The impact of medical comorbidity on mental health and functional health outcomes among children with anxiety disorders

Shared Genetic Liability across Systems of Psychiatric and Physical Illness

Epidemiological literature has shown that there are extensive comorbidity patterns between psychiatric and physical illness. However, our understanding of the multivariate systems of relationships underlying these patterns is poorly understood. Using Genomic SEM and Genomic E-SEM, an extension for genomic exploratory factor analysis that we introduce and validate, we evaluate the extent to which latent genomic factors from eight domains, encompassing 76 physical outcomes across 1.9 million cases, evince genetic overlap with previously identified psychiatric factors. We find that internalizing, neurodevelopmental, and substance use factors are broadly associated with increased genetic risk sharing across all physical illness domains. Conversely, we find that a compulsive factor is protective against circulatory and metabolic illness, whereas genetic risk sharing between physical illness factors and psychotic/thought disorders was limited. Our results reveal pervasive risk sharing between specific groups of psychiatric and physical conditions and call into question the bifurcation of psychiatric and physical conditions.

Associations of depression and anxiety symptoms in childhood and adolescence with epigenetic aging

BACKGROUND

Childhood anxiety and depression symptoms are potential risk factors for accelerated biological aging. In child and adolescent twins, we tested whether these symptoms were associated with DNA methylation (DNAm) aging, a measure of biological aging.

METHODS

276 twins (135 pairs, 6 singletons) had DNAm assayed from saliva in middle childhood (mean = 7.8 years). Residuals of five different DNAm age estimates regressed on chronological age were used to indicate accelerated aging. Anxiety and depression symptoms were assessed in middle childhood and early adolescence using the Child Behavior Checklist. Mixed effect regression was used to examine potential relationships between anxiety or depression symptoms, and accelerated DNAm age. MZ twin difference analysis was then utilized to determine if associations were environmentally-driven or due to genetic or shared-environment confounding.

RESULTS

Anxiety and depression symptoms were not associated with accelerated DNAm aging in middle childhood. In early adolescence, only the Wu clock was significant and indicated that each one symptom increase in anxiety symptoms had an associated age acceleration of 0.03 years (~0.4 months; p = 0.019). MZ twin difference analysis revealed non-significant within-pair effects, suggesting genetic and shared environmental influences.

LIMITATIONS

Sample is predominantly male and white. Generalizability to other populations may be limited.

CONCLUSION

Accelerated DNAm aging of the Wu clock in middle childhood is associated with anxiety, but not depression, symptoms in early adolescence. Further, this association may be the result of shared genetic and environmental influences. Accelerated DNAm aging may serve as an early risk factor or predictor of later anxiety symptoms.

Screening for Anxiety and Depression in Children with Congenital Adrenal Hyperplasia

Objective

Congenital adrenal hyperplasia (CAH) is an inherited condition in which individuals require multiple daily doses of medication and are at risk for life-threatening adrenal crisis. The chronic nature and severity of CAH place children at risk for psychiatric morbidity. The aim was to assess the degree of anxiety and depressive symptoms in children with CAH.

Methods

A cross-sectional cohort study of children (7-17 years) with CAH and their caregivers were recruited between May and December 2021. Children with hypothyroidism (HT) and their caregivers served as unaffected controls. Validated mental health questionnaires [Children’s Depression Inventory 2 Self Report-Short (CDI-2), Screen for Child Anxiety Related Disorders (SCARED), Patient Health Questionnaire modified for Adolescents (PHQ-A); self and proxy] were completed by participants at one clinic visit. Higher scores indicated greater symptoms of anxiety and depression.

Results

A total of 60 children and 56 parents participated. Among the children 34 had CAH (68% female, mean age 11.41±2.5, CAH duration 8.5±4.1) and 26 had HT (73% female, mean age 12.7±2.9 years, HT duration 6.0±4.2 years). There was no increase in anxiety and depression symptoms in children with CAH compared to controls. In sub-analyses, children with CAH and controls reported a greater number of anxiety and depression symptoms than their caregivers on the SCARED and CDI-2, respectively. There was no association between adrenal control and the degree of anxiety or depression symptoms.

Conclusion

Children with CAH do not have more symptoms of anxiety or depression compared to controls. Child and caregiver-proxy responses lack agreement, suggesting that children with CAH may continue to benefit from routine mental health evaluation, regardless of voiced caregiver concern.

Measurement invariance of the 12-item self-administered World Health Organization Disability Assessment Schedule (WHODAS) 2.0 across early and late adolescents in Canada

PURPOSE

This study examined whether the 12-item self-administered World Health Organization Disability Assessment Schedule (WHODAS) 2.0 demonstrated measurement invariance between young adolescents aged 10-16 years with a physical illness and older adolescents aged 15-19 years from the general population.

MATERIALS AND METHODS

Young adolescent data come from the baseline wave of the Multimorbidity in Youth across the Life-course study (n = 117) and older adolescent data come from the Canadian Community Health Survey-Mental Health (n = 1851). Multiple-group confirmatory factor analysis was used to test measurement invariance. WHODAS 2.0 scores were compared across morbidity subgroups using multiple regression.

RESULTS

Measurement invariance of the WHODAS 2.0 was demonstrated: (χ2=635.2(144), p<.001; RMSEA = 0.059 (0.054, 0.064); CFI = 0.967; TLI = 0.970; and, SRMR = 0.068). Adjusting for data source, sex, race, immigrant status, and household income, WHODAS 2.0 scores were associated with morbidity status in a dose-response manner: physical illness only (B = 1.50, p<.001), mental illness only (B = 2.92, p<.001), and physical-mental comorbidity (B = 4.44, p<.001).

CONCLUSIONS

Measurement invariance of the WHODAS 2.0 suggests that young adolescents interpret the items and disability construct similarly to older adolescents - a group that previously demonstrated measurement invariance with an adult sample. The 12-item self-administered WHODAS 2.0 may be used to measure disability across the life-course. IMPLICATIONS FOR REHABILITATIONThe 12-item self-administered WHODAS 2.0 is one of the most widely used measures of disability and functioning.Measurement invariance of the WHODAS 2.0 suggests that young adolescents interpret the items and disability construct similarly to older adolescents and adults in Canada.Researchers and health professionals can be confident that differences in 12-item self-administered WHODAS 2.0 scores are real and meaningful.The 12-item self-administered WHODAS 2.0 may be used to measure disability across the life-course.

The multifaceted consequences and economic costs of child anxiety problems: A systematic review and meta-analysis

Background

Over a quarter of people have an anxiety disorder at some point in their life, with many first experiencing difficulties during childhood or adolescence. Despite this, gaps still exist in the current evidence base of the multiple consequences of childhood anxiety problems and their costs.

Methods

A systematic review of Medline, PsycINFO, EconLit and the National Health Service Economic Evaluation Database was conducted for longitudinal and economic studies reporting on the association between childhood anxiety problems and at least one individual-, family- or societal-level outcome or cost. All studies were synthesised narratively. For longitudinal studies, 'effect direction' was used as a common metric, with random effects meta-analysis undertaken where possible.

