Practical management of chronic fatigue syndrome or myalgic encephalomyelitis in childhood

The role of psychiatry in diagnosis and treatment of paediatric chronic fatigue syndrome - a scoping literature review

OBJECTIVES

Paediatric Chronic Fatigue Syndrome (pCFS) is a common condition that significantly disrupts a healthy psychosocial development. Psychiatric symptoms associated with pCFS are conceptualized as either part of its complex etiology, its consequence, or as a comorbidity. However, patients with this condition are rarely seen by psychiatrists. This scoping review aims to explore the role of psychiatry in the diagnosis and treatment of pCFS.

CONTENT

A scoping review of literature was conducted using MEDLINE, EMBASE, Cochrane and PsycINFO. Databases were searched for articles describing psychiatric involvement in the diagnosis or treatment of children and adolescents (age ≤ 18) with pCFS. A grey literature search was also conducted to identify additional guidelines and national recommendations to identify the role of psychiatry in the diagnosis and treatment of pCFS.

SUMMARY

The search provided 436 articles of which 16 met inclusion criteria. Grey literature search identified 12 relevant guidelines. Most studies and guidelines did not include any psychiatric involvement in the care of patients with pCFS. If psychiatry was mentioned, it was used interchangeably with psychological interventions or in the context of treating distinct psychiatric comorbidities and suicidal ideation.

OUTLOOK

The role of psychiatry in diagnosis and treatment of pCFS is poorly defined. Future research is required to understand how psychiatrists can contribute to the care of patients with pCFS.

Exploring anhedonia in adolescents with Chronic Fatigue Syndrome (CFS): A mixed-methods study

BACKGROUND

Chronic Fatigue Syndrome (CFS/ME) may get in the way of enjoying activities. A substantial minority of adolescents with CFS/ME are depressed. Anhedonia is a core symptom of depression. Anhedonia in adolescents with CFS/ME has not been previously investigated.

METHOD

One hundred and sixty-four adolescents, age 12 to 18, with CFS/ME completed a diagnostic interview (K-SADS) and questionnaires (HADS, RCADS). We used a mixed-methods approach to explore the experience of anhedonia and examine how common it is, comparing those with clinically significant anhedonia to those without.

RESULTS

Forty-two percent of adolescents with CFS/ME reported subclinical or clinical levels of anhedonia. Fifteen percent had clinically significant anhedonia. Thematic analysis generated two themes: (1) stopping activities that they previously enjoyed and (2) CFS/ME obstructs enjoyment. Most (72%) of those who reported clinically significant anhedonia met the depression diagnostic criteria. Those who were depressed used more negative language to describe their experience of activities than in those who were not depressed, although the themes were broadly similar.

CONCLUSIONS

Experiencing pleasure from activities may be affected in CFS/ME, particularly in those who are depressed. Anhedonia may get in the way of behavioural strategies used within CFS/ME treatments.

"it's a medical condition … you need to support as much as possible": a qualitative analysis of teachers' experiences of chronic fatigue syndrome / myalgic encephalomyelitis (CFS/ME)

Background

An increasing number of children with complex health needs are being educated in mainstream classes. CFS/ME is a complex and disabling condition, and there is little guidance on how primary school teachers can support younger children with this condition. To improve care, it is important to understand what these children need in the school setting, and the barriers and facilitators to teachers providing this support. The aims for this qualitative study were to explore teachers’ views about CFS/ME, their experiences of supporting a pupil with CFS/ME and their perspectives on the barriers and facilitators to providing support.

Methods

We recruited families from an NHS specialist paediatric CFS/ME service and families were eligible if the child was aged between 5 and 11 years and had a diagnosis of CFS/ME. We gained written consent/assent from families to invite the child’s teacher to participate in a qualitative interview. We contacted these teachers, gained written consent and then carried out semi-structured qualitative interviews. Interviews were audio-recorded, transcribed, anonymised and analysed thematically. Interviews took place between July 2018 and December 2018.

