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Screening for Psychiatric Comorbidity in Children With Recurrent Headache or Recurrent Abdominal Pain
Pediatric Neurology 50 (2014) 49e56
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Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Original Article
Screening for Psychiatric Comorbidity in Children With Recurrent Headache or Recurrent Abdominal Pain Ditti Machnes-Maayan MD a, b,1, Maya Elazar MD b, c,1, Alan Apter MD b, c, Avraham Zeharia MD b, d, Orit Krispin PhD b, c, Tal Eidlitz-Markus MD b, d, * a
Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel c Department of Psychiatry, The Feinberg Child Study Center, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel d Ambulatory Day Care Unit, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel b
abstract BACKGROUND: Recurrent pain symptoms in children are associated with psychiatric comorbidities that could
complicate treatment. We investigated the prevalence of psychiatric comorbidity in children with recurrent headache or recurrent abdominal pain and evaluated the screening potential of the Strength and Difficulties Questionnaire compared with the Development and Well-Being Assessment (DAWBA). METHODS: Eighty-three outpatients aged 5-17 years attending a tertiary medical center for a primary diagnosis of migraine (n ¼ 32), tension-type headache (n ¼ 32), or recurrent abdominal pain (n ¼ 19), and 33 healthy matched controls completed the brief self-reporting Strength and Difficulties Questionnaire followed by the Development and Well-Being Assessment. Findings were compared among groups and between instruments. RESULTS: The pain groups were characterized by a significantly higher number of Development and Well-Being Assessment diagnoses (range 0-11) than controls and a significantly greater prevalence (by category) of Development and Well-Being Assessment diagnoses (P < 0.001 for both). Anxiety and depression were the most prevalent Development and Well-Being Assessment diagnoses. Comorbidities were more severe in the headache groups than the controls (P < 0.001). In general, any diagnosis by the Development and Well-Being Assessment was associated with a significantly higher Strength and Difficulties Questionnaire score (P < 0.001). Abnormal scores on the emotional, conduct, and hyperactivity Strength and Difficulties Questionnaire scales were significantly predictive of a Development and Well-Being Assessment diagnosis (P < 0.003). CONCLUSION: Children referred to specialized outpatient pediatric units for evaluation of recurrent pain are at high risk of psychopathology. The Strength and Difficulties Questionnaire may serve as a rapid cost-effective tool for initial screening of these patients. Keywords: Strength and Difficulties Questionnaire (SDQ), psychiatric comorbidity, children, recurrent abdominal pain, recurrent headache, Development and Well-Being Assessment (DAWBA)
Pediatr Neurol 2014; 50: 49-56 Ó 2014 Elsevier Inc. All rights reserved. Introduction
Recurrent pain symptoms are often encountered in pediatric primary care.1 Headache is the most common somatic complaint in children,2 accounting for 1% to 2%
Article History: Received March 16, 2013; Accepted in final form July 14, 2013 1 Both authors contributed equally to the manuscript * Communications should be addressed to: Dr. Tal Eidlitz-Markus; Ambulatory Day Hospitalization Unit; Schneider Children’s Medical Center of Isra; 14 Kaplan St, 49202 Petach Tikva, Israel. E-mail address: [email protected] 0887-8994/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2013.07.011
of all visits to pediatricians.1 The prevalence of headache increases throughout childhood, reaching a peak at about 13 years of age in both sexes.1,2 The two most frequent types of primary pediatric headache are migraine and tension-type headache.3,4 In a large epidemiologic study of the 7- to 14-year age group based on the diagnostic criteria of the International Classification of Headache Disorders-II, Kröner-Herwig et al.5 found that the prevalence rate of migraine was 7.5% and 18.5% for tension-type headache. Pediatric headache has been associated with psychiatric comorbidities, although the impact of the findings are still unclear. An early study found that individuals with recurrent headache had significantly more symptoms of anxiety,
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depression, and somatization than controls and were at higher risk of emotional disorders and medication overuse, suggesting the need for a multisystem treatment approach.6 Others also reported psychiatric disorders in children with recurrent headache, especially tension-type,7,8 and high rates of behavioral problems in children with migraine.9 However, in a review of 11 studies in the literature, Amouroux et al.10 reported that patients with migraine had slightly higher scores than controls on at least one of the anxiety or depression scales, but their average scores in all studies were still within the normal range established at validation of the instruments. Guidetti et al.11 found that the presence of any psychiatric comorbidity in a child with migraine or tension-type headache may be a risk factor for worsening headaches over time, whereas a more recent review study concluded that children with migraine do not exhibit more psychiatric comorbidities than healthy controls.12 The latter authors attributed the discrepancy among studies to differences in study populations, duration of follow-up, and psychiatric diagnostic tools. Recurrent abdominal pain (RAP) occurs in 7% to 25% in children7,13 and has been significantly associated with anxiety disorders and depression.1,4,14-17 In a populationbased study, children with RAP had significantly more psychiatric morbidity than children without RAP. The strongest effect was for emotional (anxiety) symptoms compared with the general population.18 The presence of psychiatric comorbidities in children with recurrent pain complicates their management.19,20 Many pediatricians feel that they do not have the time or competence to address these issues.21 In addition, there is a shortage of pediatric mental health services and a lack of valid, low-cost psychiatric diagnostic tools that are applicable in pediatric primary care. Data on problem behavioral in children are usually collected by clinical interviews and standardized questionnaires, such as the Child Behavior Checklist, a parent-report tool designed to assess behavioral and emotional problems in children and adolescents. This checklist has been found effective for use in both clinical practice and research and may serve as both a screening tool and a basis for diagnostic formulations.22 It yields a total problem score, two broadband scores (internalizing problems and externalizing problems), and eight different syndrome scales.22 However, the CBLC is very long (140 items) and time-consuming. The Strength and Difficulties Questionnaire (SDQ) is a much briefer (25 items) self- and parental-report screen.23 Its findings have been shown to correlate highly with the Child Behavior Checklist24 and it has been recommended by the Preventive Child Health Care System as the first step for the detection and classification of psychosocial problems in the adolescent age group.25 The SDQ has been validated in many studies worldwide23,26-33 and is available in more than 30 languages. It has been used in epidemiological, developmental, and clinical research as well as in routine clinical and educational practice. Its brevity makes it easier to use than the CBLC and may offer an important advantage in initial screening of children, although the differences in length between the two instruments might alter their psychometric properties.24 The Development and Well-Being Assessment (DAWBA) is a comprehensive semistructured interview for the diagnosis
of psychiatric disorders.33-38 It can either be administered by trained lay interviewers or self-completed online. It has been found to been an effective diagnostic tool in clinical and epidemiological settings in different languages and countries.23,26-28,34-38 The questions for each disorder closely follow the diagnostic criteria operationalized in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Each section contains 20-25 items, with skip-rules such that the full set of items is administered only when the initial screening items indicate a relevant problem.33 To our knowledge, the DAWBA has never been used in a study of recurrent headache or abdominal pain in children. Our aim was to determine the prevalence of psychiatric comorbidities in children with recurrent headache (migraine or tension-type) or RAP attending a tertiary hospital outpatient pediatric unit and to evaluate the applicability and reliability of the brief SDQ for initial patient assessment using the DAWBA as a reference. If effective, the SDQ could provide a valuable screening tool in this setting for practicing pediatricians. Materials and Methods Study participants
The study group consisted of children and adolescents attending a specialized headache division of a general outpatient hospitalization unit of the gastroenterology outpatient unit of the same tertiary universityaffiliated pediatric medical center. All children were referred to the unit by their primary care pediatrician in the community after diagnosis or first-line therapeutic failure, and all were referred for this study by pediatricians of the specialized units. Only children who met the standard criteria for recurrent headache or RAP were included. Migraine and tension headache were defined according to the International Classification of Headache Disorders-II.3 RAP was diagnosed according to the definition of Apley and Hale13: three or more episodes of abdominal pain sufficient to interfere with daily activities in the previous 3 months. One parent of each patient also took part in the study. Patients were divided by their primary diagnosis into three groups: migraine headache, tension-type headache, and RAP. The control group consisted of subjects attending the general outpatient unit of the same hospital for follow-up after a recovery period of a brief acute illness (gastroenteritis, pneumonia, or urinary tract infection) that occurred before discharge from their follow-up in the outpatient unit. Control subjects were matched to the study patients by age and sex. Candidates for the control group were asked if they had recurrent headaches or RAP. Those who answered positively (either the child him/herself or the parent) were excluded from the study. Instruments
