M. Elena Garralda

Neuro-cognitive Performance in Children with Type 1 Diabetes—A Meta-analysis

OBJECTIVE To conduct meta-analyses of neuropsychological performance in young people with type 1 diabetes. METHODS Meta-analysis of 24 studies. Studies published between 1980 and 2005 were identified. The inclusion criteria were: young people who were < or =19 years of age with type 1 diabetes, a case-control design and standardized neuropsychological tests of seven cognitive domains. RESULTS Diabetes was statistically associated with poorer performance on visuospatial ability (d = -0.29), motor speed (d = -0.26) and writing (d = -0.28), on sustained attention (d = -0.21) and reading (d = -0.23). Smaller effects were identified on full IQ (d = -0.14), on performance (d = -0.18) and verbal IQ (d = -0.15). Severe hypoglycemia was linked to deficits in short-term verbal memory (d = -0.14; Confidence Interval: -0.318, 0.024; p =.04). CONCLUSIONS This meta-analysis indicates that children with type 1 diabetes have mild cognitive impairments and subtly reduced overall intellectual functioning.

Maternal Expressed Emotion and Adjustment in Children with Epilepsy

Epilepsy in childhood may alter family relationships but the relevance of these changes for the increased rates of psychopathology has been little investigated. This study uses maternal expressed emotion (EE) to examine family relationships of children with epilepsy and the association with high risk for psychiatric disorder. EE was assessed using the Camberwell Family Interview carried out with the mothers of 22 schoolchildren with chronic epilepsy who were attending a general hospital outpatient clinic. Sixteen of these children had similarly aged healthy siblings who served as controls. High risk for psychiatric disorder in the children and mothers was assessed using behavioural, mood, and self-esteem questionnaires completed by mothers, teachers, and children. It was found that mothers showed significantly more emotional overinvolvement and a trend for more hostility towards their children with epilepsy than towards sibling controls. For the 22 children with epilepsy, maternal emotional overinvolvement was not associated with child behavioural deviance. High levels of criticism and, to a lesser extent, hostility did show associations with child behavioural deviance, and the strongest links were between maternal criticism and maternal rated antisocial and overactive behaviour in the child. Fewer positive comments by mothers towards the children were associated with child emotional symptoms and lower self-esteem in a number of areas. This study suggests that further research could consider the appropriateness of psychological intervention for families in which mothers are critical and hostile and whose children show antisocial behaviour.

Short-term psychiatric adjustment of children and their parents following meningococcal disease.

Objective: To assess short-term changes in child and parent psychiatric status following meningococcal disease. Design: Prospective cohort study; 3-month follow-up using parent, teacher, and child questionnaires. Setting: Hospital admissions to three pediatric intensive care units and 19 general pediatric wards. Patients: Sixty children aged 3–6 yrs, 60 mothers, and 45 fathers. Interventions: We administered measures of illness severity (Glasgow Meningococcal Septicaemia Prognostic Score, days in hospital) and psychiatric morbidity (Strengths and Difficulties Questionnaires, parent and teacher versions; Impact of Event scales; General Health Questionnaire-28). Measurements and Main Results: In children admitted to pediatric intensive care units, parental reports at 3-month follow-up showed a significant increase in emotional and hyperactivity symptoms and in related impairment; symptoms of posttraumatic stress disorder were present in four of 26 (15%) children >8 yrs old. Regarding the parents, 26 of 60 (43%) mothers in the total sample had questionnaire scores indicative of high risk for psychiatric disorder and 22 of 58 (48%) for posttraumatic stress disorder. In fathers there was high risk for psychiatric disorder in 11 of 45 (24%) and for posttraumatic stress disorder in 8 of 43 (19%). Severity of the childs physical condition on admission was significantly associated with hyperactivity and conduct symptoms at follow-up. Length of hospital admission was associated with psychiatric symptoms in the child and posttraumatic stress disorder symptoms in parents. There were also significant associations between psychiatric symptoms in children and parents. Conclusions: Admission of children to pediatric intensive care units for meningococcal disease is associated with an increase in and high levels of psychiatric and posttraumatic stress disorder symptoms in children and parents. Length of admission is associated with psychiatric symptoms in children and posttraumatic stress disorder symptoms in parents. Pediatric follow-up should explore psychiatric as well as physical sequelae in children and parents.

