John V. Campo

Annual Research Review: Functional somatic symptoms and associated anxiety and depression – developmental psychopathology in pediatric practice

BACKGROUND Medically unexplained physical symptoms, commonly referred to as functional somatic symptoms (FSS), are common in pediatric medical settings and associated with suffering, impairment, and medical help seeking. The association of pediatric FSS with anxiety and depressive symptoms and disorders across the life span is reviewed. METHOD Review and critique of controlled studies examining cross-sectional and longitudinal associations of FSS with anxiety and depressive symptoms and disorders in community-based and clinical samples of children and adolescents. RESULTS FSS are consistently associated cross-sectionally with anxiety and depressive symptoms and disorders in childhood and adolescence, and the likelihood of associated anxiety and depression increases with the number of reported FSS. The presence of one or more FSS early in life is associated with an increased likelihood of multiple FSS and anxiety and depressive symptoms and disorders later in life, and anxiety and depressive symptoms and disorders in childhood are associated with subsequent multiple FSS. CONCLUSION Strong associations between FSS, anxiety, and depression across the life span suggest the need to reconsider existing nosology and reconceptualize symptomatic relationships. Large, population-based longitudinal studies of FSS, anxiety, and depressive symptoms and disorders are needed to establish temporal relationships between the various symptoms and conditions.

Collaborative Care Outcomes for Pediatric Behavioral Health Problems: A Cluster Randomized Trial

OBJECTIVE: To assess the efficacy of collaborative care for behavior problems, attention-deficit/hyperactivity disorder (ADHD), and anxiety in pediatric primary care (Doctor Office Collaborative Care; DOCC). METHODS: Children and their caregivers participated from 8 pediatric practices that were cluster randomized to DOCC (n = 160) or enhanced usual care (EUC; n = 161). In DOCC, a care manager delivered a personalized, evidence-based intervention. EUC patients received psychoeducation and a facilitated specialty care referral. Care processes measures were collected after the 6-month intervention period. Family outcome measures included the Vanderbilt ADHD Diagnostic Parent Rating Scale, Parenting Stress Index-Short Form, Individualized Goal Attainment Ratings, and Clinical Global Impression-Improvement Scale. Most measures were collected at baseline, and 6-, 12-, and 18-month assessments. Provider outcome measures examined perceived treatment change, efficacy, and obstacles, and practice climate. RESULTS: DOCC (versus EUC) was associated with higher rates of treatment initiation (99.4% vs 54.2%; P < .001) and completion (76.6% vs 11.6%, P < .001), improvement in behavior problems, hyperactivity, and internalizing problems (P < .05 to .01), and parental stress (P < .05–.001), remission in behavior and internalizing problems (P < .01, .05), goal improvement (P < .05 to .001), treatment response (P < .05), and consumer satisfaction (P < .05). DOCC pediatricians reported greater perceived practice change, efficacy, and skill use to treat ADHD (P < .05 to .01). CONCLUSIONS: Implementing a collaborative care intervention for behavior problems in community pediatric practices is feasible and broadly effective, supporting the utility of integrated behavioral health care services.

