Recurrent abdominal pain in children: psychiatric diagnoses and parental psychopathology

The association between parent mental health and pediatric chronic pain: a systematic review and meta-analysis

ABSTRACT

Mental health problems are common among parents of children with chronic pain and associated with worse outcomes for the child with chronic pain. However, the effect sizes of these associations between parent mental health and pediatric chronic pain vary widely across studies. The aim of this systematic review and meta-analysis was to generate pooled estimates of the (1) prevalence of mental health problems among parents of children with chronic pain and (2) associations between parent mental health and the (2a) presence of child chronic pain and (2b) functioning of children with chronic pain. Embase, MEDLINE, PsycINFO, Web of Science, and CINAHL were searched up to November 2022. Observational studies that examined symptoms or diagnoses of parent anxiety, depression, or general distress and the presence of child chronic pain and/or related functioning were included. From 32,848 records, 2 coders identified 49 studies to include in random-effects meta-analyses. The results revealed that mental health problems among parents of children with chronic pain were common (anxiety: 28.8% [95% CI 20.3-39.1]; depression: 20.0% [15.7-25.2]; general distress: 32.4% [22.7-44.0]). Poorer parent mental health was significantly associated with the presence of chronic pain (anxiety: OR = 1.91 [1.51-2.41]; depression: OR = 1.90 [1.51-2.38]; general distress: OR = 1.74 [1.47-2.05]) and worse related functioning (ie, pain intensity, physical functioning, anxiety and depression symptoms; r s = 0.10-0.25, all P s < 0.05) in children. Moderator analyses were generally nonsignificant or could not be conducted because of insufficient data. Findings support the importance of addressing parent mental health in the prevention and treatment of pediatric chronic pain.

Designing unified trans-diagnostic interventions and their efficacy on the common mechanisms of the comorbid obsessive personality disorder with anxiety, depression, and obsessive-compulsive disorder: A protocol study

BACKGROUND

The immense comorbidity among disorders could be ascribed to common trans-diagnostic processes. The term trans-diagnostic has been of interest in both pathology and psychology. Trans-diagnostic treatments were created as opposed to treatments based on single-diagnosis treatments. It addresses the common underlying mechanisms in a range of comorbid disorders. Trans-diagnostic treatment is one of the new psychological treatments, and its efficacy has been proven on many psychological variables. The main focus of the current study is on designing unified trans-diagnostic interventions and their efficacy on the shared mechanisms of comorbid obsessive personality disorder with anxiety, depression, and obsessive-compulsive disorder.

MATERIALS AND METHODS

the sequential transformative strategy has two stages; qualitative and quantitative. In The first and qualitative section of the research, explanatory research will be carried out to investigate the trans-diagnostic intervention using a systematic review. To validate the trans-diagnostic intervention, and simultaneously with the trans-diagnostic intervention, a questionnaire has been prepared and given to 10 psychology experts and professionals in the treatment field concerning content validity by evaluators.

CONCLUSION

Designing unified trans-diagnosis interventions and their efficacy on the common mechanisms of comorbid obsessive personality disorder with anxiety, depression, and obsessive-compulsive disorder is an effective treatment method for helping those suffering from a personality disorder. Clinical psychologists, psychology experts, psychiatrists, and mental health experts are all the immediate beneficiaries of this study. Moreover, clients could benefit from this intervention with less money and time.

Psychogenic non-epileptic seizures in youth: Individual and family psychiatric characteristics

INTRODUCTION

Youth with psychogenic non-epileptic seizures (PNES) are an understudied group associated with significant medical and psychiatric morbidity. Several studies have examined characteristics associated with youth's development of this disorder, though the exploration of family factors including psychiatric illness, has been lacking. This study sought to establish the need for a more comprehensive future study.

METHODS

A retrospective chart review was conducted on patients who had been admitted and diagnosed with PNES at the epilepsy monitoring unit at Children's Hospitals and Clinics of Minnesota. A total of 62 patients were included. All patients were evaluated by an epileptologist and psychologist during their diagnostic admission. "Spells" in question were captured via video EEG monitoring. PNES youth and family risk factors were assessed.

RESULTS

Mean age of PNES symptom onset was 13.9 years. Patients (73%) were diagnosed within 6 months of onset of symptoms. Histories of other impairing somatic complaints were present in the youth (54%), with 67% having prior psychiatric diagnoses. Experiencing suicidal ideation or thoughts of self-harm occurred in 47% of this sample. Family members were unaware of the history of these symptoms with 12% of the parent's reporting awareness. Family history of psychiatric disorders (first-degree relatives of patient) was present in 54% of the sample, with anxiety, depression and conversion disorder being the most commonly endorsed diagnoses.

CONCLUSIONS

Youth with PNES present with comorbid psychiatric disorders, though prior assessment and treatment for these disorders was not common. Youth with PNES have history of suicidal ideation and thoughts of self-harm, though parental awareness of these co-occurring symptoms is limited. Family risk factors, such as history of psychiatric disorder in first degree relatives, was high. The impact of these family risk factors is understudied and should be further evaluated to better understand the impact on development and maintenance of this disorder in youth.

A Review of the Evidence and Recommendations on Communication Skills and the Patient-Provider Relationship: A Rome Foundation Working Team Report

BACKGROUND & AIMS

Over several decades, changes in health care have negatively impacted meaningful communication between the patient and provider and adversely affected their relationship. Under increasing time pressure, physicians rely more on technology than face-to-face time gathering data to make clinical decisions. As a result, they find it more challenging to understand the illness context and fully address patient needs. Patients experience dissatisfaction and a diminution of their role in the care process. For patients with disorders of gut-brain interaction, stigma leads to greater care dissatisfaction, as there is no apparent structural basis to legitimize the symptoms. Recent evidence suggests that practical communication skills can improve the patient-provider relationship (PPR) and clinical outcomes, but these data are limited.