Results

We interviewed 11 teachers; their pupil’s age ranged from 5 to 11 years and school attendance ranged from 0 to 80%. Theme 1: Most teachers provided rich descriptions of their pupil’s CFS/ME; they consistently described cognitive dysfunction and significant fatigue, but beyond this the symptoms varied from one account to the next (from mobility problems, to aches and pains, digestive problems, headaches, nausea and hypersensitivity). These teachers noted the ripple effects on their pupil’s social, emotional and academic functioning. Two of the eleven teachers said that they did not observe symptoms of CFS/ME, expressing a degree of scepticism about the diagnosis. Theme 2: Teachers described a close relationship with their pupil. They said they understood the individual needs of the child and portrayed positive and proactive attitudes towards providing support. The type of support provided included facilitating rest breaks and limiting strenuous activities; using practical strategies to address cognitive, physical, social and emotional difficulties; maintaining a connection with the child during their absences from school; and encouraging the child to talk about their health and wellbeing. Teachers noted that receiving formal confirmation of the child’s diagnosis enabled them to put this support in place. Theme 3: The adaptations they described were often intuitive, rather than being based on a knowledge of CFS/ME. Teachers wanted more resources to increase their understanding of the condition and its management.

Conclusions

Primary school teachers want to provide effective support for children with CFS/ME. Clinical services should consider working in collaboration with teachers to equip them with evidence-based strategies for CFS/ME management in the primary school setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-020-02461-7.

Chronic fatigue syndrome/myalgic encephalomyelitis in children aged 5 to 11 years: A qualitative study

Treatments for paediatric chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) have not been designed or evaluated for younger children (5-11-years). The development of a complex intervention for this population requires an in-depth understanding of the perspectives and psychosocial context of children and families. Children with CFS/ME (5-11-years) and their families were recruited from a specialist CFS/ME service, and interviewed using semi-structured topic guides. Data were analysed thematically. Twenty-two participants were interviewed; eight parents, two children (aged nine and ten) and six parent-child dyads (aged 5-11-years). Theme 1: CFS/ME in younger children is complex and disabling. Theme 2: Children aged eight and over (in comparison to those under eight) were more able to describe their illness, engage in clinical consultation, understand diagnosis and self-manage. Theme 3: Parents of children under eight took full responsibility for their child's treatment. As children got older, this increasingly became a joint effort between the parent and child. Parents felt unsupported in their caring role. Clinicians should consider different treatment approaches for children under eight, focusing on: parent-only clinical sessions, training parents to deliver treatment, and increasing support for parents. Children over eight may benefit from tools to help them understand diagnosis, treatment and aids for self-management.

How common are depression and anxiety in adolescents with chronic fatigue syndrome (CFS) and how should we screen for these mental health co-morbidities? A clinical cohort study

Adolescents with Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) appear to be more likely to experience anxiety and/or depression using Patient Reported Outcome Measures (PROMs). However, we do not know how accurate these are at detecting problems in this patient group given the primary symptom of fatigue. We aimed to accurately determine the prevalence of anxiety/depression using gold-standard diagnostic interviews and evaluate the accuracy of PROMs measuring mood disorders in this patient group. We conducted a cross-sectional epidemiological study in a specialist tertiary paediatric CFS/ME service, England. The participants were164 12-18-year olds with clinician confirmed CFS/ME and their parents. The measures were a semi-structured diagnostic interview, the Kiddie Schedule for Affective Disorders and Schizophrenia, K-SADS, and questionnaires (Revised Children's Anxiety and Depression Scale, RCADS; Spence Children's Anxiety Scale, SCAS; Hospital Anxiety and Depression Scale, HADS). Parents completed the RCADS-P. 35% met the criteria for at least one common mental health problem. 20% had major depressive disorder, and 27% an anxiety disorder, with social anxiety and generalised anxiety being the most common. There was high co-morbidity, with 61% of those who were depressed also having at least one anxiety disorder. The questionnaires were moderately accurate (AUC > 0.7) at detecting clinically significant anxiety/depression, although only the RCADS-anxiety reached the predefined 0.8 sensitivity, 0.7 specificity target. Mental health problems are particularly common amongst adolescents with CFS/ME. Most screening tools were not sufficiently accurate in detecting clinically significant anxiety and depression, so these should be used with care in combination with thorough psychological/psychiatric assessment.

Sleep problems in adolescents with CFS: A case-control study nested within a prospective clinical cohort

Sleep problems have a negative impact on a range of outcomes and are very common in adolescents with chronic fatigue syndrome (CFS). We aimed to (a) establish whether adolescents with CFS have more self-reported sleep problems than illness controls as well as healthy controls, (b) investigate changes in sleep problems and (c) explore the extent to which sleep problems at baseline predict fatigue and functioning at follow-up in adolescents with CFS. The Insomnia Scale was completed by 121 adolescents with CFS, 78 healthy adolescents and 27 adolescents with asthma. Eighty (66%) treatment-naïve adolescents with CFS completed questionnaires approximately 3 months later. Adolescents with CFS reported increased sleep problems compared to healthy controls and adolescents with asthma. In CFS, there was no significant change in sleep problems without treatment over a 3-month follow-up. Sleep problems at baseline predicted a significant proportion of the variance in sleep problems at follow-up. Sleep problems should be targeted in treatment. Regulating the 'body clock' via the regulation of sleep could influence outcomes not assessed in this study such as school attainment.