Suicide Trends Among Youths Aged 10 to 19 Years in the United States, 1996-2005

To the Editor: Following a decade of steady decline, the suicide rate among US youth younger than 20 years increased by 18% from 2003 to 2004, the largest singleyear change in the pediatric suicide rate over the past 15 years. Federal health officials have urged caution in interpreting this 1-year apparent spike in youth suicide until data from additional years are available for comparison. We examined available national fatal injury data to assess whether the increase in suicide rates among US youth persisted from 2004 to 2005, the latest year for which data are available. Methods. Data on deaths for which suicide (coded E950-E959 for International Classification of Diseases, Ninth Revision [ICD-9] [1996-1998] and X60-X84, Y87.0, and U03 for ICD-10 [1999-2005]) was listed as the underlying cause of death among 10to-19-year-olds were obtained from the National Vital Statistics Systems using WISQARS (Web-based Injury Statistics Query and Reporting System; National Center for Injury Prevention and Control, Atlanta, Georgia). There is excellent agreement between classification of suicide deaths in ICD-9 and ICD-10 (comparability ratio = 1.002). The 10to 19-year age group was selected to facilitate comparison with previous research; the 1996-2005 time period was selected to provide a relatively recent context for evaluating single-year changes in suicide rates in 2004 and 2005. Information was extracted regarding number of suicide deaths per year, age, and sex. Rates of suicide per 100 000 persons were calculated with the use of population estimates obtained from WISQARS. The trend in suicide rates from 1996-2003 was estimated using log-linear regression. There was no evidence of serial correlation, overdispersion, or nonconstant variance in the fitted model. Using the 1996-2003 trend line, we estimated the expected suicide rates in 2004 and 2005 and calculated 95% prediction intervals (PIs) for each year. We then calculated total excess suicide deaths in 2004 and 2005 by taking the difference between the observed number of deaths and the expected number of deaths estimated from the 1996-2003 trend. Analyses were performed using R statistical software version 2.6.0 (R Foundation for Statistical Computing, Vienna, Austria). Results. Although the overall observed rate of suicide among youth aged 10 to 19 years decreased by 5.3% between 2004 and 2005 (4.74 to 4.49 per 100 000), both the 2004 and 2005 rates were still significantly greater than the expected rates based on the 1996-2003 trend (2004 95% PI, 3.64-4.30; 2005 95% PI, 3.47-4.15). This same pattern of significance was also found for males and females separately (FIGURE 1) and in the 10to 17-year and 18to 19-year age groups (FIGURE 2). In absolute numbers, in 2004 there were an estimated 326 excess suicide deaths among youth aged 10 to 19 years (167 females, 159 males) compared with the number of deaths predicted by the regression model. In 2005, the overall number of excess suicide deaths was 292 (105 females, 187 males). Comment. The significant excess mortality due to youth suicide in 2004 and 2005 suggests that the marked increase in suicide rates from 2003 to 2004 was not a single-

Management of pediatric mental disorders in primary care: where are we now and where are we going?

Purpose of review Pediatric mental disorders are among the most common disorders of childhood and are routinely seen in primary care. We review innovative management strategies, treatment technologies, and models of collaboration with behavioral health specialists in general medical settings. Our goal is to advance the integration of behavioral health services into primary care. Recent findings The application of mental health interventions with proven efficacy holds great promise for youths with mental disorders. Unfortunately, traditional primary-care management of pediatric mental disorders is characterized by nonspecific counseling, low-dose prescribing, and referrals to specialty settings that are often not completed. Summary The development, study, and refinement of new assessment and treatment technologies, supplemental treatments, and collaborative models of care delivery will be necessary to ensure more effective care for youths with mental disorders and their families. The promise of pediatric mental healthcare will not be fulfilled unless primary-care clinicians and behavioral health specialists forge new collaborative relationships that enhance the delivery of evidence-based care to affected children and their families.

Improving Access to Care and Clinical Outcome for Pediatric Behavioral Problems: A Randomized Trial of a Nurse-Administered Intervention in Primary Care

Objective: To determine the effectiveness of an on-site modular intervention in improving access to mental health services and outcomes for children with behavioral problems in primary care relative to enhanced usual care. The study includes boys and girls from six primary care offices in metropolitan Pittsburgh, PA. Methods: One hundred sixty-three clinically referred children who met a modest clinical cutoff (75th percentile) on the externalizing behavior scale of the Pediatric Symptom Checklist-17 were randomized to a protocol for on-site, nurse-administered intervention or to enhanced usual care. Protocol for on-site, nurse-administered intervention applied treatment modules from an evidence-based specialty mental health treatment for children with disruptive behavior disorders that were adapted for delivery in the primary care setting; enhanced usual care offered diagnostic assessment, recommendations, and facilitated referral to a specialty mental health provider in the community. The main outcome measures such as standardized rating scales, including the Pediatric Symptom Checklist-17, individualized target behavior ratings, treatment termination reports, and diagnostic interviews were collected. Results: Protocol for on-site, nurse-administered intervention cases were significantly more likely to receive and complete mental health services, reported fewer service barriers and more consumer satisfaction, and showed greater, albeit modest, improvements on just a few clinical outcomes that included remission for categorical behavioral disorders at 1-year follow-up. Both conditions also reported several significant improvements on several clinical outcomes over time. Conclusions: A psychosocial intervention for behavior problems that was delivered by nurses in the primary care setting is feasible, improves access to mental health services, and has some clinical efficacy. Options for enhancing clinical outcome include the use of multifaceted collaborative care interventions in the pediatric practice.

