBDs. On average, 24.2% of children with at least four CPCs had SEBDs. These children had 8.83-fold increased odds (95% CI 6.9 to 11.31) of total SEBDs compared with children without a CPC. Age was positively related to the odds of SEBDs.

CONCLUSION

Children with a CPC have a significantly increased risk of having SEBDs than those without. These findings highlight the need for routine assessment and integrated intervention for SEBDs among children with CPCs.

Dynamic modeling of experience sampling methodology data reveals large heterogeneity in biopsychosocial factors associated with persistent fatigue in young people living with a chronic condition

OBJECTIVE

To evaluate associations between self-reported biopsychosocial factors and persistent fatigue with dynamic single-case networks.

METHODS

31 persistently fatigued adolescents and young adults with various chronic conditions (aged 12 to 29 years) completed 28 days of Experience Sampling Methodology (ESM) with five prompts per day. ESM surveys consisted of eight generic and up to seven personalized biopsychosocial factors. Residual Dynamic Structural Equation Modeling (RDSEM) was used to analyze the data and derive dynamic single-case networks, controlling for circadian cycle effects, weekend effects, and low-frequency trends. Networks included contemporaneous and cross-lagged associations between biopsychosocial factors and fatigue. Network associations were selected for evaluation if both significant (α < 0.025) and relevant (β ≥ 0.20).

RESULTS

Participants chose 42 different biopsychosocial factors as personalized ESM items. In total, 154 fatigue associations with biopsychosocial factors were found. Most associations were contemporaneous (67.5%). Between chronic condition groups, no significant differences were observed in the associations. There were large inter-individual differences in which biopsychosocial factors were associated with fatigue. Contemporaneous and cross-lagged associations with fatigue varied widely in direction and strength.

CONCLUSIONS

The heterogeneity found in biopsychosocial factors associated with fatigue underlines that persistent fatigue stems from a complex interplay between biopsychosocial factors. The present findings support the need for personalized treatment of persistent fatigue. Discussing the dynamic networks with the participant can be a promising step towards tailored treatment.

TRIAL REGISTRATION

No. NL8789 (http://www.trialregister.nl).

A prospective analysis of the long-term impact of the COVID-19 pandemic on well-being and health care among children with a chronic condition and their families: a study protocol of the KICK-COVID study

BACKGROUND

There is consistent evidence that the COVID-19 pandemic is associated with an increased psychosocial burden on children and adolescents and their parents. Relatively little is known about its particular impact on high-risk groups with chronic physical health conditions (CCs). Therefore, the primary aim of the study is to analyze the multiple impacts on health care and psychosocial well-being on these children and adolescents and their parents.

METHODS

We will implement a two-stage approach. In the first step, parents and their underage children from three German patient registries for diabetes, obesity, and rheumatic diseases, are invited to fill out short questionnaires including questions about corona-specific stressors, the health care situation, and psychosocial well-being. In the next step, a more comprehensive, in-depth online survey is carried out in a smaller subsample.

DISCUSSION

The study will provide insights into the multiple longer-term stressors during the COVID-19 pandemic in families with a child with a CC. The simultaneous consideration of medical and psycho-social endpoints will help to gain a deeper understanding of the complex interactions affecting family functioning, psychological well-being, and health care delivery.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), no. DRKS00027974. Registered on 27th of January 2022.

Mental Health and Health-Related Quality of Life in Austrian Adolescents with Chronic Physical Health Conditions: Results from the MHAT Study

Chronic physical health conditions (CPHC) are on the rise in younger age groups and might have a negative impact on children and adolescents. In a representative sample of Austrian adolescents aged 10-18 years, internalizing, externalizing, and behavioral problems were assessed cross-sectionally using the Youth Self-Report and health-related quality of life (HrQoL) using the KIDSCREEN questionnaire. Sociodemographic variables, life events, and chronic illness specific parameters were considered as associated variables with mental health problems in individuals with CPHC. Of 3469 adolescents, 9.4% of girls and 7.1% of boys suffered from a chronic pediatric illness. Of these individuals, 31.7% and 11.9% had clinically relevant levels of internalizing and externalizing mental health problems, respectively, compared to 16.3% and 7.1% adolescents without a CPHC. Anxiety, depression, and social problems were twice as high in this population. Medication intake due to CPHC and any traumatic life-event were related to mental health problems. All HrQoL domains were deteriorated in adolescents with a double burden of mental and CPHC, whereas adolescents with a CPHC without mental health problems did not differ significantly from adolescents without a chronic illness. Targeted prevention programs for adolescents with a CPHC are urgently needed to prevent mental health problems in the long term.

