Quality of life in inflammatory bowel disease: background and definitions

Crohn disease: effect on children's lifestyles

BACKGROUND AND AIM

Crohn disease (CD) presents a range of physical, social, and psychological challenges, and can adversely affect the quality of life of those affected by it. The present study aimed to investigate the health-related quality of life of paediatric patients with CD in the Wellington region. Measuring health-related quality of life assists with resource allocation decisions and assesses various forms of interventions.

METHODS

Patients ages 9 to 18 years with CD in the Wellington region were assessed using the IMPACT-III inflammatory bowel disease-specific questionnaire (n = 16). Eight participants filled it out and returned it by post; the remaining 8 filled it out in a meeting with the researcher and then underwent cognitive debriefing as part of a cross-cultural adaptation of the questionnaire.

RESULTS

Of a maximum possible value of 175, the total health-related quality of life score had a mean value of 119.2 (standard deviation 30.7). Using Spearman rank correlation analysis, significant findings included a positive correlation between disease duration and quality of life (ρ = 0.534, sig. <0.05) and a negative correlation between disease activity and quality of life (ρ = -0.596, sig. <0.05). Qualitative information included difficulties in coping with long-term and unpleasant treatments and feelings of isolation.

CONCLUSIONS

Children with Crohn disease in the Wellington region may benefit from age-specific social and psychological support. Because there is limited information on quality of life in young patients with CD in New Zealand, the results of the present study may be used as baseline data for future studies.

Validation of an instrument to measure quality of life in British children with inflammatory bowel disease

OBJECTIVE

To validate IMPACT-III (UK), a health-related quality of life (HRQoL) instrument, in British children with inflammatory bowel disease (IBD).

PATIENTS AND METHODS

One hundred six children and parents were invited to participate. IMPACT-III (UK) was validated by inspection by health professionals and children to assess face and content validity, factor analysis to determine optimum domain structure, use of Cronbach alpha coefficients to test internal reliability, ANOVA to assess discriminant validity, correlation with the Child Health Questionnaire to assess concurrent validity, and use of intraclass correlation coefficients to assess test-retest reliability. The independent samples t test was used to measure differences between sexes and age groups, and between paper and computerised versions of IMPACT-III (UK).

RESULTS

IMPACT-III (UK) had good face and content validity. The most robust factor solution was a 5-domain structure: body image, embarrassment, energy, IBD symptoms, and worries/concerns about IBD, all of which demonstrated good internal reliability (α = 0.74-0.88). Discriminant validity was demonstrated by significant (P  < 0.05, P < 0.01) differences in HRQoL scores between the severe, moderate, and inactive/mild symptom severity groups for the embarrassment scale (63.7 vs 81.0 vs 81.2), IBD symptom scale (45.0 vs 64.2 vs 80.6), and the energy scale (46.4 vs 62.1 vs 77.7). Concurrent validity of IMPACT-III (UK) with comparable domains of the Child Health Questionnaire was confirmed. Test-retest reliability was confirmed with good intraclass correlation coefficients of 0.66 to 0.84. Paper and computer versions of IMPACT-III (UK) collected comparable scores, and there were no differences between the sexes and age groups.

CONCLUSIONS

IMPACT-III (UK) appears to be a useful tool to measure HRQoL in British children with IBD.

Inflammatory bowel disease in children: psychological and psychiatric issues

The overlap between inflammatory bowel disease (IBD) and psychiatric disorders has been studied extensively. We reviewed the limited literature targeting the complex relationship between IBD and psychiatric disorders in children and adolescents. Findings from this review were compared with findings from available studies in adults. Results reflecting an association between IBD and psychiatric illnesses were observed in children and adolescents and were consistent with results in adults. In adults with IBD, many studies have reflected the advantages of psychotherapeutic treatment, including faster recovery, improved quality of life, and reduced health care use. Unfortunately, such studies are scarce in the child and adolescent population. Psychopharmacologic studies also are limited in adult and pediatric populations. At this time, the literature on treatment of the pediatric IBD population remains minimal, and the need to study screening and treatment modalities is critical.