Impaired Decision Making in Adolescent Suicide Attempters

OBJECTIVE Decision-making deficits have been linked to suicidal behavior in adults. However, it remains unclear whether impaired decision making plays a role in the etiopathogenesis of youth suicidal behavior. The purpose of this study was to examine decision-making processes in adolescent suicide attempters and never-suicidal comparison subjects. METHOD Using the Iowa Gambling Task, the authors examined decision making in 40 adolescent suicide attempters, 13 to 18 years old, and 40 never-suicidal, demographically matched psychiatric comparison subjects. RESULTS Overall, suicide attempters performed significantly worse on the Iowa Gambling Task than comparison subjects. This difference in overall task performance between the groups persisted in an exact conditional logistic regression analysis that controlled for affective disorder, current psychotropic medication use, impulsivity, and hostility (adjusted odds ratio = 0.96, 95% confidence interval = 0.90-0.99, p < 0.05). A two-way repeated-measures analysis of variance revealed a significant group-by-block interaction, demonstrating that attempters failed to learn during the task, picking approximately the same proportion of disadvantageous cards in the first and final blocks of the task. In contrast, comparison subjects picked proportionately fewer cards from the disadvantageous decks as the task progressed. Within the attempter group, overall task performance did not correlate with any characteristic of the index attempt or with the personality dimensions of impulsivity, hostility, and emotional lability. CONCLUSIONS Similar to findings in adults, impaired decision making is associated with suicidal behavior in adolescents. Longitudinal studies are needed to elucidate the temporal relationship between decision-making processes and suicidal behavior and to help frame potential targets for early identification and preventive interventions to reduce youth suicide and suicidal behavior.

Suicide trends among elementary school-aged children in the United States From 1993 to 2012

IMPORTANCE Suicide is a leading cause of death among school-aged children younger than 12 years but little is known about the epidemiology of suicide in this age group. OBJECTIVE To describe trends in suicide among US children younger than 12 years by sociodemographic group and method of death. DESIGN, SETTING, AND PARTICIPANTS Period trend analysis of national mortality data on suicide in children aged 5 to 11 years in the United States from January 1, 1993, to December 31, 2012. Data were analyzed per 5-year periods, between 1993 to 1997 and 2008 to 2012. MAIN OUTCOMES AND MEASURES Number of suicide deaths and crude suicide rates. Period trends in rates of suicide were estimated using negative binomial regression incidence rate ratios (IRRs). RESULTS The overall suicide rate among children aged 5 to 11 years remained stable between 1993 to 1997 and 2008 to 2012 (from 1.18 to 1.09 per 1 million; IRR = 0.96; 95% CI, 0.90-1.03). However, the suicide rate increased significantly in black children (from 1.36 to 2.54 per 1 million; IRR = 1.27; 95% CI, 1.11-1.45) and decreased in white children (from 1.14 to 0.77 per 1 million; IRR = 0.86; 95% CI, 0.79-0.94). The overall firearm suicide rate (IRR = 0.69; 95% CI, 0.57-0.85) and firearm suicide rate among white boys (IRR = 0.72; 95% CI, 0.59-0.88) decreased significantly during the study. The rate of suicide by hanging/suffocation increased significantly in black boys (IRR = 1.35; 95% CI, 1.14-1.61), although the overall change in suicide rates by hanging/suffocation or other suicide methods did not change during the study. CONCLUSIONS AND RELEVANCE The stable overall suicide rate in school-aged children in the United States during 20 years of study obscured a significant increase in suicide incidence in black children and a significant decrease in suicide incidence among white children. Findings highlight a potential racial disparity that warrants attention. Further studies are needed to monitor these emerging trends and identify risk, protective, and precipitating factors relevant to suicide prevention efforts in children younger than 12 years.

