Laura C. Reigada

Illness‐specific anxiety: Implications for functioning and utilization of medical services in adolescents with inflammatory bowel disease

PURPOSE. Adolescents with inflammatory bowel disease (IBD) may be at heightened risk for developing anxiety and depression. This cross-sectional pilot study examined the relationship between anxiety and depression and health-related behaviors. METHODS. Thirty-six adolescents with diagnosed IBD, ages 12-17, and their parents were recruited from two pediatric gastroenterology medical centers. RESULTS. Clinical levels of anxiety (22%) and depressive symptoms (30%) were reported by patients. Regression analyses revealed that IBD-specific anxiety was significantly associated with greater utilization of medical services and worsened psychosocial functioning. PRACTICE IMPLICATIONS. Results provide preliminary support that IBD-specific anxiety may play an important role in disease management, yet concerns are rarely systematically assessed by health professionals.

CBT for Anxiety and Associated Somatic Complaints in Pediatric Medical Settings: An Open Pilot Study

Objective To examine the initial feasibility and potential efficacy of a cognitive-behavioral intervention for youth with anxiety disorders and non-medical somatic symptoms. Background Based on a strong relationship between somatic complaints and anxiety disorders, screening youngsters seeking medical care due to physical symptoms with no organic basis may enhance the recognition of anxiety disorders and facilitate access to appropriate services. Method Seven boys and girls, ages 8 through 15, with medically unexplained gastrointestinal complaints and anxiety disorders received a 12-session cognitive-behavioral intervention targeting anxiety and physical symptoms. Assessments were conducted at baseline and following treatment. Results All participants were classified as treatment responders. Three of the seven participants no longer met diagnostic criteria for their principal anxiety disorder. Children’s physical discomfort decreased from a moderate to minimal level based on self- and parent-reports. Conclusions Our modified cognitive-behavioral approach has promise for reducing anxiety and somatic symptoms in children seeking medical care.

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.

Integrating illness concerns into cognitive behavioral therapy for children and adolescents with inflammatory bowel disease and co-occurring anxiety.

PURPOSE To examine the feasibility and preliminary benefits of an integrative cognitive behavioral therapy (CBT) with adolescents with inflammatory bowel disease and anxiety. DESIGN AND METHODS Nine adolescents participated in a CBT program at their gastroenterologists office. Structured diagnostic interviews, self-report measures of anxiety and pain, and physician-rated disease severity were collected pretreatment and post-treatment. RESULTS Postintervention, 88% of adolescents were treatment responders, and 50% no longer met criteria for their principal anxiety disorder. Decreases were demonstrated in anxiety, pain, and disease severity. PRACTICE IMPLICATIONS Anxiety screening and a mental health referral to professionals familiar with medical management issues is important.

Patient-reported Anxiety: A Possible Predictor of Pediatric Inflammatory Bowel Disease Health Care Use.

Background:Anxiety is linked with adverse health-related outcomes and increased health-seeking behaviors among patients with chronic illness. Yet, this relationship has received little attention in pediatric inflammatory bowel disease. The aim of this study was to examine whether anxiety symptoms predicted youth at increased risk for repeated disease relapse and greater gastrointestinal health care use over the subsequent 12 months. Methods:Eighty-six pediatric patients aged 11 to 18 years (M = 14.7, SD = 2.0), and their caregivers completed a validated anxiety questionnaire during a gastrointestinal specialty appointment (baseline). Medical records were reviewed for the subsequent year to record the number of disease relapses and gastrointestinal health care services and generate disease activity scores at baseline and 12 months. Analysis of variance was used to examine anxiety levels between those who experienced ⩽1 versus ≥2 disease relapses. Poisson regressions were used to model the relationship between child- and caregiver-reported anxiety and health care use, controlling for disease activity. Results:The sample was predominantly white (81%) and male (56%). Patients with higher anxiety at baseline (M = 19.6; SD = 13.7) had more frequent (≥2) disease relapses compared with those with lower anxiety at baseline (M = 12.6; SD = 10.3). Higher anxiety, irrespective of reporter, also predicted greater total gastrointestinal health care use (P < 0.01). This included hospital-based interventions (P < 0.01), but not office encounters or outpatient endoscopic procedures. Findings remained significant after controlling for disease severity (P < 0.05). Conclusions:Assessment of anxiety may be one mechanism by which to identify those youth who are most vulnerable for disease exacerbation and costly interventions in the near future.

