9/7/2012 1 ………………..…………………………………………………………………………………………………………………………………….. Comorbidities of Depression, Anxiety and Chronic Pain in Children & Adolescents Sharon Wrona, MS, RN-BC, PNP ASPMN 22 nd National Conference ………………..…………………………………………………………………………………………………………………………………….. Objectives • Identify chronic pain conditions in children and adolescents. • Review prevalence of depression and anxiety in children and adolescents. Discuss the relationship of chronic pain and co-morbidity of anxiety and/or depression in children and adolescents with chronic pain. • Review treatment options for chronic pain and anxiety and/or depression in children and adolescents. • Present case studies of children and adolescents with chronic pain and comorbid anxiety and/or depression. Nothing to disclose “Chronic and recurrent pain not associated with a disease is very common in childhood and adolescence” Chronic pain is more common in girls and commonly increases with age. Studies suggest prevalence of chronic pain in children is from 23% to 51%. King, S., et al. (2011)
• Identify chronic pain conditions in children and adolescents.
• Review prevalence of depression and anxiety in children and adolescents. Discuss the relationship of chronic pain and co-morbidity of anxiety and/or depression in children and adolescents with chronic pain.
• Review treatment options for chronic pain and anxiety and/or depression in children and adolescents.
• Present case studies of children and adolescents with chronic pain and comorbid anxiety and/or depression.
Nothing to disclose
“Chronic and recurrent pain not associated with a disease is very common in
childhood and adolescence”
Chronic pain is more common in girls and commonly increases with age.
Studies suggest prevalence of chronic pain in children is from 23%
to 51%. King, S., et al. (2011)
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Chronic pain in Children and Adolescents
Table 2. Summary of prevalence rates by pain type.
Pain typePrevalence range
Median quality criteria met
Age differences
Sex differences
Psychosocial/demographic factors associated with increased prevalence
Headache 8‐82.9% 9Older > younger Girls > boys
Presence of anxiety and depression; low self‐esteem (girls only); positive family history of headache; low SES (conflicting findings)
Abdominal pain 3.8‐53.4% 8Younger > older Girls > boys
SES (conflicting findings); emotional symptoms; school stress
Back pain 13.5‐24% 7Older > younger Girls > boys
Emotional symptoms (conflicting findings); relation between back pain and sociodemographic/psychosocial factors is unclear
Musculoskeletal/limb pain 3.9‐40% 7
Older > younger Girls > boys Feeling sad (girls only)
Multiple pains 3.6‐48.8% 8 Unclear Girls > boys
Chronic health problems; frequent change of residence; frequent television watching; poor school performance; fewer interactions with peers
Other/general pain 5‐88% 8
Unclear − possible age × sex interaction Girls > boys
Poor self‐rated health; feeling low or irritable; bad temper; feeling nervous
Treatment of Chronic Pain in Children and Adolescents
• Mind-based approaches can be helpful non-invasive treatment options for chronic pain– Hypnosis– Biofeedback– Art therapy
Tsao, J, et al., 2006
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Anxiety in Children & Adolescents
• One of the most prevalent MH disorders in children
• Females are more likely to have diagnosis
• Common onset of anxiety occurs around age 14
• Neuroimaging studies have shown that youth with anxiety have a hyperactivated amygdala and their ventrolateral prefrontal region does not modulate anxiety as quickly as seen in non-anxious youths
(American Psychiatric Association, 2000)
Anxiety in Children & Adolescents
• Symptom manifestation may be more somatic including fatigue, muscle tension, insomnia, malaise, dry mouth, syncope, SOB, diarrhea, nausea, and abdominal pain
• Most frequently treated psychiatric d/o • Quality of performance or competence • Overly conforming, perfectionist, and unsure of themselves• Seeking approval and reassurance• May have less physical symptoms than adults• Diagnostic Criteria C: ONLY ONE ITEM IS REQUIRED FOR
CHILDREN.• May be over diagnosed• Higher rates of suicidal behavior, early parenthood, drug &
alcohol dependence, and education underachievement. (Boyd, 2008)
• Rejection of closeness• Child’s sense of a loss of the vigor and magic of youth• Cognitive impairment or forgetfulness• Sleep disturbances that persist more than several days• Dependency behaviors such as clinging, separation anxiety, and
reluctance to attend school• Extreme fear of distress associated with events that remind the
child of the trauma• Behavioral or emotional changes• Dissociations• Intrusive reexperiencing of the event• Persistent avoidance of related stimuli• Regression to previous development stage• Questions about self-worth and expression of need for solitude
• There must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interaction with adults.
• The anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
• The child may not recognize the fear is excessive or unreasonable.
Social Phobia: Considerations for Pediatrics
DSM-IV-TR
Depression in Children & Adolescents
• Estimated that 20% of adolescents have depressive episode by adulthood
• 50% adolescents that show symptoms of depression will have symptoms as an adult
• Estimated that 20% youths showing signs of depression will develop BPAD
• Symptoms may be different than seen in adult patients such as anger, irritability, and anxiety (Bolfek et al., 2006)
• Young children may show symptoms of school phobia and excessive clinginess to parents (Sadock & Sadock, 2003)
• Other symptoms include poor academic functioning, substance abuse, antisocial behavior, truancy, promiscuity, and running away from home (Sadock & Sadock, 2003)
• May be helpful to use specific rating scales for children such as – Child Depression Rating Scale– Children’s Depression Inventory– Beck Depression Inventory
Chronic Abdominal Pain and Depressive Symptoms: Analysis of the National
Longitudinal Study of Adolescent Health
Rare pain Daily pain P value
Feel sad 5.3% 25.3% <.001
Feel like crying 1.0% 12.1% <.001
Feel lonely 6.4% 25.2% <.001
Feel low energy 4.8% 19.1% <.001
Feel life is a failure 3.3% 10.7% <.001
Table 1. Abdominal Pain and Associated Depressive Symptoms
Children with daily pain were more likely to have changed their primary residence in the prior 5 years (P < .05). Frequency of abdominal pain or risk of depression was not related to family socioeconomic status.