METHODS

The Rome Foundation convened a multidisciplinary working team to review the scientific evidence with the following aims: a) to study the effect of communication skills on patient satisfaction and outcomes by performing an evidence-based review; b) to characterize the influence of sociocultural factors, health care system constraints, patient perspective, and telehealth on the PPR; c) to review the measurement and impact of communication skills training on these outcomes; and d) to make recommendations to improve communication skills training and the PPR.

RESULTS

Evidence supports the fact that interventions targeting patient-provider interactions improve population health, patient and provider experience, and costs. Communication skills training leads to improved patient satisfaction and outcomes. The following are relevant factors to consider in establishing an effective PPR: addressing health care system constraints; incorporating sociocultural factors and the role of gender, age, and chronic illness; and considering the changing role of telehealth on the PPR.

CONCLUSIONS

We concluded that effective communication skills can improve the PPR and health outcomes. This is an achievable goal through training and system change. More research is needed to confirm these findings.

Psychological Stresses in Children Trigger Cytokine- and Kynurenine Metabolite-Mediated Abdominal Pain and Proinflammatory Changes

Recurrent abdominal pain (RAP) is a common medically unexplained symptom among children worldwide. However, the biological mechanisms behind the development of functional and behavioral symptoms and changes in blood markers have not been well explored. This study aimed to assess changes in the concentrations of inflammatory markers, including cytokines and tryptophan catabolites, in the serum of children with RAP compared to those with subclinical infections. Children with RAP but without organic diseases were included, and those with asymptomatic intestinal parasitic infections were used as a subclinical infection cohort. Blood samples were collected and used to measure the cytokine profile using Multiplex Immunoassay and tryptophan catabolites using high performance liquid chromatography. Children with RAP showed significantly higher concentrations of serum tumor necrotic factor-α, p<0.05, but lower concentrations of IL-10, p<0.001, IL-6, p<0.001 and brain-derived neurotrophic factors (BDNF) p<0.01. In addition, a significant increase in the metabolite of the kynurenine pathway, 3-hydroxyanthranilic acid (3-HAA) p<0.01, a significant decrease in the concentrations of anthranilic acid (AA) p<0.001, together with an increased ratio of serum 3-HAA to AA (3-HAA/AA) p<0.001, was found in this cohort. These findings indicate the significant activation of the immune system and presence of inflammation in children with RAP than those with subclinical parasitic infections. Moreover, children with RAP tested with the Strengths and Difficulties Questionnaire (SDQ), displayed high psychological problems though these SDQ scores were not statistically associated with measured cytokines and kynurenine metabolites. We however could hypothesize that the pro-inflammatory state together with concomitant low concentrations of BDNF in those children with RAP could play a role in psychological stress and experiencing medically unexplained symptoms.

Mind and gut: Associations between mood and gastrointestinal distress in children exposed to adversity

Gastrointestinal and mental disorders are highly comorbid, and animal models have shown that both can be caused by early adversity (e.g., parental deprivation). Interactions between the brain and bacteria that live within the gastrointestinal system (the microbiome) underlie adversity-gastrointestinal-anxiety interactions, but these links have not been investigated during human development. In this study, we utilized data from a population of 344 youth (3-18 years old) who were raised with their biological parents or were exposed to early adverse caregiving experiences (i.e., institutional or foster care followed by international adoption) to explore adversity-gastrointestinal-anxiety associations. In Study 1, we demonstrated that previous adverse care experiences were associated with increased incidence of gastrointestinal symptoms in youth. Gastrointestinal symptoms were also associated with concurrent and future anxiety (measured across 5 years), and those gastrointestinal symptoms mediated the adversity-anxiety association at Time 1. In a subsample of children who provided both stool samples and functional magnetic resonance imaging of the brain (Study 2, which was a "proof-of-principle"), adversity was associated with changes in diversity (both alpha and beta) of microbial communities, and bacteria levels (adversity-associated and adversity-independent) were correlated with prefrontal cortex activation to emotional faces. Implications of these data for supporting youth mental health are discussed.

Nausea exacerbates symptom burden, quality of life, and functioning in adolescents with functional abdominal pain disorders

BACKGROUND

Nausea frequently co-exists with functional abdominal pain disorders (FAPDs) and may be linked to a higher disease burden. This study aimed to prospectively compare multisystem symptoms, quality of life, and functioning in FAPDs with and without nausea.

METHODS

Adolescents ages 11-18 years fulfilling Rome III criteria for a FAPD were grouped by the presence or absence of chronic nausea. Subjects completed validated instruments assessing nausea (Nausea Profile Questionnaire = NPQ), quality of life (Patient-Reported Outcome Measurement Information System), functioning (Functional Disability Inventory), and anxiety (State-Trait Anxiety Inventory for Children). Group comparisons were performed for instruments, multisystem symptoms, school absences, and clinical diagnoses.

KEY RESULTS

A total of 112 subjects were included; 71% reported chronic nausea. Patients with Nausea compared to No Nausea had higher NPQ scores (P ≤ 0.001), worse quality of life (P = 0.004), and greater disability (P = 0.02). State and trait anxiety scores were similar (P = 0.57, P = 0.25). A higher NPQ score correlated with poorer quality of life, more disability, and higher anxiety. Specific comorbidities were more common in Nausea vs No Nausea group: dizziness (81% vs 41%; P ≤ 0.001), concentrating difficulties (68% vs 27%; P ≤ 0.001), chronic fatigue (58% vs 20%; P = 0.01), and sleep disturbances (73% vs 48%; P = 0.02). The Nausea group reported more school absences (P = 0.001) and more commonly met criteria for functional dyspepsia (P = 0.034).