Impaired pulmonary function mediates inattention in young adults born extremely preterm

AIM

To test whether poor childhood pulmonary function explains the relationship between extremely preterm (EP) birth and attention-deficit/hyperactivity disorder (ADHD) symptoms in young adulthood.

METHODS

EPICure birth cohort participants include children born <26 weeks' gestation in the United Kingdom and Ireland in 1995 and their term-born classmates. Predictor was EP birth. Outcomes were inattention/hyperactivity subscale z-scores at 19 years. Forced expiratory volume (FEV1) z-scores in childhood and young adulthood were mediators. We used recursive path analysis to determine the direct effect of EP birth on inattention/hyperactivity and its indirect effect through pulmonary function.

RESULTS

Ninety EP and 47 term-born participants had pulmonary function testing at 11 and 19 years. Inattention z-scores were higher in the EP group (mean difference 0.55 [95% CI 0.11, 0.99]) but not hyperactivity. Compared to term-born peers, EP participants had lower FEV1 z-scores at 11 (mean difference-1.35 [95% CI -1.72, -0.98]) and 19 (mean difference-1.29 [95% CI -1.65, -0.92]). Path models revealed that childhood pulmonary function explained the relationship between EP birth and inattention.

CONCLUSIONS

Extremely preterm young adults have increased risk for inattention compared to term-born peers. Poor pulmonary function appears to underlie this risk. The mechanisms responsible remain unclear and warrant further study.

Mental health symptoms in children and adolescents during COVID-19 in Australia

OBJECTIVE

COVID-19 has led to disruptions to the lives of Australian families through social distancing, school closures, a temporary move to home-based online learning, and effective lockdown. Understanding the effects on child and adolescent mental health is important to inform policies to support communities as they continue to face the pandemic and future crises. This paper sought to report on mental health symptoms in Australian children and adolescents during the initial stages of the pandemic (May to November 2020) and to examine their association with child/family characteristics and exposure to the broad COVID-19 environment.

METHODS

An online baseline survey was completed by 1327 parents and carers of Australian children aged 4 to 17 years. Parents/carers reported on their child's mental health using five measures, including emotional symptoms, conduct problems, hyperactivity/inattention, anxiety symptoms and depressive symptoms. Child/family characteristics and COVID-related variables were measured.

RESULTS

Overall, 30.5%, 26.3% and 9.5% of our sample scored in the high to very high range for emotional symptoms, conduct problems and hyperactivity/inattention, respectively. Similarly, 20.2% and 20.4% of our sample scored in the clinical range for anxiety symptoms and depressive symptoms, respectively. A child's pre-existing mental health diagnosis, neurodevelopmental condition and chronic illness significantly predicted parent-reported child and adolescent mental health symptoms. Parental mental health symptoms, having a close contact with COVID-19 and applying for government financial assistance during COVID-19, were significantly associated with child and adolescent mental health symptoms.

CONCLUSION

Our findings show that Australian children and adolescents experienced considerable levels of mental health symptoms during the initial phase of COVID-19. This highlights the need for targeted and effective support for affected youth, particularly for those with pre-existing vulnerabilities.

The Legacy of Mental Distress Following Physical Illness in Childhood: Findings From the Australian Temperament Project

OBJECTIVE

Childhood physical illnesses have been associated with heightened risk for mental health problems in adolescence and young adulthood; however, little is known about the natural history of this relationship. Here, we examine the nature of mental health adjustment to illness from diagnosis in childhood into adolescence and young adult life.

