Category Archives: Psychology

Chronic fatigue syndrome

General paediatrics, Mental health, Neurology, OPD, Psychology, Rheumatology

NICE update 2021 a bit depressing:

  • Therapy based on physical exercise should NOT be offered “as a cure”, nor should graded exercise programmes (which by definition use fixed increments in exercise) be used!
  • Instead, self management, flexible and tailored
  • CBT should only be offered to manage symptoms, improve functioning and reduce distress.
  • Talks about “energy management” – includes emotional, social, cognitive.
  • “Care and support plan” – physical activity including mobility but also activities of daily living.  Plan periods of rest and activity, and incorporate the need for pre-emptive rest.  Management of relapses and flares.

Main thrust of update is that CFS/ME is a complex, chronic medical condition affecting multiple body systems and its pathophysiology is still being investigated. It affects everyone differently and its impact varies widely – for some people symptoms still allow them to carry out some activities, whereas for others they cause substantial incapacity.  It is a fluctuating condition in which a person’s symptoms can change unpredictably in nature and severity over a day, week or longer.

Often it profoundly affects different aspects of the lives of both people with ME/CFS and their families/carers including social life, emotional wellbeing and education.

Another big theme is prejudice, disbelief and stigma experienced by patients.

US IOM expert panel have rejected the name “chronic fatigue syndrome”, as patients hate it!  Myalgic encephalitis (ME) also rejected on basis of insufficient evidence that this is the pathological process.  They suggest “Systemic exertion intolerance”, which is probably even more rubbish, in my opinion.

Diagnostic criteria: all of the following 3 [BMJ 2015; 350]

  1. Substantial reduction/impairment in pre-illness levels of activity, that persists for more than six months [NICE 2007 says 3/12 for children], and accompanied by fatigue (often profound, new or definite onset, not the result of ongoing excessive exertion and not substantially alleviated by rest)

  2. Worsening of symptoms after any type of exertion (including cognitive and emotional stress) – “post-exertional malaise“

  3. Unrefreshing sleep, and/or sleep disturbance.

In addition, should have at least one of:

  • Cognitive impairment

  • Orthostatic intolerance.

Doesn’t mention chronic pain?! NICE says reconsider diagnosis in absence of cognitive difficulties or chronic pain.

Causes

Evidence (reproducible) implicating certain infections as a trigger. Co-existing mood disorder in substantial proportion of patients, sometimes sleep-wake disorder – likely to perpetuate/exacerbate.

Brain imaging has identified alternations suggesting that it is a brain problem.

Investigations

[NICE 2007]
  • Urinalysis
  • FBC, LFTs
  • TFTs
  • Coeliac disease screening
  • CK
  • ESR/CRP
  • Glucose
  • Ferritin

NOT microbiology unless indicated: borrelia, HIV, Hepatitis viruses, EBV, CMV, toxoplasmosis

Management

Exercise

Cochrane review of graded exercise therapy – may benefit sleep, physical function, self-perceived general health, and no evidence that it worsens outcomes. Curiously, no evidence for loss of aerobic fitness! Perhaps graded exercise tackles a hyper-reactive CNS response to exercise-related physiological signals. Note that fear of physical activity becomes conditioned when it commonly exacerbates symptoms.

Warn that exercise programmes can make things worse rather than better. Exercise should only be done as part of supervised programme, with physiotherapist – don’t just tell them to go the gym more! Start below baseline activity level.

Other

Relaxation techniques recommended by NICE.

CBT – should only be offered to manage symptoms, improve functioning and reduce distress.  Again, not a “cure”. Analysis of both CBT and graded exercise suggests that benefit comes from reducing inactivity.

Sleep hygiene important.  Include rest periods in plan but avoid day time naps, especially since sleep doesn’t usually help anyway!

Many people find exclusion diets useful, esp bowel symptoms, not recommended but involve dietician if attempted anyway.

Equipment to maintain independence can improve quality of life and should be part of overall management.

Beware boom-bust! Many patients over do it when they have a period of relative wellness. Flares and relapses are to be expected.  Trigger? New medical problem? Adjust plan as necessary.

Pain and orthostatic intolerance are big issues for some people.

Severe CFS can increase risk of pressure ulcers, DVT, vitamin D deficiency and contractures.

Prognosis

Important to be honest at time of diagnosis.  More optimistic in young people.  Most adults improve, some are able to return to usual activities but others experience long term symptoms or relapse.

PACE trial aimed for less than full restoration of health as “recovery”, future trials should use clinically relevant improvement and patient self-perception.

