Somatic symptoms in anxious-depressed school refusers

Somatic symptoms in school refusal: a qualitative study among children, adolescents, and their parents during the COVID-19 pandemic

School refusal (SR) is commonly associated with somatic symptoms that are temporally related to school attendance. Abdominal pain, headache, vomiting, and musculoskeletal pain are frequently encountered and are usually not caused by a physical disease. School refusers, parents and health care workers are often puzzled by these impairing symptoms. In this qualitative study, we assessed somatic symptoms in a population encompassing both school refusers and their parents. We aimed at better understanding experiences and strategies in the management of these debilitating symptoms, while also investigating the journey of these symptoms and their behavioral consequences on the said population. We conducted qualitative interviews both within an Integrated Youth Health Care Unit in Paris and through a French parent-led support group improving care for school refusers. We interviewed 19 young persons with SR (aged 6-21 years old) and 20 parents. Using the Grounded Theory, three themes were identified: (1) somatic symptoms' journey in four phases (emergence, coping, crisis, and disappearance in the context of school dropout); (2) their deconstruction, indicating the patients' emotional state; and (3) their management through self-care practices as well as increased emotional and body awareness. Some parents, who could portray similar symptoms at a younger age, mentioned familial pattern of heightened emotional and sensorial sensitivity as a possible cause. Findings suggested that somatic symptoms in SR offer an insight into the patients' emotional state. We recommend that psychotherapies targeting somatic symptoms could be further assessed in SR, along with educational content aimed at increasing emotional literacy in schools and health care settings.

Assessment of autonomic symptom scales in patients with neurodevelopmental diagnoses using electronic health record data

Background

Sleep disturbances, gastrointestinal problems, and atypical heart rate are commonly observed in patients with autism spectrum disorder (ASD) and may relate to underlying function of the autonomic nervous system (ANS). The overall objective of the current study was to quantitatively characterize features of ANS function using symptom scales and available electronic health record (EHR) data in a clinically and genetically characterized pediatric cohort.

Methods

We assessed features of ANS function via chart review of patient records adapted from items drawn from a clinical research questionnaire of autonomic symptoms. This procedure coded for the presence and/or absence of targeted symptoms and was completed in 3 groups of patients, including patients with a clinical neurodevelopmental diagnosis and identified genetic etiology (NPD, n=244), those with an ASD diagnosis with no known genetic cause (ASD, n=159), and age and sex matched controls (MC, n=213). Symptoms were assessed across four main categories: (1) Mood, Behavior, and Emotion; (2) Secretomotor, Sensory Integration; (3) Urinary, Gastrointestinal, and Digestion; and (4) Circulation, Thermoregulation, Circadian function, and Sleep/Wake cycles.

Results

Chart review scores indicate an increased rate of autonomic symptoms across all four sections in our NPD group as compared to scores with ASD and/or MC. Additionally, we note several significant relationships between individual differences in autonomic symptoms and quantitative ASD traits.

Conclusion

These results highlight EHR review as a potentially useful method for quantifying variance in symptoms adapted from a questionnaire or survey. Further, using this method indicates that autonomic features are more prevalent in children with genetic disorders conferring risk for ASD and other neurodevelopmental diagnoses.

Climate change and extreme weather disasters: evacuation stress is associated with youths' somatic complaints

Objective

Climate-change has brought about more frequent extreme-weather events (e.g., hurricanes, floods, and wildfires) that may require families to evacuate, without knowing precisely where and when the potential disaster will strike. Recent research indicates that evacuation is stressful for families and is associated with psychological distress. Yet, little is known about the potential impact of evacuation stressors on child health. After Hurricane Irma, which led to a mass evacuation in Florida, we examined whether evacuation stressors and hurricane exposure were uniquely associated with youth somatic complaints, and whether youth psychological distress (i.e., symptoms of posttraumatic stress, anxiety, and depression) served as a potential mediating pathway between evacuation stressors, hurricane experiences, and somatic complaints.

Method

Three months after Irma, 226 mothers of youth aged 7-17 years (N=226; M age = 9.76 years; 52% boys; 31% Hispanic) living in the five southernmost Florida counties reported on evacuation stressors, hurricane-related life threat and loss/disruption, and their child's psychological distress and somatic complaints using standardized measures.

Results

Structural equation modeling revealed a good model fit (χ² = 32.24, p = 0.003, CFI = 0.96, RMSEA = 0.08, SRMR = 0.04). Even controlling for life-threatening hurricane experiences (β = 0.26) and hurricane loss and disruption (β = 0.26), greater evacuation stressors were associated with greater symptoms of youth psychological distress (β = 0.34; p's < 0.001), and greater psychological distress was associated with more somatic complaints (β = 0.67; p < 0.001). Indirect effects revealed that evacuation stressors (p < 0.001), actual life-threatening events (p < 0.01), and loss and disruption (p < 0.01) were all uniquely and indirectly associated with youths' somatic complaints via youth psychological distress.

Discussion

Findings suggest that even coping with the threat of a disaster may be sufficient to prompt psychological and physical health symptoms in youth. Due in part to climate change, threats of disaster occur much more often than actual disaster exposure, especially for areas that are prone to hurricanes or wildfires. Preparing youth and families residing in vulnerable areas for potential disaster evacuation or sheltering-in-place appears critical. Encouraging families to develop Disaster Plans and teaching stress management skills may reduce both youth distress and somatic health problems.

Adverse Effects of Antidepressant Medications and their Management in Children and Adolescents

INTRODUCTION

Selective serotonin reuptake inhibitors (SSRIs) and, to a lesser extent, serotonin-norepinephrine reuptake inhibitors (SNRIs) are the cornerstone of pharmacotherapy for children and adolescents with anxiety and depressive disorders. These medications alleviate symptoms and restore function for many youths; however, they are associated with a distinct adverse effect profile, and their tolerability may complicate treatment or lead to discontinuation. Yet, SSRI/SNRI tolerability has received limited attention in the pediatric literature.

METHODS

This review examines the early- (e.g., activation, gastrointestinal symptoms, sedation) and late-emerging (e.g., weight gain) adverse effects of SSRIs and some SNRIs in pediatric patients.

RESULTS

We provide a framework for discussing SSRI/SNRI tolerability with patients and their families and describe the pharmacologic basis, course, and predictors of adverse events in youth. Strategies to address specific tolerability concerns are presented. For selected adverse events, using posterior simulation of mean differences over time, we describe their course based on Physical Symptom Checklist measures in a prospective, randomized trial of anxious youth aged 7-17 years who were treated with sertraline (n = 139) or placebo (n = 76) for 12 weeks in the Child/Adolescent Anxiety Multimodal Study (CAMS).

MAIN RESULTS

In CAMS, the relative severity/burden of total physical symptoms (p < 0.001), insomnia (p = 0.001), restlessness (p < 0.001), nausea (p = 0.002), abdominal pain (p < 0.001), and dry mouth (p = 0.024) decreased from baseline over 12 weeks of sertraline treatment, raising the possibility that these symptoms are transient. No significant changes were observed for sweating (p = 0.103), constipation (p = 0.241), or diarrhea (p = 0.489). Finally, we review the antidepressant withdrawal syndrome in children and adolescents and provide guidance for SSRI discontinuation, using pediatric pharmacokinetic models of escitalopram and sertraline-two of the most used SSRIs in youth.

CONCLUSION

SSRI/SNRIs are associated with both early-emerging (often transient) and late-emerging adverse effects in youth. Pharmacokinetically-informed appraoches may address some adverse effects and inform SSRI/SNRI discontinuation strategies.