Results

Eighty-three studies met inclusion criteria and were synthesised narratively. We identified 788 separate analyses from the longitudinal studies, which we grouped into 15 overarching outcome domains. Thirteen of the studies were incorporated into 13 meta-analyses, which indicated that childhood anxiety disorders were associated with future anxiety, mood, behaviour and substance disorders. Narrative synthesis also suggested associations between anxiety problems and worse physical health, behaviour, self-harm, eating, relationship, educational, health care, employment, and financial outcomes. 'Effect direction' was conflicting in some domains due to a sparse evidence base. Higher economic costs were identified for the child, their families, healthcare providers and wider society, although evidence was limited and only covered short follow-up periods, up to a maximum of 2 years. Total annual societal costs per anxious child were up to £4040 (2021 GBP).

Conclusions

Childhood anxiety problems are associated with impaired outcomes in numerous domains, and considerable economic costs, which highlight the need for cost-effective interventions and policies to tackle them. More economic evidence is needed to inform models of the long-term, economic-related, consequences of childhood anxiety problems.

Has Anything Changed in the Frequency of Emergency Department Visits and the Profile of the Adolescent Seeking Emergency Mental Care during the COVID-19 Pandemic?

We described changes caused by the COVID-19 pandemic in the frequency of Emergency Department (ED) visits for mental health disorders (MHDs) in adolescents on a wider temporal range—that is, not just “the waves” of the pandemic—and characterized the profile of the adolescent seeking emergency psychiatric care. We conducted a retrospective longitudinal study by analyzing ED visits for MHDs from 10 March 2019 to 10 March 2021. A total of 1407 ED visits for MHDs were registered: 702 in the pre-COVID-19 and 707 in the COVID-19 period. The cumulative incidence of ED visits for MHDs was 1.22% in the pre-COVID-19 period and 1.77% in the COVID-19 period, with a statistically significant difference (p < 0.001). The principal characteristics of the adolescent with MHDs during the pandemic period: the odds of comorbidities decreased by 26% (p = 0.02), and the odds of transfer from other hospitals decreased by 71% (p < 0.001), while the odds of the ED presentation as first psychiatric episode were twice greater (p < 0.001). The risk of hospitalization increased by 54% (p = 0.001). Regarding psychopathology, the likelihood of attempted suicide increased by 74% during the pandemic (p = 0.02). The rate of mood and eating disorders grew significantly during the COVID-19 pandemic period (p = 0.005 and p = 0.031, respectively). Monitoring ED visits for MHDs and understanding changes in the profile of adolescents presenting to ED helps to reinforce the role of ED in identifying special clinical needs for these vulnerable patients in case of a future public health crisis.

A bidirectional relationship between diabetes mellitus and anxiety: A systematic review and meta-analysis

BACKGROUND

Due to the existence of inconsistencies in the evidence regarding the direction and extent of association between diabetes and anxiety disorders, the anxiety-diabetes comorbidity remains an issue of debate.

AIM

To estimate the proportion and risk of diabetes among individuals with anxiety disorder and vice versa.

METHODS

A systematic review was conducted using studies retrieved from databases and grey literature, with the last database search being conducted on April 15, 2021. The methodological rigor of studies was assessed using the National Institute of Health quality assessment tool. Prevalence and effect size (ES) estimates were pooled using a random effect model. Heterogeneity was assessed using the Higgins' I² statistical test, and subgroup analysis conducted.

RESULTS

We included 68 studies presenting data from 2,128,029 participants. The prevalence of anxiety disorders in diabetic patients was 28% (95% CI: 26%, 31%); however, subgroup analysis showed significant differences based on type of anxiety assessment scales, study location, and type of diabetes. The prevalence of diabetes among patients with anxiety disorders was 12% (95% CI: 9%, 16%). Patients with anxiety disorders were found to have a 19% higher risk of diabetes (pooled effect size (ES) = 1.19, 95% CI: 1.13, 1.26). Diabetic patients were found to have a 41% higher risk of developing anxiety disorders (ES = 1.41, 95% CI: 1.19, 1.62).

CONCLUSIONS

There is a higher risk of anxiety disorders in patients with diabetes mellitus and vice versa. It is recommended to screen diabetic patients for anxiety at initial diagnosis and follow-up visits. Similarly, patients with anxiety disorders should have regular screening for diabetes.

REVIEW REGISTRATION

PROSPERO registration number CRD42021252475.

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.

Impact of growing up with somatic long-term health challenges on school completion, NEET status and disability pension: a population-based longitudinal study

Background

Young adulthood is an important transitional life phase that can determine a person’s educational and employment trajectories. The aim of this study was to examine the impact of somatic long-term health challenges in adolescence on upper secondary school completion, not in education, employment or training (NEET status) and receiving disability pension in early adulthood. Additional disparities in educational and employment achievements were also investigated in relation to socioeconomic background.

Methods

The sample consisted of all young adults born in the period 1990 to 1996, (N = 421,110). Data were obtained from the Norwegian Patient Registry which is linked to the Central Population Register, education and income registries and the Historical Event Database in Statistics Norway. These data sources provide longitudinal population data. Statistical analyses were performed using multiple logistic regression and computed average marginal effects after the multiple logistic regression.

Results

The results showed that, compared to young adults without long-term health challenges, young adults with the diagnoses inflammatory bowel disease, epilepsy, diabetes, sensory impairment, spinal muscular atrophy (SMA), spina bifida (SB) and cerebral palsy (CP) had lower odds of completing upper secondary education. Moreover, young adults with long-term health challenges had higher odds of NEET status by age 21 compared to those without a long-term health challenge. As for the odds of NEET status by age 21, the results showed that young adults with epilepsy, SMA, SB and CP in particular had the highest odds of receiving disability pension compared to young adults without long-term health challenges.

Conclusions

This longitudinal study revealed that on average young adults with long-term health challenges, compared to those without, struggle to participate in education and employment. The findings highlight the need for preventive measures especially in relation to young adults with neurological conditions such as epilepsy, SMA, SB, and CP.

The relationship between chronic paediatric feeding disorders and caregiver stress

Paediatric feeding disorders (PFDs) are common. Earlier studies have shown an association between PFD and caregiver stress, but these studies have been hampered by insufficient power. This study reports stress for caregivers of children diagnosed with PFD. These caregivers were then compared to community norms of the Parental Stress Index-Short Form. Caregivers also completed the Mealtime Behaviour Questionnaire, Child Behaviour Checklist and Child Development Inventory. Linear regression and hierarchical regression analyses assessed the relationship among the variables. Caregivers of 840 children with PFD responded. Negative child behaviours and lower child developmental function predicted higher levels of total parenting stress, parental distress, parent-child dysfunctional interaction and caregiver perceptions of their child as difficult. Higher rates of child internalizing and externalizing problems and child mealtime aggression were associated with parent perceptions of their child as difficult and contributed to total parental stress. Parents of older children reported higher levels of stress, whereas parents of younger children were more likely to be defensive responders. Overall, parents of children with PFD have more caregiver-related stress. These caregivers may benefit from consultations with mental health professionals to provide the most appropriate care to affected families.