METHODS

Data were drawn from a large population-based cohort. Parents reported whether their child had a physical illness at 5-6 and 7-8 years and whether they believed their child was so sick it was thought they might die. Depression and anxiety symptoms were reported by parents (for children 7-10 years) and self-reports (11-28 years).

RESULTS

A total of 1,001 (56%) parents reported their child had a physical illness. Of these parents, 143 (8%) believed their child might die. Findings indicated there was some evidence of higher levels of depressive and anxious symptoms across late childhood and into early adolescence for those reporting a physical illness in childhood. A similar pattern was observed for those who were so sick it was thought they might die, although symptoms were elevated to a greater extent.

CONCLUSION

Although physical illness in middle childhood is associated with higher levels of depressive and anxious symptoms, by early adolescence, these differences diminish, indicating a process of adaptation that persists into young adulthood. This suggests a potentially sensitive period of adjustment to illness for some, especially for children who it was feared might die. Additional psychosocial assessment and support may be warranted across the "acute" illness period.

Behavior Problems, Self-Esteem, and Prosocial Behavior in Siblings of Children With Chronic Physical Health Conditions: An Updated Meta-Analysis

OBJECTIVE

Chronic physical health conditions (CPHC) of children affect the whole family. The aim of the present meta-analysis was to compare levels of internalizing, externalizing, and total problems as well as self-esteem/positive self-concept and prosocial behavior of the healthy siblings with children from families not affected by CPHC and test norms, respectively.

METHODS

A systematic search for literature was conducted using the electronic data bases CINAHL, PsycInfo, PubMed, PSYNDEX, and Web of Science. In total, results from 216 studies were included in random-effects meta-analyses that had been published or made available online before February 15, 2022.

RESULTS

Healthy siblings of children with CPHC had elevated levels of internalizing (g = .18 standard deviation units), externalizing (g = .13), and total behavior problems (g = .22), and effect sizes were found to be small to very small. While levels of self-esteem did, on average, not vary between healthy children with and without a sibling with CPHC or test norms (g = .08), higher levels of prosocial behavior were found in the healthy siblings of children with CPHC (g = .18). In addition, some moderating effects of kind of CPHC and its intrusiveness as well as mortality risk, country, sociodemographic equivalence of the compared groups, and year of publication were identified.

CONCLUSIONS

It is concluded that CPHC of a child can have negative as well as positive effects on psychosocial outcomes of healthy siblings. Psychosocial interventions are recommended for healthy siblings at elevated risk for psychological problems.

A cross-sectional study on gaming intensity and social vulnerability in adolescents that have a chronic condition

Background

Adolescents growing up with a chronic condition might experience more social vulnerabilities compared to their healthy peers as an indirect result of their conditions. This can lead to a relatedness need frustration for these adolescents. Consequently, they might spend more time playing video games compared to their peers. Research shows that both social vulnerability and gaming intensity are predictors for problematic gaming. Therefore, we investigated if social vulnerability and gaming intensity are more pronounced in adolescents that have a chronic condition compared to the general population; and if these levels reflect the levels of a clinical group being treated for Internet Gaming Disorder (IGD).

Methods

Data on peer problems and gaming intensity were compared from three separate samples: a national representative sample of adolescents, a clinical sample of adolescents that are undergoing treatment for IGD, and a sample of adolescents diagnosed with a chronic condition.

Results

No differences were found on either peer problems or gaming intensity between the group of adolescents that have chronic conditions and the national representative group. The group with chronic conditions scored significantly lower on gaming intensity than the clinical group. No significant differences were found between these groups on peer problems. We repeated the analyses for boys only. Similar results were found for the group with chronic conditions compared to the national representative group. The group with chronic conditions now scored significantly lower on both peer problems and gaming intensity than the clinical group.

Conclusion

Adolescents growing up with a chronic condition appear similar in their gaming intensity and peer problems compared to their healthy peers.