Do adolescents with chronic fatigue syndrome (CFS/ME) and co-morbid anxiety and/or depressive symptoms think differently to those who do not have co-morbid psychopathology?

BACKGROUND

Co-morbid anxiety and/or depression is common in adolescents with Chronic Fatigue Syndrome (CFS/ME). Adolescents with psychopathology typically endorse more negative cognitive errors. We do not know whether they make negative cognitive errors in response to fatigue. We examined the thinking patterns of adolescents with CFS/ME and co-morbid psychopathology compared to those without this co-morbidity.

METHODS

This cross-sectional study recruited 205 adolescents (age 11-18) with CFS/ME, who completed measures of anxiety and depression, information processing biases and responses to fatigue. We grouped participants as having co-morbid psychopathology (or not) by applying a threshold score. We compared groups' thinking pattern subscale scores using independent samples T tests. We examined the association between psychopathology and general negative thinking and specific responses to fatigue symptoms.

RESULTS

Adolescents with CFS/ME with co-morbid psychopathology more strongly endorsed general negative cognitive errors (d = 0.61-1.31). They also more strongly endorsed damage beliefs (d = 0.49), embarrassment avoidance (d = 1.05), catastrophising (d = 0.97) and symptom focusing (d = 0.75) in response to fatigue but did not differ significantly on fear avoidance from those without co-morbid psychopathology. Both negative cognitive errors and unhelpful responses to symptoms explained 43% of the variance in psychopathology.

CONCLUSIONS

Adolescents with CFS/ME with co-morbid psychopathology tend to be negatively biased in their thinking, both generally and about their symptoms of fatigue specifically. This may have implications for the sequencing of cognitive and behavioural strategies to address both fatigue and psychopathology.

Assessing functioning in adolescents with chronic fatigue syndrome: psychometric properties and factor structure of the School and Social Adjustment Scale and the Physical Functioning Subscale of the SF36

BACKGROUND

Chronic fatigue syndrome (CFS) has a major impact on functioning. However, no validated measures of functioning for this population exist.

AIMS

We aimed to establish the psychometric properties of the 5-item School and Social Adjustment Scale (SSAS) and the 10-item Physical Functioning Subscale of the SF-36 in adolescents with CFS.

METHOD

Measures were completed by adolescents with CFS (n = 121).

RESULTS

For the Physical Functioning Subscale, a 2-factor solution provided a close fit to the data. Internal consistency was satisfactory. For the SSAS, a 1-factor solution provided an adequate fit to the data. The internal consistency was satisfactory. Inter-item and item-total correlations did not indicate any problematic items and functioning scores were moderately correlated with other measures of disability, providing evidence of construct validity.

CONCLUSION

Both measures were found to be reliable and valid and provide brief measures for assessing these important outcomes. The Physical Functioning Subscale can be used as two subscales in adolescents with CFS.

Child and adolescent chronic fatigue syndrome/myalgic encephalomyelitis: where are we now?

PURPOSE OF REVIEW

The current review aims to determine the recent evidence regarding cause, impact, effective treatment and prognosis of children and young people (CYP) affected by chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) at a time when the National Institute for Clinical Excellence guidelines in the United Kingdom are being reviewed and more research is called for worldwide.

RECENT FINDINGS

CFS/ME is a debilitating illness with no clear cause. This review describes the heterogeneous clinical picture and the effects on the young person and family. Comorbidities such as mood disorders and pain are discussed including evidence for treatment. The various aetiological hypotheses are discussed and the precipitating factors identified. The evidence base is limited regarding effective treatment for CYP with CFS/ME, particularly the severely affected group. A large trial of online cognitive behavioural therapy with teenagers is being explored in the United Kingdom. The Lightning Process has been shown to be effective when added to medical care.

SUMMARY

Current evidence is hampered by different diagnostic criteria, the heterogeneous nature of the condition, and limited number of small studies. There is a clear need for more research and larger studies exploring the cause of and most effective treatment for CYP with CFS/ME.