Among the swedish generation of adolescents who experience an increased trend of psychosomatic symptoms. Do they develop depression and/or anxiety disorders as they grow older?

BACKGROUND

Despite an increase in mental health problems, with psychosomatic symptoms having been observed in new generations of Swedish youth, the extent to which these problems correspond to an increase in adult mental problems is unknown. The present study investigates whether Swedish adolescents with high levels of psychosomatic symptoms are at risk of developing depression and anxiety problems in adulthood and whether sex moderates any association. Moreover, we aim to understand whether different clusters of youth psychosomatic symptoms - somatic, psychological and musculoskeletal - have different impacts on adult mental health.

METHODS

One thousand five hundred forty-five Swedish adolescents - aged 13 (49%) and 15 (51%) - completed surveys at baseline (T1) and 3 years later (T2); of them, 1174 (61% females) also participated after 6 years (T3). Multivariate logistic models were run.

RESULTS

Youth with high levels of psychosomatic symptoms had higher odds of high levels of depressive symptoms at T2 and T3. Moreover, psychosomatic symptoms at T1 predicted a high level of anxiety symptoms and diagnoses of anxiety disorders at T3. When analyzed separately, musculoskeletal symptoms predicted higher odds of having high levels of depressive symptoms at T2 and T3 while somatic symptoms predicted high levels of anxiety symptoms at T2. Moreover, somatic symptoms at T1 predicted diagnoses of depression and anxiety disorders at T3. Sex did not moderate any of the relationships.

CONCLUSIONS

The study supports the idea that an increase in mental health problems, such as psychosomatic symptoms, can seriously impact the psychological health of new generations of young adults.

Higher scores on autonomic symptom scales in pediatric patients with neurodevelopmental disorders of known genetic etiology

INTRODUCTION

Features of underlying autonomic dysfunction, including sleep disturbances, gastrointestinal problems, and atypical heart rate, have been reported in neurodevelopmental conditions, including autism spectrum disorder (ASD). The current cross-sectional, between-groups study aimed to quantify symptoms of autonomic dysfunction in a neurodevelopmental pediatric cohort characterized by clinical diagnoses as well as genetic etiology.

METHOD

The Pediatric Autonomic Symptom Scales (PASS) questionnaire was used to assess autonomic features across a group of patients with clinical neurodevelopmental diagnoses (NPD; N = 90) and genetic etiologies. Patients were subdivided based on either having a clinical ASD diagnosis (NPD-ASD; n = 37) or other non-ASD neurodevelopmental diagnoses, such as intellectual disability without ASD, speech and language disorders, and/or attention deficit hyperactivity disorder (NPD-OTHER; n = 53). Analyses focused on characterizing differences between the NPD group compared to previously published reference samples, as well as differences between the two NPD subgroups (NPD-ASD and NPD-OTHER).

RESULTS

Our results indicate higher PASS scores in our NPD cohort relative to children with and without ASD from a previously published cohort. However, we did not identify significant group differences between our NPD-ASD and NPD-OTHER subgroups. Furthermore, we find a significant relationship between quantitative ASD traits and symptoms of autonomic function.

CONCLUSION

This work demonstrates the utility of capturing quantitative estimates of autonomic trait dimensions that may be significantly linked with psychosocial impairments and other core clinical features of ASD.

A Systematic Review of Somatic Symptoms in School Refusal

OBJECTIVE

School refusers often display somatic symptoms that are temporally related to school attendance. The aim of this systematic review is to summarize characteristics and causes of somatic symptoms and their management in the context of school refusal. Findings of this review may help clinicians in their daily practice.

METHODS

PubMed and PsycINFO databases were systematically searched (according to PRISMA guidelines) for articles mentioning somatic symptoms in school refusal by May 2020. Among 1025 identified studies, 148 were included.

RESULTS

Unspecific somatic symptoms were frequently the first complaints in school refusal. Abdominal pain, headache, nausea, vomiting, muscular or joint ache, diarrhea, dizziness, fatigue, and palpitation were the most commonly encountered symptoms and were usually not accounted for by an identifiable physical disease. Anxiety was the most recurrent etiology found, but physicians' lack of awareness about psychological comorbidities often delayed psychological/psychiatric referral. Successful therapies consisted of dialectical behavior therapy, anxiety management through relaxation/breathing training, and ignoring the somatic symptoms.

CONCLUSIONS

Somatic symptoms in school refusal are frequent but poorly understood. Their management could include interventions targeting anxiety, psychotherapies such as emotional awareness and expression therapy, third-wave behavioral therapies, and psychoeducation. A multidisciplinary approach through strengthened collaboration between school staff, physicians, and psychologists/psychiatrists is needed to improve well-being in children who experience somatic symptoms as related to school avoidance.

Effects of COVID-19 Pandemic on Emergency Medical Services

INTRODUCTION

In this study, we aimed to analyse the changes that occurred after the COVID-19 pandemic using the data of EMS of Ankara province.

MATERIALS AND METHODS

EMS data for the same time interval (March 11-April 24) in the last 3 years (2018, 2019 and 2020) were compared.

RESULTS

While the number of calls increased by 90.9% during the pandemic period (from 2019 to 2020), the number of cases increased by 9.8%. Of all cases transported to hospital, 15.2% were suspected of and 2.9% were diagnosed with COVID-19. In the pandemic period, case frequency decreased in the 0-6 age group (-4.1%) and 7-18 age group (-39.9%) while the number of patients in the 19-65 age group (12.9%) and 65+ age group (21.5%) increased. There was a statistically significant difference between pre-pandemic and pandemic period in terms of rural area case frequency. During the pandemic period, case frequency of angina pectoris (-35.2%), myocardial infarction (-45%), acute abdomen (-23.8%) and cerebrovascular diseases (-2.9%) decreased contrary to pre-pandemic period (2019). During the same period, symptoms of fever (+14.1%) and cough (+956.3%) increased. There was a statistically significant difference between pre-pandemic and pandemic period in terms of forensic case frequency (P < .05). In addition, there was a statistically significant difference between these periods in terms of the frequency of patients who died at the scene.

CONCLUSION

Although the use of ambulances has increased in the pandemic process, the use of EMS for time-sensitive diseases has decreased.

Somatoform complaints in middle childhood A developmental path-analysis

Repeatedly occurring somatoform complaints often cause disruptions in children’s daily life, both in family and school settings. Associated with these complaints, there is an increased demand for medical help in the affected children. Despite the frequent occurrence of somatoform complaints in childhood, only a small number of studies have focused on this subject, and the development and maintenance of somatoform complaints have not sufficiently explained to date. Previous research suggests that many different factors are involved, including insecure attachment, a lack of emotion regulation (ER) strategies, and psychiatric behavior problems. The aim of this study is to examine possible pathways describing the interplay of aforementioned factors, in order to contribute to a deeper understanding of the underlying mechanisms. A nonexperimental cross-sectional study was conducted. Questionnaires were completed by 221 children (female n = 115; Mage = 9.70 years, SDage = .56) reporting on their attachment and ER strategies, and their parents reported on the behavior problems and somatoform complaints. Path analysis revealed a good model fit (Χ2 = p .798, Χ2/df = .415, NFI = .994, CFI = 1.000, RMSEA = .000). Results revealed that attachment anxiety predicted maladaptive ER strategies, and attachment avoidance predicted emotion control. In turn significant paths were found between ER strategies, behavior problems, and somatoform complaints. This study provides a first insight into the underlying mechanisms describing the occurrence of somatoform complaints. Results revealed two developmental pathways, based on attachment quality and mediated through different emotion regulation strategies.