CONCLUSION AND INFERENCES

Nausea co-existing with FAPDs is associated with a higher extra-intestinal symptom burden, worse quality of life, and impaired functioning in children. Assessing and targeting nausea therapeutically is essential to improve outcomes in FAPDs.

Use of the PROMIS-29® to identify subgroups of mothers with chronic pain

OBJECTIVE

Children of mothers with chronic pain are at increased risk for poor health, but few studies have examined what characteristics of maternal chronic pain may be associated with children's risk. This study identified subgroups of mothers based on patterns of pain, physical function, and emotional function on the 29-item Patient-Reported Outcomes Measurement Information System® (PROMIS-29®) and evaluated associations between maternal subgroups and children's pain and emotional functioning.

METHODS

Mothers with chronic pain (n = 334) completed the PROMIS-29® and reported on pain intensity, pain interference, physical functioning, anxiety, depression, fatigue, sleep disturbance, and participation in social activities. Mothers and their school-age children also completed measures of child pain and emotional functioning.

RESULTS

Latent profile analysis of PROMIS® domains indicated a 4-class solution (Group 1: 13.5%, Group 2: 9.9%, Group 3: 43.5%, and Group 4: 32.9%). Group 4 reported the most severe pain, psychological distress, and sleep disturbances and the lowest functioning. Group 1 reported the lowest pain, psychological distress, and sleep disturbances and the highest functioning, while Groups 2 and 3 represented moderate symptoms. Groups significantly differed on maternal reports of children's pain frequency, but not intensity, and children's self-reported somatic symptoms. Further, child depressive symptoms (mother-proxy and self-reported), anxiety (mother-proxy reported), and pain catastrophizing (self-reported) differed by maternal group.

CONCLUSIONS

Patterns of maternal symptoms and functioning were associated with pain frequency and emotional symptoms in children. Further examination of individual differences in mothers with chronic pain that may confer risk for chronic pain and psychological disorders in children is warranted. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Parental Factors in Pediatric Functional Abdominal Pain Disorders: A Cross-sectional Cohort Study

OBJECTIVES

Parental factors are suggested to play a role in pediatric irritable bowel syndrome (IBS) and functional abdominal pain-not otherwise specified (FAP-NOS) and may influence treatment. Since studies on parental factors mainly focus on mothers, this study aims to compare physical health, psychological distress, personality dimensions, and parenting behavior of both parents of children with IBS or FAP-NOS to parents of controls.

METHODS

Parents of 91 children with IBS or FAP-NOS were included in this explorative cross-sectional cohort study. Parents of 74 age-matched healthy children were used as controls. Questionnaires were used to measure demographics, physical health, psychological distress and symptoms, personality dimensions, and child-rearing practices.

RESULTS

A total of 59 mothers and 52 fathers of 61 children with IBS/FAP-NOS (response rate 61.0%) and 56 mothers and 49 fathers of 59 controls completed the study (response rate 70.9%). Mothers of children with IBS/FAP-NOS reported more physical problems. Psychological distress and symptoms, personality dimensions, and child-rearing practices did not differ between mothers of both groups. Fathers of children with IBS/FAP-NOS had significantly lower scores on the child-rearing practice subscale of ignoring of unwanted behavior. In the IBS/FAP-NOS group, fathers were more depressed and less agreeable than mothers. No differences on all assessed outcomes were found between parents of children with IBS and children with FAP-NOS.

CONCLUSIONS

Mothers of children with IBS/FAP-NOS and healthy peers differ with respect to physical health. Fathers in both groups differ with respect to child-rearing style. Clinicians should be aware of these differences when treating children with these disorders.

Seasonal Association of Pediatric Functional Abdominal Pain Disorders and Anxiety

OBJECTIVES

Abdominal pain-related pediatric functional gastrointestinal disorders (AP-FGIDs) are defined by abdominal discomfort or pain that may provide obstacles to everyday activities, such as school attendance. It has been reported that AP-FGID symptoms may be reduced in summer, but it is unclear what drives this seasonal variation. This pilot study aimed to explore whether the seasonal variation in AP-FGID symptoms could be explained by various psychological and behavioral factors.

METHODS

Parents of children with AP-FGID symptoms completed online questionnaires on symptoms, anxiety, parental responses to pain, sleep, diet, and physical activity once during spring months and again in the summer months.

RESULTS

In a sample of 34 participants who completed both questionnaires, 22 reported improvements during the summer months. These participants reported a significantly higher seasonal decrease in anxiety than participants whose children's symptoms did not improve from spring to summer (mean decrease 2.21 vs 0.08, P = 0.017). Both groups reported equal improvements in sleep and decreased stress from spring to summer. Neither group experienced statistically significant seasonal change in physical activity or fruit, vegetables, dairy, or caffeine consumption.

CONCLUSIONS

This study suggests that amelioration of gastrointestinal symptoms in pediatric patients with AP-FGID during summer months is associated with amelioration of anxiety in the same time period. It is not yet clear whether decreased anxiety is the cause or effect of decreased AP-FGID symptoms.

