Jessica W. Guite

Recurrent abdominal pain: A potential precursor of irritable bowel syndrome in adolescents and young adults

OBJECTIVES To assess symptoms of irritable bowel syndrome (IBS) in patients with recurrent abdominal pain (RAP) 5 years after their initial evaluation, to identify the relation of IBS symptoms to functional disability and health service use, and to determine the extent to which IBS symptoms are associated with life stress and poor psychosocial adjustment. METHODS Patients with RAP (n = 76) and control subjects (n = 49) completed a telephone interview; measures included the Bowel Disease Questionnaire, the Functional Disability Inventory, the Life Events Questionnaire, the Family Inventory of Life Events, the Center for Epidemiological Studies Depression Scale, the Self-Perception Profile for Adolescents, and the Health Resources Inventory. RESULTS Five years after the initial evaluation, patients with RAP reported significantly more episodes of abdominal pain than did control subjects, as well as significantly higher levels of functional disability, school absence, and clinic visits for abdominal distress. Female patients with RAP were more likely than female control subjects to meet the Manning criteria for IBS. Among patients with RAP, higher levels of IBS symptoms were associated with significantly greater functional disability, more clinic visits, more life stress, higher levels of depression, and lower academic and social competence. CONCLUSION Female patients with a history of RAP may be at increased risk of IBS during adolescence and young adulthood. Among adolescents and young adults with a history of RAP, IBS symptoms are likely to be associated with high levels of disability and health service use.

Impact of Adversity on Functioning and Comorbidity in Children with Attention-Deficit Hyperactivity Disorder

OBJECTIVE Prior research on risk factors for attention-deficit hyperactivity disorder (ADHD) has shown that familial risk factors play a role in the disorders etiology. This study investigated whether features of the family environment were associated with ADHD. METHOD One hundred forty children with ADHD and 120 normal control probands were studied. Subjects were Caucasian, non-Hispanic males between the ages of 6 and 17 years. Exposure to parental psychopathology and exposure to parental conflict were used as indicators of adversity, and their impact on ADHD and ADHD-related psychopathology and dysfunction in children was assessed. RESULTS Increased levels of environmental adversity were found among ADHD compared with control probands. The analyses showed significant associations between the index of parental conflict and several of the measures of psychopathology and psychosocial functioning in the children. In contrast, the index of exposure to parental psychopathology had a much narrower impact, affecting primarily the childs use of leisure time and externalizing symptoms. CONCLUSIONS A relationship appears to exist between adversity indicators and the risk for ADHD as well as for its associated impairments in multiple domains. These findings confirm previous work and stress the importance of adverse family-environment variables as risk factors for children who have ADHD.

Pregnancy, delivery and infancy complications and attention deficit hyperactivity disorder: Issues of gene-environment interaction

We evaluated the role of pregnancy, delivery, and infancy complications (PDICs) in the etiology of attention deficit hyperactivity disorder (ADHD) and addressed issues of comorbidity and familiarity by testing multiple hypotheses. Subjects were 6-17-year-old boys with DSM-III-R ADHD (n = 140) and normal controls (n = 120) and their first-degree biologic relatives. Information on PDICs was obtained from mothers in a standardized manner blind to the probands clinical status. Using linear and logistic regression models, a positive association was found between ADHD and PDICs in the probands. Additionally, PDICs were associated with the correlates of ADHD (i.e., impaired cognitive functioning and poor school performance). Moreover, it was those specific complications that reflect chronic exposure, such as maternal bleeding, smoking, family problems, and illicit drug use during pregnancy that accounted for these findings. No interaction between genetic factors and PDICs were found. Our findings add to the literature supporting an association between ADHD and PDICs. Our results may help clinicians focus on particular complications rather than the wide range of possible perinatal complications.

Clinical utility and validity of the Functional Disability Inventory among a multicenter sample of youth with chronic pain.

