Pediatric Clinical Samples Research Articles

Implications of DSM‐5 for the diagnosis of pediatric eating disorders

The aim of the study was to compare the DSM-IV, DSM-5, and ICD-10 eating disorders (ED) nomenclatures to assess their value in the classification of pediatric eating disorders. We investigated the prevalence of the disorders in accordance with each system's diagnostic criteria, diagnostic concordance between the systems, and interrater reliability. Participants were 1062 children and adolescents assessed at intake to a specialist Eating Disorders Program (91.6% female, mean age 14.5 years, SD = 1.75). Measures were collected from routine intake assessments. DSM-5 categorization led to a lower prevalence of unspecified EDs when compared with DSM-IV. There was almost complete overlap for specified EDs. Kappa values indicated almost excellent agreement between the two coders on all three diagnostic systems, although there was higher interrater reliability for DSM-5 and ICD-10 when compared with DSM-IV. DSM-5 nomenclature is useful in classifying eating disorders in pediatric clinical samples.

Abstract PR04: Progress towards development of an exosome-based biomarker assay in Ewing sarcoma

Abstract Background: Ewing sarcoma (EWS) is the second most common primary pediatric bone malignancy in the United States. Despite significant advancements made in the management/treatment of localized EWS, the 5-year overall survival for patients with metastatic or recurrent EWS is less than 30%. Sadly, outside of scans, no clinically relevant predictive biomarkers currently exist; therefore, there is a glaring need for complementary biomolecular approaches to help predict drug resistance, metastasis, and recurrence, with the overall aim of enhancing the management of EWS patients. Recent advancements in the field of biomarker development have demonstrated that nano-sized vesicles, termed exosomes, are actively released by tumor cells and carry content (such as proteins and RNAs) which are representative of their cell of origin. Importantly, these vesicles can be isolated from various biologic fluids including plasma and have the potential to provide a minimally invasive, real-time “shapshot” of the genetic and proteomic content of these tumor cells, thereby providing a rich source of potential diagnostic and predictive biomarkers. We hypothesize that analysis of the proteomic content of EWS-derived exosomes may result in the ability to selectively enrich for EWS-specific exosomes from patient plasma and, upon analysis of the content, provide a novel and clinically relevant source of disease-specific biomarkers. Methods: We isolated exosomes from five EWS cell line derived exosomes with varying EWS-Ets fusions (TC-71, CHLA-258, RD-ES, SK-ES-1, and COG-E-352). We characterized the proteomic and nucleic acid content of these extracellular vesicles using Western blot analysis, Nanoparticle Tracking Analysis, and real-time PCR in order to establish exosome purity and identified already established EWS markers such as the CD99/MIC2 protein and the EWS-Ets fusion transcripts. We next conducted mass spectrometry to obtain a global proteomic assessment of these EWS cell line derived exosomes. Longitudinal pediatric clinical samples collected through an established pediatric sarcoma biobank (16 Ewing sarcoma, 5 rhabdomyosarcoma and 7 osteosarcoma pediatric patients) were utilized for this study. Through the use of this proteomic data set and a portion of the pediatric sarcoma clinical sample set, we have developed a magnetic bead-based immunoprecipitation approach requiring the use of only 250 µL of patient plasma to isolate tumor-derived exosomes in pediatric EWS patients (with localized, metastatic or recurrence of disease). These isolated extracellular vesicles were then evaluated for the presence of EWS markers by Western blot and the EWS-Ets fusion transcripts by nested qPCR. Results: Exosomes from each of the experimental cell lines contained typical exosomal markers (i.e., ALIX and CD81) and had a mean size of 170 nm. EWS cell line derived exosomes demonstrated the presence of EWS-Ets fusion transcripts at both the mRNA level and proteomic level. The analysis of the mass spectrometry data revealed 619 commonly shared proteins. Upon comparison with the content of plasma proteomic and exosomal specific databases, 3 unique proteins of interest were identified. Lastly, exosomes immunoprecipitated from both patient plasma and exosome-spiked plasma displayed EWS markers such as MIC2/CD99 and EWS-FLI1, and contained the EWS-Ets mRNA transcripts. Conclusions: For the first time reported, tumor-derived exosomes from EWS pediatric patients are demonstrated to be isolated by immunoprecipitation techniques and express presence of EWS-specific markers. The future evaluation and analysis of these exosomal EWS markers should provide a simple and cost effective “liquid biopsy” that would allow clinicians to diagnose and monitor tumor burden, detect tumor responsiveness to therapy, monitor changes within the tumor including determining drug sensitivity alterations, and thus enable clinicians to better manage patients with EWS. This abstract is also being presented as Poster A31. Citation Format: Glenson Samuel, Jennifer Crow, Safinur Atay, Andrew K. Godwin. Progress towards development of an exosome-based biomarker assay in Ewing sarcoma [abstract]. In: Proceedings of the AACR Conference on Advances in Sarcomas: From Basic Science to Clinical Translation; May 16-19, 2017; Philadelphia, PA. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(2_Suppl):Abstract nr PR04.