The DAWBA was developed by Goodman et al.33 to generate International Classification of Diseases-10 and Diagnostic and Statistical Manual of Mental Disorders, 4th edition, psychiatric diagnoses, as follows: separation anxiety disorder, specific phobia, social phobia, generalized anxiety disorder, panic disorder, posttraumatic stress disorder, obsessive-compulsive disorder, depressive disorder, attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder. Trained nonclinical interviewers administer the structured questionnaire to the subject (adolescent version, for ages 11-17 years) and to his or her parent (parent version). If definite symptoms are identified, the interviewers use open-ended questions and supplementary prompts to get parents to describe the problem in their own words. The descriptions are transcribed verbatim by the interviewers but not rated by them. The information from the different sources is then drawn together by a computer program that generates a summary sheet and a likely diagnosis. These, combined with the verbatim transcriptions, form a good starting point for experienced clinical
D. Machnes-Maayan et al. / Pediatric Neurology 50 (2014) 49e56 raters, who may accept or reject the computerized diagnosis after reviewing all the data. In previous studies, the DAWBA showed excellent discrimination between community and clinic samples in rates of diagnosed disorders.33,35 At least one International Classification of Diseases-10 or Diagnostic and Statistical Manual of Mental Disorders, 4th edition, disorder was diagnosed in 11% of the community sample compared with 92% of the clinic sample. This corresponded to a minimum estimate of 89% specificity in the community sample and 92% sensitivity in the clinic sample. The SDQ, developed by Goodman,23 is a 25-item screen for the detection of behavioral problems in children and adolescents aged 4-16 years. The items are divided into five scales of five items each, generating separate scores for conduct problems, hyperactivity/ inattention, emotional symptoms, peer problems, and prosocial behaviors. Internal consistency has been shown to be good for each of the subscales (mean Cronbach’s alpha, 0.73).23 The scores for the first four subscales (except prosocial behaviors) may be summed to generate a total difficulties score. The SDQ can be completed in about 5 minutes by either parents or teachers; a self-report version is available for children aged 11 years or more.39 It has been shown to discriminate between child mental health clinic attendees and community controls.39,40 In a previous study, multi-informant SDQs (parents, teachers, older children) successfully identified individuals with a psychiatric diagnosis with a specificity of 80% and a sensitivity of 85%.29
Procedure
The study protocol was approved by the local Institutional Review Board. Before enrollment, patients and parents were given a detailed explanation of the purpose and procedure of the study and the patients or their parents (for minors) signed a consent form. The SDQ was administered first, followed by the DAWBA, in a single session of about 60 minutes’ duration during the patients’ first visit to the clinic. The instruments were administered by a trained nonclinical interviewer. Each diagnosis in every patient was coded for severity on a scale of 0 (not present) to 3 (severe). The interview was supervised by an experienced child and adolescent psychiatrist who determined the clinical rating. For statistical convenience, we divided the 11 possible DAWBA diagnoses into three main psychiatric categories: anxiety disorder (separation anxiety disorder, specific phobia, social phobia, generalized anxiety disorder, posttraumatic stress disorder, obsessive-compulsive disorder, panic disorder); depressive disorder (depressive disorder); and externalizing disorder (ADHD, ODD, conduct disorder). For every child with at least one subdiagnosis within a main category, that category was counted as a single diagnosis (regardless of the number of subdiagnoses). In children with at least one subdiagnosis from more than one category, each category was counted once. We also added a fourth category, any psychiatric disorder, to which we allocated all children who had at least one diagnosed psychiatric comorbidity. Each of the diagnoses was coded on a 3-point severity scale.
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The value of the SDQ in predicting a diagnosis by the DAWBA was analyzed by calculating the odds ratios and 95% confidence intervals (CI). A P value of <0.05 was considered statistically significant.
Results Patient characteristics
Study participants included 116 subjects, 44 boys and 72 girls, of mean age 12.9 2.867 years (range 5-17 years). Eighty-three (29 boys, 64 girls; mean age 12.7 2.8 years) were evaluated for recurrent headache or abdominal pain and 33 (15 boys, 18 girls; mean age 13.9 2.885 years) served as controls. The primary diagnoses in the recurrent pain group were migraine in 32 patients (9 boys, 23 girls; mean age 12.4 2.539 years), tension-type headache in 32 patients (16 boys, 16 girls; mean age 12.4 2.769 years), and RAP in 19 patients (4 boys, 15 girls; mean age 12.8 3.267 years). There was no significant difference among the groups in age distribution (P ¼ 0.112) or sex ratio (P ¼ 0.10). Comparing the patients with migraine to the patients with tension headache, patients with migraine had a significantly lower frequency of headache attacks per month (13.14 8.47 vs 21 11.47). The difference was statistically significant. To compare the number of psychiatric diagnoses among the three pain groups and the control group, we summed the total subdiagnoses of each participant, from 0 (none) to 11 (maximum in the DAWBA). The results are shown in Fig 1. ANOVA yielded a significant difference among the groups (P < 0.001). There was a significant difference in the number of diagnoses between the tension-type headache group and the other groups (P ¼ 0.01), and between the migraine group and the control group (P ¼ 0.014) but not the RAP group (P ¼ 0.50). There was no significant difference between the RAP group and the control group (P ¼ 0.141). Table 1 shows the prevalence rates of the three categories of psychiatric diagnoses by the DAWBA (anxiety disorder, depressive disorder, externalizing disorder), in addition to a fourth category of at least one psychiatric disorder, in each of the four groups. All three pain groups had a higher rate of main psychiatric comorbidities (migraine 65.6%, tension headache 75%, RAP 52%) than the control group (21%); P < 0.001. Table 2 shows the prevalence rates of the subdiagnoses. The number of patients in
Sample size calculation
To calculate the size of the sample, we assumed a 10% incidence of anxiety and depression disorders in the control group, similar to the general population41 and of 55% in the headache groups and 80% in the RAP group, based on earlier publications.14-16,42 The criterion for significance (alpha) was set at 0.050 (two-tailed). With a proposed sample size of 96 (32 participants in each pain group), the study had power exceeding 98% to yield a statistically significant result. Statistical analysis
Data were analyzed with the SPSS 13.0. Values for continuous variables are given as mean standard deviation. Analysis of variance (ANOVA) was used to compare continuous variables among the groups. The chi-square test was used to assess differences among the groups in patient age and in prevalence of the main DAWBA diagnostic categories.
FIGURE 1. Mean number of psychiatric diagnoses (Development and Well-Being Assessment) in the three pain groups and controls. RAP, recurrent abdominal pain.
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TABLE 1. Prevalence of psychiatric disorders (by category) using the development and Well-Being Assessment Questionnaire
Psychiatric Diagnostic Category
Migraine Group (n ¼ 32)
Tension-Type Headache Group (n ¼ 32)
Recurrent Abdominal Pain Group (n ¼ 19)
Control Group (n ¼ 33)
P Value (Chi-Square)
Any anxiety disorder
18 56.3% 4 12.5% 4 12.5% 21 65.6%
22 68.8% 8 25% 8 25% 24 75%
9 47.4% 1 5.3% 3 15.8% 10 52.6%
3 9.1% 0 0% 4 12.1% 7 21.2%
<0.001
Any depressive disorder Any externalizing disorder At least one psychiatric disorder
each psychiatric subcategory was too small for statistical analysis by pain group. The average severity scores of the total psychiatric diagnoses within each group are shown in Fig 2. ANOVA revealed significant differences among the four groups (P < 0.001). There was a significant difference in severity score between the migraine group and the tension-type headache group (P ¼ 0.015), between the migraine group and the control group (P ¼ 0.014), and between the tensiontype headache group and both the RAP group (P ¼ 0.006) and control group (P ¼ 0.001). Analysis of the severity of the psychiatric comorbidities (by category) yielded a significant difference among the four pain groups (P ¼ 0.001). Three ANOVA tests were then performed for each category. There was a significant difference in the severity of anxiety disorder between the migraine and control groups (P ¼ 0.005), between the tension-type headache and control groups (P < 0.001), and between the RAP and control groups (P < 0.05). There was a
0.012 0.470 <0.001
significant difference in the severity of depressive disorder between the tension-type headache group and both the control group (P ¼ 0.001) and RAP group (P ¼ 0.011). No statistically significant difference was found between the pain groups in severity of externalizing disorder. Intercorrelations of SDQ scores and DAWBA diagnoses
ANOVA was used to analyze the SDQ scores against the DAWBA diagnoses. For each participant, we compared the scores of the three SDQ scales (emotional, conduct, and hyperactivity) with the psychiatric diagnosis (by category) obtained with the DAWBA. The results are shown in Table 3. In general, children who had any psychiatric disorder on the DAWBA had significantly higher scores on all three SDQ scales. Findings were statistically significant between the emotional scale of the SDQ and the presence of any anxiety disorder or any depressive disorder by the DAWBA, and between the hyperactivity scale of the SDQ and the
TABLE 2. Prevalence of psychiatric disorders (by individual subdiagnoses) using the development and Well-Being Assessment Questionnaire*
Psychiatric Subdiagnosis
Migraine Group (n ¼ 32)
Tension-type Headache Group (n ¼ 32)
Recurrent Abdominal Pain Group (n ¼ 19)
Control Group (n ¼ 33)
Separation anxiety disorder
5 15.6% 17 53.1% 2 6.3% 0 0% 0 0% 2 6.3% 3 9.4% 4 12.5% 4 12.5% 2 6.3% 0
7 21.9% 16 50% 6 18.8% 3 9.4% 2 6.3% 2 6.3% 7 21.9% 8 25% 7 21.9% 6 18.8% 0
3 15.8% 5 26.3% 2 10.5% 0 0% 2 10.5% 1 5.3% 2 10.5% 1 5.3% 2 10.5% 2 10.5% 0
0 0% 3 9.1% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 3 9.1% 3 9.1% 0
Specific phobia Social phobia Panic disorder PTSD OCD Generalized anxiety disorder Depressive disorder ADHD ODD Conduct disorder
Abbreviations: ADHD ¼ Attention deficit hyperactivity disorder OCD ¼ Obsessive-compulsive disorder ODD ¼ Oppositional defiant disorder PTSD ¼ Posttraumatic stress disorder * The number of patients in each psychiatric subcategory was too small for statistical analysis by pain group.