Health values in adolescents with or without inflammatory bowel disease

OBJECTIVE

To examine for differences in and predictors of health value/utility scores in adolescents with or without inflammatory bowel disease (IBD).

STUDY DESIGN

Adolescents with IBD and healthy control subjects were interviewed in an academic health center. We collected sociodemographic data and measured health status, personal, family, and social characteristics, and spiritual well-being. We assessed time tradeoff (TTO) and standard gamble (SG) utility scores for current health. We performed bivariate and multivariable analyses with utility scores used as outcomes.

RESULTS

Sixty-seven patients with IBD and 88 healthy control subjects 11 to 19 years of age participated. Among subjects with IBD, mean (SD) TTO scores were 0.92 (0.17), and mean (SD) SG scores were 0.97 (0.07). Among healthy control subjects, mean (SD) TTO scores were 0.99 (0.03) and mean (SD) SG scores were 0.98 (0.03). TTO scores were significantly lower (P= .001), and SG scores trended lower (P= .065) in patients with IBD when compared with healthy control subjects. In multivariable analyses controlling for IBD status, poorer emotional functioning and spiritual well-being were associated with lower TTO (R(2)=0.17) and lower SG (R(2)=0.22) scores.

CONCLUSION

Direct utility assessment in adolescents with or without IBD is feasible and may be used to assess outcomes. Adolescents with IBD value their health state highly, although less so than healthy control subjects. Emotional functioning and spiritual well-being appear to influence utility scores most strongly.

A qualitative study of youth living with Crohn disease

Little is known about what it is like to live in adolescence with a chronic inflammatory bowel disease. This article reports the findings of a small qualitative study that explored the experience of four New Zealand youth aged between 16 and 21 years, who had been recently diagnosed with Crohn disease. Semistructured interviews focused on discovering the youth' thoughts, feelings, and perceptions of living with this condition. Analysis of the transcribed data is presented thematically. The findings reveal stress as integral to living with Crohn disease. They illuminate the paradoxical relationship between fear and hope and provide insight into what helps and what hinders young people's ability to cope with the disease and its treatments. Collectively, these three themes describe the ways in which the lives of young adults are drastically and almost irreparably changed by Crohn disease. The findings contribute to the "promoting wellness" literature and will inform those who support the increasing number of young people living and coping with a chronic inflammatory bowel disease.

Measuring quality of life in pediatric patients with inflammatory bowel disease: psychometric and clinical characteristics

OBJECTIVE

To extend development of a pediatric inflammatory bowel disease (IBD) health-related quality of life (HRQoL) measure by determining its factor structure and associations of factors with generic HRQoL measures and clinical variables.

PATIENTS AND METHODS

Cross-sectional survey of children and adolescents ages 8 years to 18 years and their parents attending any of 6 US IBD centers, recruited from either existing registry of age-eligible subjects or visits to participating centers. The survey included generic (Pediatric Quality of Life Inventory) and IBD-specific (Impact Questionnaire) quality of life measures, disease activity, and other clinical indicators. We carried out factor analysis of Impact responses, comparing resulting factors with results on the generic HRQoL and the clinical measures.

RESULTS

We included 220 subjects (161 with Crohn disease and 59 with ulcerative colitis). Initial confirmatory factor analysis did not support the 6 proposed Impact domains. Exploratory factor analysis indicated 4 factors with good to excellent reliability for IBD responses: general well-being and symptoms, emotional functioning, social interactions, and body image. Two items did not load well on any factor. The 4 factors correlated well with the Pediatric Quality of Life Inventory and subscales. Children with higher disease activity scores and other indicators of clinical activity reported lower HRQoL.

CONCLUSIONS

This study provides further characteristics of a HRQoL measure specific to pediatric IBD and indicates ways to score the measure based on the resulting factor structure. The measure correlates appropriately with generic HRQoL measures and clinical severity indicators.