Doctor-Office Collaborative Care for Pediatric Behavioral Problems: A Preliminary Clinical Trial

OBJECTIVES To evaluate the feasibility and clinical benefits of an integrated mental health intervention (doctor-office collaborative care [DOCC]) vs enhanced usual care (EUC) for children with behavioral problems. DESIGN Cases were assigned to DOCC and EUC using a 2:1 randomization schedule that resulted in 55 DOCC and 23 EUC cases. SETTING Preassessment was conducted in 4 pediatric primary care practices. Postassessment was conducted in the pediatric or research office. Doctor-office collaborative care was provided in the practice; EUC was initiated in the office but involved a facilitated referral to a local mental health specialist. PARTICIPANTS Of 125 referrals (age range, 5-12 years), 78 children participated. INTERVENTIONS Children and their parents were assigned to receive DOCC or EUC. MAIN OUTCOME MEASURES Preassessment diagnostic status was evaluated using the Schedule for Affective Disorders and Schizophrenia for School-aged Children. Preassessment and 6-month postassessment ratings of behavioral and emotional problems were collected from parents using the Vanderbilt Attention-Deficit/Hyperactivity Disorder Diagnostic Parent Rating Scale, as well as individualized goal achievement ratings forms. At discharge, care managers and a diagnostic evaluator completed the Clinical Global Impression Scale, and pediatricians and parents completed satisfaction and study feedback measures. RESULTS Group comparisons found significant improvements for DOCC over EUC in service use and completion, behavioral and emotional problems, individualized behavioral goals, and overall clinical response. Pediatricians and parents were highly satisfied with DOCC. CONCLUSION The feasibility and clinical benefits of DOCC for behavioral problems support the integration of collaborative mental health services for common mental disorders in primary care.

Long-Term Outcome of Functional Childhood Constipation

We investigated whether functional childhood constipation (FCC) is an early expression in the continuum of functional disorders such as adult constipation, irritable bowel syndrome (IBS), and dyspepsia. Adults ≥18 years with a diagnosis of FCC verified by one pediatric gastroenterologist participated in the questionnaire-based study. Controls were comprised of adults who underwent tonsillectomy as otherwise healthy children during the period corresponding to the FCC diagnosis. The prevalence of constipation, IBS, and dyspepsia was determined by the Bowel Disease Questionnaire. Twenty FCC adults (8 females), median age 22 years, were compared with 17 adult controls (10 females), median age 22.9 years. The frequency of constipation in FCC adults was not different from that in controls (25% versus 23.5%). The frequency of IBS in FCC adults was higher than in controls (55% versus 23.5%; P < 0.05). Dyspepsia was reported by 25% of both groups. The median follow-up period of the FCC adults was 14 years. In a long-term follow-up of a small sample, the prevalence of constipation in FCC adults is comparable to that in controls. Childhood constipation appears to be a predictor of IBS in adulthood.

Expert survey for the management of adolescent depression in primary care

OBJECTIVE. Primary care clinics have become the “de facto” mental health clinics for teens with mental health problems such as depression; however, there is little guidance for primary care professionals who are faced with treating this population. This study surveyed experts on key management issues regarding adolescent depression in primary care where empirical literature was scant or absent. METHODS. Participants included experts from family medicine, pediatrics, nursing, psychology, and child psychiatry, identified through nonprobability sampling. The expert survey was developed on the basis of information from focus groups with patients, families, and professionals and from the research literature and included sections on early identification, assessment and diagnosis, initial management, treatment, and ongoing management. Means, standard deviations, and confidence intervals were calculated for each survey item. RESULTS. Seventy-eight of 81 experts agreed to participate (return rate of 96%). Fifty-three percent of the experts (n = 40) were primary care professionals. Experts endorsed routine surveillance for youth at high risk for depression, as well as the use of standardized measures as diagnostic aids. For treatment, “active monitoring” was deemed appropriate in mild depression with recent onset. Medication and psychotherapy were considered acceptable options for treatment of moderate depression without complicating factors such as comorbid illness. Fluoxetine was rated as the most appropriate antidepressant for use in this population. Finally, experts agreed that patients who are started on antidepressants should be followed within 2 weeks after initiation. CONCLUSIONS. Survey results support the identification and management of adolescent depression in the primary care setting and, in specific situations, referral and co-management with specialty mental health professionals. Even with the recent controversies around treatment, experts across primary care and specialty mental health alike agreed that active monitoring, pharmacotherapy with selective serotonin reuptake inhibitors, and psychotherapy can be appropriate under certain clinical circumstances when initiated within primary care settings.