Risk factors for PTSD symptoms following PICU admission for childhood septic shock.

ObjectivePaediatric intensive care unit (PICU) admission represents a traumatic event for many children. Follow-up studies have found post-traumatic stress disorder (PTSD) rates of 10-30%, with a particular prevalence following admission for sepsis. Dysregulated inflammatory responses are associated with PTSD. Sepsis involves a marked inflammatory response but the relationship between this and PTSD have not been clearly established. In this study we investigate associations between the inflammatory response, psychosocial risk factors, and PTS symptoms following PICU admission for septic shock.We investigate the outcomes for children aged > 3 years, discharged from one PICU following admission for septic shock between 2010 and 2017. The study was a retrospective analysis of PICU-specific PTS symptoms reported by parents at any time since discharge via the Trauma and Behavior Health screen. Demographics, pre-morbid health characteristics, and exposure to other traumatic events were assessed. Clinical characteristics and blood test results at admission and at 48 h were recorded from clinical records. Multiple linear regression was used to investigate relationships between PTS symptom scores and predictor variables.Data for 65 participants (48% male, median assessment age 8.0 years) was available. Median time since admission was 5.1 years. 30.8% children scored at risk of PTSD at any time since discharge Symptoms were significantly associated with acute CRP rise (p 0.03), other trauma exposures (p = 0.01), and female gender (p =0.04).PTS symptoms in children who have survived septic shock are prevalent. These findings support a possible contribution of acute inflammatory changes, cumulative traumatic exposure, and female gender in post-PICU PTSD development.

Commentary: Against the widespread use of other types of PD diagnosis - a commentary on the May 2022 debate (should CAMH professionals be diagnosing personality disorder in adolescence?).

Recent debate papers in Child and Adolescent Mental Health (Debate CAMH, May 2022) advocate a more widespread and appropriate use by CAMH clinicians of borderline personality disorder diagnoses. This paper makes the case against the widespread use of other types of PD diagnosis in children and young people. Nevertheless, it would be of interest to establish to what extent adult PDs have their roots in early neurodevelopmental anomalies, and ascertainment of personality traits can help clarify children's response to environmental or traumatic stresses in those presenting with problems such as at the interface between physical and mental health.

A new measure of excessive parental worries about children's health: Development of the Health Anxiety by Proxy Scale (HAPYS).

OBJECTIVE: Health anxiety by proxy is a newly introduced term to describe parents' experience of excessive and unpleasant worries about their child's health. This article describes the development of a new measure, the Health Anxiety by Proxy Scale (HAPYS), for systematic assessment of health anxiety by proxy. METHOD: The development of the HAPYS was performed over three phases. (1) Patients clinically assessed to have health anxiety by proxy participated in semi-structured interviews to elaborate their experience of worries regarding their child's health and their related behaviours, and to examine the face validity of items in an existing questionnaire: 'Illness Worry Scale - parent version'. (2) Based on the findings from Phase 1 the project group and a panel of experts selected and formulated questionnaire items and scoring formats. (3) The HAPYS was pilot-tested twice using cognitive interviewing with healthy parents and parents with health anxiety by proxy followed by further adjustments. RESULTS: The final version of HAPYS consists of 26 items characteristic of health anxiety by proxy and of an impact section with five items. CONCLUSION: Based on the pilot testing the HAPYS showed good face and content validity. It holds the potential to be a valid questionnaire to help clinicians across health care settings assess parents suffering from health anxiety by proxy.

Stress hormones and posttraumatic stress symptoms following paediatric critical illness: an exploratory study.

In this exploratory case-control study, we investigated basal cortisol regulation in 5-16-year-old children, 3-6 months following PICU (paediatric intensive care) admission. This was nested within a study of child psychological and cognitive function; 47 children were assessed alongside 56 healthy controls. Saliva samples were collected three times per day (immediately after waking, waking +30 min, and waking +12 h) over two consecutive weekdays. In addition, data on posttraumatic stress symptoms were ascertained from 33 PICU admitted children using the Impact of Events Scale-8 (IES-8). Primary analysis revealed no significant differences in basal cortisol concentrations between PICU discharged children and healthy controls (p > 0.05). Secondary analysis in the PICU group identified a significant positive association between posttraumatic stress symptoms and evening (waking +12 h) cortisol concentrations (p = 0.004). However, when subject to multivariate analysis, evening cortisol was a modest independent predictor of IES-8 scores, relative to the presence of septic illness and poor pre-morbid health. We conclude that paediatric critical illness does not appear to result in marked perturbations to basal cortisol at 3-6 month following discharge. There was evidence of a link between evening cortisol and symptoms of PTSD, but this was not a robust effect and requires further elucidation.