Clinical Trial Registration: The project “Impact factors and conditions of somatoform symptoms in childhood within familial and school contexts” is listed in the German Clinical Trails Register (DRKS-ID: DRKS00012444) and the WHO International Clinical Trials Registry Platform.

Advancing health equity by addressing social determinants of health: Using health data to improve educational outcomes

Data from two social determinants of health—access to health care and access to a quality education—are combined to examine the impact of health on student achievement. Data from a high poverty, high performing K-8 school revealed a significant negative correlation between the number of visits to a school-based nurse and standardized academic assessments. Fixed effect regression confirmed the effect of total number of visits to the school-based nurse on performance on standardized assessments, and also revealed that two types of visits, neurological and gastrointestinal, were predictive of student performance. Taken together, these results suggest that when students are suffering from ill health their academic performance is negatively impacted. Implications for improving health equity through data-driven educational interventions are discussed.

Bridging Anxiety and Depression: A Network Approach in Anxious Adolescents

BACKGROUND

The phenomenology and neurobiology of depressive symptoms in anxious youth is poorly understood.

METHODS

Association networks of anxiety and depressive symptoms were developed in adolescents with generalized anxiety disorder (GAD; N=52, mean age: 15.4±1.6 years) who had not yet developed major depressive disorder. Community analyses were used to create consensus clusters of depressive and anxiety symptoms and to identify "bridge" symptoms between the clusters. In a subset of this sample (n=39), correlations between cortical thickness and depressive symptom severity was examined.

RESULTS

Ten symptoms clustered into an anxious community, 5 clustered into a depressive community and 5 bridged the two communities: impaired schoolwork, excessive weeping, low self-esteem, disturbed appetite, and physical symptoms of depression. Patients with more depressive cluster burden had altered cortical thickness in prefrontal, inferior and medial parietal (e.g., precuneus, supramarginal) regions and had decreases in cortical thickness-age relationships in prefrontal, temporal and parietal cortices.

LIMITATIONS

Data are cross-sectional and observational. Limited sample size precluded secondary analysis of comorbidities and demographics.

CONCLUSIONS

In youth with GAD, a sub-set of symptoms not directly related to anxiety bridge anxiety and depression. Youth with greater depressive cluster burden had altered cortical thickness in cortical structures within the default mode and central executive networks. These alternations in cortical thickness may represent a distinct neurostructural fingerprint in anxious youth with early depressive symptoms. Finally, youth with GAD and high depressive symptoms had reduced age-cortical thickness correlations. The emergence of depressive symptoms in early GAD and cortical development may have bidirectional, neurobiological relationships.

Under Pressure to Perform: Impact of Academic Goal Orientation, School Motivational Climate, and School Engagement on Pain and Somatic Symptoms in Adolescents

OBJECTIVES

Various academic factors are known to influence pain and somatic symptoms in adolescents, but the roles of academic goal orientation, school motivational climate, and school engagement are unknown. This study examined how these understudied academic factors are associated with adolescent pain and somatic symptoms and whether sex moderates the relations.

MATERIALS AND METHODS

High school students (n=90) from a high-achieving community completed questionnaires assessing academic variables, various pain characteristics, and somatic symptoms.

RESULTS

The majority of adolescents (67%) experienced pain and somatic symptoms in the past month, with 56% reporting multisite pain and 58% reporting at least 1 severe somatic symptom. Headache and abdominal pain were the most frequently reported "most bothersome" pains, and pain was rated, on average, as moderately severe, typically occurring several times per month, and was primarily chronic in nature (duration, ≥3 mo). Higher levels of ego goal orientation and perceived performance motivational climate were associated with more somatic symptoms, and ego goal orientation was also associated with more intense and frequent pain. Alternatively, greater school engagement was associated with fewer somatic symptoms. Task goal orientation and mastery motivational climate were unassociated with all pain and somatic symptom outcomes.

DISCUSSION

This study demonstrates that adolescents from a high-achieving community report more somatic symptoms and pain when they are less engaged in school and when their academic focus is on grades and outperforming peers. Results suggest that de-emphasizing competition and performance outcomes may support physical well-being in adolescents.

Relationship of Children's Emotional and Behavioral Disorders With Health Care Utilization and Missed School

OBJECTIVE

To assess the association between emotional and behavioral disorders (EBD), missed school days and health care visits while controlling for sociodemographic factors, and comorbid medical conditions in a nationally representative sample.

METHODS

Data from the 2016 National Health Interview Survey were used to assess the associations between EBD, in children aged 4 to 11 and 12 to 17 years, on missed days of school, health care office visits, and emergency department visits. EBD was assessed utilizing a validated screener. Multiple logistic regression was used to control for comorbid medical conditions and sociodemographic factors.

RESULTS

Adolescents who screened positive for anxiety, depression, peer problems, and severe impairment had 4 to 8 times the odds of missing more school than their peers that screened negative. Young children with anxiety had 4 times increased odds of missing more school whereas positive emotional and behavioral health was protective against missing school. Young children and adolescents who screened positive for anxiety, depression, and severe impairment had 3 to 6 and 2 to 4 times the odds of more office visits respectively. Emergency department utilization was significantly increased in adolescents with anxiety and younger children with severe impairment.

CONCLUSIONS

This study shows that children with EBD are more likely to have increased office visits and missed days of school, even after adjusting for sociodemographic factors and comorbid medical conditions. Recognition of early associations of EBD can create an opportunity for early identification of children with EBD in the pediatric practice.

The relationship between attachment and somatoform symptoms in children and adolescents: A systematic review and meta-analysis

OBJECTIVE

Problems in childhood and adolescence are often present with recurring physical signs of illness, called somatoform symptoms. These symptoms are a common reason for consultation at both paediatric care and psychotherapeutic/psychiatric praxis. We propose that attachment is a possible predictive factor. This article provides a systematic overview of the existing research literature concerning the relationship between attachment and somatoform symptoms in children and adolescents.

METHODS

A systematic search for empirical articles from 1990 up to August 2018 focusing on this association was conducted. Out of six databases, 4994 studies were detected by using defined keywords. One study was added identified by checking reference lists. Finally, 15 studies were selected, which were the bases for the narrative review. Ten studies were included in meta-analysis.

RESULTS

Combining study results, we found that attachment cannot solely predict somatoform symptoms. Mixed results are shown. The quantitative analysis substantiated these narrative results, revealing a small but significant combined effect size of Δ ≈ .12 (95% CI .04 - .19).

CONCLUSIONS

The findings suggest that a relationship exists, but further investigations need to demonstrate that these are not only superficial. There are many developmental factors that affect the relationship between attachment and somatoform symptoms in children and adolescents. Further research should explore this interplay in order to gain a holistic and comprehensive understanding of the underlying mechanisms that lead to these correlations and to discover possible predicting factors.

School Refusal Behavior in Indian Children: Analysis of Clinical Profile, Psychopathology and Development of a Best-Fit Risk Assessment Model

OBJECTIVES

School refusal is seen as an emergency in child psychiatry and various risk factors have been analyzed. Children who present with school refusal have been shown to have several associated psychiatric comorbidities. However, risk assessment of psychiatric comorbidities is lacking, particularly in the Indian context. The authors aimed to study the sociodemographic profile and associated psychopathology in children with school refusal. They compared the prevalence rates of psychiatric illnesses to that of the community. A best-fit model for risk assessment of psychopathology was formulated.