Public Health Coverage and Access to Mental Health Care for Youth with Complex Behavioral Healthcare Needs

Drawing upon the National Survey of Children with Special Healthcare Needs (2009/2010), multilevel logistic regression analysis assessed the relationship between parent report of a youth having an emotional, behavioral, or developmental problem (EBDP), their level of reported functional limitations, and parents' report of unmet mental health care needs and experience with cost-barriers to accessing needed healthcare services. Results indicate that, compared to all privately insured youth with special health care needs, parents of privately insured youth with EBDP are much more likely to report their child having unmet mental health care needs (OR 12.16; p < 0.001) and experiencing cost barriers to care (OR 2.37; p < 0.001). Parents of privately insured youth with EBDP with functional limitations are even more likely to report these concerns (Unmet Mental Health Needs: OR 17.09; p < 0.001; Cost Barriers: OR 5.77; p < 0.001). However, findings suggest that having public insurance is associated with reductions in the odds of having unmet needs for youth with SED by 50%. Public insurance and dual coverage is associated with reductions in the odds of encountering cost barriers to care by almost 50% for children with EBDP, and by more 50% for youth with EBDP and functional impairments.

Interventions to improve the mental health of children and young people with long-term physical conditions: linked evidence syntheses

BACKGROUND

Although mental health difficulties can severely complicate the lives of children and young people (CYP) with long-term physical conditions (LTCs), there is a lack of evidence about the effectiveness of interventions to treat them.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of interventions aiming to improve the mental health of CYP with LTCs (review 1) and explore the factors that may enhance or limit their delivery (review 2).

DATA SOURCES

For review 1, 13 electronic databases were searched, including MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Science Citation Index. For review 2, MEDLINE, PsycINFO and CINAHL were searched. Supplementary searches, author contact and grey literature searches were also conducted.

REVIEW METHODS

The first systematic review sought randomised controlled trials (RCTs) and economic evaluations of interventions to improve elevated symptoms of mental ill health in CYP with LTCs. Effect sizes for each outcome were calculated post intervention (Cohen's d). When appropriate, random-effects meta-analyses produced pooled effect sizes (d). Review 2 located primary qualitative studies exploring experiences of CYP with LTCs, their families and/or practitioners, regarding interventions aiming to improve the mental health and well-being of CYP with LTCs. Synthesis followed the principles of metaethnography. An overarching synthesis integrated the findings from review 1 and review 2 using a deductive approach. End-user involvement, including topic experts and CYP with LTCs and their parents, was a feature throughout the project.

RESULTS

Review 1 synthesised 25 RCTs evaluating 11 types of intervention, sampling 12 different LTCs. Tentative evidence from seven studies suggests that cognitive-behavioural therapy interventions could improve the mental health of CYP with certain LTCs. Intervention-LTC dyads were diverse, with few opportunities to meta-analyse. No economic evaluations were located. Review 2 synthesised 57 studies evaluating 21 types of intervention. Most studies were of individuals with cancer, a human immunodeficiency virus (HIV) infection or mixed LTCs. Interventions often aimed to improve broader mental health and well-being, rather than symptoms of mental health disorder. The metaethnography identified five main constructs, described in an explanatory line of argument model of the experience of interventions. Nine overarching synthesis categories emerged from the integrated evidence, raising implications for future research.

LIMITATIONS

Review 1 conclusions were limited by the lack of evidence about intervention effectiveness. No relevant economic evaluations were located. There were no UK studies included in review 1, limiting the applicability of findings. The mental health status of participants in review 2 was usually unknown, limiting comparability with review 1. The different evidence identified by the two systematic reviews challenged the overarching synthesis.

CONCLUSIONS

There is a relatively small amount of comparable evidence for the effectiveness of interventions for the mental health of CYP with LTCs. Qualitative evidence provided insight into the experiences that intervention deliverers and recipients valued. Future research should evaluate potentially effective intervention components in high-quality RCTs integrating process evaluations. End-user involvement enriched the project.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001716.

FUNDING

The National Institute for Health Research (NIHR) Health Technology Assessment programme and the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Family resilience and health among adolescents with asthma only, anxiety only, and comorbid asthma and anxiety

OBJECTIVES

The objectives were to examine the relationships between current asthma and anxiety and family resilience and overall health status in US adolescents.

METHODS

Data were from parents of adolescents (12-17 years) who completed the 2017-2018 National Survey of Children's Health (NSCH). Examined variables included: current asthma and anxiety diagnoses, family resilience, child health status, number of adverse childhood experiences (ACEs), family poverty, parent education, and child demographic factors. Multinomial logistic regression models were performed.

RESULTS

Findings indicated that compared to adolescents with high resilience scores, adolescents with anxiety only and comorbid asthma and anxiety were more likely to have moderate or low family resilience scores than adolescents with no asthma or anxiety. Compared with adolescents with an excellent/very good health status, youth with asthma only, anxiety only, and asthma and anxiety had higher odds of having good or fair/poor health status than adolescents with no asthma or anxiety. Among those with current diagnoses, adolescents with asthma only were less likely to have moderate and low resilience scores than adolescents with asthma and anxiety. Adolescents with asthma only and anxiety only were also at reduced odds to have good or fair/poor health status than those with comorbid diagnoses.

CONCLUSIONS

Results indicated that anxiety is linked to family resilience of adolescents with and without comorbid asthma. Experiencing a higher number of ACEs was a risk factor for lower family resilience scores and health status. Future research should consider the impact of other mental health problems and family resilience and health status.

The association between current maternal psychological control, anxiety symptoms, and emotional regulatory processes in emerging adults

BACKGROUND AND OBJECTIVES

High levels of psychological control (PC), the (intentional or unintentional) attempt by parents to control their child's emotional experience, have been associated with increased risk for anxiety in youth. However, little is known regarding the association between PC and anxiety in emerging adulthood, a developmental period marked by various life transitions and high risk for the onset of internalizing symptoms, or about the relation between current parental PC and emotional regulatory processes during this stage. The current study examined whether perceived maternal PC was significantly associated with anxiety symptoms and both objective (psychophysiological; respiratory sinus arrhythmia) and subjective (self-reported) emotion regulatory processes.

METHODS

Participants (N = 125; ages 18 to 25) completed self-reports on their anxiety symptoms, emotion regulation abilities, and perceptions of their mother' behavior, and participated in a laboratory stressor, the Trier-Social Stress Test, while psychophysiological data were acquired.

RESULTS

Emerging adults who reported higher maternal PC also reported higher anxiety symptoms and evidenced greater emotion regulation difficulties on both objective and subjective indices than those who reported lower maternal PC. Moreover, the association between PC and anxiety levels was statistically mediated by self-reported emotion regulation difficulties.

LIMITATIONS

Results of this study should be interpreted in light of its limitations, which include it being cross-sectional in nature with a primarily female sample. Further, perceptions of maternal, but not paternal, parenting were examined.

CONCLUSIONS

Findings might have implications for targeting both psychological control and emotion regulation difficulties in personalized anxiety interventions during this high-risk developmental period.

Chronic Illness and Internalizing Symptomatology in a Transdiagnostic Clinical Sample of Youth

OBJECTIVE

In research with community samples, children with chronic physical illnesses have shown elevated anxiety and depressive symptoms, compared to healthy peers. Less is known about whether physical illnesses are associated with elevated internalizing symptoms even among children referred for mental health treatment-a pattern that would indicate distinctive treatment needs among physically ill children receiving mental health care. We investigated the relationship between chronic physical illness and internalizing symptomatology among children enrolling in outpatient mental health treatment.