Should Clinicians Split or Lump Psychiatric Symptoms? The Structure of Psychopathology in Two Large Pediatric Clinical Samples from England and Norway

It has been suggested that the structure of psychiatric phenomena can be reduced to a few symptom dimensions. These proposals, mainly based on epidemiological samples, may not apply to clinical populations. We tested the structure of psychiatric symptoms across two pediatric clinical samples from England (N = 8434) and Norway (N = 5866). Confirmatory factor analyses of the parent-reported Strengths and Difficulties Questionnaire (SDQ) evaluated the relative fit of several models, including a first-order model, a second-order model with the widely-established broad symptom dimensions of internalizing-externalizing, and two bi-factor models capturing a general psychopathology factor. Predictive value of the SDQ subscales for psychiatric disorders was examined. A first-order five-factor solution better fit the data. The expected SDQ subscale(s) related best to the corresponding psychiatric diagnosis. In pediatric clinical samples, a granular approach to psychiatric symptoms where several dimensions are considered seems to fit the data better than models based on lumping symptoms into internalizing/externalizing dimensions.

The Influence of Comorbid Asthma on the Severity of Symptoms in Children With Attention-Deficit Hyperactivity Disorder

AP Borschuk, C Rodweller, CF Salorio. J Asthma. 2017;1:1–7 This study examined the association between asthma and attention-deficit/hyperactivity disorder (ADHD) symptoms in a clinical pediatric sample. Children with asthma and ADHD symptoms. Demographic and neuropsychological data for children with a billing diagnosis of ADHD were extracted from a clinical database. Families completed standard rating scales. Seventy-one patients with a comorbid asthma diagnosis were identified and matched by age to a group …

4.15 Explore-Exploit Decision Making: Differences in Information-Seeking Behavior in Pediatric Psychopathology

Impairments in decision making are often associated with various types of pediatric psychopathology. Such perturbations may impact one’s ability to resolve explore-exploit dilemmas, i.e., choosing to pursue a known reward (exploitation) versus a lesser-known option (exploration). The explore-exploit dilemma has begun to be mapped using both behavioral paradigms and neuroimaging data. However, exploratory decision-making strategies have not yet been studied in a clinical pediatric sample group using the present reward choice task. The present study aims to use an explore-exploit paradigm to examine group differences in information-seeking behavior.

Validity of a Computerized Cognitive Battery in Children and Adolescents with Neurological Diagnoses.

Little is known about the validity of computerized cognitive batteries, such as CNS Vital Signs (CNSVS), in pediatric patients. The purpose of this study was to examine convergent and divergent validity of the CNSVS in a clinical pediatric sample with neurological diagnoses. Participants included 123 pediatric patients assessed in a tertiary care setting as part of clinical care. CNSVS (Memory, Psychomotor Speed, Reaction Time, Complex Attention, and Cognitive Flexibility domains, and a Neurocognition Index) and paper-and-pencil neuropsychological measures assessing learning, memory, processing speed, reaction time, attention, and executive functioning were administered. Most correlations between CNSVS domain scores and neuropsychological measures assessing similar constructs were medium in strength. With the exception of stronger correlations between psychomotor speed tests, correlations between tests of similar constructs were not significantly higher than those between dissimilar constructs. These results provide support for validity of the CNSVS battery, but also caution that many abilities are inter-correlated.