Pilot evaluation of an instrument to measure quality of life in British children with inflammatory bowel disease

The IMPACT questionnaire was developed in Canada to measure quality of life in children with inflammatory bowel disease (IBD). In the present study, 20 children with IBD completed 2 versions of the IMPACT questionnaire with a Likert scale or visual analog scale (VAS), 5 of whom expressed problems with language or phrasing. Difficult words included "restrictions," "moderate," "diarrhea," "school break," and the abbreviation "IBD." Fifteen children preferred the Likert scale to the VAS (chi = 20, P < 0.01). Rewording the difficult words and using a Likert scale should facilitate completion of the IMPACT questionnaire in the United Kingdom. Further validation is needed to ensure that the instrument is reliable and valid.

Cognitive-behavioral therapy for adolescents with inflammatory bowel disease and subsyndromal depression

OBJECTIVE

To examine the feasibility and efficacy of a manual-based cognitive-behavioral therapy (CBT) in reducing depressive symptomatology in adolescents with inflammatory bowel disease (IBD). Primary and Secondary Control Enhancement Therapy-Physical Illness (PASCET-PI) modified for youths with IBD was compared to treatment as usual (TAU), plus an information sheet about depression, without therapist contact using assessable patient analysis.

METHOD

Following assessment, participants 11 to 17 years old with IBD and mild to moderate subsyndromal depression were randomly assigned to PASCET-PI (n = 22) or comparison treatment (n = 19). Primary outcome measures at baseline (T1) and 12 to 14 weeks posttreatment (T2) were Children's Depression Inventory (child/parent report), Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), Children's Global Assessment Scale, and Perceived Control Scale for Children.

RESULTS

The PASCET-PI group showed significantly greater improvement in Children's Depression Inventory (child/parent report), Children's Global Assessment Scale, and Perceived Control Scale for Children posttreatment than the comparison group.

CONCLUSIONS

Screening and treatment of depressive symptoms in pediatric settings is feasible. PASCET-PI may be an efficacious intervention for subsyndromal depression in adolescents with IBD, although comparison with a more active treatment is necessary to attribute the improvement to PASCET-PI.

CLINICAL TRIAL REGISTRATION INFORMATION

URL: http://clinicaltrials.gov. Unique identifier: NCT00446238.

Fecal lactoferrin is a sensitive and specific marker of disease activity in children and young adults with inflammatory bowel disease

BACKGROUND AND AIMS

Fecal lactoferrin (FLA) is a neutrophil-derived surrogate marker of intestinal inflammation that is elevated in patients with inflammatory bowel disease. However, the correlation between FLA levels and serological markers of disease activity has not been previously reported, to our knowledge. In the present study we evaluated the ability of FLA levels to reflect disease activity in pediatric patients with inflammatory bowel disease. We further assessed the relationship between FLA levels and customary laboratory and clinical measures of inflammation.

PATIENTS AND METHODS

Fecal specimens were collected from 148 consecutive pediatric patients (79 with Crohn disease, 62 with ulcerative colitis, and 7 with irritable bowel syndrome) and 22 healthy control individuals. Lactoferrin was measured by enzyme-linked immunosorbent assay (IBD-SCAN, TECHLAB, Inc). Disease activity was assessed at the time of sample provision by laboratory measures (including erythrocyte sedimentation rate [ESR] and albumin) and previously validated disease activity indices (Pediatric Crohn Disease Activity Index, Kozarek, Harvey Bradshaw Activity Index).

RESULTS

Lactoferrin levels were significantly higher in patients with ulcerative colitis (1880 +/- 565 microg/mL) (mean +/- SE) or Crohn disease (1701 +/- 382 microg/mL) than in healthy control individuals under 21 years of age (1.17 +/- 0.47 microg/mL, P < 0.001). Lactoferrin levels correlated significantly with ESR, hematocrit, albumin, and platelet count (P < 0.001). Receiver operating characteristic curve analysis revealed that FLA levels were comparable to ESR in detecting patients with clinically active disease (P < 0.001). Patients who experienced a clinical flare within 2 months of specimen collection displayed higher lactoferrin levels (845 +/- 452 microg/mL) than did those who remained in clinical remission (190 +/- 90 microg/mL, P = 0.003).