Perfectionism and beliefs about emotions in adolescents with chronic fatigue syndrome and their parents: a preliminary investigation in a case control study nested within a cohort

Objectives: To investigate perfectionism and beliefs about emotions in adolescents with chronic fatigue syndrome (CFS) and their parents. Design: Case-control comparing adolescents (age 11-18) with CFS (N = 121), asthma (N = 27) and healthy controls (N = 78) with a 3-month follow up for CFS participants. Main outcome measures: Adolescents: Chalder Fatigue Questionnaire, physical functioning, Beliefs about Emotions scale (BES), Child and Adolescent Perfectionism Scale, Frost Multidimensional Perfectionism Scale (FMPS). Parents: BES, FMPS, Self-sacrificing scale, Affective styles questionnaire. Results: Adolescents with CFS did not consistently report higher levels of perfectionism and unhelpful beliefs about emotions than adolescents with asthma or healthy adolescents. Mothers' and adolescents' beliefs about emotions and unhelpful perfectionism were significantly associated (p = .007). Linear regression found that neither adolescent perfectionism nor beliefs about emotions accounted for variance in subsequent fatigue or physical functioning. Conclusion: Parental perfectionism and emotion regulation style may contribute to perfectionism in adolescents with CFS. Parental representations could contribute to fatigue maintenance.

Depressive symptoms in adolescents with chronic fatigue syndrome (CFS): Are rates higher than in controls and do depressive symptoms affect outcome?

INTRODUCTION

Previous research has indicated that co-morbid depression is common in adolescents with chronic fatigue syndrome (CFS).

OBJECTIVES

We sought to compare the characteristics of depressive symptoms in adolescents with CFS to those of healthy controls (HCs) and illness controls (adolescents with asthma).

DESIGN

Case-control study nested within a prospective clinical cohort.

METHODS

A total of 121 adolescents with CFS who attended an initial assessment at two specialist CFS units completed the Children's Depression Inventory (CDI). Their responses were compared to 80 HCs and 27 adolescents with asthma (illness controls). The clinical cohort of adolescents with CFS completed questionnaires at assessment, and those who were seen subsequently for treatment at the CFS unit (68%) completed the measures again at their first treatment session.

RESULTS

CFS participants scored significantly higher on all the depression subscales than participants with asthma and HCs. Depression score explained 11% of the variance in subsequent fatigue, but only 1.9% of the variance in physical functioning. Depression score also explained most (68%) of the variance in subsequent depression.

CONCLUSION

Depressive symptoms are more prominent in adolescents with CFS than in HCs or illness controls. These symptoms also appear to remain over time during a naturalistic follow-up where no treatment was provided. This highlights the need for further research into depression in CFS, including stratifying treatment outcomes by depression status to determine what is effective at addressing these symptoms.

Illness perceptions in adolescents with chronic fatigue syndrome and other physical health conditions: Application of the common sense model

BACKGROUND

The common sense model (CSM) proposes that illness perceptions guide coping and illness management, which subsequently affects outcomes. Chronic fatigue syndrome (CFS) is associated with severe functional impairment. CFS is distinct from other physical health conditions in that individuals can experience high levels of uncertainty, stigma and disbelief from others. This study aimed to compare illness perceptions in adolescents with CFS with other physical health conditions, using a cross-sectional, between-groups design.

METHODS

Adolescents (aged 11-18) with CFS (n = 49), type 1 diabetes (n = 52) and juvenile idiopathic arthritis (n = 42) were recruited through National Health Service (NHS) clinics and online, and completed a series of questionnaires.

RESULTS

Adolescents with CFS differed on the perceived consequences, timeline, personal control, treatment control, identity and understanding dimensions of illness perceptions. Except for identity, these dimensions were predicted by health condition even when accounting for age, gender, fatigue, physical functioning, anxiety and depression.

CONCLUSIONS

Results offer preliminary evidence for the applicability of the CSM in adolescents, with implications for supporting adolescents with physical health conditions. Results suggest that psychological interventions targeting perceived control, understanding and identity may have particular utility for adolescents with CFS.

Psychometric properties of the Cognitive and Behavioural Responses Questionnaire (CBRQ) in adolescents with chronic fatigue syndrome

BACKGROUND

To better understand the maintenance of chronic fatigue syndrome (CFS), a valid and reliable measure of cognitive and behavioural responses to symptoms is required. Such a measure could also assess beliefs and coping behaviours in the context of fatigue in other somatic conditions.

AIMS

We aimed to establish the psychometric properties of both the Cognitive and Behavioural Responses Questionnaire (CBRQ) and its shortened version (CBRQ-S) in adolescents with CFS.