Research into hallucinations and psychotic-like symptoms in children: implications for child psychiatric practice.

There is a growing research interest in childhood hallucinations as predictors of psychotic states. This work appears to have limited direct relevance for clinical child psychiatric practice, but it highlights the continuing relevance of research into precursors of psychotic states and into the determinants of clinically relevant hallucinations in children.

What is special about a Paediatric Liaison Child and Adolescent Mental Health service?

BACKGROUND: The paediatric population is known to be at high risk for psychiatric problems. Paediatric liaison child/adolescent mental health services (PL-CAMHS) have been developed to help increase recognition and management of psychiatric morbidity in the paediatric setting. This report describes clinical activity by a psychological medicine PL-CAMHS and considers specificity by comparing this with community/general CAMHS activity. METHOD: Clinical information was obtained on consecutive patients seen by a PL-CAMHS in a UK tertiary specialist hospital. Where feasible this was compared with published data on national/community CAMHS work. RESULTS: Data was obtained on 800 patients (mean age 11.9, SD 3.8). Most referrals came from a variety of paediatric teams, nearly two-thirds were for psychosomatic problems or difficulties adjusting to physical illness. The majority had an ICD-10 psychiatric diagnosis (mostly adjustment, mood and anxiety, and somatoform disorders); problems were often complex and in about half, family difficulties were also noted; one-third had received prior mental health treatment. Virtually all children were seen by the PL service within a month of referral and only 2% of families failed to attend for assessment. Some level of clinical improvement was noted for the majority. There were indications of differences from national/community CAMHS work in referral source, take up rates and psychiatric diagnoses. CONCLUSIONS: Paediatric liaison child and adolescent mental health services users commonly have characteristic psychiatric problems, interventions appear potentially effective and the work is specific and complementary of community CAMHS. Thus PL-CAMHS make a distinct contribution to the provision of truly comprehensive CAMHS.

Persistence of Neuropsychological Deficits Following Pediatric Critical Illness.

OBJECTIVE: To study 12-month persistence of neuropsychological deficits in PICU survivors. DESIGN: Prospective follow-up study. SETTING: Two PICUs. PARTICIPANTS: Children 5-16 years old with neuropsychological deficits 3-6 months following PICU care for meningoencephalitis, sepsis, and other critical illnesses (excluding other primary neurological disorders). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Neuropsychological function was assessed using the Cambridge Neuropsychological Test Automated Battery, the Children's Memory Scale, and the Wechsler Abbreviated Scale of Intelligence or Wide Range Intelligence Test. Forty-seven of 88 PICU admitted children (53%) were identified as neuropsychologically impaired 3-6 months after discharge; of these, 23 provided 12-month follow-up data. In spite of significant improvements in measures of memory, there was little change in intelligence quotient and visual attention over the study period, and children's educational progress remained below expectation. CONCLUSIONS: We found persistently reduced neuropsychological function following PICU admission in the critical illnesses under study.

Mental and physical well-being following admission to pediatric intensive care.

OBJECTIVE: To assess mental and physical well-being in school-aged children following admission to pediatric intensive care and to examine risk factors for worse outcome. DESIGN: A prospective cohort study. SETTING: Two PICUs. SUBJECTS: A consecutive sample of 88 patients 5-16 years old (median age, 10.00 yr; interquartile range, 6.00-13.00 yr) admitted to PICU from 2007 to 2010 with septic illness, meningoencephalitis, or other critical illnesses were assessed a median of 5 months following discharge and outcomes compared with 100 healthy controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Parents completed questionnaires documenting child mental and physical well-being, including the Strengths and Difficulties Questionnaires, Chalder Fatigue Scale, and Child Sleep Habits Questionnaire. Children over 8 years completed the Impact of Event Scale -8. The children admitted to PICU scored worse on all measures in comparison with the healthy controls, with 20% scoring at risk for psychiatric disorder, 34% with high levels of post-traumatic stress symptoms, 38% at risk for fatigue disorder, and 80% scoring at risk for sleep disturbance. In the PICU group, multivariable regression analyses identified septic illness as an independent predictor of post-traumatic stress symptoms and family status, past child health problems, and PICU length of stay as predictors of reduced general mental well-being. CONCLUSIONS: Our findings indicate that a significant minority of school-aged children admitted to PICU are at risk for reduced mental and physical well-being in the short term. Symptoms of poor mental well-being were linked to both vulnerability factors and critical illness factors.