Irritability is Common and is Related to Poorer Psychosocial Outcomes in Youth with Functional Abdominal Pain Disorders (FAPD)

Functional abdominal pain disorders (FAPD) are associated with increased emotional problems which, in turn, exacerbate functional impairment. However, irritability, which relates both to internalizing and externalizing problems, has not been specifically examined in these youths. Irritability may be common and adversely impact functioning in pediatric FAPD, particularly for males who are more likely to experience such symptoms. The current study examined the relationship between irritability and psychosocial and pain-related impairment in youth with FAPD. Data were gathered as part of a larger study examining a psychological treatment for youth with FAPD and were compared to previously published data on irritability in healthy controls and in youth with severe emotional dysregulation. For the current study, participants (ages 9–14) with FAPD and caregivers completed measures of child irritability, pain-related and psychosocial functioning, and parent functioning. Pearson correlations revealed significant positive associations between irritability and anxiety, depressive symptoms, pain catastrophizing, and caregiver distress. Results also indicated that parents reported significantly greater irritability in males, but males and females reported similar rates of irritability. Gender moderated the relationship between child-report of irritability and anxiety only. Future research may include tailoring of behavioral intervention approaches for pediatric FAPD to specifically target symptoms of irritability.

Characteristics of HIV-infected adolescents enrolled in a disclosure intervention trial in western Kenya

Knowledge of one's own HIV status is essential for long-term disease management, but there are few data on how disclosure of HIV status to infected children and adolescents in sub-Saharan Africa is associated with clinical and psychosocial health outcomes. We conducted a detailed baseline assessment of the disclosure status, medication adherence, HIV stigma, depression, emotional and behavioral difficulties, and quality of life among a cohort of Kenyan children enrolled in an intervention study to promote disclosure of HIV status. Among 285 caregiver-child dyads enrolled in the study, children's mean age was 12.3 years. Caregivers were more likely to report that the child knew his/her diagnosis (41%) compared to self-reported disclosure by children (31%). Caregivers of disclosed children reported significantly more positive views about disclosure compared to caregivers of non-disclosed children, who expressed fears of disclosure related to the child being too young to understand (75%), potential psychological trauma for the child (64%), and stigma and discrimination if the child told others (56%). Overall, the vast majority of children scored within normal ranges on screenings for behavioral and emotional difficulties, depression, and quality of life, and did not differ by whether or not the child knew his/her HIV status. A number of factors were associated with a child's knowledge of his/her HIV diagnosis in multivariate regression, including older age (OR 1.8, 95% CI 1.5-2.1), better WHO disease stage (OR 2.5, 95% CI 1.4-4.4), and fewer reported caregiver-level adherence barriers (OR 1.9, 95% CI 1.1-3.4). While a minority of children in this cohort knew their HIV status and caregivers reported significant barriers to disclosure including fears about negative emotional impacts, we found that disclosure was not associated with worse psychosocial outcomes.

Pediatric Psychogenic Nonepileptic Seizures: A Concise Review

Psychogenic nonepileptic seizures is a complicated biopsychosocial disorder with significant morbidity and high cost in children's social, emotional, family, and academic functioning as well as health care service utilization. Misdiagnosis and diagnostic delay, resulting from both lack of access to approved standards for diagnosing and service providers comfortable with diagnosing and treating this disorder, impact prognosis. Treatment in close proximity to symptom onset is thought to provide the best chance for remission.

I. INTRODUCTION: UNDERSTANDING THE TRANSITION TO SIBLINGHOOD FROM A DEVELOPMENTAL PSYCHOPATHOLOGY AND ECOLOGICAL SYSTEMS PERSPECTIVE

The birth of an infant sibling is a common occurrence in the lives of many toddler and preschool children. Early childhood is also a time for the emergence of disruptive behavior problems that may set the stage for later problem behaviors. The current study examined individual differences in young children’s behavioral and emotional adjustment after the birth of a sibling in an effort to uncover developmental trajectories reflecting sudden and persistent change (maladaptation), adjustment and adaptation (resilience), gradual linear increases, and no change (stability and continuity). Growth mixture modeling (GMM) was conducted with a sample of 241 families expecting their second child using a longitudinal research design across the first year after the sibling’s birth (prenatal, 1, 4 8 and 12 months) on seven syndrome scales of the Child Behavior Checklist (CBCL 1.5–5:(Achenbach & Rescorla, 2000 ): aggression, attention problems, anxiety/depression, emotional reactivity, withdrawal, somatic complaints, and sleep problems. For all scales, multiple classes describing different trajectory patterns emerged that reflected predominantly intercept differences; children high on problem behavior after the birth were those high before the birth. There was no evidence of a sudden, persistent maladaptive response indicating children underwent a developmental crisis for any of the problem behaviors examined. Most children were low on all problem behaviors examined and showed little change or actually declined in problem behaviors over time, although some children did experience more pronounced changes in the borderline clinical or clinical range. Only in the case of aggressive behavior was there evidence of an Adjustment and Adaptation Response showing a sudden change (prenatal to 1 month) that subsided by 4 months, suggesting that some young children react to stressful life events but adapt quickly to these changing circumstances. Further, children’s withdrawal revealed a curvilinear, quadratic path, suggesting children both increased and decreased in their withdrawal over time. Guided by a developmental ecological systems framework, we employed data mining procedures to uncover the child, parent, and family variables that best discriminated the different trajectory classes and found that children’s temperament, coparenting, parental self-efficacy, and parent-child attachment relationships were prominent in predicting children’s adjustment after the birth of an infant sibling. Finally, when trajectory classes were used to predict sibling relationship quality at 12 months, children high on aggression, attention problems, and emotional reactivity in the year after the birth engaged in more conflict and less positive involvement with the infant sibling at the end of the first year.