&NA; The Functional Disability Inventory (FDI) is a well‐established and commonly used measure of physical functioning and disability in youth with chronic pain. Further validation of the measure has been called for, in particular, examination of the clinical utility and factor structure of the measure. To address this need, we utilized a large multicenter dataset of pediatric patients with chronic pain who had completed the FDI and other measures assessing pain and emotional functioning. Clinical reference points to allow for interpretation of raw scores were developed to enhance clinical utility of the measure, and exploratory factor analysis was performed to examine its factor structure. Participants included 1300 youth ages 8 to 18 years (mean = 14.2 years; 76% female) with chronic pain. Examination of the distribution of FDI scores and validation with measures of depressive symptoms and pain intensity yielded 3 distinct categories of disability: No/Minimal Disability, Moderate Disability, and Severe Disability. Factor analysis of FDI scores revealed a 2‐factor solution representing vigorous Physical Activities and non‐physically strenuous Daily Activities. The 3‐level classification system and factor structure were further explored via comparison across the 4 most commonly encountered pain conditions in clinical settings (head, back, abdominal, and widespread pain). Our findings provide important new information regarding the clinical utility and validity of the FDI. This will greatly enhance the interpretability of scores for research and clinical use in a wide range of pediatric pain conditions. In particular, these findings will facilitate use of the FDI as an outcome measure in future clinical trials. Clinical reference points and a preliminary factor structure for the Functional Disability Inventory (FDI) increase the clinical and research utility of the measure.

Effects of Family History and Comorbidity on the Neuropsychological Performance of Children with ADHD: Preliminary Findings

OBJECTIVE Because ADHD is heterogeneous with respect to psychiatric comorbidity, familiality, and learning disabilities, it was hypothesized that such features might influence the severity and pattern of neuropsychological function in ADHD. METHOD Subjects were 9- to 20-year-old males with DSM-III-R ADHD (n = 65) and normal controls (n = 45). Information on neuropsychological performance was obtained in a standardized manner, blind to the probands clinical status. RESULTS ADHD probands were significantly impaired on neuropsychological functions compared with controls irrespective of composite psychiatric comorbidity status, and those with a family history of ADHD were most impaired. ADHD probands with learning disabilities showed a pattern suggestive of reduced motor dominance and extremely slow reading speed. CONCLUSIONS These results indicate that neuropsychological performance in ADHD is significantly affected by familial status and presence of learning disabilities. The similarity of findings between ADHD children with and without comorbid psychiatric disorders suggests that the neuropsychological impairments in our sample were associated with ADHD. These findings raise the possibility of alterations of cerebral dominance and of frontal networks in ADHD. Further research is needed to replicate these findings in larger samples, to clarify the role of specific comorbid psychiatric disorders, and to assess directly cerebral functioning in subjects with ADHD.

Associations between childhood asthma and ADHD: issues of psychiatric comorbidity and familiality.

OBJECTIVE In this paper we evaluate the association between asthma and attention-deficit hyperactivity disorder (ADHD), addressing issues of comorbidity and familiality by formulating and testing competing hypotheses. METHOD Subjects were 6- to 17-year-old boys with DSM-III-R ADHD (N = 140) and normal controls (N = 120) and their first-degree relatives. Information on asthma was obtained from the mothers in a standardized manner blind to the probands clinical status. RESULTS The risk for asthma did not meaningfully differ between ADHD and control children. Relatives of ADHD probands with and without asthma were at significantly greater risk for ADHD than relatives of normal controls. In contrast, the risk for asthma was significantly elevated only among relatives of children with ADHD plus asthma. CONCLUSIONS These findings argue against a substantial etiological or pathophysiological relationship between the two conditions but suggest that ADHD and asthma are independently transmitted in families. Thus, the observation of ADHD symptoms in an asthmatic child should not be dismissed out of hand as being a consequence of asthma since many asthmatic ADHD children may actually have ADHD.

Discordance Between Sibling and Parent Reports of the Impact of Chronic Illness and Disability on Siblings

This study compared sibling and parent reports of sibling adjustment to chronic illness/developmental disability (CI/DD) in 51 siblings (ages 8 to 13). Discordance between sibling and parent reports on the Sibling Perception Questionnaire was common, with parents tending to report more sibling adjustment problems than did siblings. Siblings who reported more problems than parents tended to be younger and male. There was a trend for parents who reported more problems than siblings to also report greater negative impact of CI/DD on family social functioning than other parents. Findings highlight the importance of obtaining sibling self-reports in research and clinical settings.