Fifteen minute consultation on children 'hearing voices': when to worry and when to refer.

Auditory hallucinations are uncommon paediatric presentations, but they can be alarming and lead to emergency consultations. This review outlines the phenomenology of auditory hallucinations, their assessment and clinical significance. Auditory hallucinations are seen in the course of acute medical disorders, often together with decreased levels of consciousness, as in febrile illness and in toxic, neurologically compromised states; they can also be a feature of episodic neurological conditions such as migraine and temporal lobe epilepsy. Auditory hallucinations are key symptoms in psychiatric disorders such as schizophrenic and other psychotic states, but they can also present with depressive and anxiety disorders, and in the context of virtually every psychiatric disorder of childhood. In fact hallucinations--usually simple and transient--are common in the general child populations. Auditory hallucinations become clinically significant when they occur as part of a medical disorder or in the context of acute psychotic states and schizophrenia, when they are frequent, complex, distressing and cause impairment. The treatment of clinically relevant hallucinations is that of the primary medical or psychiatric disorder. Occasionally they require treatment in their own right with psychological treatments, and only when these have been tried and fail, a careful trial of antipsychotic medication may be appropriate.

Neuropsychologic function three to six months following admission to the PICU with meningoencephalitis, sepsis, and other disorders: a prospective study of school-aged children.

OBJECTIVE: To assess short-term neuropsychological function and academic performance in school children following admission to intensive care and to explore the role of critical neurologic and systemic infection. DESIGN: A prospective observational case-control study. SETTING: Two PICUs. SUBJECTS: A consecutive sample of 88 children aged 5-16 years (median age=10.00, interquartile range=6.00-13.00) who were admitted to intensive care between 2007 and 2010 with meningoencephalitis, septic illness, or other critical illnesses. They were assessed 3 to 6 months following discharge, and their performance was compared with that of 100 healthy controls. Patients were without prior neurologic or neurodevelopmental disorder. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data encompassing demographic and critical illness details were obtained, and children were assessed using tests of intellectual function, memory, and attention. Questionnaires addressing academic performance were returned by teachers. After adjusting for covariates, the children admitted to PICUs significantly underperformed on neuropsychological measures in comparison to healthy controls (p<0.02). Teachers deemed more children admitted to PICUs than controls as performing educationally worse and having problems with school work (ps=0.001), as well as performing below average on aspects of executive function and attention (ps<0.04). Analysis of the effect of illness type on outcome revealed that aspects of neuropsychological function, such as memory function, and teacher-rated academic performance were most reduced in children with meningoencephalitis and septic illness. In the PICU group, multivariable linear regression revealed that worse performance on a composite score of neuropsychologic impairment was more prevalent when children were younger, from a lower social class, and had experienced seizures during their admission (ps<0.02). CONCLUSIONS: Admission to intensive care is followed by deficits in neuropsychologic performance and educational difficulties, with more severe difficulties noted following meningoencephalitis and septic illness. These results highlight the importance of future studies on cognition and educational outcome incorporating type of illness as a moderating factor.

Sub-syndromal depression in adolescents attending primary care: frequency, clinical features and 6 months outcome.

BACKGROUND: The nature of adolescent sub-syndromal depression has not been investigated in primary care. AIMS: To document frequency, characteristics and 6 month outcome of sub-syndromal depression amongst adolescent primary care attenders. METHOD: Primary care attenders (13-18 years) completed depression screening questionnaires (Mood and Feelings Questionnaires) at consultation and at 6 month follow-up. Those screening positive were interviewed with the K-SADS. Sub-syndromal depression was defined as high levels of depressive symptoms in the absence of depressive disorder. RESULTS: Two hundred and seventy four questionnaires were completed at consultation: the estimated rate of sub-syndromal depression was 25 %. These young people were clinically intermediary between those without depressive symptoms and those with depressive disorder; at 6-months follow-up 57 % had persistent depressive symptoms and 12 % had developed a depressive disorder. Negative life events during the follow-up period and a positive family history of depression were the strongest predictors of symptom persistence and the development of depressive disorder, respectively. CONCLUSION: Sub-syndromal depression is common and persistent, in adolescent primary care attenders and it deserves attention.