CONCLUSIONS

Data presented here demonstrate that FLA is a sensitive and specific biochemical marker of inflammation for use in the diagnosis and interval assessment of pediatric patients with IBD, and its level correlates well with both clinical disease activity indices and ESR. Elevated levels of FLA may also identify patients at greater risk for the development of subsequent clinical flares.

Review article: the intestinal lumen as a therapeutic target in inflammatory bowel disease

Undigested carbohydrates reaching the colon can act as competitors for epithelial bacterial receptors, making it difficult for noncommensal bacteria to adhere to them. On the contrary, fermentation of these carbohydrates by anaerobic flora produces - among other substrates - butyrate that is involved in numerous important metabolic processes. These include the provision of energy to the colonocytes, the enhancement of sodium and water absorption and the synthesis of mucus and cell membranes. In addition, butyrate inhibits the nuclear translocation of the transcription factor NFkappaB, which exerts a potent anti-inflammatory activity. Clinical experience with probiotics in inflammatory bowel disease (IBD) is controversial. Whereas some probiotic preparations appear to be useful in ulcerative colitis (UC) and pouchitis, most attempts to use probiotics for treating or preventing recurrence in Crohn's disease have failed. It should be pointed out that - unlike in the small bowel - the colon and ileal pouches are well-established microbiological ecosystems with increasing amounts of a wide variety of bacterial strains. These bacterial strains have a high degree of metabolic interaction with luminal nutrients and a greater probability of developing dysbiosis. With this in mind, the rationale for using pre- and probiotics appears to be stronger for colonic IBD (UC or Crohn's colitis) and pouchitis than for IBD mostly involving the small bowel.

Psychosocial functioning in pediatric inflammatory bowel disease

BACKGROUND

The purpose of this article is to review research on psychosocial functioning in pediatric inflammatory bowel disease (IBD) and to provide recommendations for future research.

METHODS

A literature search was conducted using the MEDLINE and PsychInfo computerized databases and bibliographies of relevant articles.

RESULTS

Compared with healthy children, children with IBD are at greater risk of difficulties behavioral/emotional functioning, particularly depression and anxiety, social functioning, and self-esteem. Conflicting results have been reported for the areas of family dysfunction and body image, and few studies have been published in the areas of stress and coping and eating problems. Psychosocial difficulties are clinically significant in only a subset of those with IBD and are generally similar to those found in other pediatric chronic illnesses.

CONCLUSIONS

The scant existing research limits conclusions about which children are most likely to experience problems. Future research should investigate a range of psychosocial outcomes, including developmentally appropriate outcomes for adolescents, and risk factors for developing problems. Prevention and intervention strategies aimed at improving psychosocial functioning in children with IBD should be developed and evaluated.

Cognitive-behavioral therapy for depression in adolescents with inflammatory bowel disease: a pilot study

OBJECTIVE

To evaluate the safety and feasibility of cognitive-behavioral therapy (CBT) for depression in physically ill adolescents.

METHOD

In an open trial, 11 adolescents (12-17 years) with inflammatory bowel disease and either major or minor depression underwent 12 sessions of a manual-based CBT enhanced by social skills, physical illness narrative, and family psychoeducation components. Standardized instruments assessed pre- to posttreatment changes in depression, physical health, global psychological functioning, and social functioning. Perceived helpfulness and satisfaction with CBT were assessed.

RESULTS

There were significant reductions in DSM-IV depression diagnoses and depressive symptoms and improvements in global psychological and social functioning. Adolescents' perceptions of their general health and physical functioning improved, although illness severity measures were unchanged. High subject satisfaction and helpfulness ratings for CBT were found along with no adverse events and high subject adherence.

CONCLUSIONS

A manual-based CBT approach adapted to treat depression in physically ill adolescents appears to be a safe, feasible, and promising intervention.

Assessing the demand for psychological care in chronic diseases: development and validation of a questionnaire based on the example of inflammatory bowel disease

BACKGROUND

This study was designed to develop and validate the ADAPT (Assessment of the Demand for Additional Psychological Treatment), a questionnaire assessing the demand for disease-oriented counseling (DOC), integrated psychosomatic care (IPC), and psychotherapy (PT) in chronically ill patients on the example of inflammatory bowel diseases (IBDs).