METHODS

Past records of children aged 5-16 y, who presented with school refusal in the period from June 2013 through June 2015 to authors' Child Guidance Clinic were studied and their sociodemographic details, symptoms and diagnoses were obtained. Chi square test of proportion was used to compare the prevalence rates between the study population and community. Multinomial analysis was used to elucidate a best-fit model of risk assessment.

RESULTS

School refusal was seen in 3.6% of children. 77.8% of the children had a psychiatric diagnosis, most common being depression (26.7%), followed by anxiety (17.7%). Prevalence of psychiatric disorders was significantly higher in the study population than community (p < 0.05). A best-fit model of 4 factors: academic difficulties, adjustment problems at school, behavioral problems and parental conflicts is suggested (p < 0.05).

CONCLUSIONS

School refusal is associated with significant psychopathology, most commonly depression, followed by anxiety. The best-fit model for risk assessment can predict the likelihood of psychopathology and help in early diagnosis.

Somatic symptoms in adolescence as a predictor of severe mental illness in adulthood: a long-term community-based follow-up study

BACKGROUND

Somatic symptoms are common and costly for society and correlate with suffering and low functioning. Nevertheless, little is known about the long-term implications of somatic symptoms. The objective of this study was to assess if somatic symptoms in adolescents with depression and in their matched controls predict severe mental illness in adulthood by investigating the use of hospital-based care consequent to different mental disorders.

METHODS

The entire school population of 16-17-year-olds in the city of Uppsala, Sweden, was screened for depression in 1991-1993 (n = 2300). Adolescents with positive screenings (n = 307) and matched non-depressed controls (n = 302) participated in a semi-structured diagnostic interview for mental disorders. In addition, 21 different self-rated somatic symptoms were assessed. The adolescents with depression and the matched non-depressed controls were engaged in follow-up through the National Patient Register 17-19 years after the baseline study (n = 375). The outcome measures covered hospital-based mental health care for different mental disorders according to ICD-10 criteria between the participants' ages of 18 and 35 years.

RESULTS

Somatic symptoms were associated with an increased risk of later hospital-based mental health care in general in a dose-response relationship when adjusting for sex, adolescent depression, and adolescent anxiety (1 symptom: OR = 1.63, CI 0.55-4.85; 2-4 symptoms: OR = 2.77, 95% CI 1.04-7.39; ≥ 5 symptoms: OR = 5.75, 95% CI 1.98-16.72). With regards to specific diagnoses, somatic symptoms predicted hospital-based care for mood disorders when adjusting for sex, adolescent depression, and adolescent anxiety (p < 0.05). In adolescents with depression, somatic symptoms predicted later hospital-based mental health care in a dose-response relationship (p < 0.01). In adolescents without depression, reporting at least one somatic symptom predicted later hospital-based mental health care (p < 0.05).

CONCLUSIONS

Somatic symptoms in adolescence predicted severe adult mental illness as measured by hospital-based care also when controlled for important confounders. The results suggest that adolescents with somatic symptoms need early treatment and extended follow-up to treat these specific symptoms, regardless of co-occurring depression and anxiety.

[Processes of attention to children and adolescents under 20 years in La Castañeda: evolution of the concept of childhood in psychiatry]

Today, there is evidence that shows that children and adolescents can experience developmental problems and psychiatric disorders. This was possible because of two main reasons, the evolution of the concept of infancy and the progress made in medical and psychiatric diagnostic classification. This manuscript offers a glance to early psychiatric attention in Mexico, particularly the care processes provided to 36 children and adolescents under twenty, admitted in the mental asylum La Castañeda, during the first half of the XX century. Admission causes, length of stay, diagnosis, treatment and discharge motives, are some of the aspects described in this study. Finally, it also reflects about the challenge it is for a child psychiatric hospital nowadays, with such a history, to become an innovative institution able to claim a place in the medical field in favor of those minors that can barely defend themselves.

The association between child and adolescent emotional disorder and poor attendance at school: a systematic review protocol

BACKGROUND

Anxiety and depression are common in young people and are associated with a range of adverse outcomes. Research has suggested a relationship between emotional disorder and poor school attendance, and thus poor attendance may serve as a red flag for children at risk of emotional disorder. This systematic review aims to investigate the association between child and adolescent emotional disorder and poor attendance at school.

METHODS

We will search electronic databases from a variety of disciplines including medicine, psychology, education and social sciences, as well as sources of grey literature, to identify any quantitative studies that investigate the relationship between emotional disorder and school attendance. Emotional disorder may refer to diagnoses of mood or anxiety disorders using standardised diagnostic measures, or measures of depression, anxiety or "internalising symptoms" using a continuous scale. Definitions for school non-attendance vary, and we aim to include any relevant terminology, including attendance, non-attendance, school refusal, school phobia, absenteeism and truancy. Two independent reviewers will screen identified papers and extract data from included studies. We will assess the risk of bias of included studies using the Newcastle-Ottawa Scale. Random effects meta-analysis will be used to pool quantitative findings when studies use the same measure of association, otherwise a narrative synthesis approach will be used.

DISCUSSION

This systematic review will provide a detailed synthesis of evidence regarding the relationship between childhood emotional disorder and poor attendance at school. Understanding this relationship has the potential to assist in the development of strategies to improve the identification of and intervention for this vulnerable group.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016052961.

Chronic Fatigue Syndrome in Children and Adolescents: A Review Article

Clinicians have been describing individuals with chronic fatigue states for over 100 years, although chronic fatigue syndrome is often regarded as a modern disease. The aetiology of chronic fatigue syndrome is uncertain. For young individuals with chronic fatigue syndrome there are neither reliable prevalence figures nor scientific evidence concerning the effectiveness of treatments. Information obtained from research into adult individuals with chronic fatigue syndrome may be helpful but is not necessarily directly applicable to children and adolescents. Developmental factors and the influence of other family members on the course of the disorder in young sufferers should be considered. The uncertainties surrounding chronic fatigue syndrome should not deter child and adolescent mental health workers from becoming involved in the assessment and management of individual patients. The mainstay of treatment is rehabilitation with an emphasis on gradually increasing activities. Considerable attention will need to be given to engaging the young people and their families and working effectively with a multidisciplinary team. If mental health workers do not become involved in treating young people with chronic fatigue syndrome there is a risk that psychological factors will not be addressed and that chronic functional impairment will ensue.

The Functional Profiles of School Refusal Behavior

School refusal behavior is a common problem seen by mental health professionals and by educators but little consensus is available as to its classification, assessment, and treatment. This study assessed 143 youth with primary school refusal behavior and their parents to examine diagnoses that are most commonly associated with proposed functions of school refusal behavior. As expected, results indicated that great heterogeneity in diagnoses marks this population. In general, anxiety-related diagnoses were associated more with negatively reinforced school refusal behavior; separation anxiety disorder was associated more with attention-seeking behavior; and oppositional defiant disorder and conduct disorder were associated more with pursuit of tangible reinforcement outside of school. These results are discussed within the context of classification, assessment, and treatment of this population.

Comorbid Anxiety and Depressive Symptoms in Children and Adolescents: A Systematic Review and Analysis

BACKGROUND

A large and extensive body of research has examined comorbid anxiety and depression in adults. Children and adolescents also frequently present with comorbid anxiety and depression; however, research and treatment require unique environmental and neurodevelopmental considerations in children. As a result, our understanding of comorbid anxiety and depression in children and adolescents is limited.

OBJECTIVE

The goal of this systematic review was to examine the current literature focused on comorbid anxiety and depression in children and adolescents. The review included theoretical conceptualizations as well as diagnostic, neurobiological, prevention, and treatment considerations. In addition, a proposed algorithm for the treatment of comorbid anxiety and depression in children/adolescents is provided.