Adolescents who are frequent attenders to primary care: contribution of psychosocial factors.

BACKGROUND: Frequent attendance to primary care services has shown an association with psychosocial factors in adult and child populations. Little is known about the psychosocial correlates of attendance in adolescents. AIMS OF THE STUDY: To study the contribution of psychosocial factors to frequent primary care attendance in a community sample of young British people. METHOD: The method used was a cross-sectional survey of 1,251 secondary school pupils, using self-report questionnaires for socio-demographic, physical and psychological health data. RESULTS: A total of 1,116 pupils [mean age 13.51 years (SD 1.5), 52% female] completed questionnaires and provided information about contact with their general practitioner (GP) in the previous year; 30% were frequent attenders (≥4 appointments). Frequent attenders were significantly younger; they were more likely to come from lower socioeconomic backgrounds, report significantly more past and current physical problems, have more hospital visits in the previous year, have more recent intense somatic symptoms made worse by stress and causing impairment, and have more days off school. Frequent attendance was also significantly associated with the presence of emotional symptoms and a history of mental health consultations. Logistic regression analysis identified seeing a hospital doctor, current illness, having days off school, a history of mental health consultations and younger age as independent predictors of frequent attendance. CONCLUSION: In addition to physical health problems, social factors and psychiatric difficulty are linked to and require attention in young people who are frequent attenders at primary care health services.

The short-term outcome of depressive disorder in adolescents attending primary care: a cohort study.

BACKGROUND: Depressive disorder is common amongst adolescents attending primary care, but little is known about its time course. AIM: To determine the 6-month outcome of depressive disorder in adolescent primary care attendees with regard to the time to recovery from (1) the date of index GP consultation and (2) the date of depressive episode onset, and to identify risk factors associated with time to recovery. METHOD: A prospective cohort study of 13-18-year-olds attending a general practice in northwest London. Attendees were screened for depressive disorder at consultation: high scorers underwent a psychiatric research interview. Six months later, adolescents who were depressed at consultation were interviewed using a research psychiatric follow-up interview. RESULTS: Of the 274 young people who completed the baseline questionnaires, 26 had a depressive disorder at consultation; over 50% failed to recover by the 6-month follow-up. Median episode duration from illness onset was 13 months. Multivariate cox regression showed that fewer positive life events and more physical symptoms predicted a longer time to recovery from consultation. Younger age, fewer recent positive life events and more depressive symptoms predicted a longer time to recovery from illness onset. CONCLUSIONS: Adolescent depressive disorders in general practice attendees are persistent, highlighting the appropriateness of intervention.

Neuro-cognitive performance in children with type 1 diabetes--a meta-analysis.

OBJECTIVE: To conduct meta-analyses of neuropsychological performance in young people with type 1 diabetes. METHODS: Meta-analysis of 24 studies. Studies published between 1980 and 2005 were identified. The inclusion criteria were: young people who were < or =19 years of age with type 1 diabetes, a case-control design and standardized neuropsychological tests of seven cognitive domains. RESULTS: Diabetes was statistically associated with poorer performance on visuospatial ability (d = -0.29), motor speed (d = -0.26) and writing (d = -0.28), on sustained attention (d = -0.21) and reading (d = -0.23). Smaller effects were identified on full IQ (d = -0.14), on performance (d = -0.18) and verbal IQ (d = -0.15). Severe hypoglycemia was linked to deficits in short-term verbal memory (d = -0.14; Confidence Interval: -0.318, 0.024; p =.04). CONCLUSIONS: This meta-analysis indicates that children with type 1 diabetes have mild cognitive impairments and subtly reduced overall intellectual functioning.

Assessment of somatic symptoms in British secondary school children using the Children's Somatization Inventory (CSI).

