Journal of Psychosomatic Research 68 (2010) 325–327

Editorial

Pediatric consultation–liaison psychiatry

This month's edition of the Journal of PsychosomaticResearch focuses, in part, on various aspects of pediatricconsultation–liaison psychiatry (CLP). The subjects coveredrange from delirium in pediatric populations to medicallyunexplained symptoms in children, via atopic dermatitis(AD) and the assessment of pain. This focus on pediatricCLP reflects a growing awareness of the importance of thearea within the European Association for Consultation–Liaison Psychiatry and Psychosomatics and a timelyreminder of the wide range of interests within the area.

Pediatric delirium has long been a relatively neglectedarea. However, there is increasing evidence of the physicaland psychological comorbidities associated with pediatricdelirium [1,2] and emerging evidence concerning itsmanagement and treatment [1]. Hatherill and Flisher [3]provide a comprehensive review of the existing literature.Although the prevalence of pediatric delirium ranges from17% to 66% across studies [4,5], it accounts forapproximately 10% of referrals to pediatric CLP services[6]. A wide range of predisposing and precipitating factorshave been identified, but there are significant differencesacross sites. Turkel and Tavare [6] found that infections(33%), drug-induced (19.5%), and serious trauma (9.5%)accounted for more than 50% of cases. In contrast,Schieveld et al. [5] found that neurological disordersaccounted for 55% of referrals. These differences arepresumably site specific and reinforce the need formulticenter studies. Hatherill and Flisher [3] emphasizethat medications are frequently implicated in pediatricdelirium and suggest that children may be particularlysusceptible to anticholinergic agents.

The presentation of delirium in children is both similarand different to that in adults. An interesting finding is thatsubtle disruptions in the parent–child relationship can be anearly warning sign of delirium [7]. Pediatric deliriumpresents in the hyperactive, hypoactive, and mixed forms,often with marked fluctuations over time [5]. It has beensuggested that these different forms have different correlatesin differing neurotransmitter pathways which should governthe pharmacological management of delirium [1]. Hencehyperactive delirium is thought to result from D2 pathwayoveractivity and so responds to D2 antagonists such ashaloperidol, whereas atypical antipsychotics affect a wider

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range of pathways and are more effective in hypoactivedelirium and have a better side-effect profile.

Hatherill and Flisher [3] report a limited number ofstudies on the prevention of pediatric delirium, including arandomized controlled trial (RCT) aimed at reducingpreoperative anxiety [8]. These findings are supported byan RCT of a psychoeducational intervention for childrenadmitted to pediatric intensive care [9]. Finally, there isemerging evidence to suggest that, when opiates are used assedatives in pediatric intensive care unit (PICU), theyincrease the risk of posttraumatic stress symptoms inchildren admitted to PICU [10].

Pediatric AD is a common condition affecting 5–20% ofthe childhood population [11]. Pediatric AD affects childrenand families alike. It is often seen as a relatively trivialdisorder by professionals but can have a major impact onmany areas of children's lives. Children report significantlylowered quality of life [12] and higher rates of psychosocialdifficulties, particularly behavioral problems [13]. Given thatstress is widely implicated in AD flare-ups and the scratch–itch cycle [14], the findings of Kupfer et al. [15] that theirpsychosocial intervention led to improvements in children'scoping behavior and parents' sense of efficacy in handlingtheir children are welcome.

In the first findings from this study [16], the authors,using an RCT multicenter design with waiting list control,showed a significant improvement in the somatic severity ofAD, quality of life, and cognitive factors relating to itching at1 year. In a reanalysis of their original data, Kupfer et al. [15]found that social anxiety and depressed mood, as measuredby a self-report instrument, improved in children and youngpeople, but that there was no significant change in the itch–scratch/stress cycle. They found a significant reduction in“catastrophizing” and a concomitant increase in “coping”cognitions in children and young people. There were similarimprovements in parental beliefs about their children's ADbut no reduction in overprotective behavior. These arepromising findings, but the study has two significantlimitations. Firstly, there was a significantly greater dropoutrate in the control group (83/101) in comparison to theintervention group (102/105). Secondly, the authors did notuse an intention-to-treat analysis. Pediatric AD is a commoncondition with a significant associated burden of care. These

326 Editorial / Journal of Psychosomatic Research 68 (2010) 325–327

weaknesses underscore the importance of conducting areplication study because, if the efficacy of the interventionwas confirmed, it would have important implications forpediatric dermatology and pediatric CLP practice.