Risk factors for learning problems in youth with psychogenic non-epileptic seizures

OBJECTIVES

This study examined the risk factors for learning problems (LP) in pediatric psychogenic non-epileptic seizures (PNES) and their specificity by comparing psychopathology, medical, cognitive/linguistic/achievement, bullying history, and parent education variables between subjects with PNES with and without LP and between subjects with PNES and siblings with LP.

METHODS

55 subjects with PNES and 35 siblings, aged 8-18years, underwent cognitive, linguistic, and achievement testing, and completed somatization and anxiety sensitivity questionnaires. A semi-structured psychiatric interview about the child was administered to each subject and parent. Child self-report and/or parent report provided information on the presence/absence of LP. Parents also provided each subject's medical, psychiatric, family, and bullying history information.

RESULTS

Sixty percent (33/55) of the PNES and 49% (17/35) of the sibling subjects had LP. A multivariable logistic regression demonstrated that bullying and impaired formulation of a sentence using a stimulus picture and stimulus word were significantly associated with increased likelihood of LP in the PNES youth. In terms of the specificity of the LP risk factors, a similar analysis comparing LP in the youth with PNES and sibling groups identified anxiety disorder diagnoses and bullying as the significant risk factors associated with LP in the PNES youth.

CONCLUSIONS

These findings emphasize the need to assess youth with PNES for LP, particularly if they have experienced bullying, have linguistic deficits, and meet criteria for anxiety disorder diagnoses.

Systematic review of childhood and adolescent risk and prognostic factors for persistent abdominal pain

This review aimed to identify childhood and adolescence risk and prognostic factors associated with onset and persistence of persistent abdominal pain and related disability and assess quality of the evidence. While findings suggest a possible role for negative emotional symptoms and parental mental health as risk and prognostic factors for onset and persistence of persistent abdominal pain, the evidence is of poor quality overall and nonexistent when it comes to prognostic factors associated with disability.

CONCLUSION

Further research is needed to increase confidence in existing evidence and to explore new factors. This research will inform prevention.

Mental Health Comorbidities in Pediatric Chronic Pain: A Narrative Review of Epidemiology, Models, Neurobiological Mechanisms and Treatment

Chronic pain during childhood and adolescence can lead to persistent pain problems and mental health disorders into adulthood. Posttraumatic stress disorders and depressive and anxiety disorders are mental health conditions that co-occur at high rates in both adolescent and adult samples, and are linked to heightened impairment and disability. Comorbid chronic pain and psychopathology has been explained by the presence of shared neurobiology and mutually maintaining cognitive-affective and behavioral factors that lead to the development and/or maintenance of both conditions. Particularly within the pediatric chronic pain population, these factors are embedded within the broader context of the parent-child relationship. In this review, we will explore the epidemiology of, and current working models explaining, these comorbidities. Particular emphasis will be made on shared neurobiological mechanisms, given that the majority of previous research to date has centered on cognitive, affective, and behavioral mechanisms. Parental contributions to co-occurring chronic pain and psychopathology in childhood and adolescence will be discussed. Moreover, we will review current treatment recommendations and future directions for both research and practice. We argue that the integration of biological and behavioral approaches will be critical to sufficiently address why these comorbidities exist and how they can best be targeted in treatment.

Screening for Psychosocial and Family Risk in Pediatric Gastrointestinal Disorders

OBJECTIVES

Screening for psychosocial comorbidity is recommended for pediatric patients presenting at an initial gastroenterology (GI) outpatient consultation. We developed and evaluated the psychometric properties of the GI Screener to address the need for a screening tool specific to pediatric GI patients.

METHODS

128 patients (8-18 years old, 63% female) and 126 parents completed age-specific versions of the GI Screener and 3 validated psychosocial comparison instruments (The Behavioral Assessment System for Children, The Functional Disability Inventory, The General Functioning scale of the Family Assessment Device) at their initial GI consultation. (30%) of families repeated the measures 2 weeks later. We identified GI Screener content domains and retained items using exploratory factor analysis. We evaluated internal consistency, construct validity, cross-informant reliability, and test-retest reliability of the trimmed measures.

RESULTS

Exploratory factor analysis identified 2 factors in both the parent and child scales: Symptom Impact and Emotional Functioning. Internal consistency estimates for the trimmed scales were good (Cronbach's alpha >0.75) for both Child and Parent scales. We found that the GI Screener for both patient and parents had good construct validity. Cross-informant reliability between Parent and Child scales at baseline had an estimated correlation of 0.56, while intra class correlation coefficients between baseline and 2-week scores showed high test-retest reliability (>0.7).

CONCLUSIONS

The GI Screener is a brief, valid and reliable measure that can aid in identifying families who are at high risk for psychosocial comorbidity facilitating the targeted delivery of psychosocial intervention and efficient use of health care resources.

A Broad Consideration of Risk Factors in Pediatric Chronic Pain: Where to Go from Here?

Pediatric chronic pain is a significant problem associated with substantial functional impairment. A variety of risk factors have been found to be associated with chronic pain in youth. The greatest amount of evidence appears to support that temperament, anxiety, depression, subjective experience of stress, passive coping strategies, sleep problems, other somatic-related problems, and parent and/or family factors are important variables. However, a great deal of this research focuses on a single risk factor or on multiple risk factors in isolation. Much of the literature utilizes older diagnostic criteria and would benefit from replication, larger sample sizes, and comparison across pain disorders. Problems also exist with disagreement across definitions, resulting in inconsistency or unclear use of terms. Furthermore, recent consideration has suggested that outcome measures should include functional disability in addition to pain. A second generation of research is needed to shed light on the complex interactions that likely play a role in the transition from acute to chronic pain. Building on recent calls for changes in research in this area, we propose the next steps for this research, which involve consideration of both biopsychosocial and developmental contexts.