METHOD

A total of 262 treatment-seeking children ages 7-15 and their caregivers completed a demographic questionnaire, Child Behavior Checklist, and Youth Self-Report during a pre-treatment assessment. Physical illnesses were identified through caregiver report.

RESULTS

There was no overall association between the presence/absence of chronic physical illness and parent- or child-reported symptoms. However, number of chronic physical illnesses was related to parent- and child-reported affective symptoms. Children with two or more chronic physical illnesses had more severe depressive symptoms than those with fewer physical illnesses.

CONCLUSION

Having multiple chronic illnesses may elevate children's risk of depression symptomatology, even in comparison to other children seeking mental health care. This suggests a need to identify factors that may exacerbate depression symptoms in physically ill children who are initiating therapy and to determine whether different or more intensive services may be helpful for this group. The findings suggest the potential utility of screening for depression in youth with chronic physical illnesses, as well as addressing mental and physical health concerns during treatment.

Capturing temporal dynamics of fear behaviors on a moment-to-moment basis

Identifying patterns of fearful behaviors early and accurately is essential to identify children who may be at increased risk for psychopathology. Previous work focused on the total amount of fear by using composites across time. However, considering the temporal dynamics of fear expression might offer novel insights into the identification of children at risk. One hundred and twenty-five toddlers participated in high- and low-fear tasks. Data were modeled using a novel two-step approach. First, a hidden Markov model estimated latent fear states and transitions across states over time. Results revealed children's behavior was best represented by six behavioral states. Next, these states were analyzed using sequence clustering to identify groups of children with similar dynamic trajectories through the states. A four-cluster solution found groups of children varied in fear response and regulation process: "external regulators" (using the caregiver as a regulation tool), "low reactive" (low reaction to stimulus), "fearful explorers" (managing their own internal state with minimal assistance from the caregiver), and "high fear" (fearful/at-caregiver state regardless of task). The combination of analytic tools enabled fine-grained examination of the processes of fearful temperament. These insights may help prevention programs target behaviors that perpetuate anxious behavior in the moment.

Multimorbidity in Children and Youth Across the Life-course (MY LIFE): protocol of a Canadian prospective study

INTRODUCTION

Multimorbidity, the co-occurrence of a chronic physical condition and mental disorder, affects a substantial number of children and youth and can lead to compromised quality of life, hardship for families, and an increased burden on the healthcare system. We are conducting a study to document the course of mental disorder in children and youth diagnosed with a chronic physical condition; identify predictors of child and youth multimorbidity; examine whether the effects of these predictors are moderated by relevant psychosocial and biological factors; explore potential inflammatory and stress biomarkers that mediate the onset of child and youth multimorbidity; and, assess whether multimorbidity in children and youth alters patterns of mental health service use.

METHODS AND ANALYSIS

Multimorbidity in Children and Youth Across the Life-course (MY LIFE) is a prospective study. Two hundred and fifty children and youth aged 2-16 years diagnosed with a chronic physical condition along with one parent will be recruited from the outpatient clinics at a paediatric tertiary care centre. Data will be collected using a multi-informant, multimethod design at four time-points (at recruitment, and at 6, 12 and 24 months postrecruitment). Parents will provide reports for all children/youth. In addition, youth ≥10 years will self-report. Mental disorder will be assessed using structured interviews. On completion of data collection, participant-reported data will be linked to provincial health records to identify mental health services use. Multilevel analyses (survival, proportional hazard, structural equation modelling) will be used to address MY LIFE objectives.

ETHICS AND DISSEMINATION

This study has been approved by the University of Waterloo Human Research Ethics Board and the Hamilton Integrated Research Ethics Board. Findings will be disseminated to key stakeholders using a number of outlets (peer-reviewed publications and conferences, lay informational pamphlets, social media).

Implementation of a Mental Health Screening Program in a Pediatric Tertiary Care Setting

We evaluated the acceptability and usefulness of brief mental health screening during pediatric subspecialty clinic visits. Patients (8-17 years) and parents (of patients 5-17 years) in pediatric allergy, immunology, and hematology clinics completed the PROMIS (Patient-Reported Outcomes Measurement Information System) Pediatric Profile. Medical providers reviewed results and interpretations to guide discussion of mental health during visits. Almost all providers (96%) reported discussing mental health during visits but fewer parents (60%) said this discussion occurred. All parents who reported that mental health discussions occurred liked that this happened. Some parents (25%) who said no mental health discussion occurred wished it had. Most parents strongly agreed that screening completion was easy and appropriate. Most providers (79%) believed the screening was useful and 87% reported using screening results to guide discussion. Brief electronic mental health screening in pediatric subspecialty clinics is feasible, useful in guiding discussion, and viewed favorably by providers and parents of children with chronic illnesses.

Mental-Physical Multimorbidity in Youth: Associations with Individual, Family, and Health Service Use Outcomes

Prevalence, correlates, and outcomes of youth with comorbid mental and physical conditions (i.e., multimorbidity) were examined in this cross-sectional study. Participants were 92 youth (14.5 years [SD 2.7]; 69.6% female) and their parents. Mental disorder was assessed using structured interviews and physical health using a standardized questionnaire. Twenty-five percent of youth had multimorbidity and no child or parent demographic or health characteristics were correlated with multimorbidity. Youth with multimorbidity reported similar quality of life and better family functioning [B = - 4.80 (- 8.77, - 0.83)] compared to youth with mental disorder only (i.e., non-multimorbid). Youth with multimorbidity had lower odds of receiving inpatient services [OR = 0.20 (0.05, 0.85)] and shorter stays in hospital for their mental health [OR = 0.74 (0.57, 0.91)] over the past year. Family functioning was found to mediate the association between youth multimorbidity and length of stay [αβ = 0.14 (0.01, 0.27)]. Findings reinforce the need for family-centered youth mental health care.

Measurement Invariance of the WHODAS 2.0 Across Youth With and Without Physical or Mental Conditions

Initial evidence suggests that the WHO Disability Assessment Schedule (WHODAS 2.0) is valid and reliable in general youth populations; however, its psychometric properties in specific subgroups are less established. The primary objective was to test for measurement invariance of the 12-item WHODAS 2.0 in an epidemiological sample of youth aged 15 to 19 years with and without physical or mental conditions. Using data from 1,851 youth in the Canadian Community Health Survey-Mental Health, invariance was tested using multiple-group confirmatory factor analysis. Within-domain item correlations were significant and ordinal coefficient alphas were .91, .94, .93, and .92 for the healthy control, physical, mental, and comorbid groups, respectively. Partial measurement invariance was demonstrated for the WHODAS 2.0, with evidence of noninvariance for item residuals and factor variances related to cognition and participation. While these domain-specific comparisons may be biased, valid comparisons of overall disability across subgroups of youth can be made with confidence.

The Health and Well-being of Children and Adolescents Accessing In-Patient Psychiatry: A Brief Report

OBJECTIVE

People with mental illness have high rates of physical illness that are not detected and that shorten their lifespan. Health behaviours are central to physical health, and many children and adolescents with psychiatric illness may be at risk for poor physical health. The purpose for this study was to explore the self-reported health behaviours and well-being of pediatric psychiatric patients and their association with mental health problems.