Emotional Experience and Regulation in Juvenile Primary Headaches: A Cross-Sectional Pilot Study

A headache is the most common neurological symptom in children. Its subtypes are migraine (MH) and tension-type headache (TTH). Internalizing rather than externalizing symptoms are more frequent in children with headaches, but little is known about the reasons why. We aim to: (a) examine the interplay between emotional experience, affective regulation, and internalizing symptoms in children suffering from primary headaches and their caregivers; (b) identify potential predictors of children with migraines' internalizing symptoms. Fifty children and adolescents with a diagnosis of primary headaches and their caregivers were compared to a sample of fifty-one healthy peers and caregivers. Self-reports and parent-reports were administered. Results indicate higher negative affect and internalizing symptoms and lower bodily awareness of emotions in the clinical sample (n = 50; Mage = 11.66, SD = 2.25) compared to controls (n = 51; Mage = 11.73, SD = 2.32); mothers of TTH children self-reported lower emotional awareness and higher difficulties in engaging in goal-directed behavior; a higher frequency of headaches was associated with greater emotional regulation difficulties. Internalizing symptoms were predicted by higher self-reported negative affect and parent-reported internalizing symptoms, and lower self-reported ability in the verbal sharing of emotions. These findings suggest the importance of assessing the psychological features linked to children with primary headaches' psychological well-being.

Health-Related Quality of Life and mental health of families with children and adolescents affected by rare diseases and high disease burden: the perspective of affected children and their siblings

Background

Advances in genetic and pharmaceutical technology and pediatric care have enabled treatment options for an increasing number of rare diseases in affected children. However, as current treatment options are primarily of palliative nature, the Health-Related Quality of Life (HRQoL) and mental health of this impaired population and their siblings are of increasing importance. Among children and adolescents with rare diseases, those who are technology-dependent carry a high disease burden and are selected as the target population in our study. In a cross-sectional observational design, the children’s HRQoL was assessed with the DISABKIDS (DCGM-37) as well as KIDSCREEN-27, while mental health was assessed with the Strengths and Difficulties Questionnaire (SDQ) by both the affected children, their parents, and siblings.

Results

Results of the study sample were compared to normative data. Affected children scored significantly lower than the norm on almost all HRQoL subscales as reported by parent and child. From the parental perspective, more mental health subscales were significantly impaired compared to the child’s perspective. Siblings showed no impairment in HRQoL as well as significantly fewer behavioral problems and higher prosocial behavior regarding their mental health compared to the norm.

Conclusion

Children and adolescents with rare diseases seem particularly impaired in social and emotional aspects of HRQoL and mental health. Interventions may focus primarily on promoting social skills, fostering prosocial behavior and peer relationships.

Role of Psychologists in Pediatric Subspecialties: Integrated Psychological Services Overarching Concepts Across Pediatric Subspecialties

This article addresses, in more general terms, the overarching concepts of the role of integrated psychologists and how their services are incorporated in the medical home with the use of provider consultation, administering assessments in identifying common mental health concerns, providing interventions for treatment adherence and providing short-term therapy within pediatric subspecialties.

Clinical and psychosocial factors affecting treatment adherence in children with rheumatic heart disease

INTRODUCTION

The present study aimed to investigate the outcomes of psychiatric symptoms and family functions on treatment adherence in children, in addition to sociodemographic characteristics and clinical factors related to the disease.

MATERIAL AND METHOD

The research sample consisted of 43 children who were followed up with rheumatic heart disease diagnosis during the study. Clinical features were obtained from the patient files. The family assessment device evaluating family functioning and the strengths and difficulties questionnaire scale to screen emotional and behavioural problems in children were used.

RESULTS

Considering the regularity of treatment in our patients, there were 31 (72%) patients adherent to secondary prophylaxis regularly, 7 (6.9%) patients were partially adherent, and 5 (11.6%) patients non-adherent. Patients were divided into treatment adherent (Group 1) and non-adherent (Group 2). There was no statistically significant impact on treatment adherence whether the patients receive enough information, lifestyle, fear of developing adverse effects, fear of addiction, lack of health insurance, difficulties in reaching the drug or hospital. However, the fear of syringes on treatment adherence had an effect statistically significantly (p = 0.047). Forgetting to get a prescription and/or take the drug when the time comes was statistically higher in the non-adherent group (p = 0.009). There was no statistically significant effect of psychosocial factors on treatment adherence between groups.