Psychometric Evaluation of the IBD-Specific Anxiety Scale: A Novel Measure of Disease-Related Anxiety for Adolescents With IBD

Anxiety related to pediatric inflammatory bowel disease (IBD) is a common comorbidity; yet, this construct is understudied because of lack of available valid measurement. Objective The present study will report the preliminary validation of the 20-item IBD-Specific Anxiety Scale (IBD-SAS) in a large, geographically diverse sample of adolescents aged 12-18 years with IBD. Method A total of 281 adolescents, ages 12-18 (M = 14.8, SD = 1.78; 51% male), completed the IBD-SAS along with measures of IBD-related quality of life, anxiety, depressive symptoms, and disease activity. Factor structure was assessed using exploratory and confirmatory factor analyses (EFA and CFA). Results EFA (Sample 1; n = 141) yielded one-, two-, three- and four-factor models. The CFA (Sample 2; n = 140) demonstrated that a four-factor model was superior to three- and two-factor model for the amended scale. In total, the IBD-SAS showed excellent internal consistency (Cronbachs α = .95) and was most strongly associated with health-related quality of life. Moderate to strong associations were observed between IBD-SAS and general measures of anxiety and depressive symptoms, and IBD disease activity providing additional support that health-specific anxiety is a valid and distinct construct. Conclusions Based on the results of this study, the IBD-SAS displayed adequate psychometric properties and can meaningfully contribute to the assessment of IBD-specific anxiety in adolescents diagnosed with IBD, thus filling an empirical and clinical need in this population.

Omega-3 fatty acids and anxiety: A systematic review of the possible mechanisms at play

Introduction: Anxiety is prevalent, costly, and associated with significant adverse outcomes. The importance of nutrition is underestimated in the management of mental health disorders. In particular, omega-3 fatty acids (ω-3 FAs) are a critical component for healthy development and have been shown to reduce anxiety symptoms. Objective: This paper reviews the current state of the research to identify potential mechanisms underlying the relationship between ω-3 FAs and anxiety reduction. Method: Studies were identified using PubMed, PsycINFO, and CINAHL databases. Results: Of the 197 full-text studies screened, six met criteria for inclusion. Four mechanisms were identified based on primary outcomes reported by each study, Inflammatory Response, Brain-Derived Neurotrophic Factor (BDNF), Cortisol, and Cardiovascular Activity. Conclusion: Five key recommendations are provided to guide future research examining ω-3 FAs and anxiety. They include: (1) standardization of dosage and duration of ω-3 supplementation, (2) more rigorous measurement of variables, (3) effective blinding of participants, (4) designing experiments that test mediation, and (5) increasing sample diversity.

Analysis of anxiety symptoms and disease severity in children and adolescents with Crohn′s disease

Typhoid fever with classical features presents no difficulty in recognition. However, when it presents atypically in the guise of one of its rare complications, diagnosis becomes difficult and appropriate treatment is delayed. Typhoid glomerulonephritis is one such rare complication. We present a 7-year-old boy who presented with high grade fever, abdominal symptoms with signs of glomerulonephritis (edema, oliguria, hypertension and hematuria). Salmonella typhi resistant to chloramphenicol, ampicillin and cotrimoxazole was isolated from a blood culture. He had a complete recovery of his renal abnormality following treatment for his typhoid feverAn 8-yr-old Japanese boy was hospitalized, complaining of active hematochezia. He was shown to have a cherry-red, blood-oozing area of vascular dilation with mucosal prominence in the sigmoid colon by endoscopy, but had no other mucocutaneous vascular abnormalities. A family history was noncontributory. Under the clinical diagnosis of angiodysplasia of the sigmoid colon, he underwent an elliptical resection of the part, based on the intraoperative endoscopic findings. However, histological examination of the surgical specimen revealed a totally different picture from that seen in angiodysplasia: the thin-walled, markedly ectatic, nontortuous veins with hemorrhage were seen only just below the muscularis mucosae, around which the normal ones were shown to coexist. He has had no rebleeding for the past 3 yr. This lesion is considered to be an isolated congenital visceral telangiectasia involving veins.

O-019 Anxiety in Pediatric IBD: A Predictor for Disease Relapse and Increased Health Care Use.