METHODS

Pediatric patients hospitalized for psychiatric care were invited to complete a survey containing items on amount of physical activity, nutrient intake and sleep, a standardized perceived stress scale, and the Strengths and Difficult Questionnaire.

RESULTS

Informed consent was provided by 161 patients who completed the survey. Youth reported: engaging in very little physical activity, eating fruits and vegetables about 2-3 times per week, not sleeping well and very high perceived stress.

DISCUSSION

Implications for practice include increasing opportunities for and monitoring of health behaviours in youth hospitalized for psychiatric illness. Further research is needed to explore interventions designed to improve the physical health and mental well-being of youth with psychiatric illness and possibly the inpatient environment.

Profile of a national sample of Canadian children with participation and activity limitations

Little is known about the nature of Canadian children with participation or activity limitations. Our objective was to profile a nationally representative sample of Canadian children with report of participation or activity limitation including identifying the major medical reasons attributed to these limitations and describe their sociodemographic and functional characteristics. We used data from the Canadian 2006 Participation and Activity Limitation Survey, a post-census Statistics Canada national survey of adults and children whose everyday activities were limited because of a condition or health problem. Data were collected by telephone interview of children's (<15 years) parents. A sample of those who answered 'yes' to the 2006 Canada Census disability filter questions was chosen for follow-up. Functional ability was assessed using the Health Utility Index. Mental health (26.1%) was the most common reason reported for participation and activity limitations followed by respiratory (9.8%), neurological (5.5%), and congenital (4.6%) conditions. Having a comorbid condition was associated with each major reason for limitation. Mental health, neurological, and congenital conditions showed the highest risk of functional limitation. In conclusion, mental health conditions and those with multiple conditions should be a primary focus for interventions aimed at reducing the impact of health conditions.

Measuring Anxiety in Children: The Importance of Separate Mother and Father Reports

Background

Previous research suggests that it is important to use parental reports when assessing children’s anxiety, but it remains unclear to what extent there are differences between mothers’ and fathers’ scores and whether these potential differences have any repercussions for the psychometric properties of the scale being used.

Objective

This study was conducted to investigate parental differences on the Parent version of the Screen for Child Anxiety Related Emotional Disorders-Revised (SCARED-RP), a rating scale for measuring child anxiety symptoms. The second aim was to re-examine the reliability and validity of the SCARED-RP, in light of these possible differences.

Methods

The SCARED-RP and the Child Behaviour Checklist (CBCL) were administered to parents of clinically anxious children (n = 81), and control children (n = 108). All children (n = 189) completed the SCARED-R.

Results

Significant correlations between mother and father reports were found within the clinically anxious sample. Mothers showed significantly more correspondence with their children in the control group than fathers. The SCARED-RP internal consistency on total scale was excellent (mothers: .94; fathers: .94) and moderate to good for all subscales (from .66 Situational-Environmental Phobia to .93 Animal Phobia). The SCARED-RP differentiated well between clinically anxious and control children (mother and father data). The concurrent validity was supported by strong correlations with the CBCL anxious-depressed scale.

Conclusion

Differences between mother and father reports suggest the importance of obtaining information from both parents separately. Furthermore, the SCARED-RP is a useful instrument for assessing children’s anxiety disorder symptoms in clinical and research settings.

Family Report Compared to Clinician-Documented Diagnoses for Psychiatric Conditions Among Hospitalized Children

BACKGROUND

Psychiatric comorbidity is common in pediatric medical and surgical hospitalizations and is associated with worse hospital outcomes. Integrating medical or surgical and psychiatric hospital care depends on accurate estimates of which hospitalized children have psychiatric comorbidity.

OBJECTIVE

We conducted a study to determine agreement of family report (FR) and clinician documentation (CD) identification of psychiatric diagnoses in hospitalized children.

DESIGN AND SETTING

This was a cross-sectional study at a tertiary-care children's hospital.

PATIENTS

The patients were children and adolescents (age, 4-21 years) who were hospitalized for medical or surgical indications.

MEASUREMENTS

Psychiatric diagnoses were identified from structured interviews (FR) and from inpatient notes and International Classification of Diseases codes in medical records (CD). We compared estimates of point prevalence of any comorbid psychiatric diagnosis using each method, and estimated FR--CD agreement in identifying psychiatric comorbidity in hospitalized children.

RESULTS

Of 119 study patients, 26 (22%; 95% confidence interval [CI], 14%-29%) had a psychiatric comorbidity identified by FR, 30 (25%; 95% CI, 17%-34%) had it identified by CD, and 37 (23%-40%) had it identified by FR or CD. Agreement between FR and CD was low overall (κ = .46; 95% CI, .27-.66), highest for attention-deficit/hyperactivity disorder (κ = .78; 95% CI, .59-.97), and lowest for anxiety disorders (κ = .11; 95% CI, -.16 to .56).

CONCLUSIONS

Current methods may underestimate the prevalence of psychiatric conditions in hospitalized children. Information from multiple sources may be needed to develop accurate estimates of the scope of the population in need of services so that mental health resources can be appropriately allocated. Journal of Hospital Medicine 2017;12.

Mental Health Screening Among Adolescents and Young Adults in the Emergency Department

OBJECTIVE

To determine if a new, non-validated mental health screener can detect the prevalence of alcohol/drug abuse, traumatic exposure, and behavioral symptoms in adolescents and young adults seeking care in a pediatric emergency department (ED) for medical complaints.

METHODS

An 11-item mental health screener (Emergency Department Distress Response Screener [ED-DRS] investigator developed) was created. Patients 12 years or older seen for medical complaints were assessed by physicians using the ED-DRS. Data were analyzed using the Kuder-Richardson Formula 20, χ test, Mann-Whitney U test, and Spearman correlation.

RESULTS

Among 992 ED patients, mean age was 15.11 ± 2.10 years (46.2% boys; 53.8% girls). Approximately 77.9% were Hispanic/Latino. Symptomatic patients (S) answered "yes" to at least 1 ED-DRS item; asymptomatic patients answered "no" to all items. The S patients comprised 47.5% of the sample; asymptomatic patients comprised 52.5%. Among S patients, alcohol/drug abuse frequency was 14%. The traumatic exposure frequencies included: 33.5% physically or emotionally traumatized, 29.3% bullied, 21.2% physically abused, 8.1% touched inappropriately and 7.0% exposed to domestic violence. Behavioral symptom frequencies included: 33.8% depressed mood, 30.4% anxiety, 23.8% high energy behavior, 6.6% hallucinations, and 6.2% suicidal/homicidal ideation.

CONCLUSIONS

Although patients present to the ED with medical complaints, they may be at risk for concomitant mental health problems potentially discoverable using the ED-DRS.