[bmj 2015;350:h2087]

[NICE 2021] 

2010 Scottish Good Practice statement needs update.

Attention Deficit & Hyperactivity Disorder

Community, OPD, Psychology

NICE guideline 2018

ADHD defined as at least 6 months of

  • Inattention,
  • Hyperactivity,
  • Impulsivity.

ICD requires all 3, DSM requires just 1.

Plus,

  • social and/or academic difficulties not explained by anxiety or depression,
  • child should be under 7 yrs.
  • cause at least moderate psychological, social, or educational or occupational impairment based on interview or direct observation in multiple settings and
  • be happening often, occurring in 2 or more important settings including social, familial, educational or occupational settings. [2008, amended 2018]

DSM does not give guidance on assessing severity. UK guidelines do not mention mild ADHD, which of course is harder to define.

Commonly associated with peer rejection, increased risk of injury. Long term, less likely to enter higher education or find employment, more likely to have delinquent/criminal behaviour, more likely to smoke, use alcohol and illegal drugs.

There is high concordance for monozygotic twins, which supports a genetic cause. There are also MRI/PET lesions, which support a physical cause (cortical abnormalities in the frontal, temporal, and parietal lobes, Lancet 2003). It is 3 times more common in boys. It may be related to traumatic experience in infancy.

Computer based assessment tools exist including Conners (94% sensitive). QbTest is recommended by NICE. None are in themselves diagnostic.

NICE recommend you also check parental mental health!

Examples of inattention:

  • Careless mistakes
  • Does not seem to listen when spoken to directly
  • Does not follow through instructions (NOT simply oppositional)
  • Avoids sustained mental effort
  • Loses things necessary for tasks/activites

Examples of hyperactivity/impulsivity:

  • Fidgets, squirms, leaves seat when expected to remain
  • Runs about, climbs in appropriate situations
  • Acts as if “driven by a motor”
  • Blurts out answers before question finished
  • Interrupts, intrudes on others

Management

Parent training programmes are effective for preschool children.

Techniques are:

  • Understanding (patient/tolerance)
  • Give clear instructions, simple steps
  • Set clear boundaries
  • Separate behaviour from child – avoid shaming/labels – find other ways to express upset/overwhelm
  • Involve whole famly
  • Build healthy routines of sleep, meal times, physical activity
  • Help organise – checklists, visual timetables, sticky notes, phone alarms
  • Lots of positive feedback
  • Manage triggers
  • Support wellbeing – talk about feelings
  • Find support for parents (online or local)

Methylphenidate, a dopamine agonist, is effective, esp for concentration, hyperkinesis and impulsiveness. Clonidine has been suggested.

Behaviour modification (NOT cognitive behavioural) is effective for age 6yr+ only when combined with medication.

Hyperactivity tends to improve over time, but there are associated antisocial behaviours and learning difficulties long term. The longest trial showed better performance up to 8yrs after entry (compared with baseline), but still underperforming compared with peers.

A diagnosis can help parents but also carries stigma: children with ADHD are perceived as lazier and less clever by peers, and teachers/parents have lower academic expectations.

BMJ 2013;347:18a

Parenting and constipation

Common, General paediatrics, OPD, Psychology

Parental child-rearing attitudes (as assessed by the Amsterdam version of the Parental Attitude Research Instrument, A-PARI), are associated with constipation in children in Dutch study.

More specifically, both higher and lower scores on the autonomy attitude scale were associated with decreased defecation frequency and increased faecal incontinence. High scores on the overprotection and self-pity attitude scales were associated with increased faecal incontinence.

“Autonomy” reflects emphasis on encouraging independence.  “Overprotection” refers to concern about child with respect to prevention of disappointment and problems for the child, and need to know what’s going on inside child.  “Self pity” refers to irritability and frustration with respect to upbringing, which implies rejection.

More and stronger associations were found for children aged ≥6 years than for younger children.

Authors recommend addressing parenting issues during treatment and even referral to mental health services when parenting difficulties hinder treatment or when the parent–child relationship is at risk.  [Arch Dis Child 2015;100:329-333 doi:10.1136/archdischild-2014-305941]]

 

Psychosocial interventions

General paediatrics, Psychology

Flashpoints are transition eg from nursery to primary, to secondary, to adult services.

At diagnosis, constantly try to normalise.

Other triggers are new or difficult situations: staff changes esp specialist nurses. Effect on parent’s work, parent’s role in family, child’s fears.

Past experience of medical condition, procedure, hospital/doctors will colour.

Parenting in chronic illness – limit setting vs laxity (love!) in face of illness.

