Youth with Chronic Pain and Postural Orthostatic Tachycardia Syndrome (POTS): Treatment Mediators of Improvement in Functional Disability.

Intensive pain rehabilitation programs are effective in increasing functioning for youth with chronic pain (CP). However, the utility of such programs for youth with CP and co-morbid postural orthostatic tachycardia syndrome (POTS) is rarely examined. In addition, studies examining mediators of treatment for CP are sparse. This paper compares treatment outcomes for youth with CP (n = 117) and youth with CP + POTS (n = 118). Additionally, depression and pain catastrophizing were tested as potential mediators of treatment effects. Significant treatment improvements were found for functional disability, depression, pain catastrophizing, and perceived pain intensity but with no differences between groups. Improvements in depressed mood, pain catastrophizing (helplessness subscale), and pain severity partially mediated functioning improvement. Pain severity was not a significant mediator in the CP + POTS group. We concluded that depression and pain catastrophizing, especially the helplessness domain, can impact functioning improvement in adolescents with CP and POTS and are particularly important to target in treatment.

Development of an Interdisciplinary Pediatric Pain Rehabilitation Program: The First 1000 Consecutive Patients.

OBJECTIVE: To describe the development of a clinically and financially successful interdisciplinary pediatric pain rehabilitation program at a large tertiary academic medical center and present demographic and clinical information on the first 1000 patients. PATIENTS AND METHODS: All patients who were consecutively admitted to this program between October 1, 2008, and March 31, 2015 were included in this review. The patients ranged in age from 9 to 24 years. The program is a 3-week, hospital-based outpatient treatment program that requires substantial parental involvement. At admission and discharge, patients completed the Center for Epidemiologic Studies of Depression Scale for Children, the Functional Disability Inventory, and the Pain Catastrophizing Scale for Children. Opioid use was also assessed. RESULTS: At admission, patients reported substantial pain-associated disability and depressive symptoms; they had elevated pain catastrophizing scores, and 16% were taking opioids. Primary sites/types of pain included head, abdomen, and generalized. Functional disability scores decreased significantly, from 27 to 9 after the program (P<.001). Depression scale scores improved from 27 to 14 (P<.001). Pain catastrophizing scores decreased significantly, from 26 to 14 (P<.001), at discharge from the program. All but 4 patients successfully tapered off of all opioid use by the conclusion of the program. CONCLUSION: Participation in a multidisciplinary pediatric pain rehabilitation program can be successful, with significant decreases in disability, depression symptoms, and pain catastrophizing, as well as discontinuation of opioid use.

Getting Back to Living: Further Evidence for the Efficacy of an Interdisciplinary Pediatric Pain Treatment Program.

OBJECTIVE: This study examined key functional outcomes following a 3-week interdisciplinary pediatric pain rehabilitation program for adolescents with chronic pain. Maintenance of gains was evaluated at 3-month follow-up. METHODS: Participants included 171 adolescents (12 to 18 y of age) with chronic pain who completed a hospital-based outpatient pediatric pain rehabilitation program. Participants completed measures of functional disability, depressive symptoms, pain catastrophizing, opioid use, school attendance, and pain severity at admission, discharge, and at 3-month follow-up. RESULTS: Similar to other interdisciplinary pediatric pain rehabilitation program outcome studies, significant improvements were observed at the end of the program. These improvements appeared to be maintained or further improved at 3-month follow-up. Nearly 14% of the patients were taking daily opioid medication at admission to the program. All adolescents were completely tapered off of these medications at the end of the 3-week program and remained abstinent at 3-month follow-up. DISCUSSION: This study adds to the available data supporting interdisciplinary pediatric pain rehabilitation as effective in improving functioning and psychological distress even when discontinuing opioids. Implications for future research and limitations of the study are discussed.

Use of evidence-based assessments for childhood anxiety disorders within a regional medical system.

Anxiety disorders represent a common and serious threat to mental health in children and adolescents. To effectively treat anxiety in children, clinicians must conduct accurate assessment of patients' symptoms. However, despite the importance of assessment in the treatment of childhood anxiety disorders, the literature lacks a thorough analysis of the practices used by clinicians' when evaluating such disorders in community settings. Thus, the current study examines the quality of assessment for childhood anxiety disorders in a large regional health system. The results suggest that clinicians often provide non-specific diagnoses, infrequently document symptoms according to diagnostic criteria, and rarely administer rating scales and structured diagnostic interviews. Relatedly, diagnostic agreement across practice settings was low. Finally, the quality of assessment differed according to the setting in which the assessment was conducted and the complexity of the patient's symptomatology. These results highlight the need to develop and disseminate clinically feasible evidence-based assessment practices that can be implemented within resource-constrained service settings. (PsycINFO Database Record

Improvement in Functioning and Psychological Distress in Adolescents With Postural Orthostatic Tachycardia Syndrome Following Interdisciplinary Treatment.