The Role of Experiential Avoidance in the Relation between Anxiety Disorder Diagnoses and Future Physical Health Symptoms in a Community Sample of Young Adult Women

Individuals diagnosed with an anxiety disorder report more physical health problems than those without an anxiety disorder. Few studies have examined the relation of anxiety disorders to later physical health symptoms, or the processes that may explain this relation. One process of interest is experiential avoidance (EA), which is commonly reported in populations characterized by high anxiety and often leads to health-compromising behaviors. The present study examined the relations between anxiety disorder diagnostic status, EA, and physical health symptoms in a community sample of young adult women. Results revealed a significant association between an anxiety disorder diagnosis and physical health problems four months later. Furthermore, levels of EA accounted for this relation. Findings highlight the potential utility of targeting EA as a method for improving health outcomes among individuals with anxiety disorders.

Functioning Among Youth with Comorbid Mood Disorder and Chronic Physical Illness in Public Sector Care

OBJECTIVE

The current study examines parent/caregiver and youth report of psychosocial and health-related functioning among youth served in public systems of care, with mood disorder only, comorbid mood disorder and chronic physical illness, and chronic physical illness only.

METHOD

Participants were 539 youths (ages, 11-18; 64% male) with a mood disorder and/or chronic physical illness enrolled in a study of public sector care. Presence of mood disorder was based on youth report on the Diagnostic Interview Schedule for Children-IV. Parents reported whether they had been told by a school or health professional that their child had 1 of 8 categories of chronic physical illnesses. Psychosocial functioning was assessed with the Child Behavior Checklist and Youth Self Report. Parent and child versions of the Child Health Questionnaire assessed health-related functioning. Covariates included demographic variables, substance use, mental health service utilization, disruptive behavior disorders, and anxiety disorders. Multivariate analysis of covariances assessed differences on outcome measures among the 3 groups.

RESULTS

Parents and youths reported significantly worse psychosocial and health-related functioning for youth with comorbid mood and physical illnesses. Generally, parents reported lower functioning in youth with a physical illness compared with mood disorder, and youth with mood disorders reported lower functioning than those with physical illness.

CONCLUSION

Youth with comorbid mood disorder and chronic physical illness experience high levels of impairment. Increased screening of mood disorders in pediatric health settings is warranted. Health systems, clinics, and clinicians should focus on integrating mental and physical health diagnosis and treatment.

Barriers to recovery in communities exposed to disasters: Sri Lankan voices speak

Disasters experienced by a community place all members at risk for physical and psychological harm. While natural resilience may help many to recover, there may be barriers that hinder the recovery process. This qualitative study was conducted to examine barriers to recovery in a community impacted by both war and the tsunami. A group of 43 ethnically diverse Sri Lankans (F = 63%) participated in six focus groups and provided their perspectives on barriers they perceived to impede their recovery from traumatic events. Grounded-theory-based data analysis revealed culture-general and culture-specific socio-economic, environmental, sociocultural, and individual barriers that participants identified as impeding their recovery. Interventions and health policies targeting these groups could focus on helping communities to overcome these barriers as a means of facilitating recovery in these beleaguered communities.

Association of Childhood Anxiety Disorders and Quality of Life in a Primary Care Sample

Anxiety disorders are associated with measurable deficits in quality of life (QOL) in adult samples. However, this association has largely been unexplored in pediatric samples. In this study, we examined relationships between child anxiety-including number of anxiety disorders (comorbidity), symptom severity, and subtypes of anxiety-and QOL in a pediatric primary care sample.

RESULTS

Anxiety comorbidity was common in the current sample (n = 73), with 3-quarters being diagnosed with more than one anxiety disorder. QOL in the current sample did not vary significantly by age, gender, or race/ethnicity. Both greater comorbidity and higher total anxiety symptom severity were inversely associated with QOL across multiple domains, although anxiety comorbidity did not reach significance in multivariate models adjusted for gender, income, and externalizing symptoms. On the anxiety severity subscales, both physical symptoms and social anxiety had independent associations with QOL.

CONCLUSIONS

Anxiety-related outcomes, as measured by anxiety comorbidity, symptom severity, and type of anxiety, are associated with significantly worse QOL in a pediatric sample. Providers should be aware that QOL is impacted by both severity and type of anxiety-related conditions, particularly social anxiety and somatic-related anxiety.

Point Prevalence of Co-Occurring Behavioral Health Conditions and Associated Chronic Disease Burden Among Adolescents

OBJECTIVE

To examine the point prevalence of behavioral health conditions (BHCs) and co-occurring chronic medical conditions among adolescents in an integrated health system.

METHOD

The sample consisted of adolescents in an integrated health care system diagnosed with at least 1 of the 5 most prevalent BHCs in 2014 (n = 30,643), and patients without a BHC matched on age, sex, and medical home facility (n = 30,643). Electronic health record data was used to identify all adolescents aged 11 to 18 years with at least 1 BHC diagnosis on their diagnosis list, which included current and pre-existing diagnoses from an outpatient (including psychiatry and chemical dependency specialty treatment), inpatient, or emergency department visit at a Kaiser Permanente Northern California (KPNC) facility between January 1, 2014, and December 31, 2014. The odds of having general medical conditions and specific chronic diseases were compared between adolescents with and without BHCs.

RESULTS

Among adolescents with at least 1 BHC in 2014, the 5 most common BHCs were: depressive disorders (42%), anxiety disorders (40%), attention-deficit/hyperactivity disorders (ADHDs; 37%), substance use disorders (SUDs; 10%), and bipolar spectrum disorders (8%). Overall, patients with a BHC did not have higher odds of any medical comorbidity compared with non-BHC patients. However, compared to individuals without BHCs, adolescents with depression (odds ratio [OR] = 1.16, 95% CI = 1.08-1.26), anxiety (OR = 1.30, 95% CI = 1.20-1.41), and substance use (OR = 1.25, 95% CI = 1.05-1.49) disorders had significantly higher odds of any medical comorbidities; individuals with ADHD and bipolar disorder did not differ from patients without BHCs.

CONCLUSION

BHCs were common and were associated with a disproportionately higher burden of chronic medical disease among adolescents in a large, private health care delivery system. As comorbidity can lead to elevated symptom burden, functional impairment, and treatment complexity, the study findings call for implementation of effective collaborative models of care for these patients.

Association of Mental Disorders and Consultation with Family Members and Friends in Children and Adolescents: The CASPIAN-IV Study

Background:

Behavioral disorders are common in the pediatric age group. This study aims to assess the relationship between the frequency of behavioral and mental disorders and counseling with family members and friends in a representative sample of Iranian children and adolescents.

Methods:

In this nationwide study, 14880 school students, aged 6–18 years, were selected by cluster and stratified multi-stage sampling method from 30 provinces in Iran. The World Health Organization Global School-based Health Survey questionnaire was used.

Results:

Overall, 13486 students (49.2% girls) with the mean (standard deviation) age of 12.47 (3.36) years completed the study. According to the students’ self-report, 56.1% of boys and 42.2% of girls shared their problems with their fathers. All behavioral disorders were less prevalent in children and adolescents who consulted with their father compared with those who did not (P < 0.001). In addition, 84.6% of boys and 84.0% of girls shared their problem with their mother. All behavioral disorders were less prevalent in children and adolescents who consulted with their mother compared with those who did not (P < 0.001). 45.6% of boys and 44.8% of girls shared their problem with their brother or sister. Some behavioral disorders were less prevalent in children and adolescents who consulted with their brother or sister (P < 0.01); however, the prevalence was not statistically different for most disorders (P > 0.05). Moreover, 60.4% of boys and 66.0% of girls shared their problems with their friends. The prevalence of most behavioral disorders was lower in those who consulted with their friends (P < 0.001).