Lactobacillus reuteri DSM 17938 for the Management of Functional Abdominal Pain in Childhood: A Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVE

To determine whether administration of Lactobacillus reuteri DSM 17938 is beneficial in functional abdominal pain (FAP) of childhood.

STUDY DESIGN

A total of 101 children, aged 6-15 years, who fulfilled the Rome III criteria for FAP were enrolled in a randomized double-blind, placebo-controlled trial, and were randomly assigned to receive either L reuteri DSM 17938 or placebo for 4 weeks, with further follow-up of additional 4 weeks. Response to therapy was based on a self-reported daily questionnaire monitoring frequency and intensity of abdominal pain, using the faces scoring system by Hicks.

RESULTS

L reuteri (n = 47) was significantly superior to placebo (n = 46) in relieving frequency (1.9 ± 0.8 vs 3.6 ± 1.7 episodes/wk, P < .02) and intensity (4.3 ± 2.2 vs 7.2 ± 3.1 Hicks score/wk, P < .01) of abdominal pain following 4 weeks of supplementation. There was no difference in school absenteeism rate or other gastrointestinal symptoms, except for a lower incidence of perceived abdominal distention and bloating, favoring L reuteri.

CONCLUSIONS

L reuteri DSM 17938, compared with placebo, significantly reduced the frequency and intensity of FAP in children.

TRIAL REGISTRATION

ClicalTrials.gov: NCT01180556.

Practical management of functional abdominal pain in children

Functional abdominal pain (FAP) is common in childhood, but is not often caused by disease. It is often the impact of the pain rather than the pain itself that results in referral to the clinician. In this review, we will summarise the currently available evidence and discuss the functional dimensions of the presentation, within the framework of commonly expressed parental questions. Using the Rome III criteria, we discuss how to classify the functional symptoms, investigate appropriately, provide reassurance regarding parental worries of chronic disease. We outline how to explain the functional symptoms to parents and an individualised strategy to help restore function.

Psychosocial mechanisms for the transmission of somatic symptoms from parents to children

AIM

To examine familial aggregation of irritable bowel syndrome (IBS) via parental reinforcement/modeling of symptoms, coping, psychological distress, and exposure to stress.

METHODS

Mothers of children between the ages of 8 and 15 years with and without IBS were identified through the Group Health Cooperative of Puget Sound. Mothers completed questionnaires, including the Child Behavior Checklist (child psychological distress), the Family Inventory of Life Events (family exposure to stress), SCL-90R (mother psychological distress), and the Pain Response Inventory (beliefs about pain). Children were interviewed separately from their parents and completed the Pain Beliefs Questionnaire (beliefs about pain), Pain Response Inventory (coping) and Child Symptom Checklist [gastrointestinal (GI) symptoms]. In addition, health care utilization data was obtained from the automated database of Group Health Cooperative. Mothers with IBS (n = 207) and their 296 children were compared to 240 control mothers and their 335 children, while controlling for age and education.

RESULTS

Hypothesis 1: reinforcement of expression of GI problems is only related to GI symptoms, but not others (cold symptoms) in children. There was no significant correlation between parental reinforcement of symptoms and child expression of GI or other symptoms. Hypothesis 2: modeling of GI symptoms is related to GI but not non-GI symptom reporting in children. Children of parents with IBS reported more non-GI (8.97 vs 6.70, P < 0.01) as well as more GI (3.24 vs 2.27, P < 0.01) symptoms. Total health care visits made by the mother correlated with visits made by the child (rho = 0.35, P < 0.001 for cases, rho = 0.26, P < 0.001 for controls). Hypothesis 3: children learn to share the methods of coping with illness that their mothers exhibit. Methods used by children to cope with stomachaches differed from methods used by their mothers. Only 2/16 scales showed weak but significant correlations (stoicism rho = 0.13, P < 0.05; acceptance rho = 0.13, P < 0.05). Hypothesis 4: mothers and children share psychological traits such as anxiety, depression, and somatization. Child psychological distress correlated with mother's psychological distress (rho = 0.41, P < 0.001 for cases, rho= 0.38, P < 0.001 for controls). Hypothesis 5: stress that affects the whole family might explain the similarities between mothers and their children. Family exposure to stress was not a significant predictor of children's symptom reports. Hypothesis 6: the intergenerational transmission of GI illness behavior may be due to multiple mechanisms. Regression analysis identified multiple independent predictors of the child's GI complaints, which were similar to the predictors of the child's non-GI symptoms (mother's IBS status, child psychological symptoms, child catastrophizing, and child age).

CONCLUSION

Multiple factors influence the reporting of children's gastrointestinal and non-gastrointestinal symptoms. The clustering of illness within families is best understood using a model that incorporates all these factors.

Predicting persistence of functional abdominal pain from childhood into young adulthood

BACKGROUND & AIMS

Pediatric functional abdominal pain has been linked to functional gastrointestinal disorders (FGIDs) in adulthood, but little is known about patient characteristics in childhood that increase the risk for FGID in young adulthood. We investigated the contribution of gastrointestinal symptoms, extraintestinal somatic symptoms, and depressive symptoms in pediatric patients with functional abdominal pain and whether these predicted FGIDs later in life.