Significant functional impairment and psychological distress have been observed in adolescent patients with postural orthostatic tachycardia syndrome (POTS). Interdisciplinary rehabilitation programs have been shown to be beneficial in the treatment of chronic pain in adults and adolescents. Only preliminary data have examined interdisciplinary rehabilitation efforts in patients with POTS. This study evaluated the impact of an interdisciplinary rehabilitation program on the functional impairment and psychological distress in 33 adolescents diagnosed with POTS. Patients included in the study were adolescents ages 11 to 18 diagnosed with POTS. Measures completed at admission and discharge from the program included the Functional Disability Index, Center for Epidemiological Studies-Depression-Child scale, and the Pain Catastrophizing Scale for Children. After participation in the 3-week program, adolescents with POTS demonstrated a significant increase in overall functional ability and significant reductions in depression and catastrophizing.

The Length of Child Anxiety Treatment in a Regional Health System.

Anxiety disorders are often undertreated due to unsuccessful dissemination of evidence-based treatments (EBTs). Lack of empirical data regarding the typical length of treatment in clinical settings may hamper the development of clinically relevant protocols. The current study examined billing records for 335 children ages 7-17 years to quantify the treatment received for newly diagnosed anxiety disorders within a regional health system. The vast majority of patients did not receive a sufficient number of appointments to complete the typical cognitive behavioral therapy protocol or reach the sessions introducing exposure. Although half of the sample received pharmacotherapy, the vast majority received fewer follow-up appointments than participants in pharmacotherapy research studies. Further, the type of treatment (i.e., number of sessions and medication) differed depending on utilization of specialty care. These results underscore the need to develop brief and flexible EBT protocols that can be standardized and implemented in community practice.

The feasibility of improving CBT for childhood anxiety disorders through a dismantling study.

This preliminary randomized controlled trial (RCT) examines the feasibility of dismantling cognitive behavioral therapy (CBT) for childhood anxiety disorders. Fourteen children (10 girls) ages 7 to 14 (m = 10.2) with social phobia, generalized anxiety disorder, separation anxiety disorder, or panic disorder were randomized to receive 6 sessions of either a) the pre-exposure anxiety management strategies presented in traditional CBT, or b) parent-coached exposure therapy. The sample was selected from a treatment seeking population and is representative of children in clinical settings. Examination of fidelity ratings, dropouts, and satisfaction ratings indicated that the interventions were distinguishable, safe, and tolerable. The overall sample improved significantly with pre-post effect sizes generally in the large range for both conditions. Between-group effect sizes indicating greater improvement with parent-coached exposure therapy were moderate or large for ten of 12 variables (i.e., 0.53 to 1.52). Re-evaluation after three months of open treatment suggested that the intervention emphasizing exposure early maintained its superiority while requiring fewer appointments.

Components of Cognitive Behavioral Therapy Related to Outcome in Childhood Anxiety Disorders.

The present article uses meta-analysis to examine treatment components related to outcome within 35 randomized controlled trials (RCTs) for childhood anxiety disorders (CADs) and eight RCTs for childhood obsessive compulsive disorder (OCD). Examination of the RCTs of cognitive behavioral therapy (CBT) for CADs suggested that adding relaxation and delaying exposures until after the introduction of other anxiety management strategies does not increase the efficacy of exposure-based treatment. In addition, compared to the large effect size (ES) associated with exposure and response prevention (ERP) for OCD (k = 9, mean ES = 1.93), the effect size associated with CBT for CADs (k = 44, mean ES = 0.89) did not differentiate from attention placebo (k = 11, mean ES = 0.55), although it was more effective than waitlist control (k = 24, mean ES = 0.22). Instructively, ERP for OCD involved more exposure initiated earlier and less relaxation than CBT for CADs. In addition, RCTs of ERP were more likely to use clinician-administered measures as opposed to self-report and to be conducted in clinical versus recruited samples. These results suggest that dismantling studies using a gold-standard clinician-rated outcome measure to compare the value of adding anxiety management strategies to exposure will be necessary to increase the efficacy of CBT for CADs to levels achieved by ERP for OCD.

A baseline controlled examination of a 5-day intensive treatment for pediatric obsessive-compulsive disorder.

This study extends support for a 5-day intensive exposure and response prevention (ERP) treatment protocol for pediatric obsessive compulsive disorder (OCD). Twenty-two children with OCD received ERP treatment twice daily for 5 days. The treatment also emphasized teaching children and parents how to conduct ERP independently after they returned home. Symptoms were assessed at four time-points: Baseline, 4 weeks later at pre-treatment, one week after the intensive treatment 5-day treatment, and at 3 month follow-up. Changes on the primary outcome measure, clinician severity ratings on the Anxiety Disorders Interview Schedule for Children, and secondary measures, indicated that OCD symptoms remained stable from the evaluation to baseline and improved significantly from baseline to follow-up. Moreover, parental accommodation of OCD decreased significantly from baseline to post-treatment and from post-treatment to follow-up. These data suggest that the 5-day intervention demonstrates efficacy in reducing OCD symptoms and may initiate change in parent accommodation that continues to improve after the family returns home.