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FIGURE 2. Mean severity score of the psychiatric diagnoses (Development and WellBeing Assessment) in the three pain groups and control groups. Each diagnosis was scored for severity on a scale of 0 to 3 in every patient. RAP, recurrent abdominal pain.
presence of any externalizing disorder by the DAWBA (P < 0.001 for both). There was no significant association of the SDQ hyperactivity scale with DAWBA diagnoses of anxiety or depressive disorder. Table 4 shows the probabilities of obtaining a psychiatric diagnosis with the DAWBA compared with the SDQ. A high correlation was found between the SDQ subscale scores and any psychiatric diagnosis, between the emotional subscale score and a diagnosis of conduct disorder, any anxiety disorder, or any depressive disorder, and between the conduct and hyperactivity scores and any externalizing disorder. The other correlations were not statistically significant. Discussion
The use of the DAWBA interview in children with recurrent headache or abdominal pain revealed high rates of psychiatric comorbidity in terms of both number and TABLE 3. Comparison of mean SDQ scores and DWABA diagnoses
SDQ Scale
DAWBA Diagnosis Positive
At least one psychiatric diagnosis Emotional scale 2.45 1.83 Conduct scale 1.35 1.4 Hyperactivity scale 0.8 1.3 Any anxiety diagnosis Emotional scale 2.53 1.8 Conduct scale 1.4 1.42 Hyperactivity scale 1.73 2.7 Any depressive diagnosis Emotional scale 3.29 2.34 Conduct scale 1.67 1.6 Hyperactivity scale 2.03 2.72 Any externalizing diagnosis Emotional scale 3.38 2.4 Conduct scale 1.56 1.5 Hyperactivity scale 1.32 1.81
Negative
P Value (ANOVA)
5.28 2.23 2.28 1.79 4.0 3.44
<0.001 0.003 <0.001
5.9 2.04 2.43 1.83 2.93 2.82
<0.001 0.002 NS
5.5 2.43 1.67 1.5 2.33 4.04
0.027 NS NS
3.75 2.25 3.13 2.17 7.7 2.43
NS 0.007 <0.001
Abbreviations: ANOVA ¼ Analysis of variance DAWBA ¼ Development and Well-Being Assessment NS ¼ Not significant SDQ ¼ Strength and Difficulties Questionnaire SDQ scores are presented as mean standard deviation.
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severity of diagnoses in the patients with recurrent headache, but not in those with RAP. The patients with tensiontype headache had the highest rate of psychiatric comorbidity (75%), followed by individuals with migraine (65.6%). The rate in the tension-type headache group is in line with the study of Liakopoulou-Kairis et al.,7 conducted in a similar outpatient setting, using the Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Life version. However, for the RAP group, our 52.6% rate of psychiatric comorbidity is considerably lower than the 81.6% reported in the earlier study.7 This discrepancy may be attributable to the small size of our RAP group (n ¼ 19). We assume our RAP group was smaller than the headache groups because the study was conducted in a tertiary center, and most patients with RAP are identified and treated at the initial evaluation by their primary physician. The most prevalent category of psychiatric comorbidity was anxiety disorder (Table 1), documented in 68.8% of the patients with tension-type headache, 56.3% of the patients with migraine, and 47.4% of the patients with RAP, compared with 9.1% of the control subjects. Other studies also indicated a high risk of anxiety disorders in these patient groups: 30% for tension-type headache8 and 42.1%7 and 79%42 for RAP. The prevalence rate in our patients with migraine was considerably lower than the 15% reported by Pakalnis et al.9 This difference, given the paucity of studies in the literature, points to a need for more research on comorbid anxiety in this patient group. Depressive disorder was documented in 25% of our patients with tension-type headache, close to the rate reported by Sarioglu et al. (20%),8 but its prevalence in the RAP group (5.3%) was considerably lower than reported by Campo et al. (42.9%).42 Our patients with migraine had a higher rate of depressive disorder (25%) than those evaluated by Pakalnis et al. (4.7%).9 These differences, as for overall psychiatric morbidity, were probably at least partly attributable to the setting of the present study. The study group was restricted to patients attending a dedicated headache clinic in a tertiary medical center, who may therefore have had more severe disease than communityderived patients. The statistically significant difference of headache frequency, which was higher for the tension type headache compared with migraine (13.14 8.47 vs 21 11.47), may influence the psychiatric comorbidity in tension headache because chronic daily headache is prone to psychiatric comorbidity. Furthermore, the average time from onset of headache symptoms to referral to our clinic was 22 months. This long lag may have had a different effect on the psychiatric comorbidity by type of headache, biasing the study results. It should also be borne in mine that tension-type headache is a vague negative definition, whereas the diagnosis of migraine is based on precise criteria. The long interval from symptom onset to admission may mask comorbid psychiatric diagnoses. Assessment of the individual externalizing disorders yielded a diagnosis of ADHD in 12.5% of the patients with migraine and a diagnosis of ODD in 6.3%. Rates reported for the general pediatric population were similar: ADHD, 4.1%; ODD, 11.3%.41 In the study of Palkanis et al.,9 19% of patients with migraine had ADHD, 17% had ODD, and 4.2% had conduct disorder. In our tension-type headache group,
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TABLE 4. Correlations between the SDQ scales and the DAWBA diagnoses*
SDQ Scales
Emotional Conduct Hyperactivity
DAWBA Diagnoses At Least One Psychiatric Disorder
Any Anxiety Disorder
Any Depressive Disorder
Any Externalizing Disorder
1.90 (1.48-2.44) P ¼ 0.003 1.44 (1.11-1.87) P ¼ 0.003 1.72 (1.20-2.33) P < 0.001
2.22 (1.64-3.00) P < 0.001 1.48 (1.13-1.93) P ¼ 0.003 P > 0.05
1.42 (1.09-1.98) P ¼ 0.035 P > 0.05
P > 0.05
P > 0.05
1.63 (1.10-2.41) P ¼ 0.015 2.91 (1.42-5.98) P < 0.001
Abbreviations: DAWBA ¼ Development and Well-Being Assessment SDQ ¼ Strength and Difficulties Questionnaire * Correlations presented as odds ratio (95% confidence interval).
ADHD was diagnosed in 21.9% and ODD in 18.8%. By contrast, Liakopoulou-Kairis et al.7 reported rates of 6.5% for both disorders in clinical groups of children with chronic headaches and RAP. The high rates of externalizing psychopathology in the tension-type headache group in our study relative to the other groups may indicate that children with tension-type headache are particularly prone to emotional and behavioral disorders. In the RAP group, we diagnosed ADHD and ODD in 10.5% of patients each; Campo et al.42 found a 19% rate of disruptive behavior disorders in children with RAP. Given the strong possibility of psychiatric comorbidities in young patients with complaints of recurrent pain, better screening tools are urgently needed in pediatric primary care. Although screening, which is a rapid low-cost assessment, is inappropriate for diagnosis, when well implemented, it can effectively identify children who may benefit from early or more in-depth intervention and ensure that their families receive the proper support and services.43-45 Two currently available screens for chronically ill children are the Pediatric Symptom Checklist46 and the Eyberg Child Behavior Inventory.47-49 The Pediatric Symptom Checklist was developed to help clinicians identify the growing number of children with psychosocial dysfunction; the Eyberg Child Behavior Inventory was designed to assess types of behavioral problems and the degree to which parents find them problematic. The Eyberg Child Behavior Inventory has shown good internal consistency and discriminative validity in chronically ill samples and was able to differentiate children referred or treated for learning and/or behavioral problems from children without a history of behavioral problems.48 Johnson and Rodrigue,47 using the Eyberg Child Behavior Inventory, found that 16% of their outpatient group of chronically ill children was at risk of psychiatric comorbidity, similar to the 14% identified with the Pediatric Symptom Checklist. However, despite the A Assessment Rating (reliability and validity demonstrated) of the Eyberg Child Behavior Inventory, data on its value for predicting psychiatric diagnoses are lacking. Furthermore, Canning and Kelleher48 showed that the application of certain specific tools developed for the pediatric population, including the Pediatric Symptom Checklist, the Child Depression Inventory, and the Child Behavior Checklist as well as some other instruments widely applied in healthy subjects may occasionally yield inflated maladjustment scores.47,49 All had low sensitivity and low positive and negative predictive values
but high specificity. Therefore, the use of these instruments could undermine the pediatrician’s clinical judgment.48 The present study is important because it demonstrates the possibility of using an easy, low-cost, already widely available screening tool, the SDQ, for the initial psychiatric assessment of patients with recurrent pain symptoms attending specialized pediatric referral units. In a previous study, multi-informant SDQs (parents, teachers, older children) successfully identified individuals with a psychiatric diagnosis, with a specificity of 80% and a sensitivity of 85%.33 In the present study, odds ratio analyses yielded highly significant correlations: between the SDQ emotional scale score and DAWBA diagnoses of any psychiatric disorder, particularly anxiety disorder, and any depressive disorder; between the SDQ conduct scale scores and diagnoses of any psychiatric disorder, any anxiety diagnosis, and any externalizing disorder; and between the SDQ hyperactivity scale score and any psychiatric disorder. The other correlations were not significant. There were no weak correlations, although this may have been due to the small sample size (Table 3). The findings indicate that children with recurrent pain have problems in certain areas of functioning and accordingly, a high probability of a specific psychiatric disorder. They support the suggestion that the SDQ could serve as a useful tool in the initial assessment of psychopathology in children with recurrent headaches or RAP evaluated in clinical settings. Further studies are needed to assess the sensitivity of the SDQ in predicting specific psychiatric disorders in these and other patient groups with larger numbers. The major limitation of the present study is the crosssectional design, which restricted our ability to draw conclusions beyond the recognition of significant predefined characteristics that exist in a population, but not to determine cause-and-effect relationships between different variables. Although the study was sufficiently powered to identify statistically significant differences, a similar study with larger groups may be helpful to corroborate our findings. Nevertheless, this study supports earlier evidence of a high risk of psychiatric comorbidity in children with recurrent pain. In another cross-sectional study, Campo et al.,42 referring to their RAP group, suggested that “artefact alone is unlikely to provide an explanation for the strong association between RAP and anxiety.” To determine the precise nature of the association of recurrent headaches and RAP with psychiatric comorbidity, well-designed longitudinal prospective studies are needed.