Behaviour as communication of fear, displeasure!

Signs and symptoms – changes in appearance, mood, behaviour, thoughts.

Support at diagnosis: names, phone numbers! Normalise experience and feelings. Signpost peer support, online or other. Written. Practical eg financial, family routines. Joint working for consistent info. Deciding what chats are appropriate with child present. Reiteration.

“Other people in your situation have tried x, y and z. Do any of those sound good?”

Pre-5: encourage play and exploration, avoid interfering with parental proximity.

5-7 May develop magical thinking (I think, and it comes true). Guilt, punishment, contagion? Accept what other children say as true! Imitate parental behaviour. Death as reversible.

Drawing! Check understanding of bodily functions.

Sue Robinson, hospital passport (Janie donnan). For primary school age, app for teens to follow.

Concrete reminder of achievements and rewards.

Alphabet. Backwards!

Hand on tummy, feel rise and fall.

Guidance for parents!

Sucrose. Video for juniors, showing expected techniques.

Functional analysis (ABC) – immediate antecedent (context as much as events), consequences (esp people’s actions, any difference in attention (anything given or taken away)?  What would usually happen otherwise?) use diary again. Bedside table! 5-7 days max, can be repeated. Review within 2 weeks.

Pacing – beware boom/bust cycles. Rest before exhausted but maintains daily activity.

Activity record: enjoyment vs pain impact.

Smart goal. Low hanging fruit first! Goal diary – did you achieve it? Rate pain. How did you feel?

If/then plan – beware abandoning at first set back. If you can’t get to school one day, then what will you do? Phone to update? Try harder next day?

How confident? What benefits, what difficulties?

Visualisation – can child describe a scene easily? Else unlikely to work.  Personally relevant dream place. Safe and happy. Real or imagined. Describe it in as much detail as you can – all senses. As long as possible; but 5 mins is plenty.

Record positive achievements.

Positivity – but listen empathetically.

Negative beliefs.

 

[NES study day – Liz Hunter, Ashley Sikoura]

Obesity prevention

General paediatrics, Nutrition, Psychology

Childhood obesity can be prevented – Cochrane updated evidence 2011!

Most effective interventions change social and physical environments and norms, not just individual behaviour.  Policies for healthy eating and physical activity in schools and early childcare settings, support for teachers to do health promotion, parent support and home activities that encourage children to be more active, eat more nutritious foods and spend less time in screen based activities.  Esp 6-12yrs but heterogeneous.

Fast food patronage is a frequent reality for many children and their parents. Although there are increasingly healthier alternatives for popular menu items (apple slices instead of French fries), they are infrequently selected.

Lifestyle factors cluster of course.  Boys’ adherence to a healthy lifestyle pattern (combining a nutrient‐dense diet and limited screen time) at 5 years was positively associated with prosocial behaviours (β = 0.14; 95% confidence interval [CI] 0.01, 0.26) and inversely related to hyperactivity‐inattention symptoms (β = −0.12; 95% CI −0.23, −0.01) at 8 years. But in the EDEN cohort, there was no association with BMI, and for girls, a mixed lifestyle pattern (sugar or artificially sweetened beverages, high screen, physical activity and low sleep times) was still associated with prosocial behaviours (β = 0.12; 95% CI 0.01, 0.23). [DOI:10.1111/ppe.12926]

What would Batman eat? Priming

Study of 22 children presented with 12 photos of 6 admirable and 6 less admirable models incl Batmand and Superman.  Asked, ‘Would this person order apple fries or French fries?’ In the health prime condition, the same children were shown 12 photos of 6 healthy foods and 6 less healthy foods and asked to indicate if each food was healthy or unhealthy.

Results

When children were asked what various admirable people – such as Batman or Spiderman – would eat, 45% then chose apple slices over French fries (cf 9% in control group).  Incidentally, knowing which foods were healthy or not made no sigificant difference to food choice.  [Wansink et al,  Pediatric Obesity, 7: 121–123. doi: 10.1111/j.2047-6310.2011.00003.x]

Weight talk in the home—parents talking to their children about their weight, shape or size— is associated with many negative health outcomes in children and adolescents, although the majority of research has been with adolescents.   Most psychological (e.g., emotional problems) and social (e.g., peer problems) outcomes differed significantly by race/ethnicity!

  • no significant associations between weight talk and biopsychosocial outcomes were found for Hmong and Latino children;
  • negative association (e.g., less healthy functioning) was found for African American and Somali children;
  • a positive association (e.g., healthier functioning) was found for Native American children. [DOI:10.1007/s10826-022-02351-9]