Sara King

The epidemiology of chronic pain in children and adolescents revisited: A systematic review

Summary Chronic pain is prevalent in children and adolescents, with headaches being most common. Quality assessment indicated that most epidemiological studies do not meet quality criteria. ABSTRACT Chronic and recurrent pain not associated with a disease is very common in childhood and adolescence, but studies of pain prevalence have yielded inconsistent findings. This systematic review examined studies of chronic and recurrent pain prevalence to provide updated aggregated prevalence rates. The review also examined correlates of chronic and recurrent pain such as age, sex, and psychosocial functioning. Studies of pain prevalence rates in children and adolescents published in English or French between 1991 and 2009 were identified using EMBASE, Medline, CINAHL, and PsycINFO databases. Of 185 published papers yielded by the search, 58 met inclusion criteria and were reviewed, and 41 were included in the review. Two independent reviewers screened papers for inclusion, extracted data, and assessed the quality of studies. Prevalence rates ranged substantially, and were as follows: headache: 8–83%; abdominal pain: 4–53%; back pain: 14–24%; musculoskeletal pain: 4–40%; multiple pains: 4–49%; other pains: 5–88%. Pain prevalence rates were generally higher in girls and increased with age for most pain types. Lower socioeconomic status was associated with higher pain prevalence especially for headache. Most studies did not meet quality criteria.

Effects of Methylphenidate and Behavior Modification on the Social and Academic Behavior of Children With Disruptive Behavior Disorders: The Moderating Role of Callous/Unemotional Traits

This study examined whether response to behavior modification with and without methylphenidate differed for children with attention-deficit/hyperactivity disorder (ADHD) and conduct problems (CP) depending on the presence of callous/unemotional (CU) traits. Participants were 37 children ages 7 to 12, including 19 with ADHD/CP-only and 18 with ADHD/CP-CU, referred to a university-based summer treatment program. Results showed that ADHD/CP-CU children had worse behavior in the behavior-therapy-only (BT-only) condition, especially on measures of CP, noncompliance, and rule violations, but these differences largely disappeared when medication was added to BT. Children with ADHD/CP-CU were also less likely to be normalized by treatment than were children with ADHD/CP-only. These findings, though tentative, suggest that children with ADHD/CP-CU may not show a sufficient positive response to BT alone and that the combination of medication and BT may be especially important for them.

Treatment response in CP/ADHD children with callous/unemotional traits.

The current study examines the role of callous/unemotional (CU) traits in response to treatment among children with conduct problems (CP) and attention-deficit/hyperactivity disorder (ADHD). Fifty-four children with CP/ADHD and 16 controls (age = 9.48, SD = 1.58) took part in a summer treatment and research program. Simple correlations showed that CU and CP were associated with a number of treatment outcome measures. When examined together in regression analyses, CU and CP were uniquely associated with three treatment outcomes each (CU—improvement in social skills and problem solving, negative behaviors in time-out; CP—time-outs per day, peer ratings, peer dislike). The implications for these findings with regard to treatment response in children with CP/ADHD with and without CU traits are explored.

Should sex-specific norms be used to assess attention-deficit/hyperactivity disorder or oppositional defiant disorder?

The authors investigated whether sex-specific norms should be used to assess symptoms of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) in girls. It was hypothesized that (a) there would be a group of girls who exhibit ADHD or ODD symptoms using sex-specific norms but not using Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria; (b) these girls would be significantly impaired relative to typically developing girls. These hypotheses were examined using behavior ratings completed by mothers and teachers of 1,491 elementary school students. Results showed that there was a small group of girls who did not meet DSM-IV criteria for ADHD or ODD but who had elevated ADHD and ODD scores when sex-specific norms were used. The same was not true for boys. The girls identified with sex-specific norms were more impaired than other girls. These results suggest that there may be a small number of girls who have behaviors and impairment that are consistent with ADHD and ODD, but they are not currently being identified by DSM-IV criteria.

Aggression in children with attention-deficit/hyperactivity disorder.

Research shows that aggression is an important associated feature of attention-deficit/hyperactivity disorder (ADHD) and is important in understanding the impact of the disorder and its treatment. The occurrence of aggressive behavior in combination with ADHD does not appear to be spurious and the severity and/or presence of aggression and ADHD may significantly impact long-term prognosis. This article defines subtypes of aggression in relation to ADHD, identifies individual differences contributing to aggressive behavior in children with ADHD and discusses selected possible underlying mechanisms of aggression in ADHD, as well as current and emerging treatment approaches. Although aggressive behavior in children with ADHD is common, the reasons for this are not yet well understood. Multidisciplinary research should focus on investigating underlying mechanisms related to aggression in ADHD, as well as the utility of various treatment modalities.