METHODS

After its development, the ADAPT was distributed to 39 IBD patients along with the Hospital Anxiety and Depression scale (HAD), the Rating Form of IBD Patient Concerns (RFIPC), and a questionnaire on social support (SOZU-K22). For construct validity, 19 hypotheses were made on how DOC, IPC, and PT should correlate with HAD, RFIPC, SOZU-K22, and disease-related variables. To analyze interindividual responsiveness, patients were classified according to their bio-psycho-social state, and DOC, IPC, and PT scores were compared between these classes. The test-retest method with a 4-week time lapse was used to analyze reliability and intraindividual responsiveness. DOC, IPC, and PT scores between baseline and follow-up were compared separately for patients classified as "stable" or "changed" according to changes in HAD and disease activity.

RESULTS

Observed correlations were largely in agreement with the 19 hypotheses. DOC, IPC, and PT achieved significantly different scores between different patients. After 4 weeks, DOC, IPC, and PT revealed stable scores in patients with "stable" HAD and revealed significantly different scores in patients with "changed" HAD. Changed disease activity was not associated with significant changes of the ADAPT.

CONCLUSIONS

The ADAPT is the first questionnaire to assess subjective demand for additional psychological care in chronically ill patients. The first application of the ADAPT to 39 IBD patients suggests its validity, reliability, and responsiveness.

Shortened questionnaire on quality of life for inflammatory bowel disease

Questionnaires for measuring quality of life in patients with inflammatory bowel disease usually include a large number of items and are time-consuming for both administration and interpretation. Our aim was to elaborate and validate a short quality-of-life questionnaire with the most representative items from the Spanish version of the 36-item Inflammatory Bowel Disease Questionnaire (IBDQ-36) using the Rasch analysis. The responses to 311 IBDQ-36 questionnaires from 167 patients with ulcerative colitis (UC) and 144 with Crohn's disease (CD) were analyzed. IBDQ-36 was shortened with successive Rasch analyses until all the remaining items showed acceptable separation and goodness-of-fit properties. Validation of the short questionnaire was studied in a new group of 125 patients by determining its validity and reliability. A 9-item short questionnaire was obtained (IBDQ-9). Its correlation with IBDQ-36 was excellent (r = 0.91). Correlation between IBDQ-9 and clinical indices of activity was statistically significant in UC (r = 0.70) and CD (r= 0.70). IBDQ-9 score discriminates adequately between patients in clinical remission or relapse (P < 0.01). Sensitivity to change was determined in 14 patients who improved clinically, showing significant IBDQ-9 changes between both determinations (P < 0.01), with an effect size of -2.67 in UC and -5.29 in CD. IBDQ-9 was also homogeneous, with a Cronbach's alpha of 0.95 in UC and 0.91 in CD. In 35-clinically stable patients, test-retest reliability was good, with a statistically-significant correlation between both questionnaires (r = 0.76 in UC and 0.86 in CD, P < 0.01) and an intraclass correlation coefficient of 0.82 in UC and 0.84 in CD. In conclusion, a short and valid questionnaire to measure quality of life in patients with inflammatory bowel disease was obtained using a new measurement model. Its use should facilitate comprehension of the impact of inflammatory bowel disease.

Inflammatory bowel diseases in pediatric and adolescent patients: clinical, therapeutic, and psychosocial considerations

Inflammatory bowel diseases (Crohn's disease and ulcerative colitis) primarily affect young adults, but in 15%-25% of cases, the initial disease starts in childhood. Many aspects of inflammatory bowel disease, including initial evaluation, nutritional support, medical and surgical intervention, and the direction of future research, are encountered in both adult and pediatric patients. However, it is important to delineate issues specific to pediatric patients, especially growth velocity impairment, derangements in and treatment of abnormal bone mineralization, and transitional care issues; the lack of extensive randomized, controlled pediatric therapeutic trials is also a concern. This article reviews the epidemiology of pediatric inflammatory bowel disease incidence and prevalence worldwide, clinical issues (including impairments of growth velocity and bone density), diagnostic and therapeutic interventions, and psychosocial issues unique to pediatric patients. Future research directions defined by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and opportunities provided by existing pediatric research databases are highlighted.