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It should also be noted that our control group consisted of children after an acute intercurrent illness attending the same unit as the patients. It is possible that their hospital stay made them prone to anxiety and stress disorders. Therefore, we might have found even more pronounced differences between the patients and controls had the study been done in another setting. Conclusion
Children referred to hospital outpatient pediatric units in tertiary center for recurrent migraine, tension-type headache, or abdominal pain have a significantly high prevalence of psychiatric comorbidity. The SDQ, a rapid selfreport instrument, may be applicable for routine initial screening of this patient population. A high score on the SDQ alerts clinicians to the possibility of a psychiatric disorder and the need to refer the patient to a mental health professional. In primary care, especially when resources or skilled manpower is lacking, a finding of a high score on the emotional, behavioral, or hyperactivity/inattention SDQ scale might be followed by the DAWBA interview,31 which is easy to administer, even by research assistants. Welldesigned longitudinal studies are needed to investigate the interconnections of recurrent headaches and RAP with psychiatric symptoms, to define treatment in cases of diagnosed psychiatric comorbidity and recurrent pain, and to investigate the influence of psychopharmacological or psychological treatment on the severity and frequency of recurrent pain symptoms. References 1. Egger HL, Costello EJ, Erkanli A, Angold A. Somatic complaints and psychopathology in children and adolescents: stomach aches, musculoskeletal pains, and headaches. J Am Acad Child Adolesc Psychiatry. 1999;38:852-859. 2. Fearon P, Hotopf M. Relation between headache in childhood and physical and psychiatric symptoms in adulthood: national birth cohort study. BMJ. 2001;322:1145. 3. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 2nd edition. Cephalalgia. 2004;24(Suppl 1):9-160. 4. Zwart JA, Dyb G, Holmen TL, Stovner LJ, Sand T. The prevalence of migraine and tension-type headaches among adolescents in Norway; the Nord-Trøndelag Health Study (Head- HUNT-Youth): a large population-based epidemiological study. Cephalalgia. 2004;24: 373-379. 5. Kröner-Herwig B, Heinrich M, Morris L. Headache in German children and adolescents: a population-based epidemiological study. Cephalalgia. 2007;27:6519-6527. 6. Pakalnis A, Butz C, Splaingard D, Kring D, Fong J. Emotional problems and prevalence of medication overuse in pediatric chronic daily headache. J Child Neurol. 2007;22:1356-1359. 7. Liakopoulou-Kairis M, Alifieraki T, Protagora D, et al. Recurrent abdominal pain and headache - psychopathology, life events and family functioning. Eur Child Adolesc Psychiatry. 2002;11:115-122. 8. Sarioglu B, Erhan E, Serdaroglu G, Doering BG, Erermis S, Tutuncuoglu S. Tension-type headache in children: a clinical evaluation. Pediatr Int. 2003;45:186-189. 9. Pakalnis A, Gibson J, Colvin A. Comorbidity of psychiatric and behavioral disorders in pediatric migraine. Headache. 2005;45: 590-596. 10. Amouroux R, Rousseau-Salvador C. Anxiety and depression in children and adolescents with migraine: a review of the literature. Encephale. 2008;34:504-510.
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11. Guidetti V, Galli F, Fabrizi P, et al. Headache and psychiatric comorbidity: clinical aspects and outcome in an 8-year follow-up study. Cephalalgia. 1998;18:455-462. 12. Bruijn J, Locher H, Passchier J, Dijkstra N, Arts WF. Psychopathology in children and adolescents with migraine in clinical studies: a systematic review. Pediatrics. 2010;126:323-332. 13. Apley J, Hale B. Children with recurrent abdominal pain: how do they grow up? Br Med J. 1973;3:7-9. 14. Dorn LD, Campo JC, Thato S, et al. Psychological co morbidity and stress reactivity in children and adolescents with recurrent abdominal pain and anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2003;42:66-75. 15. Boey CC, Goh KL. Psychosocial factors and childhood recurrent abdominal pain. J Gastroenterol Hepatol. 2002;17:1250-1253. 16. Dufton L, Dunn MJ, Compas BE. Anxiety and somatic complaints in children with recurrent abdominal pain and anxiety disorders. J Pediatr Psychol. 2009;34:176-186. 17. Ramchandani P, Fazel M, Stein A. The impact of recurrent abdominal pain: predictors of outcome in a large population cohort. Acta Paediatr. 2007;96:697-701. 18. Ramchandani PG, Hotopf M, Sandhu B, Stein A. The epidemiology of recurrent abdominal pain from 2 to 6 years of age: results of a large, population-based study. Pediatrics. 2005;116:46-50. 19. Kelleher KJ, Campo JV, Gardner WP. Management of pediatric mental disorders in primary care: Where are we now and where are we going? Curr Opin Pediatr. 2006;18:649-653. 20. Connor DF, McLaughlin TJ, Jeffers-Terry M, O’Brien WH, Stille CJ, Young LM. Targeted child psychiatric services: a new model of pediatric primary clinician child psychiatry. Clin Pediatr. 2006;45: 423-434. 21. Kutner L, Olson CH, Schlozman S, Goldstein M, Warner D, Beresin EV. Training pediatric residents and pediatricians about adolescent mental health problems: a proof-of-concept pilot for a proposed national curriculum. Acad Psychiatr. 2008;32:429-437. 22. Pauschardt J, Remschmidt H, Mattejat F. Assessing child and adolescent anxiety in psychiatric samples with the Child Behavior Checklist. J Anxiety Disord. 2010;24:461-467. 23. Goodman R. Psychometric properties of the strengths and difficulties questionnaire. J Am Acad Child Adolesc Psychiatry. 2001;40: 1337-1345. 24. Goodman R, Scott S. Comparing the Strengths and Difficulties Questionnaire and the child behavior checklist: is small beautiful? J Abnorm Child Psychol. 1999;27:17-24. 25. Crone MR, Vogels AGC, Hoekstra F, Treffers PD, Reijneveld SA. A comparison of four scoring methods based on the parent-rated Strengths and Difficulties Questionnaire as used in the Dutch preventive child health care system. BMC Public Health. 2008;8:106. 26. Goodman R, Slobodskaya H, Knyazev G. Russian child mental health: a cross-sectional study of prevalence and risk factors. Eur Child Adolesc Psychiatry. 2005;14:28-33. 27. Alyahri A, Goodman R. The validation of the Arabic Strengths and Difficulties Questionnaire and the Development and Well-Being Assessment. East Mediterr Health J. 2006;12:138-146. 28. Goodman A, Fleitlich-Bilyk B, Patel V, Goodman R. Child, family, school and community risk factors for poor mental health in Brazilian schoolchildren. J Am Acad Child Adolesc Psychiatry. 2007;46: 448-456. 29. Mathai J, Anderson P, Bourne A. Comparing psychiatric diagnoses generated by the Strengths and Difficulties Questionnaire with diagnoses made by clinicians. Aust N Z J Psychiatry. 2004;38:639-643. 30. Goodman R, Ford T, Corbin T, Meltzer H. Using the Strengths and Difficulties Questionnaire (SDQ) multi-informant algorithm to screen looked-after children for psychiatric disorders. Eur Child Adolesc Psychiatry. 2004;13(Suppl 2):II25-II31. 31. Becker A, Woerner W, Hasselhorn M, Banaschewski T, Rothenberger A. Validation of the parent and teacher SDQ in a clinical sample. Eur Child Adolesc Psychiatry. 2004;13(Suppl 2): II11-II16. 32. Woerner W, Becker A, Rothenberger A. Normative data and scale properties of the German Parent SDQ. Eur Child Adolesc Psychiatry. 2004;13(Suppl 2):10-13. 33. Goodman R, Ford T, Richards H, Gatward R, Meltzer H. The Development and Well-Being Assessment: description and initial validation of an integrated assessment of child and
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D. Machnes-Maayan et al. / Pediatric Neurology 50 (2014) 49e56 adolescent psychopathology. J Child Psychol Psychiatry. 2000;41: 645-655. Goodman A, Heiervang E, Collishaw S, Goodman R. The “DAWBA bands” as an ordered-categorical measure of child mental health: description and validation in British and Norwegian samples. Soc Psychiatry Psychiatr Epidemiol. 2011;46:521-532. Ford T, Goodman R, Meltzer H. The British Child and Adolescent Mental Health Survey 1999: the prevalence of DSM-IV disorders. J Am Acad Child Adolesc Psychiatry. 2003;42:1203-1211. Pillai A, Patel V, Cardozo P, Goodman R, Weiss HA, Andrew G. Non-traditional life styles and the prevalence of mental disorders in young adolescents in Goa, India. Br J Psychiatry. 2008;192: 45-51. Farbshtein I, Mansbach-Kleinfeld I, Levinson D, et al. Prevalence and correlates of mental disorders in Israeli adolescents: results from a national mental health survey. J Child Psychol Psychiatry. 2010;51: 630-639. Mansbach-Kleinfeld I, Farbstein I, Levinson D, et al. Service use for mental disorders and unmet need: results from the Israel survey on mental health among adolescents. Psychiatr Serv. 2010;61:241-249. Goodman R, Meltzer H, Bailey V. The Strengths and Difficulties Questionnaire: a pilot study on the validity of the self-report version. Eur Child Adolesc Psychiatry. 1998;7:125-130. Goodman R. The Strengths and Difficulties Questionnaire: a research note. J Child Psychol Psychiatry. 1997;38:581-586.