Practitioner Review: Assessment and Management of Somatisation in Childhood and Adolescence: A Practical Perspective

The assessment and treatment of somatisation in childhood require explicit recognition that many families frequently hold strong belief in the presence of physical disorders. Engaging the family, recognising and focusing on their beliefs and concerns, and paediatric/psychiatric liaison are usually required. Our knowledge on the management of children with somatisation is largely based on clinical reports but a number of open trials and methodologically increasingly stronger studies show that somatisation can respond to family treatments involving cognitive-behavioural techniques as well as to sensitive, psychologically sound advice by paediatricians. Antidepressants should be considered when there are comorbid mood disorders.

Training General Practitioners in the Identification and Management of Adolescent Depression within the Consultation: A Feasibility Study.

BACKGROUND Depressive disorders are common in adolescent general practice attenders. METHOD Adolescent attenders were screened/interviewed for depressive disorders, general practitioners (GPs) completed a checklist indicating recognition of psychopathology prior to and following GP training in the identification/management of adolescent depression. RESULTS One hundred and thirty consecutive adolescent attenders were screened before and 184 after training. Ten GPs completed the training. Psychiatric interviews with 38 adolescents with high depressive scores prior to and 44 following training identified 10 (26%) and 21 (48%), respectively, as clinically depressed. Sensitivity of GP identification improved from 2/10 (20%) to 9/21 (43%) without loss of specificity; predictive validity from 2/6 (33%) to 9/12 (75%). Adolescents interviewed appreciated the intervention. CONCLUSIONS Training GPs is feasible and may improve recognition of adolescent depression.

Annotation: Chronic fatigue syndrome in children and adolescents

BACKGROUND Over the past two decades Chronic Fatigue Syndrome (CFS) of childhood has gained increasing prominence. A number of clinical reports and case-control studies have examined the nature of the disorder, its associations, response to treatment and outcome. METHOD A review of publications on childhood CFS was undertaken and reference to work on adult CFS made. Most studies on childhood CFS have been on markedly affected children attending specialist pediatric clinics and very little is known about the condition as it presents in the community or to general medical services. RESULTS The main symptom is fatigue in association with a variety of physical symptoms and with marked and prolonged functional impairment. CFS is commonly reported as being brought on by acute infections. Co-morbid psychiatric (usually mood) disorders are present in at least a half. Personality problems and health attitudes have been described as possible predisposing and maintaining factors. Clinical reports indicate that family work focused on engagement and on a rehabilitation programme (including graded increasing activity and treatment of psychiatric co-morbidity) can help even the more severely impaired children. Recovery may be expected in over two-thirds. CONCLUSIONS CFS presents as a distinct, markedly impairing disorder of childhood. In its severe form, it is often associated with mood disorders. Further research into milder forms and into the efficacy of different treatment interventions is specially needed.

An empirically based alternative to DSM-5's disruptive mood dysregulation disorder for ICD-11

The World Health Organization (WHO)s priorities for the development of the classification of mental and behavioural disorders in the ICD-11 include increasing its clinical utility in global mental health settings (1) and improving the identification and diagnosis of mental disorders among children and adolescents (2). An issue that has been hotly debated in the area of childhood psychopathology is the assessment, diagnosis and treatment of children with severe irritability and anger (3,4). Although virtually all children display irritable and angry behaviours at times, some children exhibit them more frequently and more intensely, to the extent that they become an impairing form of emotional dysregulation. Recent findings indicate that these children with chronic and severe irritability/anger have not been adequately identified through existing classification systems, are at an increased risk for particular negative outcomes, and have not received appropriate treatment. To the extent that ICD-11 can help clarify the clinical picture of irritability/anger, children and families will benefit from more accurate diagnoses, more useful prognoses, and more effective interventions. This paper provides a brief overview of the issue, followed by several possible options and the current proposal for the classification of childhood irritability/anger in ICD-11. This proposal represents a markedly different – but we believe more scientifically justifiable – solution to the problems in this area than that selected for DSM-5 (5).