METHODS

This systematic literature review included 3 discrete searches in Ovid SP Medline, PsycInfo, and PubMed.

RESULTS

The review included and synthesized 115 articles published between 1987 and 2015. The available evidence suggests that anxiety and depression are common in clinical populations of children and adolescents, and that comorbidity is likely underestimated in children and adolescents. Children and adolescents with comorbid anxiety and depression have unique presentations, greater symptom severity, and treatment resistance compared with those who have either disease in isolation. A dimensional approach may be necessary for the future development of diagnostic strategies and treatments for this population. Nascent neuroimaging work suggests that anxiety and depression each represents a distinct neurobiological phenotype.

CONCLUSIONS

The literature that is currently available suggests that comorbid anxiety and depression is a common presentation in children and adolescents. This diagnostic picture underscores the importance of comprehensive dimensional assessments and multimodal evidence-based approaches given the high disease severity. Future research on the neurobiology and the treatment of these common clinical conditions is warranted.

Pharmacotherapy for Pediatric Generalized Anxiety Disorder: A Systematic Evaluation of Efficacy, Safety and Tolerability

BACKGROUND

Randomized controlled trials consistently support the efficacy of antidepressants in treating youth with generalized anxiety disorder (GAD), although integrated examinations of efficacy, safety, and tolerability of psychotropic medications in GAD, specifically, are rare. With this in mind, we sought to describe the efficacy, safety, and tolerability of psychopharmacologic interventions in pediatric patients with GAD.

METHODS

Randomized, double-blind, placebo-controlled, prospective trials of psychopharmacologic interventions in youth with GAD were identified through a PubMed/Medline (1966-2015) search. Both authors manually reviewed trials and, to evaluate comparative efficacy and tolerability across medications, numbers needed to treat (NNT) [based on Pediatric Anxiety Rating Scale (PARS) remission criteria (PARS ≤8)] and number needed to harm (NNH) for selected treatment-emergent adverse events (TEAEs) were calculated. Finally, treatment-emergent suicidality and taper-emergent/post-study adverse events are reported descriptively.

RESULTS

Five trials that involved 1186 patients and evaluated four medications were reviewed and efficacy data were extracted with regard to dimensional measures of anxiety. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) demonstrated efficacy in the reduction of anxiety symptoms with NNTs ranging from 2.8 to 9.3. TEAEs varied considerably between studies but tended to be mild and generally did not lead to discontinuation.

CONCLUSIONS

Data from five trials of SSRI/SNRI in youth with GAD, many of whom had co-occurring separation and social anxiety disorders, suggest superiority to placebo and favorable tolerability profiles.

Exploring somatization types among patients in Indonesia: latent class analysis using the Adult Symptom Inventory

<b>Background</b><br /> The aim of this study was to explore somatization types by reducing patient complaints to their most basic and parsimonious characteristics. We hypothesized that there were latent groups representing distinct types of somatization.<br /> <br /> <b>Participants and procedure</b><br /> Data were collected from patients undergoing both inpatient and outpatient treatment at two hospitals in Yogyakarta, Indonesia (N = 212).<br /> <br /> <b>Results</b><br /> Results from latent class analysis revealed four classes of somatization: two classes (Classes 1 and 2) referring to levels of somatization and two classes (Classes 3 and 4) referring to unique types of somatization. The first two classes (Classes 1 and 2; low and high levels of somatization, respectively) corresponded to the number of different symptoms that patients reported out of the list of physical symptoms in the Adult Symptom Inventory. The second two classes (Classes 3 and 4; non-serious and critical complaints, respectively) corresponded to two different sets of symptoms. Patients in Class 3 tended to report temporary mild complaints that are common in daily life, such as dizziness, nausea, and stomach pain. Patients in Class 4 tended to report severe complaints and medical problems that require serious treatment or medication, such as deafness or blindness.<br /> <br /> <b>Conclusions</b><br /> The present study do confirm somatization as a unidimensional experience reflecting a general tendency to report somatic symptoms, but rather support the understanding of somatization as a multidimensional construct.

Possible cultural effects on the increments of somatic symptoms in subjectively resilient depressed patients

INTRODUCTION

While previous literatures have provided substantial evidence on the burden of somatic symptoms and the prognostic value of resilience in the treatment course of depression, little is speculated on the relationship between resilience and somatic symptoms in depressed patients. We aimed to clarify the relationship between resilience and somatic symptoms in depressed patients retrospectively.

METHODS

Two hundred and fifty-four outpatients with depressive disorders participated in the study and completed self-administered questionnaires regarding demographic, clinical and psychological factors. We divided the patients into four groups based on their scores of Connor-Davidson Resilience Scale and Beck Depression Inventory. The partial correlation analysis was implemented to show the relationship between somatic symptoms and resilience after controlling for depression, and one-way analysis of variance was conducted to demonstrate the differences in somatization scores of Symptoms Checklist-90-Revised in the aforementioned four groups.

RESULTS

After the correlation analysis, somatization was significantly correlated with resilience even after controlling for depressive symptoms. The one-way analysis of vairance and post-hoc analysis revealed statistically significant differences in somatization scores between the four groups, with the high Beck Depression Inventory, high Connor-Davidson Resilience Scale group having the highest somatization scores.

DISCUSSION

Striving to be resilient during the peak of depression, cultural factors and positive illusions of depressed patients can result in high resilience scores and high somatization scores in depressed patients, and such clinical implications would help clinicians evaluate resilience and somatization in depressed patients with multidimensional aspects.

Characterizing the longitudinal relations between depressive and menstrual symptoms in adolescent girls

OBJECTIVE

This study examined the association between depressive and menstrual symptoms in adolescent girls in a 3-year longitudinal study. It was hypothesized that menstrual symptoms would increase in early adolescence and decrease in later adolescence, that girls with greater depressive symptoms would report greater menstrual symptoms, and that effects would persist after adjusting for general somatic complaints.

METHODS

A community sample of girls (n = 262) enrolled in an observational study by age cohort (11, 13, 15, 17 years) completed three annual visits. At each time point, girls completed the Menstrual Symptom Questionnaire, Children's Depression Inventory, and the Youth Self Report to assess general somatic complaints.

RESULTS

Menstrual symptoms increased significantly across adolescence (p = .006) and began to plateau in later adolescence (p = .020). Depressive symptoms at study entry were significantly associated with menstrual symptoms (p < .001). When general somatic complaints were included in the models, the effect of depressive symptoms on menstrual symptoms remained significant for the sum score (p = .015) and the menstrual somatic symptoms subscale (p = .001). After adjusting for somatic complaints, initial report of depressive symptoms predicted change in menstrual symptoms only for girls with the lowest menstrual symptoms sum score (p = .025). Initial report of somatic complaints predicted change in menstrual symptoms (p = .020).

CONCLUSIONS

Girls with higher depressive symptoms and higher somatic complaints are at greater risk for experiencing menstrual symptoms and increasing symptoms across adolescence, with a heightened vulnerability for girls with lower baseline menstrual symptoms.

Physical complaints in girls with major depression--a controlled study

Major depression is a frequent affective disorder in young adolescents. Patients do not only suffer from severe psychological but also from physical impairments. Aim of the present study is a description of physical complaints in girls with major depression. Seventy-three patients fulfilling DSM-IV criteria for major depression were compared to 72 controls. Physical complaints were assessed by a standardised and validated German questionnaire (Giessen Scale of Physical Complaints in Children and Adolescents). Patients reported significantly more complaints, in particular exhaustion and circulation problems. Physical problems are more likely to be a consequence rather than a cause of depression. Treatment of adolescents׳ depression should consider coping with body dysfunction during depressive episodes.