41. Costello EJ, Mustillo S, Alaattin E, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry. 2003;60:837-844. 42. Campo JV, Bridge J, Ehmann M, et al. Recurrent abdominal pain, anxiety, and depression in primary care. Pediatrics. 2004;113: 817-824. 43. Frankenburg WK. Developmental screening. Primary Care. 1984;11: 535-547. 44. Squires JK. Identifying social/emotional and behavioral problems in infants and toddlers. Transdisciplinary J. 2000;10:107-119. 45. Briggs-Gowan MJ, Carter A. Social-emotional screening status in early childhood predicts elementary school outcomes. Pediatrics. 2008;121:957-962. 46. Jellinek MS, Murphy MJ, Little M, Pagano ME, Comer DM, Kelleher KJ. Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care. A national feasibility study. Arch Pediatr Adolesc Med. 1999;153:254-260. 47. Johnson SB, Rodrigue JR. Health-related disorders. In: Mash EJ, Terdal LG, eds. Assessment of Childhood Disorders. 3rd ed. New York: Guilford Press; 1997:481-591. 48. Canning EH, Kelleher K. Performance of screening tools for mental health problems in chronically ill children. Arch Pediatr Adolesc Med. 1994;148:272-278. 49. Colvin A, Eyberg SM, Adams CD. Restandardization of the Eyberg Child Behavior Inventory. 1999; Available at http://www.pcit.org.
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Original Article
Screening for Psychiatric Comorbidity in Children With Recurrent Headache or Recurrent Abdominal Pain Ditti Machnes-Maayan MD a, b,1, Maya Elazar MD b, c,1, Alan Apter MD b, c, Avraham Zeharia MD b, d, Orit Krispin PhD b, c, Tal Eidlitz-Markus MD b, d, * a
Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel c Department of Psychiatry, The Feinberg Child Study Center, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel d Ambulatory Day Care Unit, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel b
abstract BACKGROUND: Recurrent pain symptoms in children are associated with psychiatric comorbidities that could
complicate treatment. We investigated the prevalence of psychiatric comorbidity in children with recurrent headache or recurrent abdominal pain and evaluated the screening potential of the Strength and Difficulties Questionnaire compared with the Development and Well-Being Assessment (DAWBA). METHODS: Eighty-three outpatients aged 5-17 years attending a tertiary medical center for a primary diagnosis of migraine (n ¼ 32), tension-type headache (n ¼ 32), or recurrent abdominal pain (n ¼ 19), and 33 healthy matched controls completed the brief self-reporting Strength and Difficulties Questionnaire followed by the Development and Well-Being Assessment. Findings were compared among groups and between instruments. RESULTS: The pain groups were characterized by a significantly higher number of Development and Well-Being Assessment diagnoses (range 0-11) than controls and a significantly greater prevalence (by category) of Development and Well-Being Assessment diagnoses (P < 0.001 for both). Anxiety and depression were the most prevalent Development and Well-Being Assessment diagnoses. Comorbidities were more severe in the headache groups than the controls (P < 0.001). In general, any diagnosis by the Development and Well-Being Assessment was associated with a significantly higher Strength and Difficulties Questionnaire score (P < 0.001). Abnormal scores on the emotional, conduct, and hyperactivity Strength and Difficulties Questionnaire scales were significantly predictive of a Development and Well-Being Assessment diagnosis (P < 0.003). CONCLUSION: Children referred to specialized outpatient pediatric units for evaluation of recurrent pain are at high risk of psychopathology. The Strength and Difficulties Questionnaire may serve as a rapid cost-effective tool for initial screening of these patients. Keywords: Strength and Difficulties Questionnaire (SDQ), psychiatric comorbidity, children, recurrent abdominal pain, recurrent headache, Development and Well-Being Assessment (DAWBA)
Pediatr Neurol 2014; 50: 49-56 Ó 2014 Elsevier Inc. All rights reserved. Introduction
Recurrent pain symptoms are often encountered in pediatric primary care.1 Headache is the most common somatic complaint in children,2 accounting for 1% to 2%
Article History: Received March 16, 2013; Accepted in final form July 14, 2013 1 Both authors contributed equally to the manuscript * Communications should be addressed to: Dr. Tal Eidlitz-Markus; Ambulatory Day Hospitalization Unit; Schneider Children’s Medical Center of Isra; 14 Kaplan St, 49202 Petach Tikva, Israel. E-mail address: [email protected] 0887-8994/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2013.07.011
of all visits to pediatricians.1 The prevalence of headache increases throughout childhood, reaching a peak at about 13 years of age in both sexes.1,2 The two most frequent types of primary pediatric headache are migraine and tension-type headache.3,4 In a large epidemiologic study of the 7- to 14-year age group based on the diagnostic criteria of the International Classification of Headache Disorders-II, Kröner-Herwig et al.5 found that the prevalence rate of migraine was 7.5% and 18.5% for tension-type headache. Pediatric headache has been associated with psychiatric comorbidities, although the impact of the findings are still unclear. An early study found that individuals with recurrent headache had significantly more symptoms of anxiety,
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depression, and somatization than controls and were at higher risk of emotional disorders and medication overuse, suggesting the need for a multisystem treatment approach.6 Others also reported psychiatric disorders in children with recurrent headache, especially tension-type,7,8 and high rates of behavioral problems in children with migraine.9 However, in a review of 11 studies in the literature, Amouroux et al.10 reported that patients with migraine had slightly higher scores than controls on at least one of the anxiety or depression scales, but their average scores in all studies were still within the normal range established at validation of the instruments. Guidetti et al.11 found that the presence of any psychiatric comorbidity in a child with migraine or tension-type headache may be a risk factor for worsening headaches over time, whereas a more recent review study concluded that children with migraine do not exhibit more psychiatric comorbidities than healthy controls.12 The latter authors attributed the discrepancy among studies to differences in study populations, duration of follow-up, and psychiatric diagnostic tools. Recurrent abdominal pain (RAP) occurs in 7% to 25% in children7,13 and has been significantly associated with anxiety disorders and depression.1,4,14-17 In a populationbased study, children with RAP had significantly more psychiatric morbidity than children without RAP. The strongest effect was for emotional (anxiety) symptoms compared with the general population.18 The presence of psychiatric comorbidities in children with recurrent pain complicates their management.19,20 Many pediatricians feel that they do not have the time or competence to address these issues.21 In addition, there is a shortage of pediatric mental health services and a lack of valid, low-cost psychiatric diagnostic tools that are applicable in pediatric primary care. Data on problem behavioral in children are usually collected by clinical interviews and standardized questionnaires, such as the Child Behavior Checklist, a parent-report tool designed to assess behavioral and emotional problems in children and adolescents. This checklist has been found effective for use in both clinical practice and research and may serve as both a screening tool and a basis for diagnostic formulations.22 It yields a total problem score, two broadband scores (internalizing problems and externalizing problems), and eight different syndrome scales.22 However, the CBLC is very long (140 items) and time-consuming. The Strength and Difficulties Questionnaire (SDQ) is a much briefer (25 items) self- and parental-report screen.23 Its findings have been shown to correlate highly with the Child Behavior Checklist24 and it has been recommended by the Preventive Child Health Care System as the first step for the detection and classification of psychosocial problems in the adolescent age group.25 The SDQ has been validated in many studies worldwide23,26-33 and is available in more than 30 languages. It has been used in epidemiological, developmental, and clinical research as well as in routine clinical and educational practice. Its brevity makes it easier to use than the CBLC and may offer an important advantage in initial screening of children, although the differences in length between the two instruments might alter their psychometric properties.24 The Development and Well-Being Assessment (DAWBA) is a comprehensive semistructured interview for the diagnosis
of psychiatric disorders.33-38 It can either be administered by trained lay interviewers or self-completed online. It has been found to been an effective diagnostic tool in clinical and epidemiological settings in different languages and countries.23,26-28,34-38 The questions for each disorder closely follow the diagnostic criteria operationalized in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Each section contains 20-25 items, with skip-rules such that the full set of items is administered only when the initial screening items indicate a relevant problem.33 To our knowledge, the DAWBA has never been used in a study of recurrent headache or abdominal pain in children. Our aim was to determine the prevalence of psychiatric comorbidities in children with recurrent headache (migraine or tension-type) or RAP attending a tertiary hospital outpatient pediatric unit and to evaluate the applicability and reliability of the brief SDQ for initial patient assessment using the DAWBA as a reference. If effective, the SDQ could provide a valuable screening tool in this setting for practicing pediatricians. Materials and Methods Study participants