METHODS

In a longitudinal study, consecutive new pediatric patients, diagnosed with functional abdominal pain in a subspecialty clinic, completed a comprehensive baseline evaluation of the severity of their physical and emotional symptoms. They were contacted 5 to 15 years later and evaluated, based on Rome III symptom criteria, for abdominal pain-related FGIDs, including irritable bowel syndrome, functional dyspepsia, functional abdominal pain syndrome, and abdominal migraine. Controlling for age, sex, baseline severity of abdominal pain, and time to follow-up evaluation, multivariable logistic regression was used to evaluate the association of baseline gastrointestinal, extraintestinal somatic, and depressive symptoms in childhood with FGID in adolescence and young adulthood.

RESULTS

Of 392 patients interviewed an average of 9.2 years after their initial evaluation, 41% (n = 162) met symptom criteria for FGID; most met the criteria for irritable bowel syndrome. Extraintestinal somatic and depressive symptoms at the initial pediatric evaluation were significant predictors of FGID later in life, after controlling for initial levels of GI symptoms. Age, sex, and abdominal pain severity at initial presentation were not significant predictors of FGID later in life.

CONCLUSIONS

In pediatric patients with functional abdominal pain, assessment of extraintestinal and depressive symptoms may be useful in identifying those at risk for FGID in adolescence and young adulthood.

Nonspecific abdominal pain is a safe diagnosis

AIM

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

METHODS

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

MAIN RESULTS

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

CONCLUSION

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

Mebeverine for pediatric functional abdominal pain: a randomized, placebo-controlled trial

We evaluated the effectiveness of an antispasmodic, mebeverine, in the treatment of childhood functional abdominal pain (FAP). Children with FAP (n = 115, aged 6–18 years) received mebeverine (135 mg, twice daily) or placebo for 4 weeks. Response was defined as ≥2 point reduction in the 6-point pain scale or “no pain.” Physician-rated global severity was also evaluated. Patients were followed up for 12 weeks. Eighty-seven patients completed the trial (44 with mebeverine). Per-protocol and intention-to-treat (ITT) analyses were conducted. Treatment response rate in the mebeverine and placebo groups based on per-protocol [ITT] analysis was 54.5% [40.6%] and 39.5% [30.3%] at week 4 (P = 0.117 [0.469]) and 72.7% [54.2%] and 53.4% [41.0] at week 12, respectively (P = 0.0503 [0.416]). There was no significant difference between the two groups in change of the physician-rated global severity score after 4 weeks (P = 0.723) or after 12 weeks (P = 0.870) in per-protocol analysis; the same results were obtained in ITT analysis. Mebeverine seems to be effective in the treatment of childhood FAP, but our study was not able to show its statistically significant effect over placebo. Further trials with larger sample of patients are warranted.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Anxiety and depression predicted by medically unexplained symptoms in Pakistani children: a case-control study

OBJECTIVE

To explore association between medically unexplained symptoms in children in Pakistan with emotional difficulties and functional impairments.

METHODS

We conducted a matched three-group case-control study of 186 children aged 8-16 years in Lahore, Pakistan. Cases were 62 children with chronic somatic symptoms for which no organic cause was identified after investigations. Two control groups of 62 children with chronic medical paediatric conditions, and 62 healthy children were identified. Cases and controls were matched for gender, age, and school class. Somatisation was measured with the Children's Somatisation Inventory (CSI-24) while anxiety and depression were measured with the Spencer Children's Anxiety Scale and the Short Mood and Feelings Questionnaire respectively. All questionnaires were translated into Urdu.

RESULTS

Mean age was 11.7 years (SD=2.1). Cases scored significantly higher on somatisation (CSI-24), anxiety and depression than both control groups. Paediatric controls scored significantly higher than healthy controls on all three measures. Two hierarchical linear regression models were used to explore if somatisation predicted depression and anxiety while controlling for several confounders. Somatisation (higher CSI-24 scores) independently and significantly predicted higher anxiety (β=.37, p=.0001) and depression (β=.41, p=.0001) scores.

CONCLUSION

This is the first study to show an association between medically unexplained symptoms and anxiety and depression in Pakistani children. This highlights the importance of screening for emotional difficulties in children presenting with unexplained somatic symptoms in this region.

Parental anxiety at initial acute presentation is not associated with prolonged symptoms following pediatric concussion

OBJECTIVES

Anxiety modulates symptom perception in adults following concussion, prolonging the time to full recovery. The authors sought to determine whether parental anxiety was associated with persistent postconcussive symptoms (PCS) in their children following concussion.

METHODS

A prospective observational cohort with 98 children aged 5 to 17 years following concussion participated from a tertiary pediatric emergency department (ED). The main exposure was parental anxiety at the time of acute presentation following pediatric concussion, measured using the self-administered, validated Spielberger State-Trait Anxiety Inventory-State Anxiety Scale (STAI-S). The primary outcome measured was presence of PCS in the child at 1 month, per the validated Post-Concussive Symptom Inventory (PCSI). Secondary outcome measures included parental anxiety score over time, school absenteeism, and return to sports. Data were collected during the initial ED visit and at 3-day, 7-day, 2-week, 1-month, and 3-month follow-ups.

RESULTS

Of 98 children enrolled, 27% (95% confidence interval [CI] = 19% to 36%) developed PCS at 1 month. No significant associations were detected between parental anxiety at the index visits and the number of previous pediatric concussions (p = 0.73), sex (p = 0.61), loss of consciousness (p = 0.43), history of migraines (p = 0.31), or history of anxiety diagnosed in the patients (p = 0.09). A significant association was noted between patient diagnosis of attention deficit hyperactivity disorder (ADHD) and parental anxiety at the index visits (p = 0.001). Parental anxiety at acute presentation was not associated with children's prolonged symptoms at 1 month (p = 0.63). Parental anxiety remained elevated in parents whose children had prolonged symptoms compared to those parents whose children's symptoms resolved (median = 30, interquartile range [IQR] = 22 to 44; and median = 21, IQR = 20 to 25, respectively; p < 0.001). Initial parental anxiety presentation was not associated with school absenteeism (p = 0.23) or not returning to sport or gym class (p = 0.89). There were no significant effects involving ADHD alone (p = 0.44) or together with baseline parental anxiety (p = 0.36 for ADHD and p = 0.55 for anxiety) using logistic regression analysis to examine potential predictive effects of child's ADHD combined with parental anxiety at the index visit on persistent symptoms at 1 month.