METHOD

The full questionnaire was completed by a clinical cohort of adolescents (n = 121) presenting to specialist CFS units in the UK.

RESULTS

Both the CBRQ and CBRQ-S had good internal consistency. The CBRQ scores were strongly associated with depression, anxiety, school and social functioning, but weakly associated with fatigue and physical functioning, providing evidence of validity.

CONCLUSION

Both the 40-item and the 18-item versions of the CBRQ were found to be reliable and valid in adolescents with CFS. To minimize unnecessary burden, the 18-item version is favoured. Using this assessment tool in future studies, including intervention studies, may help to better target interventions during clinical practice and improve outcomes.

"It's not one size fits all"; the use of videoconferencing for delivering therapy in a Specialist Paediatric Chronic Fatigue Service

BACKGROUND

There are few specialist paediatric Chronic Fatigue Syndrome (CFS/ME) services in the UK. Therefore, the distance some families have to travel to reach these services can be a barrier to accessing evidence-based treatment. Videoconferencing technology such as Skype provides a means of delivering sessions remotely. This study aimed to explore the views of children and young people, their parents, and healthcare professionals of treatment delivered by videoconferencing in a specialist paediatric CFS/ME team.

METHOD

To explore the experiences of the participants, a qualitative design was selected. Twelve young people (age 9-18), and 6 parents were interviewed about their experience of treatment sessions delivered via videoconferencing within a specialist CFS/ME service. A focus group explored the views of healthcare professionals (N = 9) from the service. Thematic analysis was used.

RESULTS

Three themes were identified from the data: "Challenges and concerns", "Benefits" and "Treatment provision". Challenges and concerns that participants identified were; difficulties experienced with technology; a sense of a part of communication being lost with virtual connections; privacy issues with communicating online and feeling anxious on a screen. Participants felt that benefits of videoconferencing were; improving access to the chronic fatigue service; convenience and flexibility of treatment provision; a sense of being more open online and being in the comfort of their own home. In terms of treatment provision participants talked about videoconferencing as a part of a hierarchy of communication; the function of videoconferencing within the context of the chronic fatigue service; additional preparation needed to utilise videoconferencing and an assumption that videoconferencing is "part of young people's lives".

CONCLUSIONS

Although the experience of sessions provided by videoconferencing was different to sessions attended in person, participants tended to be positive about videoconferencing as an alternative means of accessing treatment, despite some barriers. Videoconferencing could be an additional option within an individualised care plan, but should not be an alternative to face to face support.

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome-Metabolic Disease or Disturbed Homeostasis due to Focal Inflammation in the Hypothalamus?

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex disease characterized by debilitating fatigue, lasting for at least 6 months, with associated malaise, headaches, sleep disturbance, and cognitive impairment, which severely impacts quality of life. A significant percentage of ME/CFS patients remain undiagnosed, mainly due to the complexity of the disease and the lack of reliable objective biomarkers. ME/CFS patients display decreased metabolism and the severity of symptoms appears to be directly correlated to the degree of metabolic reduction that may be unique to each individual patient. However, the precise pathogenesis is still unknown, preventing the development of effective treatments. The ME/CFS phenotype has been associated with abnormalities in energy metabolism, which are apparently due to mitochondrial dysfunction in the absence of mitochondrial diseases, resulting in reduced oxidative metabolism. Such mitochondria may be further contributing to the ME/CFS symptomatology by extracellular secretion of mitochondrial DNA, which could act as an innate pathogen and create an autoinflammatory state in the hypothalamus. We propose that stimulation of hypothalamic mast cells by environmental, neuroimmune, pathogenic and stress triggers activates microglia, leading to focal inflammation in the brain and disturbed homeostasis. This process could be targeted for the development of novel effective treatments.

The Importance of Accurate Diagnosis of ME/CFS in Children and Adolescents: A Commentary

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic illness that causes a range of debilitating symptoms. While most research has focused on adults, the illness also presents in children and adolescents. Many physicians find it difficult to diagnose the illness. In this commentary paper, we discuss a range of salient themes that have emerged from our ongoing research into the prevalence of ME/CFS in children and adolescents. We discuss reasons why pediatric prevalence estimates vary widely in the literature, from almost 0% to as high as 3%. We argue that there is considerable misdiagnosis of pediatric cases and over-inflation of estimates of pediatric ME/CFS. Many children and teenagers with general fatigue and other medical complaints may meet loose diagnostic criteria for ME/CFS. We make recommendations for improving epidemiological research and identifying pediatric ME/CFS in clinical practice.