Somatic complaints in anxious youth

This study examined (a) demographic and clinical characteristics associated with physical symptoms in anxiety-disordered youth and (b) the impact of cognitive-behavioral therapy (Coping Cat), medication (sertraline), their combination, and pill placebo on physical symptoms. Youth (N = 488, ages 7-17 years) with a principal diagnosis of generalized anxiety disorder, separation anxiety disorder, or social phobia participated as part of a multi-site, randomized controlled trial and received treatment delivered over 12 weeks. Diagnostic status, symptom severity, and impairment were assessed at baseline and week 12. The total number and severity of physical symptoms was associated with age, principal diagnosis, anxiety severity, impairment, and the presence of comorbid internalizing disorders. Common somatic complaints were headaches, stomachaches, head cold or sniffles, sleeplessness, and feeling drowsy or too sleepy. Physical symptoms decreased over the course of treatment, and were unrelated to treatment condition. Clinical implications and directions for future research are discussed (ClinicalTrials.gov number, NCT00052078).

Emotional and Behavioral Problems among Impoverished Kenyan Youth: Factor Structure and Sex-Differences

Data on youth emotional and behavioral problems from societies in Sub-Saharan Africa are lacking. This may be due to the fact that few youth mental health assessments have been tested for construct validity of syndrome structure across multicultural societies that include developing countries, and almost none have been tested in Sub-Saharan Africa. The Youth Self-Report (YSR), for example, has shown great consistency of its syndrome structure across many cultures, yet data from only one developing country in Sub-Saharan Africa have been included. In this study, we test the factor structure of YSR syndromes among Kenyan youth ages 11-18 years from an informal settlement in Nairobi, Kenya and examine sex-differences in levels of emotional and behavioral problems. We find the eight syndrome structure of the YSR to fit these data well (Root Mean Square Error of Approximation=.049). While Kenyan girls have significantly higher internalizing (Anxious/Depressed, Withdrawn/Depressed, Somatic) problem scores than boys, these differences are of similar magnitude to published multicultural findings. The results support the generalizability of the YSR syndrome structure to Kenyan youth and are in line with multicultural findings supporting the YSR as an assessment of emotional and behavioral problems in diverse societies.

ADad 8: School Phobia and Anxiety Disorders among adolescents in a rural community population in India

OBJECTIVE

School Phobia (SP), although is not a formal psychiatric diagnosis, is widely prevalent debilitating phenomenon with a gamut of underlying psychiatric conditions in an overwhelming majority of cases. This study documents the prevalence, symptom presentation and the relationship between the various subtypes of Anxiety Disorders (AD) and School Phobia.

METHODS

In a prospective community survey of 500 adolescents, independent raters administered the Screen for Child Anxiety Related Emotional Disorders and Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime to identify SP and subtype of AD respectively. Descriptive statistics for the prevalence and symptom presentation, Spearman's Correlation test, Independent t tests, on-way ANOVA and Chi-square tests were done to compare the prevalence and severity of School Phobia among various age groups and gender. Univariate and multivariate analyses were done for documenting the relationship between the School Phobia and Anxiety Disorders.

RESULTS

School Phobia was noted in 4.8% of adolescents. Although age was related to SP, gender, school grade the adolescent was attending and family structure were not related to SP. Somatic symptoms were more often noted than cognitive-emotional symptoms among adolescents with SP. Panic Disorder (OR = 8.62), Social Anxiety Disorder (OR = 8.63), and Separation Anxiety Disorder (OR = 6.26), were significantly related to SP.

CONCLUSIONS

School Phobia is noted in a significant proportion of adolescents in the community. Anxiety Disorder is a major underlying factor resulting in SP. Community and clinical intervention and service models should include anxiety alleviation methods in adolescents with School Phobia.

Prevalence and patterns of polysubstance use in a nationally representative sample of 10th graders in the United States

PURPOSE

The current study examines the prevalence and demographic correlates of self-reported substance use and identifies subgroups of polysubstance users among a cohort of United States 10th-grade students.

METHODS

A nationally representative school-based cohort of United States 10th-grade students completed the NEXT Generation Health Study baseline survey in spring 2010 (N = 2,524).

RESULTS

Past-year use of marijuana was most common among illicit drugs (26%), followed by misuse of medication (9%) and use of other illicit drugs (8%). During the past month, alcohol use was reported by more than one third (35%), binge drinking by 27%, and cigarette smoking by 19%. Results further show that substance use varied somewhat by demographic characteristics. Results from the latent class analysis of polysubstance use indicated a four-class solution as the best-fitting model; class 1 (59%) included the nonuser group; class 2 (23%) comprised the predominant alcohol user group; class 3 (11%) formed the predominant marijuana user group; and class 4 (8%) was characterized as the predominant polysubstance user group. Somatic and depressive symptoms varied significantly by class membership, with predominant polysubstance users reporting elevated levels of somatic and depressive symptoms.

CONCLUSIONS

The findings from this national study of 10th-grade students indicate high rates of substance and polysubstance use. The high level of depressive and somatic symptoms among polysubstance users indicates the need for mental health screening and referral.

Performance of the Revised Children’s Manifest Anxiety Scale in a Sample of Children and Adolescents from Poor Urban Communities in Cape Town

The Revised Children’s Manifest Anxiety Scale (RCMAS) is regularly used with South African children, although its performance in this context has yet to be empirically evaluated. This study assessed the basic psychometric properties of the RCMAS using data collected in a large study examining the mental health of children and adolescents living in poor urban communities around Cape Town. Reliability of the full-scale was good, and the predicted relationships between anxiety, depression, PTSD, delinquency, age, sex, and somaticism scores offered evidence of construct validity. However, the reliabilities for the physiological, worry/oversensitivity, and concentration subscales were low, and confirmatory factor analysis revealed the hypothesized three-factor model did not adequately fit the data. Exploratory analyses suggested a four-factor solution consisting of social evaluation, worry, affective responses, and physiological symptoms/sleep disturbance factors. Further confirmatory research examining this four-factor structure is needed. Given the continued use of the RCMAS in South Africa, these findings provide an important first step in establishing its reliability and validity for use with South African youth; however, scores obtained on the three subscales should be interpreted with caution and further detailed psychometric evaluation of the RCMAS in South African samples is clearly required.

Functional gastrointestinal symptoms in children with anxiety disorders

This study examined the incidence and correlates of functional gastrointestinal symptoms in children with anxiety disorders. Participants were 6-13 year old children diagnosed with one or more anxiety disorders (n = 54) and non-clinical control children (n = 51). Telephone diagnostic interviews were performed with parents to determine the presence and absence of anxiety disorders in children. Parents completed a questionnaire that elicited information about their child's gastrointestinal symptoms associated with functional gastrointestinal disorders in children, as specified by the paediatric Rome criteria (Caplan et al., Journal of Pediatric Gastroenterology & Nutrition, 41, 296-304, 2005a). Parents and children also completed a symptom severity measure of anxiety. As expected, children with anxiety disorders were significantly more likely to have symptoms of functional gastrointestinal disorders (FGID), compared to children without anxiety disorders. That is, 40.7 % of anxious children had symptoms of a FGID compared to 5.9 % of non-anxious control children. Children with anxiety disorders were significantly more likely to have symptoms of functional constipation, and showed a trend for a higher incidence of irritable bowel syndrome symptoms compared to non-anxious control children. Furthermore, higher anxiety symptom severity was characteristic of anxious children with symptoms of FGID, compared to anxious children without FGID symptoms and non-anxious control children. Also, children with anxiety disorders, regardless of FGID symptoms, were more likely to have a biological family member, particularly a parent or grandparent, with a gastrointestinal problem, compared to non-anxious control children. The high incidence of FGID symptoms in children with anxiety disorders warrants further research on whether gastrointestinal symptoms reduce following psychological treatments for childhood anxiety disorders, such as cognitive behavioural therapy.