Assessment of Somatic Symptoms in British Secondary School Children Using the Children's Somatization Inventory (CSI)

OBJECTIVE To present normative and psychometric data on somatic symptoms using the Childrens Somatization Inventory (CSI) in a nonclinical sample of British young people, and to assess associations with stress and functional impairment. METHODS A total of 1,173 students (11- to 16-years old) completed the CSI and self-report psychopathology measures. RESULTS The median CSI total score was 12 (5, 23). Headaches, feeling low in energy, sore muscles, faintness, and nausea were most frequent. Girls scored higher than boys, and respondents aged 13-14 years lower than younger children. The CSI showed good internal consistency and exploratory factor analysis yielded three factors: pain/weakness, gastrointestinal, and pseudoneurological. A quarter of respondents reported somatic symptoms were made worse by stress. CSI scores were moderately significantly correlated with impairment and emotional symptoms. CONCLUSIONS The CSI, complemented by information on functional impairment and stress is an appropriate measure of recent somatic symptoms and somatization risk in young people for use in the UK.

Neuropsychologic function three to six months following admission to the PICU with meningoencephalitis, sepsis, and other disorders: a prospective study of school-aged children.

Objective:To assess short-term neuropsychological function and academic performance in school children following admission to intensive care and to explore the role of critical neurologic and systemic infection. Design:A prospective observational case–control study. Setting:Two PICUs. Subjects:A consecutive sample of 88 children aged 5–16 years (median age = 10.00, interquartile range = 6.00–13.00) who were admitted to intensive care between 2007 and 2010 with meningoencephalitis, septic illness, or other critical illnesses. They were assessed 3 to 6 months following discharge, and their performance was compared with that of 100 healthy controls. Patients were without prior neurologic or neurodevelopmental disorder. Interventions:None. Measurements and Main Results:Data encompassing demographic and critical illness details were obtained, and children were assessed using tests of intellectual function, memory, and attention. Questionnaires addressing academic performance were returned by teachers. After adjusting for covariates, the children admitted to PICUs significantly underperformed on neuropsychological measures in comparison to healthy controls (p < 0.02). Teachers deemed more children admitted to PICUs than controls as performing educationally worse and having problems with school work (ps = 0.001), as well as performing below average on aspects of executive function and attention (ps < 0.04). Analysis of the effect of illness type on outcome revealed that aspects of neuropsychological function, such as memory function, and teacher-rated academic performance were most reduced in children with meningoencephalitis and septic illness. In the PICU group, multivariable linear regression revealed that worse performance on a composite score of neuropsychologic impairment was more prevalent when children were younger, from a lower social class, and had experienced seizures during their admission (ps < 0.02). Conclusions:Admission to intensive care is followed by deficits in neuropsychologic performance and educational difficulties, with more severe difficulties noted following meningoencephalitis and septic illness. These results highlight the importance of future studies on cognition and educational outcome incorporating type of illness as a moderating factor.

Family Health and Characteristics in Chronic Fatigue Syndrome, Juvenile Rheumatoid Arthritis, and Emotional Disorders of Childhood

OBJECTIVE To compare family health and characteristics in children with chronic fatigue syndrome (CFS), in juvenile rheumatoid arthritis (JRA), and emotional disorders. METHOD Parents of 28 children and adolescents aged 11 to 18 years with CFS, 30 with JRA, and 27 with emotional disorders (i.e., anxiety and/or depressive disorders) were recruited from specialty clinical settings and completed interviews and questionnaires assessing family health problems, parental mental distress, illness attitudes, and family burden of illness. RESULTS Parents of children with CFS were significantly more likely than those of children with JRA to report a history of CFS-like illness, high levels of mental distress, and a tendency to experience functional impairment in response to physical symptoms. Families of children with CFS were characterized by significantly greater emotional involvement and reported greater family burden related to the childs illness in comparison with families of children with JRA. CONCLUSIONS CFS in childhood and adolescence is associated with higher levels of parental CFS-like illness, mental distress, emotional involvement, and family illness burden than those observed in association with JRA, a chronic pediatric physical illness.