Background:The impact of anxiety on disease relapse and health care use for pediatric patients diagnosed with inflammatory bowel disease (IBD) still requires further inquiry. Anxiety can influence health care utilization through multiple avenues, including manipulation of inflammatory processes central to IBD, and via somatic manifestation of psychological stress that may be misinterpreted as disease symptoms or medication side effects. The aim of this study was to examine the association between anxiety and risk for disease relapse, and test whether anxiety predicted greater gastrointestinal (GI) health care utilization over a 12-month period. Methods:Families were asked to complete Child and Parent versions of an anxiety questionnaire (Screen for Child Anxiety Related Emotional Disorders; SCARED) at their GI visit check-in, as part of a larger study (Reigada et al, in press). To be included in this study, children had to return a completed questionnaire, receive their primary IBD care at the medical practice, and remain a patient for ≥1 year. The final sample included 86 children ages 11 to 18 (M = 15.0, SD = 2.0) and their caregivers (n = 77). The number of disease relapses and GI health care utilization frequencies (i.e., GI office encounters, outpatient procedures, and hospital-based interventions) were extracted from medical records during the 12 months following completion of the anxiety questionnaire (i.e., baseline). Physicians also used documentation from patient charts to complete measures of disease activity at baseline and 12 months later. Analysis of variance was used to compare anxiety levels between those who experienced 2 or more disease relapses, and those who experienced 0 to 1. Poisson regressions were used to model relationships between child- and caregiver-reported anxiety symptoms and GI health care utilization. IBD relapses (0, 1, ≥2) and change in disease activity were also entered into the models. Results:The sample was predominantly white (81%) and the majority was male (56%). Children who experienced 2 or more disease relapses over 12 months (n = 14) had a mean baseline SCARED score of 19.6 (SD = 13.7), compared to a mean score of 12.6 (SD = 10.3) reported by children who had 0 to 1 IBD relapses (P < 0.05). Caregiver-reported anxiety symptoms did not differ between groups. Higher anxiety at baseline, irrespective of reporter, predicted greater total GI health care use (Ps < 0.01). Examination of individual GI visit types showed that child and caregiver-proxy reports predicted hospital-based interventions (P < 0.001), but not office encounters or outpatient procedures. Findings remained significant after controlling for disease severity (Ps < 0.05). Conclusions:Results suggest that elevated self-reported anxiety may signal those children at risk for repeated disease relapses. Findings also show that child anxiety predicts the use of pediatric IBD health care over the subsequent year, especially hospital-based interventions such as emergency room visits and surgery. The influences of anxiety on health care utilization remained after accounting for disease severity, suggesting that health-seeking behavior may be influenced by emotional factors in addition to disease processes. Future studies should incorporate biological markers of disease and measures of somatic symptoms, as well as test the health and cost benefits of treating anxiety in pediatric IBD.

P-216 Emotional Assessment in the Waiting Room: Are Caregivers Aware of Their Childʼs Anxiety?

Background:Anxiety symptoms are associated with worsened psychosocial and health outcomes in children and adolescents with inflammatory bowel disease (IBD). Accordingly, emotional assessments, typically consisting of separate child and caregiver reports, are being implemented within medical settings. Yet, for pediatric IBD patients, there has been little investigation into the utility of these assessments. One indicator of diagnostic accuracy is high agreement between child and caregiver reports. While rates of anxiety agreement typically have been found to be low to moderate for healthy and chronically ill populations, anxiety agreement is unknown in a pediatric IBD sample and their caregivers. The aim of this study is to identify agreement and patterns of anxiety symptom reporting in a pediatric sample diagnosed with IBD and their caregivers. Methods:A total of 237 pediatric IBD patients and their caregivers were administered the Screen for Child Anxiety Related Disorders (SCARED; Birmaher et al, 1997) in their gastroenterologists office waiting room. The SCARED, is a 41-item questionnaire consisting of a child and caregiver version that assesses the frequency of anxiety symptoms in children on a scale of 0 to 82. Excellent internal consistency was found for caregiver (&agr; = 0.93) and child (&agr; = 0.92) versions. The SCARED measures 5 domains of anxiety: panic disorder/somatic, generalized, social, school, and separation. Patients were included in the study if they (1) were between the ages of 8 and 17, (2) had a confirmed IBD diagnosis, (3) completed the SCARED, and (4) had a caregiver that completed the SCARED. Intra-class correlation coefficients (ICCs) were used to assess agreement between child and caregivers report of anxiety symptoms on the 5 domains and total score, and Kappa coefficients were calculated to assess agreement on established cutoffs (>20 = at-risk; >25 = clinical cutoff). Results:The final sample consisted of 187 pediatric patients (53% male) ages 8 to 17 (M = 13.54, SD = 2.44) with IBD. The majority of patients were white (83%), and had a diagnosis of Crohns disease (76%). Overall, a good level of agreement was found between caregiver and child self-report on all anxiety domains (ICC = 0.69–0.75) and total SCARED (ICC = 0.79). On average, children (M = 15.50, SD = 11.58) reported experiencing more anxiety symptoms than their caregiver (M = 13.55, SD = 11.68). Good agreement was found on clinical and at-risk cutoffs for the total SCARED, with 24% of children and 17% of caregivers reporting anxiety symptoms above the clinical cutoff (&kgr; = 0.49), and 33% of children and 25% of caregivers reporting anxiety symptoms above the at-risk cutoff, (&kgr; = 0.51). Conclusions:Overall, the fairly consistent reports between children and their caregivers points to strong caregiver awareness of childs anxiety symptoms. In particular, our study found good child and caregiver agreement on whether the child exceeds the threshold for clinical anxiety, supporting the use of the SCARED to identify pediatric IBD patients at risk for anxiety. Yet, the consistent trend of caregivers reporting fewer symptoms than children indicates that the childs report may provide a more inclusive assessment of anxiety symptoms. Thus, it may be useful to consider both child and caregiver anxiety reports in the identification, assessment, and future treatment of anxiety.