The study group consisted of children and adolescents attending a specialized headache division of a general outpatient hospitalization unit of the gastroenterology outpatient unit of the same tertiary universityaffiliated pediatric medical center. All children were referred to the unit by their primary care pediatrician in the community after diagnosis or first-line therapeutic failure, and all were referred for this study by pediatricians of the specialized units. Only children who met the standard criteria for recurrent headache or RAP were included. Migraine and tension headache were defined according to the International Classification of Headache Disorders-II.3 RAP was diagnosed according to the definition of Apley and Hale13: three or more episodes of abdominal pain sufficient to interfere with daily activities in the previous 3 months. One parent of each patient also took part in the study. Patients were divided by their primary diagnosis into three groups: migraine headache, tension-type headache, and RAP. The control group consisted of subjects attending the general outpatient unit of the same hospital for follow-up after a recovery period of a brief acute illness (gastroenteritis, pneumonia, or urinary tract infection) that occurred before discharge from their follow-up in the outpatient unit. Control subjects were matched to the study patients by age and sex. Candidates for the control group were asked if they had recurrent headaches or RAP. Those who answered positively (either the child him/herself or the parent) were excluded from the study. Instruments
The DAWBA was developed by Goodman et al.33 to generate International Classification of Diseases-10 and Diagnostic and Statistical Manual of Mental Disorders, 4th edition, psychiatric diagnoses, as follows: separation anxiety disorder, specific phobia, social phobia, generalized anxiety disorder, panic disorder, posttraumatic stress disorder, obsessive-compulsive disorder, depressive disorder, attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder. Trained nonclinical interviewers administer the structured questionnaire to the subject (adolescent version, for ages 11-17 years) and to his or her parent (parent version). If definite symptoms are identified, the interviewers use open-ended questions and supplementary prompts to get parents to describe the problem in their own words. The descriptions are transcribed verbatim by the interviewers but not rated by them. The information from the different sources is then drawn together by a computer program that generates a summary sheet and a likely diagnosis. These, combined with the verbatim transcriptions, form a good starting point for experienced clinical
D. Machnes-Maayan et al. / Pediatric Neurology 50 (2014) 49e56 raters, who may accept or reject the computerized diagnosis after reviewing all the data. In previous studies, the DAWBA showed excellent discrimination between community and clinic samples in rates of diagnosed disorders.33,35 At least one International Classification of Diseases-10 or Diagnostic and Statistical Manual of Mental Disorders, 4th edition, disorder was diagnosed in 11% of the community sample compared with 92% of the clinic sample. This corresponded to a minimum estimate of 89% specificity in the community sample and 92% sensitivity in the clinic sample. The SDQ, developed by Goodman,23 is a 25-item screen for the detection of behavioral problems in children and adolescents aged 4-16 years. The items are divided into five scales of five items each, generating separate scores for conduct problems, hyperactivity/ inattention, emotional symptoms, peer problems, and prosocial behaviors. Internal consistency has been shown to be good for each of the subscales (mean Cronbach’s alpha, 0.73).23 The scores for the first four subscales (except prosocial behaviors) may be summed to generate a total difficulties score. The SDQ can be completed in about 5 minutes by either parents or teachers; a self-report version is available for children aged 11 years or more.39 It has been shown to discriminate between child mental health clinic attendees and community controls.39,40 In a previous study, multi-informant SDQs (parents, teachers, older children) successfully identified individuals with a psychiatric diagnosis with a specificity of 80% and a sensitivity of 85%.29
Procedure
The study protocol was approved by the local Institutional Review Board. Before enrollment, patients and parents were given a detailed explanation of the purpose and procedure of the study and the patients or their parents (for minors) signed a consent form. The SDQ was administered first, followed by the DAWBA, in a single session of about 60 minutes’ duration during the patients’ first visit to the clinic. The instruments were administered by a trained nonclinical interviewer. Each diagnosis in every patient was coded for severity on a scale of 0 (not present) to 3 (severe). The interview was supervised by an experienced child and adolescent psychiatrist who determined the clinical rating. For statistical convenience, we divided the 11 possible DAWBA diagnoses into three main psychiatric categories: anxiety disorder (separation anxiety disorder, specific phobia, social phobia, generalized anxiety disorder, posttraumatic stress disorder, obsessive-compulsive disorder, panic disorder); depressive disorder (depressive disorder); and externalizing disorder (ADHD, ODD, conduct disorder). For every child with at least one subdiagnosis within a main category, that category was counted as a single diagnosis (regardless of the number of subdiagnoses). In children with at least one subdiagnosis from more than one category, each category was counted once. We also added a fourth category, any psychiatric disorder, to which we allocated all children who had at least one diagnosed psychiatric comorbidity. Each of the diagnoses was coded on a 3-point severity scale.
51
The value of the SDQ in predicting a diagnosis by the DAWBA was analyzed by calculating the odds ratios and 95% confidence intervals (CI). A P value of <0.05 was considered statistically significant.
Results Patient characteristics
Study participants included 116 subjects, 44 boys and 72 girls, of mean age 12.9 2.867 years (range 5-17 years). Eighty-three (29 boys, 64 girls; mean age 12.7 2.8 years) were evaluated for recurrent headache or abdominal pain and 33 (15 boys, 18 girls; mean age 13.9 2.885 years) served as controls. The primary diagnoses in the recurrent pain group were migraine in 32 patients (9 boys, 23 girls; mean age 12.4 2.539 years), tension-type headache in 32 patients (16 boys, 16 girls; mean age 12.4 2.769 years), and RAP in 19 patients (4 boys, 15 girls; mean age 12.8 3.267 years). There was no significant difference among the groups in age distribution (P ¼ 0.112) or sex ratio (P ¼ 0.10). Comparing the patients with migraine to the patients with tension headache, patients with migraine had a significantly lower frequency of headache attacks per month (13.14 8.47 vs 21 11.47). The difference was statistically significant. To compare the number of psychiatric diagnoses among the three pain groups and the control group, we summed the total subdiagnoses of each participant, from 0 (none) to 11 (maximum in the DAWBA). The results are shown in Fig 1. ANOVA yielded a significant difference among the groups (P < 0.001). There was a significant difference in the number of diagnoses between the tension-type headache group and the other groups (P ¼ 0.01), and between the migraine group and the control group (P ¼ 0.014) but not the RAP group (P ¼ 0.50). There was no significant difference between the RAP group and the control group (P ¼ 0.141). Table 1 shows the prevalence rates of the three categories of psychiatric diagnoses by the DAWBA (anxiety disorder, depressive disorder, externalizing disorder), in addition to a fourth category of at least one psychiatric disorder, in each of the four groups. All three pain groups had a higher rate of main psychiatric comorbidities (migraine 65.6%, tension headache 75%, RAP 52%) than the control group (21%); P < 0.001. Table 2 shows the prevalence rates of the subdiagnoses. The number of patients in
Sample size calculation
To calculate the size of the sample, we assumed a 10% incidence of anxiety and depression disorders in the control group, similar to the general population41 and of 55% in the headache groups and 80% in the RAP group, based on earlier publications.14-16,42 The criterion for significance (alpha) was set at 0.050 (two-tailed). With a proposed sample size of 96 (32 participants in each pain group), the study had power exceeding 98% to yield a statistically significant result. Statistical analysis
Data were analyzed with the SPSS 13.0. Values for continuous variables are given as mean standard deviation. Analysis of variance (ANOVA) was used to compare continuous variables among the groups. The chi-square test was used to assess differences among the groups in patient age and in prevalence of the main DAWBA diagnostic categories.
