Hallucinations after withdrawal of valproic acid.

We report 2 children with a history of epilepsy in whom valproic acid (VPA) withdrawal was identified as a potential cause of hallucinations. After a restart of VPA, the hallucinations disappeared. We suggest mechanisms for the occurrence of the hallucinations and a possible control of a predisposition to hallucinations by VPA.

Psychiatric disorders in children and adolescents presenting with unexplained chronic pain: what is the prevalence and clinical relevancy?

The prevalence of psychiatric disorders among children with unexplained chronic pain (UCP) is high in unselected populations and pain clinics, yet the clinical relevance of these disorders in children referred for unexplained pain is not known. This study assessed the prevalence of clinically relevant psychiatric disorders and their predictors in children referred to a children's hospital for UCP. Psychiatry morbidity was assessed in 134 children, aged 8-17 years, using the Diagnostic Interview Schedule for Children-parent version (DISC-P) and the Semi-structured Clinical Interview for Children and Adolescents (SCICA). Clinical relevance was determined using a maladjustment criterion of 61 or lower on the Children's Global Assessment Scale (CGAS). Pain parameters were measured with standardized questionnaires. Results were analysed by logistic regression. According to the DISC-P, 21% of the children had clinically relevant psychiatric disorders, predominantly anxiety disorders (18%). According to the SCICA, 28% of the children had clinically relevant psychiatric disorders, consisting of anxiety, affective, and disruptive disorders (12, 19, and 9%, respectively). Headache (compared to musculoskeletal pain) was an independent clinical predictor of psychiatric morbidity (OR = 3.10; 95% CI 1.07-8.92, p = 0.04/adjusted OR 2.99; 95% CI 1.02-8.74, p = 0.04). In conclusion, clinically relevant psychiatric disorders are common among children and adolescents referred for UCP. Adding a child psychiatrist assessment, treatable affective and disruptive disorders become identifiable. Children with an additional risk are those presenting with headache.

Psychiatric morbidity in children with medically unexplained chronic pain: diagnosis from the pediatrician's perspective.

CONTEXT: There is very little general evidence to support the clinical management, particularly diagnosis, of medically unexplained chronic pain (UCP) in children. OBJECTIVE: We sought to assess in children with UCP if clinical characteristics held important by general pediatricians help to accurately diagnose psychiatric morbidity and, alternatively, if the same can be achieved using dedicated questionnaires. METHODS: We used a cross-sectional diagnostic study in a pediatric outpatient clinic of a university hospital. Our participants were 134 patients, aged 8 to 18 years, who were referred for UCP. Performed were (1) diagnostic test reflecting the pediatricians' choice of clinical characteristics and (2) selected questionnaires. Classification was performed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, by a child psychiatrist using the Diagnostic Interview Schedule for Children-Parent Version IV and the Semi-structured Clinical Interview for Children and Adolescents. Results were analyzed by logistic regression. RESULTS: Psychiatric morbidity was present in 80 of the children. A minority had a medical explanation for the pain (15% definite, 17% probable). The clinical diagnostic model included age, social-problem indicators, family structure, parental somatization, and school problems. In the quintile of children in whom this model predicted the highest risk, 93% indeed had psychiatric morbidity at reference testing. In the quintile with the lowest predicted risk, indeed only 27% had psychiatric morbidity. The Dutch Personality Inventory for Youth and the Child Behavior Checklist matched the pediatricians' choice of clinical characteristics. In the quintile of children with the highest predicted risk based on these questionnaires, 89% had psychiatric morbidity. In the quintile with the lowest predicted risk, only 15% had psychiatric morbidity. CONCLUSIONS: A pediatrician-chosen set of clinical characteristics of children with UCP proves useful in diagnosing psychiatric morbidity. Using selected questionnaire screening yields similar results.

Children with unexplained chronic pain: do pediatricians agree regarding the diagnostic approach and presumed primary cause?

OBJECTIVE: To investigate the opinions of general pediatricians regarding children with unexplained chronic pain (UCP), with respect to the presumed cause of the pain and the optimal diagnostic approach for these children. DESIGN: Diagnostic follow-up study. SETTING: Outpatient clinic of a university children's hospital. PARTICIPANTS: A total of 134 consecutive patients, 8 to 18 years of age, referred for pain of > or =3-month duration without a satisfactory explanation at presentation. METHODS: A full copy of the patient records from routine medical practice and data from standardized psychiatric assessments, standardized questionnaires, and standardized follow-up assessments were provided to 17 pediatricians assigned to 3 panels. MAIN OUTCOME MEASURES: Agreement regarding the presumed primary cause and diagnostic approach for children with UCP, with consensus being defined as > or =80% agreement among the pediatricians. RESULTS: The mean age of the children (73% girls) was 11.8 years (SD: 2.6 years). Psychiatric (co)morbidity was present for 60% of the children. Consensus regarding the presumed primary cause was reached for 43% of the patients (58 of 134 patients), ie, 72% (42 of 58 patients) primarily dysfunctional, 17% (10 of 58 patients) primarily psychologic, and 10% (6 of 58 patients) primarily somatic. Consensus regarding the diagnostic approach was reached for 63% of the children (84 of 134 children), leaving more than one-third of the children (37%) without diagnostic consensus. CONCLUSIONS: The relatively high rates of disagreement regarding the optimal diagnostic approach and presumed primary cause illustrate the difficulties of diagnostic evaluation and subsequent therapeutic strategy design for this patient group. Therefore, children with UCP might be at risk for suboptimal care.