Children's experience of pain is an important focus ofpediatric CLP practice. As Huguet et al. [17] point out,children experience acute pain, pain in relation to pediatricinterventions, and chronic pain. Children who experiencechronic pain use more health services, have more psycho-social problems, miss more school, and do worse academ-ically than children who do not [18]. However, pain hasmany dimensions: mechanism, site, character, intensity, etc.[19], and can be self-rated or rated by external observers suchas parents or nursing staff. Huguet et al. [17] reviewmeasures of self-reported pain intensity in light of recom-mendations from the Pediatric Initiative on Methods,Measurement, and Pain Assessment in Clinical TrialsConsensus Group (Ped-IMPACT) and from the Society ofPediatric Psychologists (SPP) that self-rated pain intensityshould be the primary outcome measure in pain clinic trials.These two groups aimed to identify valid measure for ratingpain but with contrasting aims: the Ped-IMMPACT groupsought measures with scientific validity, while the SPPsought measure with clinical utility. Huguet et al. [17] reviewfour specific measures: Pieces of Hurt Tool; the FACES PainScale Revised; the Oucher-Photographic and NumericalRating Scale; and the visual analogue scales. They suggestthat there are little differences in the recommended use oftheses scales between Ped-IMMPACT and SPP, with thePieces of Hurt Tool recommended for use with youngchildren (3–4 years) and the other scales with wider ageranges, from 3 to 12+. The review of Huguet et al. [17]provides a useful summary of a complex area. They suggestthat pain measures should be used more widely and moreconsistently in the pediatric population.

Recurrent abdominal pain (RAP) is one of the mostcommon somatic symptoms experienced by children, withan estimated prevalence ranging from 2.8% to 15% ofchildren and young people [20,21]. The longitudinal studyof psychosocial risk by Helgeland et al. [22] adds furtherevidence to our understanding of the relationship betweenchild and maternal risk factors and the development offunctional somatic symptoms (FSS). The associationbetween anxiety and depression in children and theemergence of FSS is well established [23]. However,anxiety and depression are sometimes treated as a unitaryphenomenon and the direction of causality—do anxiety anddepression precede FSS or are they the consequences ofFSS?—has not, until recently, been clear. Helgeland et al.[22] used a prospective population-based cohort study toinvestigate maternal and child factors at 18 months and 12years in relation to RAP in adolescence. They found thatmaternal psychological distress when the child was 18months and a history of maternal psychological distresswhen the child was 12 both predicted RAP in adolescentsaged 14. Abdominal and nonabdominal pain at 12

described by mothers and nonabdominal pain describedby children also predicted for RAP at 14. Child-reporteddepressive symptoms also predicted RAP but negative lifeevents and physical health problems in mothers andtoddlers did not.

The study by Helgeland et al. [22] is a large-scale study(n=456), although there was a substantial dropout rate fromthe original sample of 916. Their findings in relation to childfactors are consistent with recent findings from a large-scaleDutch longitudinal study [24] which suggests that preexist-ing anxiety and depression are both significant risk factorsfor FSS in adolescents but that FSS has only a weakpredictive effect for anxiety and depression. It is perhaps notsurprising that only maternal psychological distress at 18months was found to act as a risk factor in the Helgeland etal. study [22], given the elapsed time period. However, thefinding that maternal psychological distress at 18 months and12 years predicted RAP in adolescence is consistent with awide range of findings that suggest that a range of parentalfactors are important in the emergence of FSS in children andadolescents [25].

A key difficulty in identifying children with FSS is theimportance of excluding a preexisting medical conditionor assessing whether or not the presenting symptoms canbe accounted for by a current medical condition [26], butwithout encouraging overinvestigation which may perpet-uate the problems. This generates difficulties for bothclinicians and researchers. Postilnik et al. [27] havedeveloped and tested an algorithm for the assessment ofFSS [28]. However, this does not include a robust methodfor reliably assessing pediatric records. Rask et al. [29]have developed such a method. Based on work with adultpatients with FSS they developed a systematic method,the Medical Record Review for Functional SomaticSymptoms in Children or MRFC. It rates the presenceor absence of well-defined physical disease, 36 physicalsymptoms covering all of the physical symptoms, andcategorizes symptoms as to whether or not they arefunctional. Rask et al. [29] used three pediatricians toblindly rate the medical notes of 54 children with diabetesor asthma and 59 children with functional symptoms. TheMRFC had good interrater reliability for the presence ofFSS (combined k=0.69) but was less reliable in ratingdegree of impairment (combined k=0.29). Rask et al. [29]acknowledge that there are weaknesses in the MRFC,particularly the length of time needed to complete it.However, it offers a promising avenue in a complex andchallenging field.

Peter HindleySt Thomas' Hospital

London, UKE-mail address: peter.hindley@slam.nhs.uk

doi:10.1016/j.jpsychores.2010.03.003

327Editorial / Journal of Psychosomatic Research 68 (2010) 325–327

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