Social Information Processing of Positive and Negative Hypothetical Events in Children With ADHD and Conduct Problems and Controls

Objective: This study examined social information processing (SIP) of events with varied outcomes in children with ADHD and conduct problems (CPs; defined as oppositional defiant disorder [ODD] or conduct disorder [CD]) and controls. Method: Participants were 64 children (46 boys, 18 girls) aged 6 to 12, including 39 with ADHD and 25 controls. Vignettes were developed that systematically varied with regard to peer intention (ambiguous, negative, positive) and event outcome (ambiguous, negative, positive), and were used to evaluate participants’ SIP abilities (cue encoding, interpretation, and response generation). Results: Results showed that, after controlling for CPs, children with ADHD detected fewer positive, negative, and neutral cues; attributed more negative and less positive intent to peers; focused less on situational outcomes of vignettes; and generated fewer positive responses compared with the control group. Conclusion: These results indicate that children with ADHD differ from non-ADHD children, even after controlling for CPs, in how they process positive and negative social experiences.

Subtypes of aggression in children with attention deficit hyperactivity disorder: medication effects and comparison with typical children.

We examined aggressive behavior in 6- to 12-year-old children, including 20 children with attention deficit hyperactivity disorder (ADHD) on stimulant medication, 19 children with ADHD on placebo (n = 19), and 32 controls. Children completed a laboratory provocation task designed to measure hostile, instrumental, reactive, and proactive aggression. Children in the ADHD-placebo group exhibited increased proactive and reactive aggression following high levels of provocation compared to controls. On the last trials, instrumental aggression dissipated for controls and hostile aggression dissipated for children in the ADHD-placebo group. Both instrumental and hostile aggression dissipated for children in the ADHD-medication group.

Teacher-Classified Peer Social Status: Preliminary Validation and Associations with Behavior Ratings

This study investigated whether teacher ratings may be a valid alternative measure of social status in elementary school children, and whether teacher social status ratings are distinct from their disruptive behavior ratings. Participants were 1,596 elementary school children in seven schools in eastern Canada. Teacher ratings of social status and of disruptive behavior were collected for all children, along with positive peer nominations for a large subset. Results showed that children rated by teachers as rejected and ignored received the fewest positive peer nominations, whereas children rated as popular received the most positive nominations. Analyses of covariance showed that inattention was more highly associated with peer problems than was hyperactive-impulsive, oppositional, or conduct problems, but none of these behaviors accounted for the association between teacher-rated social status and peer positive nominations. Results provide preliminary support for the validity of teacher-rated social status in elementary-aged children.

Aggression in Children with Conduct Problems and Callous-Unemotional Traits: Social Information Processing and Response to Peer Provocation

Callous/unemotional traits (CU) moderate children’s conduct problems (CP) in numerous domains, including social functioning. The present study examined whether CU traits also moderate the aggressiveness of children’s social information processing (SIP) and responses to varying intensities of peer provocation. Sixty elementary school-age children (46 males) were grouped into those without CP or CU (controls, n = 32), those with CP but not CU (CP-only; n = 14), and those with both CP and CU (CPCU, n = 14). Participants completed a task that measured two aspects of SIP (response generation and hostile attribution bias) and a computerized reaction time task (CRTT) that measured behavior, affect, and communication before and after provocation under instrumental and hostile aggressive conditions. Children with CPCU generated more aggressive responses than controls on measures of SIP. On the CRTT, all children exhibited reactive aggression following high provocation, but only children with CPCU exhibited proactive aggression, and reactive aggression following low provocation; no differences in affect were found. In a series of exploratory analyses, CPCU children communicated antisocially, while CP-only communicated prosocially. Finally, children with CPCU did not seem to hold a grudge following the final instance of provocation, instead gradually returning to baseline like their non-CU peers. These distinct social cognitive and behavioral profiles hint at different etiologies of CP and CPCU, underscoring the variability of aggression in these populations.

Effects of Intensive Behavioral Treatment for Children With Varying Levels of Conduct Problems and Callous-Unemotional Traits

The purpose of this study was to examine whether callous-unemotional (CU) traits moderated the effects of intensive behavior therapy in elementary school-age children with varying levels of conduct problems (CP). Both treatment response (magnitude of change between pre- and posttreatment) and treatment outcomes (likelihood of normalization from treatment) were examined. Participants were 67 children (n = 49 boys, Mage = 9.6 years) with varying levels of CP and CU who participated in an intensive 8-week summer treatment program (STP) in which behavior therapy was delivered to children in recreational and classroom settings and to parents via weekly parent training sessions. Effects of treatment were measured using parent and teacher ratings of oppositional defiant disorder (ODD), conduct disorder (CD), callous behavior, and impairment. Results showed that CU moderated treatment effects for CD and callous behavior but not ODD or impairment. The moderating effects showed some evidence that participants with high CP and high CU before treatment had better treatment responses (larger change between pre- and posttreatment) but worse treatment outcomes (lower likelihood of normalization after treatment). These results suggest that intensive treatment, such as the STP, may be necessary but not sufficient for children with CP and CU traits.