DISCUSSION

Providing an effective active recall system, involving primary care workers, providing training on the disease and its management, and a comprehensive pain management programme can improve the process, especially for cases where secondary prophylaxis is missed.

Comparing parental distress and children's difficulties between parents of children with rheumatic diseases and parents of healthy children in families facing the COVID-19 pandemic

The COVID-19 pandemic could be a threat for the health status of children with a chronic condition. The present study aimed to explore parents' and children's psychological adjustment during the current pandemic, pursuing a triple objective: to compare the psychological adjustment of parents of children with pediatric rheumatic diseases (PRDs) and parents of healthy children; to analyze children's psychological symptoms (emotional problems and hyperactivity) before and during the COVID-19 pandemic, and with or without a PRDs diagnosis; to explore the associations of children's emotional problems and hyperactivity with parents' psychological adjustment, parent-child interactions and belonging or not to families with PRDs. This cross-sectional study involved 56 parents of children with PRDs and 53 parents of healthy children. Self-report questionnaires about parents' depression, anxiety, parenting stress, and children's emotional symptoms and hyperactivity-inattention were administered. No differences were detected on psychological adjustment between parents of children with PRDs and parents of healthy children. Parents of children with PRDs reported statistically significant higher levels of children's emotional problems and hyperactivity before the pandemic, compared to parents of healthy children; during COVID-19 pandemic, emotional symptoms increased for both groups, while hyperactivity-inattention symptoms increased only in the group of healthy children. Children's emotional difficulties were associated with higher levels of parental anxiety, worse parent-child interaction and having PRDs; children's hyperactivity symptoms were related to parent-child difficult interaction and higher levels of parental depression. Findings suggest the importance to target the children in relation to their parents, when approaching the psychological aspects of PRDs.

Goal-based measurement in paediatric settings: implications for practice

There is an observed link between physical illness and mental health difficulties and an increased likelihood of mental health difficulties in young people with chronic health conditions. The main outcome focus in paediatric settings is on physical health outcomes and functioning. In terms of functioning, the focus is on quality of life, measures of emotional well-being and perceptions of personal change, which are likely to be multifaceted and vary between patients. To complement standardised and diagnostically based measures, goal-based outcome measurement may be considered. The aim of this paper is to build on previous research, to provide a reflective commentary based on the authors' clinical and research experience in the use and interpretation of goal-based outcomes, to address what using goal-based measures for outcome purposes in these settings means practically. Examples are provided to demonstrate the importance of considering meaningful outcomes of importance to young people and how professionals may presume that physical 'recovery' is the goal of treatment, but what recovery means to that young person may be very nuanced. Further key considerations and suggested phrasing are given to introduce and work with young people's goals.

Multimorbidity is associated with the income, education, employment and health domains of area-level deprivation in adult residents in the UK

Evidence suggests that there are social inequalities in multimorbidity, with a recent review indicating that area levels of deprivation are consistently associated with greater levels of multimorbidity. Definitions of multimorbidity, the most common of which is the co-occurrence of more than one long term condition, can include long term physical conditions, mental health conditions or both. The most commonly used measure of deprivation in England and Wales is the Index of Multiple Deprivation (IMD), an index of seven different deprivation domains. It is unclear which features of IMD may be mediating associations with multimorbidity. Thus, there may be associations because of the individual characteristics of those living in deprived areas, characteristics of the areas themselves or overlap in definitions. Data from over 25,000 participants (aged 16+) of Understanding Society (Wave 10, 1/2018–3/2020) were used to understand the most salient features of multimorbidity associated with IMD and whether physical or mental conditions are differentially associated with the seven domains of IMD. 24% of participants report multimorbidity. There is an increased prevalence of multimorbidity composed of only long-term physical conditions in the most deprived decile of deprivation (22%, 95% CI[19,25]) compared to the least deprived decile (16%, 95% CI[14,18]). Mental health symptoms but not reporting of conditions vary by decile of IMD. Associations with multimorbidity are limited to the health, income, education and employment domains of IMD. We conclude that multimorbidity represents a substantial population burden, particularly in the most deprived areas in England and Wales.