Conclusions:

Children and adolescents should be encouraged to consult with their parents and friends about their problems. Parents should offer their children an opportunity to express their views and wishes about their problems.

Condition-specific associations of symptoms of depression and anxiety in adolescents and young adults with asthma and food allergy

OBJECTIVE

This study examined associations of asthma and food allergy with symptoms of depression and anxiety at 14 and 21 years of age to determine whether condition-specific associations exist.

METHODS

Data come from 4972 adolescents in the Mater University Study of Pregnancy. Symptoms of depression and anxiety were assessed using the Youth Self-Report and Young Adult Self-Report.

RESULTS

Condition-specific associations between asthma and depression, OR = 1.37 [1.12, 1.67] and between food allergy and anxiety, OR = 1.26 [1.04, 1.76] were found during adolescence, but not in young adulthood. Whereas asthma was associated with resolved depression, OR = 1.70 [1.13, 2.55], food allergy was associated with persistent anxiety, OR = 1.26 [1.01, 1.59].

CONCLUSIONS

In adolescents, asthma is associated with an increased risk of clinically relevant symptoms of depression and food allergy with an increased risk of clinically relevant symptoms of anxiety. Future research is needed to clarify directionality and mechanisms explaining these relationships. Health professionals should be aware of the increased risk of mental health problems in adolescents with asthma or food allergy.

Examination of the Comorbidity of Mental Illness and Somatic Conditions in Hospitalized Children in the United States Using the Kids' Inpatient Database, 2009

OBJECTIVE

To examine the associations between mental and physical illness in hospitalized children.

METHODS

The data for this analysis came from the 2009 Kids' Inpatient Database (KID). Any child with an International Classification of Diseases, Ninth Revision code indicative of depressive, anxiety, or bipolar disorders or a diagnosis of sickle cell disease, diabetes mellitus type 1 or 2, asthma, or attention-deficit/hyperactivity disorder (ADHD) were included. Using SAS software, we performed χ(2) tests and multivariable logistic regression to determine degrees of association.

RESULTS

Children discharged with sickle cell disease, asthma, diabetes mellitus type 1, diabetes mellitus type 2, and ADHD were 0.94, 2.76, 3.50, 6.37, and 38.39 times more likely to have a comorbid anxiety, depression, or bipolar disorder diagnosis than other hospitalized children, respectively.

CONCLUSIONS

Children with several chronic physical illnesses (asthma, diabetes mellitus type 1, diabetes mellitus type 2) and mental illnesses (ADHD) have higher odds of being discharged from the hospital with a comorbid mood or anxiety disorder compared with other children discharged from the hospital. It is therefore important to screen children hospitalized with chronic medical conditions for comorbid mental illness to ensure optimal clinical care, to improve overall health and long-term outcomes for these children.

Shared decision making among parents of children with mental health conditions compared to children with chronic physical conditions

High quality care in pediatrics involves shared decision making (SDM) between families and providers. The extent to which children with common mental health disorders experience SDM is not well known. The objectives of this study were to examine how parent-reported SDM varies by child health (physical illness, mental health condition, and comorbid mental and physical conditions) and to examine whether medical home care attenuates any differences. We analyzed data on children (2-17 years) collected through the 2009/2010 National Survey of Children with Special Health Care Needs. The sample consisted of parents of children in one of three child health categories: (1) children with a chronic physical illness but no mental health condition; (2) children with a common mental health condition but no chronic physical condition; and (3) children with comorbid mental and chronic physical conditions. The primary dependent variable was parent-report of provider SDM. The primary independent variable was health condition category. Multivariate linear regression analyses were conducted. Multivariate analyses controlling for sociodemographic variables and parent-reported health condition impact indicated lower SDM among children with a common mental health condition-only (B = -0.40; p < 0.01) and children with comorbid conditions (B = -0.67; p < 0.01) compared to children with a physical condition-only. Differences in SDM for children with a common mental health condition-only were no longer significant in the model adjusting for medical home care. However, differences in SDM for children with comorbid conditions persisted after adjusting for medical home care. Increasing medical home care may help mitigate differences in SDM for children with mental health conditions-only. Other interventions may be needed to improve SDM among children with comorbid mental and physical conditions.

Clinical characteristics and outpatient mental health service use of transition-age youth in the USA

This study examines diagnostic and service utilization patterns of transition-age youth in outpatient care derived from the 2007 nationally representative Client/Patient Sample Survey. Comparisons between 16-17, 18-21, and 22-25 year olds are highlighted. Among transition-age outpatients, the oldest youth had the highest rates of depression and bipolar disorder and co-occurring medical and substance use problems. Controlling for sociodemographic and clinical characteristics, 18-21 year olds were less likely to receive individual therapy than 16-17 year olds, but there were no age group differences in receipt of specialized therapy or psychotropic medication. Female gender and Hispanic ethnicity were positively associated with the number of services received and specialized service use, respectively; youth with private insurance were more likely than those with public insurance to receive psychotropic medication. Implications are discussed regarding access to and adequacy of services provided for young people in the critical transition to adulthood, especially with the implementation of the 2010 Affordable Care Act.

Trajectories of depressive symptoms during the transition to young adulthood: the role of chronic illness

BACKGROUND

Little is known about the natural course of depressive symptoms among youth with chronic illness during their transition from adolescence to young adulthood.

METHODS

A representative epidemiological sample of 2825 youth aged 10-11 years from the National Longitudinal Survey of Children and Youth were followed until 24-25 years of age. Presence of chronic illness was measured using self-report and symptoms of depression were assessed using the Center for Epidemiological Studies Depression Scale. Multilevel modeling was used to investigate trajectories of depressive symptoms, adjusting for family environment and sociodemographic characteristics during the transition to young adulthood.

RESULTS

Trajectories showed cubic change over time - increasing from early to mid-adolescence, decreasing to early young adulthood, increasing again to late young adulthood. Youth with chronic illness (n=753) had significantly less favorable trajectories and significantly higher proportions of clinically relevant depressive symptoms over time compared to their peers without chronic illness (n=2072).

LIMITATIONS

This study is limited by selective attrition, self-reported chronic illness and no assessment of illness severity, and mediating effects of family environment factors could not be examined.

CONCLUSIONS

Findings support the diathesis-stress model; chronic illness negatively influenced depressive symptoms trajectories, such that youth with chronic illness had higher depression scores and less favorable trajectories over time. The health and school system are uniquely positioned to support youth with chronic illness navigate this developmental period in an effort to prevent declines in mental health.

Anxiety symptoms and disease severity in children and adolescents with Crohn disease

OBJECTIVES

Children and adolescents diagnosed as having Crohn disease (CD), a type of inflammatory bowel disease (IBD), have increased vulnerability for anxiety symptoms that may be related to disease-related processes. The aims of this article are 3-fold: to report the proportion of pediatric patients with CD whose self-reported anxiety symptoms are indicative of distress, to describe the constellation of anxiety symptoms, and to examine the relation between anxiety and disease symptoms.