OBJECTIVE: To present normative and psychometric data on somatic symptoms using the Children's Somatization Inventory (CSI) in a nonclinical sample of British young people, and to assess associations with stress and functional impairment. METHODS: A total of 1,173 students (11- to 16-years old) completed the CSI and self-report psychopathology measures. RESULTS: The median CSI total score was 12 (5, 23). Headaches, feeling low in energy, sore muscles, faintness, and nausea were most frequent. Girls scored higher than boys, and respondents aged 13-14 years lower than younger children. The CSI showed good internal consistency and exploratory factor analysis yielded three factors: pain/weakness, gastrointestinal, and pseudoneurological. A quarter of respondents reported somatic symptoms were made worse by stress. CSI scores were moderately significantly correlated with impairment and emotional symptoms. CONCLUSIONS: The CSI, complemented by information on functional impairment and stress is an appropriate measure of recent somatic symptoms and somatization risk in young people for use in the UK.

Longer-term psychiatric adjustment of children and parents after meningococcal disease.

OBJECTIVE: To ascertain whether increases in psychological symptoms in children and parents after meningococcal disease are sustained over time, and to examine the psychosocial and illness associations of 12-mo psychological outcome. DESIGN: A prospective, cohort study using repeated measures. SETTING: Three pediatric intensive care units and 19 general pediatric wards across greater London. PATIENTS: Fifty-six children, aged 3 to 16 yrs, admitted to hospital with meningococcal disease and their parents. MEASURES AND MAIN RESULTS: Child and parent psychological symptoms were measured, using the Strengths and Difficulties Questionnaire (SDQ) and the General Health Questionnaire (GHQ) at three time points: before/during hospital admission, 3 mos, and 12 mos after discharge. The Impact of Event Scale (IES) was used at the two follow-up points. During the follow-up period, there were statistically significant increases over child pre-illness levels in parent-rated emotional, conduct, hyperactivity, and impact SDQ scores; the most significant change at 12-mo follow-up was an increase in impact on daily living scores. At 12 mos, five (11%) of 43 children were at risk for posttraumatic stress disorder. The strongest correlations of 12-mo child psychological symptoms (total SDQ scores)--in addition to premorbid total SDQ score--were illness-related changes in parenting, maternal IES and GHQ scores. At 12 mos, 13 (24%) of 54 mothers and six (15%) of 40 fathers scored at high risk for posttraumatic stress disorder. The strongest correlation of maternal posttraumatic stress disorder symptoms (IES scores) was paternal posttraumatic stress disorder symptoms. CONCLUSIONS: Admission to the hospital with meningococcal disease is followed by an increase in psychological symptoms in children at home, some of which are persistent and impairing, and by continuing posttraumatic stress symptoms in a proportion of children and parents. Psychosocial (pre- and postmorbid) factors predict problems at 12-mo follow-up.

Neuropsychological function in children following admission to paediatric intensive care: a pilot investigation.

OBJECTIVE: Little is known about neuropsychological status following acute severe paediatric illness. This pilot study explored the effects on memory function of severe acute paediatric illness and associations between memory functioning and psychiatric sequelae. DESIGN AND SETTING: Case control study of children after paediatric intensive care unit (PICU) discharge and healthy volunteers. PATIENTS AND PARTICIPANTS: 16 PICU discharged children comprised of 11 boys and 5 girls (mean age 9.44 +/- 2.85 years) tested a mean of 4.8 +/- 1.4 months following hospital discharge, and 16 age- and sex-matched controls. MEASUREMENTS AND RESULTS: Visual-spatial memory and attention were assessed using the CANTAB battery (visual memory) and verbal memory with the Children Memory Scale; Intelligence Quotient was tested using the Wechsler Abbreviated Scale of Intelligence. Emotional and behavioural function was measured with the Strengths and Difficulties Questionnaire and Impact of Event Scales. Children admitted to PICU displayed statistically poorer performance on tests of spatial memory (spatial working memory) sustained attention (rapid visual information) and verbal memory (word pairs learning and delayed recognition). Septic illness was specifically associated with poorer pattern recognition memory on the CANTAB. There were significant correlations in the PICU group between cognitive functioning and emotional/behaviour scores. CONCLUSIONS: Our results suggest impaired memory and attention in children following acute severe paediatric illness, a specific deficit in children with septic illness and links between memory anomalies and emotional/behavioural problems. The findings and their clinical significance require replication and clarification in a larger sample.