Development of child- and parent-report measures of behavioral avoidance related to childhood anxiety disorders.

The current report describes 3 studies conducted to develop 8-item child- and parent-report measures to further the understanding of the role of behavioral avoidance in the development, maintenance, and treatment of childhood anxiety disorders. Participants included both clinical (N=463; ages 8 to 12) and community (N=421; ages 7 to 18) samples of children and their parents from primarily Caucasian intact families. Follow-up data were collected from 104 families in the community sample. Overall, the measures were internally consistent and related to anxiety, distress, and alternative measures of avoidance in both samples. Parent report of children's behavioral avoidance evidenced the strongest psychometric properties, differentiated among clinical and community populations, and most importantly, predicted children's anxiety at least 8 months later over and above initial anxiety ratings. Moreover, decreases in avoidance were associated with successful exposure therapy. These results are consistent with the role of behavioral avoidance in the development of anxiety and provide an efficient tool for assessing the role of avoidance in clinical and research settings.

A measurement invariance examination of the Revised Child Anxiety and Depression Scale in a Southern sample: differential item functioning between African American and Caucasian youth.

This study examined the psychometric properties of the Revised Child Anxiety and Depression Scale in a large sample of youth from the Southern United States. The authors aimed to determine (a) if the established six-factor Revised Child Anxiety and Depression Scale structure could be replicated in this Southern sample and (b) if scores were associated with measurement invariance across African American and Caucasian youth representative of youth from this region of the United States. The established six-factor model evidenced the best fit in comparison to one-, two-, and five-factor models in the total sample (N = 12,695), as well as in the African American (n = 4,906) and Caucasian (n = 6,667) subsamples. Multigroup confirmatory factor analysis also supported measurement invariance across African American and Caucasian youth at the levels of equal factor structure and equal factor loadings. Noninvariant item intercepts were identified, however, indicating differential functioning for a subset of items. Clinical and measurement implications of these findings are discussed and new norms are presented.

Rage attacks in pediatric obsessive-compulsive disorder: phenomenology and clinical correlates.

OBJECTIVE: Rage attacks have been documented in youth with varied psychiatric disorders, but few data have been reported on the clinical characteristics and correlates of rage attacks among children with obsessive-compulsive disorder (OCD). METHOD: Participants were 86 children (ages 6-16 years) with a primary diagnosis of OCD. Patients and their primary caregiver were administered clinician-rated measures of obsessive-compulsive severity and rage severity. Children completed the Center for Epidemiologic Studies Depression Scale and the Child Sheehan Disability Scale-Child, whereas parents completed the Rage Attacks Questionnaire, Aberrant Behavior Checklist-Irritability Scale, Children's Affective Lability Scale, and Child Sheehan Disability Scale-Parent. RESULTS: Rage was common among youth with OCD and was associated with varied clinical characteristics. Rage severity accounted for functional impairment beyond the influence of obsessive-compulsive symptom severity; however, these relations were explained by the impact of family accommodation. CONCLUSIONS: These data suggest that rage attacks are relatively common, have a negative impact on illness presentation, and contribute to functional impairment above and beyond obsessive-compulsive symptom severity. Rage may contribute to family accommodation of symptoms, which may further affect obsessive-compulsive symptom severity and impairment.

The role of co-occurring disruptive behavior in the clinical presentation of children and adolescents with anxiety in the context of autism spectrum disorders.

This study explored the impact of disruptive behavior disorder (DBD) comorbidity on theoretically relevant correlates among 87 children and adolescents with autism spectrum disorders (ASD) and clinically significant anxiety. Relative to youth with ASD and anxiety alone, participants with ASD, anxiety, and DBD: (a) presented with significantly more severe anxiety symptoms per clinician-, parent-, and self-report; (b) were more likely to be prescribed antipsychotic medication but were no more likely to receive additional psychosocial and educational interventions; and (c) experienced significantly greater functional impairment and family interference. These results suggest that co-occurring DBD in the context of ASD and anxiety confers greater risk for heightened symptom severity and functional impairment, and may be linked with increased prescription of antipsychotic medication.

Obsessive-compulsive disorder.

Compulsions are meant to relieve anxiety or to prevent a dreaded event. An adolescent or adult may recognize that the ritual is unreasonable or excessive, but that is not necessarily true for the young child. Children and adolescents will attempt to hide their rituals, although with more severe symptoms, this is not usually possible. To meet the diagnostic criteria for the disorder, the person must experience distress, spend more than 1 hour a day in either obsessions or compulsions, or experience significant interference in his/her life. This article reviews the phenomenology, causes, treatment, and outcome of children and adolescents with obsessive-compulsive disorder.