FIGURE 1. Mean number of psychiatric diagnoses (Development and Well-Being Assessment) in the three pain groups and controls. RAP, recurrent abdominal pain.
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TABLE 1. Prevalence of psychiatric disorders (by category) using the development and Well-Being Assessment Questionnaire
Psychiatric Diagnostic Category
Migraine Group (n ¼ 32)
Tension-Type Headache Group (n ¼ 32)
Recurrent Abdominal Pain Group (n ¼ 19)
Control Group (n ¼ 33)
P Value (Chi-Square)
Any anxiety disorder
18 56.3% 4 12.5% 4 12.5% 21 65.6%
22 68.8% 8 25% 8 25% 24 75%
9 47.4% 1 5.3% 3 15.8% 10 52.6%
3 9.1% 0 0% 4 12.1% 7 21.2%
<0.001
Any depressive disorder Any externalizing disorder At least one psychiatric disorder
each psychiatric subcategory was too small for statistical analysis by pain group. The average severity scores of the total psychiatric diagnoses within each group are shown in Fig 2. ANOVA revealed significant differences among the four groups (P < 0.001). There was a significant difference in severity score between the migraine group and the tension-type headache group (P ¼ 0.015), between the migraine group and the control group (P ¼ 0.014), and between the tensiontype headache group and both the RAP group (P ¼ 0.006) and control group (P ¼ 0.001). Analysis of the severity of the psychiatric comorbidities (by category) yielded a significant difference among the four pain groups (P ¼ 0.001). Three ANOVA tests were then performed for each category. There was a significant difference in the severity of anxiety disorder between the migraine and control groups (P ¼ 0.005), between the tension-type headache and control groups (P < 0.001), and between the RAP and control groups (P < 0.05). There was a
0.012 0.470 <0.001
significant difference in the severity of depressive disorder between the tension-type headache group and both the control group (P ¼ 0.001) and RAP group (P ¼ 0.011). No statistically significant difference was found between the pain groups in severity of externalizing disorder. Intercorrelations of SDQ scores and DAWBA diagnoses
ANOVA was used to analyze the SDQ scores against the DAWBA diagnoses. For each participant, we compared the scores of the three SDQ scales (emotional, conduct, and hyperactivity) with the psychiatric diagnosis (by category) obtained with the DAWBA. The results are shown in Table 3. In general, children who had any psychiatric disorder on the DAWBA had significantly higher scores on all three SDQ scales. Findings were statistically significant between the emotional scale of the SDQ and the presence of any anxiety disorder or any depressive disorder by the DAWBA, and between the hyperactivity scale of the SDQ and the
TABLE 2. Prevalence of psychiatric disorders (by individual subdiagnoses) using the development and Well-Being Assessment Questionnaire*
Psychiatric Subdiagnosis
Migraine Group (n ¼ 32)
Tension-type Headache Group (n ¼ 32)
Recurrent Abdominal Pain Group (n ¼ 19)
Control Group (n ¼ 33)
Separation anxiety disorder
5 15.6% 17 53.1% 2 6.3% 0 0% 0 0% 2 6.3% 3 9.4% 4 12.5% 4 12.5% 2 6.3% 0
7 21.9% 16 50% 6 18.8% 3 9.4% 2 6.3% 2 6.3% 7 21.9% 8 25% 7 21.9% 6 18.8% 0
3 15.8% 5 26.3% 2 10.5% 0 0% 2 10.5% 1 5.3% 2 10.5% 1 5.3% 2 10.5% 2 10.5% 0
0 0% 3 9.1% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 3 9.1% 3 9.1% 0
Specific phobia Social phobia Panic disorder PTSD OCD Generalized anxiety disorder Depressive disorder ADHD ODD Conduct disorder
Abbreviations: ADHD ¼ Attention deficit hyperactivity disorder OCD ¼ Obsessive-compulsive disorder ODD ¼ Oppositional defiant disorder PTSD ¼ Posttraumatic stress disorder * The number of patients in each psychiatric subcategory was too small for statistical analysis by pain group.
D. Machnes-Maayan et al. / Pediatric Neurology 50 (2014) 49e56
FIGURE 2. Mean severity score of the psychiatric diagnoses (Development and WellBeing Assessment) in the three pain groups and control groups. Each diagnosis was scored for severity on a scale of 0 to 3 in every patient. RAP, recurrent abdominal pain.
presence of any externalizing disorder by the DAWBA (P < 0.001 for both). There was no significant association of the SDQ hyperactivity scale with DAWBA diagnoses of anxiety or depressive disorder. Table 4 shows the probabilities of obtaining a psychiatric diagnosis with the DAWBA compared with the SDQ. A high correlation was found between the SDQ subscale scores and any psychiatric diagnosis, between the emotional subscale score and a diagnosis of conduct disorder, any anxiety disorder, or any depressive disorder, and between the conduct and hyperactivity scores and any externalizing disorder. The other correlations were not statistically significant. Discussion
The use of the DAWBA interview in children with recurrent headache or abdominal pain revealed high rates of psychiatric comorbidity in terms of both number and TABLE 3. Comparison of mean SDQ scores and DWABA diagnoses
SDQ Scale
DAWBA Diagnosis Positive
At least one psychiatric diagnosis Emotional scale 2.45 1.83 Conduct scale 1.35 1.4 Hyperactivity scale 0.8 1.3 Any anxiety diagnosis Emotional scale 2.53 1.8 Conduct scale 1.4 1.42 Hyperactivity scale 1.73 2.7 Any depressive diagnosis Emotional scale 3.29 2.34 Conduct scale 1.67 1.6 Hyperactivity scale 2.03 2.72 Any externalizing diagnosis Emotional scale 3.38 2.4 Conduct scale 1.56 1.5 Hyperactivity scale 1.32 1.81
Negative
P Value (ANOVA)
5.28 2.23 2.28 1.79 4.0 3.44
<0.001 0.003 <0.001
5.9 2.04 2.43 1.83 2.93 2.82
<0.001 0.002 NS
5.5 2.43 1.67 1.5 2.33 4.04
0.027 NS NS
3.75 2.25 3.13 2.17 7.7 2.43
NS 0.007 <0.001
Abbreviations: ANOVA ¼ Analysis of variance DAWBA ¼ Development and Well-Being Assessment NS ¼ Not significant SDQ ¼ Strength and Difficulties Questionnaire SDQ scores are presented as mean standard deviation.
53
severity of diagnoses in the patients with recurrent headache, but not in those with RAP. The patients with tensiontype headache had the highest rate of psychiatric comorbidity (75%), followed by individuals with migraine (65.6%). The rate in the tension-type headache group is in line with the study of Liakopoulou-Kairis et al.,7 conducted in a similar outpatient setting, using the Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Life version. However, for the RAP group, our 52.6% rate of psychiatric comorbidity is considerably lower than the 81.6% reported in the earlier study.7 This discrepancy may be attributable to the small size of our RAP group (n ¼ 19). We assume our RAP group was smaller than the headache groups because the study was conducted in a tertiary center, and most patients with RAP are identified and treated at the initial evaluation by their primary physician. The most prevalent category of psychiatric comorbidity was anxiety disorder (Table 1), documented in 68.8% of the patients with tension-type headache, 56.3% of the patients with migraine, and 47.4% of the patients with RAP, compared with 9.1% of the control subjects. Other studies also indicated a high risk of anxiety disorders in these patient groups: 30% for tension-type headache8 and 42.1%7 and 79%42 for RAP. The prevalence rate in our patients with migraine was considerably lower than the 15% reported by Pakalnis et al.9 This difference, given the paucity of studies in the literature, points to a need for more research on comorbid anxiety in this patient group. Depressive disorder was documented in 25% of our patients with tension-type headache, close to the rate reported by Sarioglu et al. (20%),8 but its prevalence in the RAP group (5.3%) was considerably lower than reported by Campo et al. (42.9%).42 Our patients with migraine had a higher rate of depressive disorder (25%) than those evaluated by Pakalnis et al. (4.7%).9 These differences, as for overall psychiatric morbidity, were probably at least partly attributable to the setting of the present study. The study group was restricted to patients attending a dedicated headache clinic in a tertiary medical center, who may therefore have had more severe disease than communityderived patients. The statistically significant difference of headache frequency, which was higher for the tension type headache compared with migraine (13.14 8.47 vs 21 11.47), may influence the psychiatric comorbidity in tension headache because chronic daily headache is prone to psychiatric comorbidity. Furthermore, the average time from onset of headache symptoms to referral to our clinic was 22 months. This long lag may have had a different effect on the psychiatric comorbidity by type of headache, biasing the study results. It should also be borne in mine that tension-type headache is a vague negative definition, whereas the diagnosis of migraine is based on precise criteria. The long interval from symptom onset to admission may mask comorbid psychiatric diagnoses. Assessment of the individual externalizing disorders yielded a diagnosis of ADHD in 12.5% of the patients with migraine and a diagnosis of ODD in 6.3%. Rates reported for the general pediatric population were similar: ADHD, 4.1%; ODD, 11.3%.41 In the study of Palkanis et al.,9 19% of patients with migraine had ADHD, 17% had ODD, and 4.2% had conduct disorder. In our tension-type headache group,
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TABLE 4. Correlations between the SDQ scales and the DAWBA diagnoses*
SDQ Scales
Emotional Conduct Hyperactivity
DAWBA Diagnoses At Least One Psychiatric Disorder
Any Anxiety Disorder
Any Depressive Disorder
Any Externalizing Disorder
1.90 (1.48-2.44) P ¼ 0.003 1.44 (1.11-1.87) P ¼ 0.003 1.72 (1.20-2.33) P < 0.001
2.22 (1.64-3.00) P < 0.001 1.48 (1.13-1.93) P ¼ 0.003 P > 0.05
1.42 (1.09-1.98) P ¼ 0.035 P > 0.05
P > 0.05
P > 0.05
1.63 (1.10-2.41) P ¼ 0.015 2.91 (1.42-5.98) P < 0.001
Abbreviations: DAWBA ¼ Development and Well-Being Assessment SDQ ¼ Strength and Difficulties Questionnaire * Correlations presented as odds ratio (95% confidence interval).