Inflammatory bowel disease in early childhood and adolescence: special considerations

Several aspects of IBD overlap between pediatric and adult population. Those include nutritional issues, bone density, and medical and surgical therapies. Some aspects like natural course of the disease, and epidemiology and genetics are more easily examined and researched in the pediatric population. Others like pubertal and growth delay, and transition of health care are unique to pediatric patients. This article examines some of the similarities, as well as differences of IBD in these two populations.

Pediatric inflammatory bowel disease

The treatment of children and families affected by pediatric IBD requires an awareness of the diverse psychobiologic effects of the disorder over the course of child, adolescent [53], and adult development [52]. Optimal treatment requires careful coordination of various medical, educational, and rehabilitative services and concerned, empathetic, continuity of care by knowledgeable clinicians [4]. In many cases, this care must also include individual psychotherapeutic work with affected youngsters at crucial junctures to help deal with the social and psychological stresses of IBD, as well supportive casework for parents and siblings.

The IMPACT questionnaire: a valid measure of health-related quality of life in pediatric inflammatory bowel disease

BACKGROUND AND AIMS IMPACT: is a disease-specific health-related quality-of-life questionnaire developed for use in pediatric inflammatory bowel disease through a process of patient interviews and analysis of patient responses to an item-reduction questionnaire. This study sought to assess the feasibility, reliability, and validity of the instrument.

METHODS

The readability statistics and number of unanswered questions were assessed among 147 patients (97 CD, 50 UC) with mean age 14.4 +/- 2.2 years (range 9.2-18.0 years) using the self-administered questionnaire. Internal consistency was assessed with Cronbach's alpha and test-retest reliability using intraclass correlation coefficient (ICC). Construct validity was based on a priori hypotheses. Mean total scores were compared by ANOVA among patients grouped according to disease activity and disease severity within the past year.

RESULTS

The readability statistic showed a Flesch-Kincaid Grade level of 4.5. Only 0.68% of questions were left blank. Reliability was excellent with Cronbach's alpha = 0.96, and an ICC of 0.90 in patients with stable disease over a two-week period (n = 32). The mean total IMPACT score for patients with quiescent disease (180 +/- 32) was significantly higher (better QOL) than for those with active disease (146 +/- 31 for mild, 133 +/- 34 for moderate/severe) (P < 0.005).

CONCLUSIONS

The IMPACT questionnaire is a valid and reliable reflection of health-related quality of life of older children and adolescents with both ulcerative colitis and Crohn's disease.

Quality of life in inflammatory bowel disease: a cross-cultural comparison of English and Canadian children

BACKGROUND

Any disease and its treatment has an important impact on health-related quality of life for affected individuals. There have been few previous studies on the quality of life for children with inflammatory bowel disease (IBD).

METHODS

A cross-cultural comparison was performed to determine whether the concerns of children with IBD in the United Kingdom are ranked similarly to those of children with IBD in Canada. An item reduction questionnaire, developed from interviews with Canadian children with IBD, was scored by 53 British children with IBD for importance and frequency, as a questionnaire had been scored previously by 117 Canadian children.

RESULTS

There was a significant correlation between the mean scores (r = 0.831, P < 0.001) and ranks (r = 0.801, P < 0.001) for the 96 questions, and 43 of the 50 highest-ranking concerns corresponded for both populations. Confidence interval analysis showed a significant difference between the mean values for 21 of the 96 items; 20 of these 21 were ranked higher in the United Kingdom than they had been in Canada, suggesting that the frequency and/or degree of concern was greater for the British children with IBD.

CONCLUSIONS

Health-related concerns of British children with Crohn disease and ulcerative colitis correlate closely with those of Canadian children with those diseases. Further studies are needed to determine the sensitivity of individual questions, the most appropriate wording of these questions, and the optimal length for a proposed instrument to assess quality of life in children with IBD.