Psychological aspects in children and parents of children with chronic kidney disease and their families

Pediatric chronic kidney disease (CKD) is a chronic illness that affects the overall quality of life of patients during childhood. This article highlights the psychological and social burden of CKD in patients and their families. Patients with CKD and their families require comprehensive treatment for psychosocial problems. Therefore, it is crucial for pediatricians to screen for these issues and refer patients and their families for therapy. Tools that are short, easy to administer, and easy to score, such as the Pediatric Quality of Life Inventory or the Childhood Depression Inventory, can be utilized during routine clinical appointments. Reducing the negative impact of CKD on the family will improve the well-being and coping skills of patients and their families.

Cost-effectiveness of a mental health drop-in centre for young people with long-term physical conditions

BACKGROUND

Paediatric patients being treated for long-term physical health conditions (LTCs) have elevated mental health needs. However, mental health services in the community are difficult to access in the usual course of care for these patients. The Lucy Project - a self-referral drop-in access point-was a program to address this gap by enrolling patients for low-intensity psychological interventions during their treatment for LTCs. In this paper, we evaluate the cost-effectiveness of the Lucy Project.

METHODS

Using a pre-post design, we evaluate the cost-effectiveness of the intervention by calculating the base-case incremental cost-effectiveness ratio (ICER) using outcomes data and expenses recorded by project staff. The target population was paediatric patients enrolled in the program with an average age of 9 years, treated over a time horizon of 6 months. Outcome data were collected via the Paediatric Quality of Life Inventory, which was converted to health utility scores using an instrument found in the literature. The QALYs were estimated using these health utility scores and the length of the intervention. We calculate a second, practical-case incremental cost-effectiveness ratio using streamlined costing figures with maximum capacity patient enrolment within a one-year time horizon, and capturing lessons learned post-trial.

RESULTS

The base-case model showed an ICER of £21,220/Quality Adjusted Life Years (QALY) gained, while the practical model showed an ICER of £4,359/QALY gained. The practical model suggests the intervention garners significant gains in quality of life at an average cost of £309 per patient. Sensitivity analyses reveal use of staff time was the greatest determinant of the ICER, and the intervention is cost-effective 75% of the time in the base-case model, and 94% of the time in the practical-case model at a cost-effectiveness threshold of £20,000/QALY gained.

CONCLUSIONS

We find the base-case intervention improves patient outcomes and can be considered cost-effective according to the National Institute for Health and Care Excellence (NICE) threshold of £20,000-£30,000/QALY gained, and the practical-case intervention is roughly four times as cost-effective as the base-case. We recommend future studies incorporate a control group to corroborate the effect size of the intervention.

Psychosocial Difficulties in Preschool-Age Children with Beckwith–Wiedemann Syndrome: An Exploratory Study

Beckwith–Wiedemann syndrome (BWS) is a rare overgrowth disease and is not usually associated with intellectual delay. Living with a chronic illness condition such as BWS, however, might affect emotional-behavioral functioning and psychosocial development. To investigate this issue, parents of 30 children with BWS between 1.5 and 6 years old compiled standardized questionnaires assessing the presence of emotional-behavioral and developmental problems. The group mean scores in each scale of behavioral problems fell within the average range. Nevertheless, 23% of the sample presented scores beyond the risk threshold for social withdrawal. As regards psychomotor development, a lower mean score was reliable in the social domain compared to other developmental scales, and in the gross-motor compared to fine-motor functions. Moreover, scores in the at-risk band were reliable in almost half of the children for social development. Notably, older age was overall associated with higher emotional-behavioral and developmental difficulties, while no other socio-demographic or clinical variables accounted for the scores obtained in the questionnaires. These findings ask for a wider consideration by health and educational professionals of the psychosocial functioning of children with BWS, so as to early detect at-risk conditions and eventually promote adequate interventions.