Primary Erythromelalgia in a Child Responding to Intravenous Lidocaine and Oral Mexiletine Treatment

Erythromelalgia is a rare, chronic, debilitating condition characterized by redness, warmth, and severe burning pain of the distal extremities. The feet are more commonly affected than the hands. Pain is precipitated by increases in temperature and by exercise. Patients often obtain relief by immersing the affected extremity in cold water. The pain is often refractory to treatment. For many patients, multiple pain medications have been useless in achieving complete relief of pain symptoms. Previous reports of erythromelalgia among adolescents indicated prolonged relief of pain with sodium nitroprusside infusions, epidural infusions of local anesthetics, or gabapentin treatment. We present a case of an 11-year-old, white, male child with primary erythromelalgia, whose initial symptoms started in his preschool years and whose childhood was marked by escalating episodes of pain with warmth and redness of his feet, precipitated especially by increases in temperature and by activity. All conventional pain management techniques had failed to relieve our patient of his symptoms, and he obtained some relief only by soaking his affected extremities in ice water. He had experienced minimal benefit from seeing a pain psychologist, who helped him develop techniques to cope with the pain. At the time of presentation, the patients episodes of pain had increased to 15 to 20 per day, and there was evidence of chronic immersion injury to the skin of his feet. Before his most recent hospitalization, the pain had spread to involve his hands as well. The patient was overwhelmed with anxiety and could not participate in school or social activities at the time of admission. During his current hospitalization, he did show some therapeutic response to sodium nitroprusside infusion, which unfortunately had to be discontinued because of side effects and because his family desired to leave the ICU environment, which was stressful to the patient. He also had some response to lumbar epidural infusion of local anesthetics, which could not be continued because he found the motor blockade that accompanied his analgesia intolerable. However, intravenous lidocaine infusion, with subsequent transition to oral mexiletine therapy, proved very effective in reducing the frequency and severity of the pain episodes. The patient was discharged from the hospital with oral mexiletine therapy and has been monitored at the pain management clinic. He returned to and completed school, attended summer camp, and enjoys an active happy life. He walks without precipitating pain in his feet and sleeps 9 to 10 hours every night. He has needed to soak his feet on only 4 occasions in the 6 months since his discharge from the hospital. His quality of life has improved significantly. He has shown no evidence of liver toxicity, and his mexiletine levels have been stable.

Relationships among pain, protective parental responses, and disability for adolescents with chronic musculoskeletal pain: the mediating role of pain catastrophizing.

ObjectivesChildren learn to cope with pain within the context of the family and parental responses to pediatric pain can impact health outcomes. The aim of this study was to examine relationships among pain, protective parental responses to pain, functional disability, and pain catastrophizing for adolescents with chronic musculoskeletal pain syndromes. MethodsInitial evaluation records for 138 adolescents with chronic musculoskeletal pain who consulted a pediatric multidisciplinary pain management clinic were examined. Measures were collected at the time of the initial evaluation and included adolescent self-reports of their own usual pain intensity, perceived parental responses to their pain, adolescent functional disability, and pain catastrophizing. ResultsPain catastrophizing was significantly correlated with pain intensity, protective parental responses to pain, and functional disability. Multiple regression analyses further suggest that pain catastrophizing serves as a mediator of relationships between: (1) pain and disability and (2) protective parenting responses and disability. Evidence supporting a significant indirect effect for pain catastrophizing on disability was found within both models through bootstrap and Sobel analyses. DiscussionPain catastrophizing seems to play an important role in understanding relationships between pain, protective parental responses, and disability for adolescents with musculoskeletal pain. Our findings suggest that strategies that help modify adolescent catastrophic pain beliefs and parental responses to pain, may help improve adolescent functioning.

Adolescent Pain Catastrophizing Mediates the Relationship Between Protective Parental Responses to Pain and Disability Over Time

OBJECTIVE Examine whether the relation between protective parenting responses to pain and functional disability is mediated by pain catastrophizing in adolescents with chronic musculoskeletal pain and their parents over time. METHODS Adolescents aged 11-18 years and their parents reported on parental protective responses to pain (PPRP), pain catastrophizing scale (PCS), and Functional Disability Inventory (FDI) before Time 1 (T1) and 2 months after Time 2 (T2) an initial interdisciplinary pain clinic evaluation. RESULTS PCS was a significant mediator of the PPRP-FDI relationship at T1 and T2 for the adolescents and T2 for their parents. A decrease in PPRP over time was associated with T2 PCS, which in turn was associated with T2 FDI for adolescents and their parents. CONCLUSION Parental protectiveness is associated with disability indirectly through pain catastrophizing at the initial visit and follow-up. Decreases in parent protectiveness, potentially initiated through the initial evaluation, were related to lower levels of disability at follow-up through pain catastrophizing.