METHODS

Retrospective medical chart review was performed for 93 youths with CD (ages 9-18 years) who had completed the Screen for Child Anxiety Related Disorders during their gastroenterology visit. Medical records were reviewed for demographic and disease characteristics. the Harvey-Bradshaw Index (HBI) was used as a measure of CD activity.

RESULTS

Thirty percent of the youths reported experiencing elevated anxiety symptoms (Screen for Child Anxiety Related Disorder score >20), and 50% had scored above the cutoff in 1 or more anxiety domains, with school anxiety, general anxiety, and separation anxiety symptoms reported most frequently. Youth rated with moderate/severe disease activity on the HBI (n = 4) self-reported more anxiety symptoms compared with youth with inactive disease (n = 78, P = 0.03). Greater school anxiety was significantly associated with decreased well-being (P = 0.003), more abdominal pain (P < 0.001), and the number of loose stools (P = 0.01). Having extraintestinal symptoms was significantly associated with higher somatic/panic anxiety (P = 0.01).

CONCLUSIONS

Implementing a brief anxiety screen in tertiary pediatric settings may be one approach to identify young patients with CD in distress. Health care providers should consider periodic assessment of school anxiety among youth with CD.

The cost of healthcare for children with mental health difficulties

OBJECTIVE

Childhood mental health difficulties affect one in every seven children in Australia, posing a potential financial burden to society. This paper reports on the early lifetime individual and population non-hospital healthcare costs to the Australian Federal Government for children experiencing mental health difficulties. It also reports on the use and cost of particular categories of service use, including the Medicare Benefits Schedule (MBS) mental health items introduced in 2006.

METHOD

Data from the Longitudinal Study of Australian Children (LSAC) were used to calculate total Medicare costs (government subsidised healthcare attendances and prescription medications) from birth to the 8th birthday associated with childhood mental health difficulties measured to 8-9 years of age.

RESULTS

Costs were higher among children with mental health difficulties than those without difficulties. While individual costs increased with the persistence of difficulties, population-level costs were highest for those with transient mental health difficulties. Although attenuated, these patterns persisted after child, parent and family characteristics were taken into account. Use of the MBS-reimbursed mental health services among children with a mental health difficulty was very low (around 2%).

CONCLUSIONS

Australian healthcare costs for young children with mental health difficulties are substantial and provide further justification for early intervention and prevention. The current provision of Medicare-rebated mental health services does not appear to be reaching young children with mental health difficulties.

An Adaptation of the Coping Cat Program

Generalized anxiety disorder (GAD) during childhood is a common condition with negative implications. This case study describes the successful cognitive-behavioral treatment of a 6-year-old boy with excessive worry and sleep disturbances. Because of the patient’s age, treatment methods were adapted for an early reader. The frequency and intensity of his symptoms (e.g., physiologic arousal, apprehensive expectations, sleep disturbances) were measured over the course of treatment and at 3 and 7 years after treatment. Recommendations are provided for clinicians and students who aim to treat young children with GAD. The results of this intervention suggest a durable and meaningful reduction in GAD-related symptoms.

Screening for adolescent anxiety disorders in a pediatric emergency department

OBJECTIVES

Adolescence is a time of increasing risk for some anxiety disorders. Scant data exist on adolescent anxiety in emergency department (ED) settings. We sought to characterize select clinical characteristics and health care use associated with anxiety disorders in a pediatric ED.

METHODS

We screened a convenience sample of 100 adolescent-parent dyads presenting to the ED for the presence of child anxiety disorders using the 5-item Screen for Child Anxiety Related Emotional Disorders, parent (SCARED-P) and child (SCARED-C) versions. Additional demographic and clinical data were also collected.

RESULTS

The SCARED-P and SCARED-C screens identified probable anxiety disorder(s) in 26% to 33% of adolescent participants, respectively. Correlates of positive SCARED-C screens were female sex, asthma, presenting complaint involving headache or migraine, and school absenteeism due to physical problems. Correlates of positive SCARED-P screens were lower parental educational level, presenting complaint involving headache or migraine, and more medical specialty and total medical visits. Few anxious adolescents had received mental health services in the past 6 months. In multivariate models, female sex was independently associated with SCARED-C total score, and presenting complaint involving headache or migraine was independently associated with SCARED-P total score.

CONCLUSIONS

The current pilot data suggest that anxiety disorders are more prevalent among adolescent ED patients than among the general population but largely untreated. Several demographic and clinical variables may help to identify occult anxiety disorders. Greater awareness of anxiety disorders in this population may assist in redirecting a pattern of low use of mental health services but higher overall health care use.

Anxiety in the pediatric medical setting

The relationship between pediatric anxiety disorders and physical health is not well-understood, but appreciation of the importance of this relationship is growing. Significant functional impairment may accompany a chronic physical health condition such as asthma, diabetes, or epilepsy, and anxiety may complicate the course. In addition, physical disease can present with symptoms of anxiety, and anxiety disorders may present or be associated with physical symptoms such as functional abdominal pain, headache, and fatigue. This article describes anxiety and its association with physical disease, outlines assessment, and presents a treatment overview including psychotherapy and pharmacotherapy.

Pediatric and adolescent mental health emergencies in the emergency medical services system

Emergency department (ED) health care professionals often care for patients with previously diagnosed psychiatric illnesses who are ill, injured, or having a behavioral crisis. In addition, ED personnel encounter children with psychiatric illnesses who may not present to the ED with overt mental health symptoms. Staff education and training regarding identification and management of pediatric mental health illness can help EDs overcome the perceived limitations of the setting that influence timely and comprehensive evaluation. In addition, ED physicians can inform and advocate for policy changes at local, state, and national levels that are needed to ensure comprehensive care of children with mental health illnesses. This report addresses the roles that the ED and ED health care professionals play in emergency mental health care of children and adolescents in the United States, which includes the stabilization and management of patients in mental health crisis, the discovery of mental illnesses and suicidal ideation in ED patients, and approaches to advocating for improved recognition and treatment of mental illnesses in children. The report also addresses special issues related to mental illness in the ED, such as minority populations, children with special health care needs, and children's mental health during and after disasters and trauma.

Anxiety in medically ill children/adolescents

Anxiety disorders are thought to be one of the most common psychiatric diagnoses in children/adolescents. Chronic medical illness is a significant risk factor for the development of an anxiety disorder, and the prevalence rate of anxiety disorders among youths with chronic medical illnesses is higher compared to their healthy counterparts. Anxiety disorders may develop secondary to predisposing biological mechanisms related to a child's specific medical illness, as a response to being ill or in the hospital, a threatening environment, as a result of other genetic and psychological factors, or as a combination of all these factors. Additionally, exposure to physical pain early in one's life and/or frequent painful medical procedures are correlated with fear and anxiety during subsequent procedures and treatments, and may lead to medical nonadherence and other comorbidities. Anxiety disorders can have serious consequences in children/adolescents with chronic and/or life-limiting medical illnesses. Therefore, proper identification and treatment of anxiety disorders is necessary and may improve not only psychiatric symptoms but also physical symptoms. Behavioral and cognitive methods as well as psychotropic medications are used to treat anxiety disorders in pediatric patients. We will review current treatments for anxiety in children/adolescents with medical illnesses and propose future research directions.