Published online March 1, 2006
PEDIATRICS Vol. 117 No. 3 March 2006, pp. 889-897 (doi:10.1542/10.1542/peds.2005-0109)
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SPECIAL ARTICLE

Psychiatric Morbidity in Children With Medically Unexplained Chronic Pain: Diagnosis From the Pediatrician's Perspective

Antoinette Y. Konijnenberg, MD, PhDa, Elisabeth R. de Graeff-Meeder, MD, PhDb, Joost van der Hoeven, MDb, Jan L. L. Kimpen, MD, PhDa, Jan K. Buitelaar, MD, PhDc, Cuno S.P.M. Uiterwaal, MD, PhDd and the Pain of Unknown Origin in Children Study Group

a Departments of General Pediatrics
b Child and Adolescent Psychiatry, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, Netherlands
c Department of Psychiatry and Academic Center for Child and Adolescent Psychiatry, Nijmegen, Netherlands
d Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, Utrecht, Netherlands

CONTEXT. There is very little general evidence to support the clinical management, particularly diagnosis, of medically unexplained chronic pain (UCP) in children.

OBJECTIVE. We sought to assess in children with UCP if clinical characteristics held important by general pediatricians help to accurately diagnose psychiatric morbidity and, alternatively, if the same can be achieved using dedicated questionnaires.

METHODS. We used a cross-sectional diagnostic study in a pediatric outpatient clinic of a university hospital. Our participants were 134 patients, aged 8 to 18 years, who were referred for UCP. Performed were (1) diagnostic test reflecting the pediatricians’ choice of clinical characteristics and (2) selected questionnaires. Classification was performed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, by a child psychiatrist using the Diagnostic Interview Schedule for Children-Parent Version IV and the Semi-structured Clinical Interview for Children and Adolescents. Results were analyzed by logistic regression.

RESULTS. Psychiatric morbidity was present in 80 of the children. A minority had a medical explanation for the pain (15% definite, 17% probable). The clinical diagnostic model included age, social-problem indicators, family structure, parental somatization, and school problems. In the quintile of children in whom this model predicted the highest risk, 93% indeed had psychiatric morbidity at reference testing. In the quintile with the lowest predicted risk, indeed only 27% had psychiatric morbidity. The Dutch Personality Inventory for Youth and the Child Behavior Checklist matched the pediatricians' choice of clinical characteristics. In the quintile of children with the highest predicted risk based on these questionnaires, 89% had psychiatric morbidity. In the quintile with the lowest predicted risk, only 15% had psychiatric morbidity.

CONCLUSIONS. A pediatrician-chosen set of clinical characteristics of children with UCP proves useful in diagnosing psychiatric morbidity. Using selected questionnaire screening yields similar results.

Key Words: chronic pain • psychiatry • predictive testing • diagnostic procedures • children • adolescents

Abbreviations: UCP—unexplained chronic pain • PUC—Chronic Pain of Unknown Origin in Children • CHQ-CF—Child Health Questionnaire Child Form • CSI—Children's Somatization Inventory • DPIY—Dutch Personality Inventory for Youth • CBCL—Child Behavior Checklist • CFP—Checklist for Family Problems • DISC-P—Diagnostic Interview Schedule for Children-Parent Version IV • SCICA—Semi-structured Clinical Interview for Children and Adolescents • DSM-IV— Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition • AUC—area under the curve • OR—odds ratio • df—degrees of freedom • CI—confidence interval

Accepted Jul 25, 2005.


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