Racial/ethnic differences in the prevalence of internalizing symptoms: do Latin-American immigrant show more symptomatology than Spanish native-born adolescents?

This study mainly compared the prevalence of internalizing symptoms of 834 Spanish and 159 Latin-American immigrant adolescents. Participants completed self-report measures about depression, anxiety and somatic symptoms and a socio-demographic questionnaire. The results indicated that being Latin-American was associated with higher levels of depressive symptoms and being female was related to higher depressive and anxiety symptoms. Gender differences were more prevalent in Spaniards than in Latinos, with girls showing more symptoms than boys. High socio-economic status was negatively related to depressive symptoms and anxiety. The results may alert clinicians of the importance of assessing depressive symptoms in Latino adolescents in order to treat this group of youths effectively.

Screening for adolescent anxiety disorders in a pediatric emergency department

OBJECTIVES

Adolescence is a time of increasing risk for some anxiety disorders. Scant data exist on adolescent anxiety in emergency department (ED) settings. We sought to characterize select clinical characteristics and health care use associated with anxiety disorders in a pediatric ED.

METHODS

We screened a convenience sample of 100 adolescent-parent dyads presenting to the ED for the presence of child anxiety disorders using the 5-item Screen for Child Anxiety Related Emotional Disorders, parent (SCARED-P) and child (SCARED-C) versions. Additional demographic and clinical data were also collected.

RESULTS

The SCARED-P and SCARED-C screens identified probable anxiety disorder(s) in 26% to 33% of adolescent participants, respectively. Correlates of positive SCARED-C screens were female sex, asthma, presenting complaint involving headache or migraine, and school absenteeism due to physical problems. Correlates of positive SCARED-P screens were lower parental educational level, presenting complaint involving headache or migraine, and more medical specialty and total medical visits. Few anxious adolescents had received mental health services in the past 6 months. In multivariate models, female sex was independently associated with SCARED-C total score, and presenting complaint involving headache or migraine was independently associated with SCARED-P total score.

CONCLUSIONS

The current pilot data suggest that anxiety disorders are more prevalent among adolescent ED patients than among the general population but largely untreated. Several demographic and clinical variables may help to identify occult anxiety disorders. Greater awareness of anxiety disorders in this population may assist in redirecting a pattern of low use of mental health services but higher overall health care use.

Cognitive mediation of cognitive-behavioural therapy outcomes for anxiety-based school refusal

BACKGROUND

Cognitive-behavioural therapy (CBT) has proven to be effective for anxiety-based school refusal, but it is still unknown how CBT for school refusal works, or through which mechanisms.

AIMS

Innovative statistical approaches for analyzing small uncontrolled samples were used to investigate the role of self-efficacy in mediating CBT outcomes for anxiety-based school refusal.

METHOD

Participants were 19 adolescents (12 to 17 years) who completed a manual-based cognitive-behavioural treatment. Primary outcomes (school attendance; school-related fear; anxiety) and secondary outcomes (depression; internalizing problems) were assessed at post-treatment and 2-month follow-up.

RESULTS

Post-treatment increases in school attendance and decreases in fear about attending school the next day were found to be mediated by self-efficacy. Mediating effects were not observed at 2-month follow-up.

CONCLUSIONS

These findings provide partial support for the role of self-efficacy in mediating the outcome of CBT for school refusal. They contribute to a small body of literature suggesting that cognitive change enhances CBT outcomes for young people with internalizing problems. Regarding methodology, the product of coefficient test appears to be a valuable way to study mediation in outcome studies involving small samples.

Anxiety and inattention as predictors of achievement in early elementary school children

The objective of this study was to examine the relations among anxiety, inattention, and math/reading achievement, as well as the mediating/moderating role of inattention in the anxiety-achievement association both concurrently and longitudinally. Participants included 161 ethnically diverse children (aged 6-8) and their teachers. At the middle and end of first grade (approximately 5 months apart), students completed measures of anxiety and achievement while their teachers completed a measure of inattention. For the concurrent analyses, greater harm avoidance anxiety was associated with better attention, which was in turn related to better achievement. For the longitudinal analyses, mid-year inattention interacted with harm avoidance and separation anxiety to predict end of year reading fluency. For those rated as more attentive, greater separation anxiety symptoms were associated with decreased fluency performance while greater harm avoidance symptoms were associated with increased performance. Findings were discussed in terms of the importance of considering socioemotional variables in the study of children's academic achievement and the potential utility of early anxiety prevention/intervention programs, especially for children experiencing academic difficulties who also show internalizing behaviors.

The relationship between emotion awareness and somatic complaints in children and adolescents: Investigating the mediating role of anxiety and depression

The objective of this study was to examine if emotion awareness in children and adolescents (age 7-18 years old) is directly related to somatic complaints, and if this relationship holds when considering symptoms of anxiety and depression as mediating factors. A number of questionnaires measuring emotion awareness, symptoms of anxiety and depression and somatic complaints were administered to Dutch schoolchildren (N = 617). A path model was constructed, with the use of structural equation modelling. The results showed that two aspects of emotion awareness (bodily awareness and differentiating between emotions) contributed to the prediction of somatic complaints. However, this was no longer the case when controlling for symptoms of anxiety and depression. Thus, in this study, no direct relation was found between emotion awareness and somatic complaints. Instead, the relation was perfectly mediated by symptoms of anxiety and depression. The results suggest that focusing only on the relation between emotion awareness and somatic complaints is an oversimplified perspective that falls short as a starting point to find therapeutic solutions for children who suffer from somatic complaints.

Contextual factors and anxiety in minority and European American youth presenting for treatment across two urban university clinics

The current study compared ethnic minority and European American clinically-referred anxious youth (N=686; 2-19 years) on internalizing symptoms (i.e., primary anxiety and comorbid depression) and neighborhood context. Data were provided from multiple informants including youth, parents, and teachers. Internalizing symptoms were measured by the Multidimensional Anxiety Scale for Children, Child Depression Inventory, Child Behavior Checklist and Teacher Report Form. Diagnoses were based on the Anxiety Disorders Interview Schedule for Children. Neighborhood context was measured using Census tract data (i.e., owner-occupied housing, education level, poverty level, and median home value). Ethnic minority and European American youth showed differential patterns of diagnosis and severity of anxiety disorders. Further, ethnic minority youth lived in more disadvantaged neighborhoods. Ethnicity and neighborhood context appear to have an additive influence on internalizing symptoms in clinically-referred anxious youth. Implications for evidence-based treatments are discussed.

Frequent emergency attenders: is there a better way?

BACKGROUND

Understanding the reasons for frequent re-attendances will assist in developing solutions to hospital overcrowding. This study aimed to identify the factors associated with frequent re-attendances in a regional hospital thereby highlighting possible solutions to the problem.