Heritable connective tissue disorders in childhood: Decreased health-related quality of life and mental health

The psychosocial consequences of growing up with Heritable Connective Tissue Disorders (HCTD) are largely unknown. We aimed to assess Health‐Related Quality of Life (HRQoL) and mental health of children and adolescents with HCTD. This observational multicenter study included 126 children, aged 4–18 years, with Marfan syndrome (MFS, n = 74), Loeys–Dietz syndrome (n = 8), molecular confirmed Ehlers–Danlos syndromes (n = 15), and hypermobile Ehlers–Danlos syndrome (hEDS, n = 29). HRQoL and mental health were assessed through the parent and child‐reported Child Health Questionnaires (CHQ‐PF50 and CHQ‐CF45, respectively) and the parent‐reported Strengths and Difficulties Questionnaire. Compared with a representative general population sample, parent‐reported HRQoL of the HCTD‐group showed significantly decreased Physical sum scores (p < 0.001, d = 0.9) and Psychosocial sum scores (p = 0.024, d = 0.2), indicating decreased HRQoL. Similar findings were obtained for child‐reported HRQoL. The parent‐reported mental health of the HCTD‐group showed significantly increased Total difficulties sum scores (p = 0.01, d = 0.3), indicating decreased mental health. While the male and female MFS‐ and hEDS‐subgroups both reported decreased HRQoL, only the hEDS‐subgroup reported decreased mental health. In conclusion, children and adolescents with HCTD report decreased HRQoL and mental health, with most adverse outcomes reported in children with hEDS and least in those with MFS. These findings call for systematic monitoring and tailored interventions.

Chronic pain and delinquency partially explain the effect of the DRD4 gene polymorphism on adult substance use

Background: The dopamine receptor D4 [DRD4] has been reported to be associated with substance use. Yet, the roles that health conditions and behaviors may play in such association are understudied.Objective: This longitudinal study investigated the potential mediation effects of chronic pain and delinquency in adolescence on the association between the DRD4 2-repeat allele and substance use in adulthood. Sex, witnessing violence, and experiencing violence were also examined as potential moderators for the mediation pathways.Methods: We used the restricted and candidate gene data from the National Longitudinal Study of Adolescent to Adult Health (Waves I-IV) to conduct secondary analysis (N = 8,671; 47% male). A two-step approach was adopted to examine the mediation effects regarding four substance use outcomes in adulthood: number of lifetime alcohol use disorder symptoms, lifetime regular smoker status, past-month smoking, and lifetime "pain killer" misuse. The moderation effects were investigated using stratification and permutation.Results: The DRD4 2-repeat allele was associated with all adulthood substance use outcomes through adolescent chronic pain and delinquency (AORs/IRR range 1.08-3.78; all ps<0.01). The association between delinquency and smoking was higher among females. The association between delinquency and substance use was lower among the participants who witnessed violence in adolescence.Conclusions: This study identified modifiable mediators underlying the association between the DRD4 2-repeat allele and substance use behaviors, concluding that chronic pain and delinquency partially explain the effect of the DRD4 gene polymorphism on adult substance use.

Effectiveness of play therapy in enhancing psychosocial outcomes in children with chronic illness: A systematic review

PROBLEM

To examine the nature, quality, and effectiveness of Play Therapy (PT) interventions in children with chronic health conditions (CHC) and to identify the measures used to evaluate psychosocial outcomes.

ELIGIBILITY CRITERIA

Systematic searches of the databases: Medline complete, PsycINFO, CINHAL, Embase and Sport Discuss were conducted to identify peer reviewed papers reporting original studies published in English between January1990 - April 2020. Studies testing any type of PT or Filial Therapy (FT) with children with CHC aged between 3 and 11 years, or their parents if FT, where outcomes were primarily psychosocial were eligible.