Youssef, et. al (2008)
Psychiatric disorders in children and adolescents presenting with unexplained chronic pain: what is the prevalence and clinical
relevancy? - Knook, et al , 2011
Table 2 Prevalence of clinically relevant psychiatric disorder: parental interview (DISC-P) by pain location, n (%) One or more psychiatric disorder per patient and CGAS < 61MP musculoskeletal pain, AP abdominal pain, HA headache * Conditions for chi-quadrate analysis not metaPsychiatric disorder without impairment criterion bADHD, ODD, Conduct Disorder
DISC‐P
Total (n = 134) MP (n = 60) AP (n = 43) HA (n = 31) p‐value
Table 2 Prevalence of clinically relevant psychiatric disorder: parental interview (DISC-P) by pain location, n (%)
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Table 3 Prevalence of clinically relevant psychiatric disorder: child psychiatrists’ assessment (SCICA) by pain location, n (%)
One or more psychiatric disorder per patient and CGAS < 61MP musculoskeletal pain, AP abdominal pain, HA headache * Conditions for chi-quadrate analysis not metaPsychiatric disorder without impairment criterion bADHD, ODD, Conduct Disorder
Psychiatric disorders in children and adolescents presenting with unexplained chronic pain: what is the prevalence and clinical
Chronic Pain in Adolescents is Associated with Suicidal Thoughts and
Behaviors (van Tilburg, et. al. 2011)
• Analyzed data from the National Longitudinal Study of Adolescent Health, a longitudinal study of a nationally representative sample of adolescents in the United States (N = 9,970)
• Most chronic pain was related to suicide ideation/attempt both in the last year (odds ratio [OR] 1.3-2.1) and during the subsequent year (OR 1.2-1.8)
• After controlling for depressive symptoms– headaches (OR = 1.3 last year, OR = 1.2 subsequent year)
– muscle aches (OR = 1.3 last year) remained associated with suicide ideation but not suicide attempt
• Findings show that chronic pain in adolescence is a risk factor for suicide ideation; this effect is partly but not fully explained by depression
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Multiple Somatic Symptoms Linked to Positive Screen for Depression in Pediatric Patients With Chronic Abdominal Pain.Little, Cheryl; Williams, Sara; Puzanovova, Martina; Rudzinski, Erin; Walker, Lynn
Journal of Pediatric Gastroenterology & Nutrition. 44(1):58‐62, January 2007.DOI: 10.1097/01.mpg.0000243423.93968.7c
FIG. 1 . Percent of patients reporting nongastrointestinal symptom presence in the previous 2 weeks by positive vs negative depression screening group.
FIG. 2 . ROC curve for sensitivity and specificity of prediction of positive depression screening based on number of nongastrointestinal symptoms endorsed.
Multiple somatic symptoms linked to positive screen for depression in pediatric patients with chronic abdominal pain. (Little, Et. Al. 2007)
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Citalopram treatment of pediatric recurrent abdominal pain and comorbid internalizing
disorders: an exploratory study • Twenty-five clinically referred children and adolescents with recurrent
abdominal pain aged 7 to 18 years– 12-week, flexible-dose, open-label trial of citalopram.
• Outcome measure was the Clinical Global Impression Scale-– Improvement, with responders defined by ratings of 1 (very much improved) or 2
(much improved). Secondary measures included self- and parent reports of abdominal pain, anxiety, depression, other somatic symptoms, and functional impairment.
• Side effects were assessed using a standardized checklist. • Twenty-one subjects (84%) were classified as responders (Clinical Global
Impression Scale-Improvement score < or =2). • Citalopram was generally well tolerated. • Ratings of abdominal pain, anxiety, depression, other somatic symptoms,
and functional impairment all improved significantly over the course of the study compared with baseline.
• This study suggest that Citalopram is a promising treatment for functional pediatric recurrent abdominal pain
• Studies currently in process Campo, et al. (2004)
Antidepressants – Treatment for Anxiety & Depression
• Tricyclics– Includes Nortriptyline, Clomipramine, Imipramine– Effective for treatment of depression, OCD, separation anxiety, & ADHD– MOA: Blocks reuptake of norepinephrine and serotonin– Side effects: fatigue, dizziness, dry mouth, sweating, weight gain, urinary retention,
tremor, and agitation– Can prolong QT interval and increase risk for fatal ventricular tachycardia – Narrow therapeutic index
• SSRIs– Fluoxetine, Sertraline, Paroxetine, Fluvoxamine, Citalopram, Escitalopram– Effective for treatment of depression, OCD– MOA: Block reuptake of Serotonin into presynaptic cleft– Long half life– Dosed one time daily– Side effects: activation, insomnia, diarrhea,– Can induce mania in children
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