ADHD was diagnosed in 21.9% and ODD in 18.8%. By contrast, Liakopoulou-Kairis et al.7 reported rates of 6.5% for both disorders in clinical groups of children with chronic headaches and RAP. The high rates of externalizing psychopathology in the tension-type headache group in our study relative to the other groups may indicate that children with tension-type headache are particularly prone to emotional and behavioral disorders. In the RAP group, we diagnosed ADHD and ODD in 10.5% of patients each; Campo et al.42 found a 19% rate of disruptive behavior disorders in children with RAP. Given the strong possibility of psychiatric comorbidities in young patients with complaints of recurrent pain, better screening tools are urgently needed in pediatric primary care. Although screening, which is a rapid low-cost assessment, is inappropriate for diagnosis, when well implemented, it can effectively identify children who may benefit from early or more in-depth intervention and ensure that their families receive the proper support and services.43-45 Two currently available screens for chronically ill children are the Pediatric Symptom Checklist46 and the Eyberg Child Behavior Inventory.47-49 The Pediatric Symptom Checklist was developed to help clinicians identify the growing number of children with psychosocial dysfunction; the Eyberg Child Behavior Inventory was designed to assess types of behavioral problems and the degree to which parents find them problematic. The Eyberg Child Behavior Inventory has shown good internal consistency and discriminative validity in chronically ill samples and was able to differentiate children referred or treated for learning and/or behavioral problems from children without a history of behavioral problems.48 Johnson and Rodrigue,47 using the Eyberg Child Behavior Inventory, found that 16% of their outpatient group of chronically ill children was at risk of psychiatric comorbidity, similar to the 14% identified with the Pediatric Symptom Checklist. However, despite the A Assessment Rating (reliability and validity demonstrated) of the Eyberg Child Behavior Inventory, data on its value for predicting psychiatric diagnoses are lacking. Furthermore, Canning and Kelleher48 showed that the application of certain specific tools developed for the pediatric population, including the Pediatric Symptom Checklist, the Child Depression Inventory, and the Child Behavior Checklist as well as some other instruments widely applied in healthy subjects may occasionally yield inflated maladjustment scores.47,49 All had low sensitivity and low positive and negative predictive values
but high specificity. Therefore, the use of these instruments could undermine the pediatrician’s clinical judgment.48 The present study is important because it demonstrates the possibility of using an easy, low-cost, already widely available screening tool, the SDQ, for the initial psychiatric assessment of patients with recurrent pain symptoms attending specialized pediatric referral units. In a previous study, multi-informant SDQs (parents, teachers, older children) successfully identified individuals with a psychiatric diagnosis, with a specificity of 80% and a sensitivity of 85%.33 In the present study, odds ratio analyses yielded highly significant correlations: between the SDQ emotional scale score and DAWBA diagnoses of any psychiatric disorder, particularly anxiety disorder, and any depressive disorder; between the SDQ conduct scale scores and diagnoses of any psychiatric disorder, any anxiety diagnosis, and any externalizing disorder; and between the SDQ hyperactivity scale score and any psychiatric disorder. The other correlations were not significant. There were no weak correlations, although this may have been due to the small sample size (Table 3). The findings indicate that children with recurrent pain have problems in certain areas of functioning and accordingly, a high probability of a specific psychiatric disorder. They support the suggestion that the SDQ could serve as a useful tool in the initial assessment of psychopathology in children with recurrent headaches or RAP evaluated in clinical settings. Further studies are needed to assess the sensitivity of the SDQ in predicting specific psychiatric disorders in these and other patient groups with larger numbers. The major limitation of the present study is the crosssectional design, which restricted our ability to draw conclusions beyond the recognition of significant predefined characteristics that exist in a population, but not to determine cause-and-effect relationships between different variables. Although the study was sufficiently powered to identify statistically significant differences, a similar study with larger groups may be helpful to corroborate our findings. Nevertheless, this study supports earlier evidence of a high risk of psychiatric comorbidity in children with recurrent pain. In another cross-sectional study, Campo et al.,42 referring to their RAP group, suggested that “artefact alone is unlikely to provide an explanation for the strong association between RAP and anxiety.” To determine the precise nature of the association of recurrent headaches and RAP with psychiatric comorbidity, well-designed longitudinal prospective studies are needed.
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It should also be noted that our control group consisted of children after an acute intercurrent illness attending the same unit as the patients. It is possible that their hospital stay made them prone to anxiety and stress disorders. Therefore, we might have found even more pronounced differences between the patients and controls had the study been done in another setting. Conclusion
Children referred to hospital outpatient pediatric units in tertiary center for recurrent migraine, tension-type headache, or abdominal pain have a significantly high prevalence of psychiatric comorbidity. The SDQ, a rapid selfreport instrument, may be applicable for routine initial screening of this patient population. A high score on the SDQ alerts clinicians to the possibility of a psychiatric disorder and the need to refer the patient to a mental health professional. In primary care, especially when resources or skilled manpower is lacking, a finding of a high score on the emotional, behavioral, or hyperactivity/inattention SDQ scale might be followed by the DAWBA interview,31 which is easy to administer, even by research assistants. Welldesigned longitudinal studies are needed to investigate the interconnections of recurrent headaches and RAP with psychiatric symptoms, to define treatment in cases of diagnosed psychiatric comorbidity and recurrent pain, and to investigate the influence of psychopharmacological or psychological treatment on the severity and frequency of recurrent pain symptoms. References 1. Egger HL, Costello EJ, Erkanli A, Angold A. Somatic complaints and psychopathology in children and adolescents: stomach aches, musculoskeletal pains, and headaches. J Am Acad Child Adolesc Psychiatry. 1999;38:852-859. 2. Fearon P, Hotopf M. Relation between headache in childhood and physical and psychiatric symptoms in adulthood: national birth cohort study. BMJ. 2001;322:1145. 3. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 2nd edition. Cephalalgia. 2004;24(Suppl 1):9-160. 4. Zwart JA, Dyb G, Holmen TL, Stovner LJ, Sand T. The prevalence of migraine and tension-type headaches among adolescents in Norway; the Nord-Trøndelag Health Study (Head- HUNT-Youth): a large population-based epidemiological study. Cephalalgia. 2004;24: 373-379. 5. Kröner-Herwig B, Heinrich M, Morris L. Headache in German children and adolescents: a population-based epidemiological study. Cephalalgia. 2007;27:6519-6527. 6. Pakalnis A, Butz C, Splaingard D, Kring D, Fong J. Emotional problems and prevalence of medication overuse in pediatric chronic daily headache. J Child Neurol. 2007;22:1356-1359. 7. Liakopoulou-Kairis M, Alifieraki T, Protagora D, et al. Recurrent abdominal pain and headache - psychopathology, life events and family functioning. Eur Child Adolesc Psychiatry. 2002;11:115-122. 8. Sarioglu B, Erhan E, Serdaroglu G, Doering BG, Erermis S, Tutuncuoglu S. Tension-type headache in children: a clinical evaluation. Pediatr Int. 2003;45:186-189. 9. Pakalnis A, Gibson J, Colvin A. Comorbidity of psychiatric and behavioral disorders in pediatric migraine. Headache. 2005;45: 590-596. 10. Amouroux R, Rousseau-Salvador C. Anxiety and depression in children and adolescents with migraine: a review of the literature. Encephale. 2008;34:504-510.
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