SAMPLE AND RESULTS

The title and abstract search identified 6742 papers and six studies (three each for PT and FT) including two randomized control trials were identified as eligible for review. All FT interventions involved group-based training, while only one PT study used a group format. Outcomes for children included emotional and behavioural issues including anxiety, depression, and self-concept and while constructs were broadly comparable across studies, the measures used differed. Sample size ranged between 4 and 58. Two studies suggested positive impact of PT on depression, with one finding improvements in self-concept. Three studies with sample sizes less than 30 found no effect.

CONCLUSION

With varied study designs, and small sample sizes, current evidence regarding the effectiveness of PT in improving psychosocial outcomes for children with chronic illnesses is inconclusive.

IMPLICATIONS

The field should move from small underpowered studies to randomized trials with comprehensive protocols and larger sample sizes.

Mental healthcare for children with chronic conditions: a qualitative study

OBJECTIVE

To explore parent perspectives on accessing mental healthcare for children with a chronic physical health condition.

DESIGN

Qualitative research using semistructured interviews and Framework Analysis. Rankings were used to select attributes for a Discrete Choice Experiment (DCE).

SETTING

Four specialty outpatient clinics (diabetes, epilepsy, bronchiectasis unrelated to cystic fibrosis and epidermolysis bullosa) at an Australian tertiary paediatric hospital.

PARTICIPANTS

Eighteen parents of children with a chronical physical health condition.

RESULTS

Most parents identified the child's general practitioner and/or hospital team as an initial pathway to seek help if they were worried about their child's mental health. Parents see mental healthcare as part of care for the whole child and want the outpatient clinics to proactively discuss child and family mental health, as well as refer to appropriate services as needed. The hospital being a familiar, child-friendly environment was identified as a key reason the hospital might be a desired place to access mental healthcare, as previous research has found. Six attributes of mental health services were identified as important and will be included in an upcoming DCE: travel time, cost, wait time, available hours, knowledge of physical health condition, and recommendation.

CONCLUSIONS

This study highlights the opportunity presented in specialist outpatient clinics to address the often unmet mental healthcare needs of children with chronic physical health conditions. Parents identified practical ways for outpatient clinics to better facilitate access to mental healthcare. These will be further explored through a quantitative study of parent preferences.

Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management

Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.

Childhood chronic condition and subsequent self-reported internalizing and externalizing problems in adolescence: a birth cohort study

Chronic conditions are common in childhood. We investigated the associations of childhood chronic conditions reported by parents with subsequent self-reported internalizing and externalizing problems in adolescence. A sample of 6290 children (3142 boys and 3148 girls) with data on chronic condition reported by parents both at 7 and at 16 years of age was obtained from the Northern Finland Birth Cohort 1986 (NFBC 1986), which is a longitudinal 1-year birth cohort (n = 9432) from an unselected, regionally defined population. Internalizing and externalizing problems were measured at 8 years of age with Rutter Children's Behavioral Questionnaire by teachers and at 16 years of age with Youth Self-Report by adolescents. When studying the effects of history of chronic conditions on these problems at 16 years of age, childhood internalizing and externalizing problems and social relations were adjusted. A history of chronic condition predicted subsequent somatic complaints among all adolescents. Early-onset chronic conditions were related to subsequent externalizing (OR 1.35; 1.02-1.79) and attention problems (OR 1.33; 1.01-1.75) and later onset of chronic conditions with internalizing (OR 1.49; 1.22-1.82) and thought problems (OR 1.50; 1.18-1.92). The effect was specific for sex and the type of chronic condition.

CONCLUSION

Childhood chronic conditions predicted internalizing and externalizing problems in adolescence. To prevent poor mental health trajectories, children with chronic conditions during their growth to adolescence need early support and long-term monitoring.

WHAT IS KNOWN

• Childhood adversities increase the risk of mental disorders. • Internalizing and externalizing problems have been suggested for measuring childhood and adolescent psychopathologies.

WHAT IS NEW

• Having a chronic condition (CC) before the age of 7 or later but before the age of 16 had different outcomes in adolescence. The early onset predicted externalizing problems, whereas the late onset predicted internalizing problems and thought problems in adolescence. The risk of somatic complaints was increased regardless of CC onset time. These findings can reflect more restricted ability to mental processing in the younger children.