METHODS

A retrospective analysis was performed on emergency department data from 2008. Frequent re-attenders were defined as those with four or more presentations in a year. Clinical, service usage and demographic patient characteristics were examined for their influence on re-presentations using multivariate analysis. RESULTS; A total of 8% of the total patients presenting to emergency re-attended four or more times in the year. Frequent re-attenders were older, presented with an unplanned returned visit and had a diagnosis of neurosis, chronic obstructive pulmonary disease (COPD), convulsions, dyspnoea or repeat prescriptions, follow-up examinations or dressings and sutures and less likely to present in summer. Frequent re-attendances were unrelated to sex, time of presentation or country of birth.

CONCLUSIONS

Diversion of patients with minor conditions to alternative services; referral of COPD patients to follow-up respiratory services and patients with neurosis to community mental health services would reduce emergency utilisation. Improving access to and resourcing of alternative non-hospital services should be investigated to reduce emergency overcrowding.

Chronic somatic complaints in adolescents: prevalence, predictive validity of the parent reports, and associations with social class, health status, and psychosocial distress

PURPOSE

Chronic somatic complaint (CSC) can cause significant impairment of psychosocial functioning and therefore is of considerable interest in medicine, psychology, and related health sciences. To date, the type, distribution, and associated factors of CSC have been examined in only a limited number of studies. Main research questions of this investigation focused on the prevalence of CSC, the predictive validity of parent reports, and the associations with social class, health status, and psychosocial distress.

METHODS

Data were obtained from a population-based, German-wide representative Health Survey (N = 1,027 self-reports, and parent reports from 11- to 18-year-olds). In addition to study-specific items, the standardized Giessen Physical Complaints Inventory for Children and Adolescents was used (GPCI).

RESULTS

The most frequent CSCs in self-report forms were skin impurities/pimples, cold hands, and fatigue; older adolescents, especially females, were at a higher risk for CSC. The sensitivity of parent reports in all complaints observed was very low (Med = 0.21) and specificity varied between 0.94 and 1.00. Parents significantly underestimated CSC that were not externally observable, as well as CSC in males. Across different predictors and CSC dimensions, psychosocial distress showed the highest predictive value.

CONCLUSIONS

The results provide data regarding the subjective physical health of adolescents, as well as an empirical reference to evaluate the distribution of chronic symptoms in specific clinical populations (which is needed for prevention and treatment).

The Role of Cognition in School Refusal: An Investigation of Automatic Thoughts and Cognitive Errors

Aims: The purpose of this study was to investigate the cognitions of anxious school refusers. The cognitive constructs under investigation included negative cognition commonly linked to youth anxiety (i.e. negative automatic thoughts and cognitive errors) and positive automatic thoughts. Method: The cognition of school refusers (n = 50) and youth from a community sample (n = 181) was assessed with the Children's Automatic Thoughts Scale-Negative/Positive and the Children's Negative Cognitive Error Questionnaire-Revised. Results: When controlling for anxiety, school refusers were found to report more negative automatic thoughts concerning personal failure, fewer negative automatic thoughts concerning hostility, and fewer positive automatic thoughts. Negative automatic thoughts concerning personal failure and hostility, and the negative cognitive error of overgeneralizing were found to independently predict school refusal. Conclusions: The findings underscore the importance of further researching the role of cognition in the development, maintenance, and treatment of anxiety-based school refusal.

Patient related factors in frequent readmissions: the influence of condition, access to services and patient choice

Background

People use emergency department services for a wide variety of health complaints, many of which could be handled outside hospitals. Many frequent readmissions are due to problems with chronic disease and are preventable. We postulated that patient related factors such as the type of condition, demographic factors, access to alternative services outside hospitals and patient preference for hospital or non-hospital services would influence readmissions for chronic disease. This study aimed to explore the link between frequent readmissions in chronic disease and these patient related factors.

Methods

A retrospective analysis was performed on emergency department data collected from a regional hospital in NSW Australia in 2008. Frequently readmitted patients were defined as those with three or more admissions in a year. Clinical, service usage and demographic patient characteristics were examined for their influence on readmissions using multivariate analysis.

Results

The emergency department received about 20,000 presentations a year involving some 16,000 patients. Most patients (80%) presented only once. In 2008 one hundred and forty four patients were readmitted three or more times in a year. About 20% of all presentations resulted in an admission. Frequently readmitted patients were more likely to be older, have an urgent Triage classification, present with an unplanned returned visit and have a diagnosis of neurosis, chronic obstructive pulmonary disease, dyspnoea or chronic heart failure. The chronic ambulatory care sensitive conditions were strongly associated with frequent readmissions. Frequent readmissions were unrelated to gender, time, day or season of presentation or country of birth.

Conclusions

Multivariate analysis of routinely collected hospital data identified that the factors associated with frequent readmission include the type of condition, urgency, unplanned return visit and age. Interventions to improve patient uptake of chronic disease management services and improving the availability of alternative non-hospital services should reduce the readmission rate in chronic disease patients.

Frequent visitors: somatization in school-age children and implications for school nurses

There is a gap in the nursing literature regarding children who frequently visit school nurses' offices with recurrent unexplained physical symptoms. A review of the scientific health literature was undertaken to examine the clinical presentation, associated variables, and implications for school nurses regarding children who are frequent school health office visitors with somatic symptoms. This subset of students with medically unexplained symptoms accounts for disproportionate use of primary care and school health resources. Common somatic complaints in school-age children, such as headache and stomachache, are associated with the psychosocial variables of anxiety and depression, childhood adversity, and school stress. Effective and practical treatment approaches to this complicated child health issue require accurate identification, appropriate referral, screening for associated conditions, and individualized treatment plans. Research to identify effective interventions for frequent health office visitors is needed.

The effect of long-term lactobacilli (lactic acid bacteria) enteral treatment on the central nervous system of growing rats

The aim of this study was to explore the relationship between consumption of large doses of lactic acid bacteria (LAB) and the behaviour and brain morphobiochemistry of normal growing rats. Four groups of rats were treated with LAB cultures twice daily for 6 months. The control group received 1 ml of saline per treatment, while two experimental groups received 1 ml of living bacteria (Lactobacillus plantarum and Lactobacillus fermentum, respectively) and the remaining group received a heat-treated (inactivated) L. fermentum culture. After 2 and 6 months of treatment, respectively, eight animals from each group were sacrificed, and specimens were taken for further analyses. The behaviour of the rats was evaluated five times in an open-field test at monthly intervals throughout the study. Lactobacilli treatment for 2 months induced changes in the motoric behaviour of the rats. The concentration of the astrocytesoluble and filament glial fibrillary acidic protein (GFAP) decreased in the posterior part of the hemispheres, including the thalamus, hippocampus and cortex of the rats treated with L. fermentum. A greater decrease in filament GFAP (up to 50%) was shown in the group receiving the live form of L. fermentum. In contrast, the GFAP in the live L. plantarum-treated group increased, showing elevated levels of the soluble and filament forms of GFAP in the posterior part of the hemispheres. A 60-66% decrease in the amount of the astrocyte-specific Ca-binding protein S-100b was shown in the posterior parts of the hemispheres and in the hindbrain of rats given LAB for 2 months. Prolonged feeding with LAB for 4 months up to full adulthood led to a further decrease in astrocyte reaction, reflected as an additional decrease in the amount of soluble GFAP and locomotor activity in all experimental groups. The changes in filament GFAP and S-100b appeared to disappear after prolonged feeding (total of 6 months) with LAB. In summary, LAB dietary treatment affected the ontogenetic development of the astrocytes, with the highest intensity observed in the early stages of rat development. It can be postulated that LAB treatment may play a preventive role in neurological diseases by decreasing astrocyte reaction and, consequently, lowering locomotor activity.