CONCLUSIONS

Parental anxiety at time of acute presentation does not appear to be associated with prolongation of postconcussive symptoms in their children. However, parents of persistently symptomatic children remain significantly more anxious than those whose children's symptoms have resolved. Future research should attempt to reduce the familial burden of concussion through expectation management strategies.

Functional abdominal pain in childhood and long-term vulnerability to anxiety disorders

BACKGROUND

Cross-sectional studies link functional abdominal pain (FAP) to anxiety and depression in childhood, but no prospective study has evaluated psychiatric status in adulthood or its relation to pain persistence.

METHODS

Pediatric patients with FAP (n = 332) and control subjects (n = 147) were tracked prospectively and evaluated for psychiatric disorders and functional gastrointestinal disorders (FGIDs) at follow-up in adolescence and young adulthood (mean age = 20.01 years). Participants were classified according to presence (FGID-POS) or absence (FGID-NEG) of FGIDs at follow-up.

RESULTS

Lifetime and current risk of anxiety disorders was higher in FAP than controls (lifetime: 51% vs 20%; current: 30% vs 12%). Controlling for gender and age, the odds ratio was 4.9 (confidence interval = 2.83-7.43) for lifetime anxiety disorder and 3.57 (confidence interval = 2.00-6.36) for current anxiety disorder at follow-up for FAP versus controls. Lifetime risk of depressive disorder was significantly higher in FAP versus controls (40% vs. 16%); current risk did not differ. In most cases, initial onset of anxiety disorders was before pediatric FAP evaluation; onset of depressive disorders was subsequent to FAP evaluation. Within the FAP group, risk of current anxiety disorders at follow-up was significantly higher for FGID-POS versus FGID-NEG (40% vs 24%), and both were higher than controls (12%); current depressive disorders did not differ across FGID-POS, FGID-NEG, and controls.

CONCLUSIONS

Patients with FAP carry long-term vulnerability to anxiety that begins in childhood and persists into late adolescence and early adulthood, even if abdominal pain resolves.

Functional gastrointestinal symptoms in children with anxiety disorders

This study examined the incidence and correlates of functional gastrointestinal symptoms in children with anxiety disorders. Participants were 6-13 year old children diagnosed with one or more anxiety disorders (n = 54) and non-clinical control children (n = 51). Telephone diagnostic interviews were performed with parents to determine the presence and absence of anxiety disorders in children. Parents completed a questionnaire that elicited information about their child's gastrointestinal symptoms associated with functional gastrointestinal disorders in children, as specified by the paediatric Rome criteria (Caplan et al., Journal of Pediatric Gastroenterology & Nutrition, 41, 296-304, 2005a). Parents and children also completed a symptom severity measure of anxiety. As expected, children with anxiety disorders were significantly more likely to have symptoms of functional gastrointestinal disorders (FGID), compared to children without anxiety disorders. That is, 40.7 % of anxious children had symptoms of a FGID compared to 5.9 % of non-anxious control children. Children with anxiety disorders were significantly more likely to have symptoms of functional constipation, and showed a trend for a higher incidence of irritable bowel syndrome symptoms compared to non-anxious control children. Furthermore, higher anxiety symptom severity was characteristic of anxious children with symptoms of FGID, compared to anxious children without FGID symptoms and non-anxious control children. Also, children with anxiety disorders, regardless of FGID symptoms, were more likely to have a biological family member, particularly a parent or grandparent, with a gastrointestinal problem, compared to non-anxious control children. The high incidence of FGID symptoms in children with anxiety disorders warrants further research on whether gastrointestinal symptoms reduce following psychological treatments for childhood anxiety disorders, such as cognitive behavioural therapy.

[Functional somatic symptoms in a Spanish sample: psychopathology and educational styles]

INTRODUCTION

Although there are many studies on functional somatic symptoms (FSS), there are few conducted with Spanish samples. The aim of this study was to assess the prevalence of frequent functional somatic symptoms in a Spanish sample, and to look for relationships with psychopathology and parenting styles.

PATIENTS AND METHODS

The sample consisted of 672 participants from 6 to 8 years-old attending primary school in the region of Osona (Catalonia, Spain). The parents reported on the presence of FSS in children, school absence, paediatric visits; psychiatric symptoms, and parenting styles. Children who complained of frequent somatic symptoms (four or more in the previous fortnight) were compared with children who did not complain.

RESULTS

A total of 429 of the 672 (63.8%) children had at least one physical complaint during the two weeks prior to the study. Almost one quarter (162, 24.1%) of the participants had frequent FSS. Significant relationships were found with, separation anxiety, social phobia, and visits to the paediatrician. A small effect of overprotection/control parenting style on FSS was observed.

CONCLUSIONS

Functional somatic symptoms are common in a Spanish sample of children between 6 to 8 years-old. These children may be considered a risk group for future emotional distress. It is also important for future research to clarify the nature of the relationship between overprotection and FSS.

Psychosocial perspectives in the treatment of pediatric chronic pain

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