Preliminary evidence for increased parasympathetic activity during social inclusion and exclusion in adolescents with functional abdominal pain

ObjectivePeer victimization (e.g. social exclusion) has been shown to be associated with physical health problems such as functional somatic complaints and especially symptoms of pain. To date, no study has investigated the mechanisms underlying this association in clinical pediatric samples. The aim of this study was to evaluate the parasympathetic activity during a social exclusion experience in adolescents with functional abdominal pain (FAP). MethodsTwenty adolecents with FAP and 21 matched healthy participants were compared regarding parameters of parasympathetic activation before, during, and after participating in the Cyberball-game, a well-established paradigm to induce social exclusion. ResultsAdolescents with FAP showed an increase in parasympathetic activation during both consecutive phases of the Cyberball game (inclusion as well as exclusion condition) whereas the healthy control group remained stable. There were no differences in subjective experience of in- and exclusion between the groups. ConclusionThe parasympathetic activation pattern may indicate altered processing of social stimuli in adolescents with FAP.

The influence of comorbid asthma on the severity of symptoms in children with attention-deficit hyperactivity disorder

ABSTRACTObjective: The current study examined the association between asthma and attention-deficit hyperactivity disorder (ADHD) symptoms in a clinical pediatric sample. Methods: Demographic and neuropsychological data for children with a billing diagnosis of ADHD were extracted from a clinical database. Families completed standard rating scales. Seventy-one patients with a co-morbid asthma diagnosis were identified and matched by age to a group of 71 patients with only ADHD. Results: Children with asthma and ADHD were more likely to display clinically elevated levels of hyperactivity, externalizing behaviors, anxiety, and hyperactive/impulsive behaviors compared to children with ADHD alone. Boys with asthma and ADHD had more symptoms than boys with only ADHD of somatization and emotional internalizing, while girls with asthma and ADHD had more symptoms of hyperactivity/impulsivity, conduct problems, anxiety, and emotional internalizing compared to girls with only ADHD. Conclusions: Findings suggest that in children with ADHD, co-morbid asthma is associated with increased behavioral and internalizing symptoms, with distinct gender differences present. Increased behavioral and internalizing symptoms seen in children with both asthma and ADHD may be due to the burden of their medical condition. No difference was found on cognitive variables, suggesting chronic hypoxia may be less influential in explaining these differences. Future research should determine the specific mechanisms of these differences.

Mindfulness-Based Interventions in Clinical Samples of Adolescents with Chronic Illness: A Systematic Review.

Mindfulness-based interventions (MBIs) have emerged as a promising strategy for individuals with a chronic illness, given their versatility in targeting both physical and mental health outcomes. However, research to date has focused on adult or community-based populations. To systematically review and critically appraise MBIs in clinical pediatric samples living with chronic physical illness. Electronic searches were conducted by a Library Information Specialist familiar with the field by using EMBASE, PsycINFO, MEDLINE, CINAHL, Web of Science, and EBM Reviews databases. Study Eligibility, Participants, and Interventions: Published English peer-reviewed articles of MBIs in clinical samples of children and adolescents (3-18 years) with chronic physical illness. Two reviewers independently selected articles for review and extracted data. Results are narratively described, and the reporting quality of each study was assessed via the STROBE Checklist. Of a total 4710 articles, 8 articles met inclusion criteria. All studies were small (n < 20, except 1 study of n = 59), included only outpatient adolescent samples, and focused on feasibility and acceptability of MBI; only 1 study included a comparison group (n = 1). No studies included online components or remote attendance. All studies found that MBI was acceptable to adolescents, whereas feasibility and implementation outcomes were mixed. Many studies were underpowered to detect significant differences post-MBI, but MBI did demonstrate improvements in emotional distress in several studies. Conclusions and Implications of Key Findings: The literature on MBIs is preliminary in nature, focusing on adapting and developing MBI for adolescents. Although MBIs appear to be a promising approach to coping with symptoms related to chronic illness in adolescents, future research with adequate sample sizes and rigorous research designs is warranted.

Questionnaire-based assessment of executive functioning: Psychometrics

ABSTRACTThe psychometric properties of the Learning, Executive, and Attention Functioning (LEAF) scale were investigated in an outpatient clinical pediatric sample. As a part of clinical testing, the LEAF scale, which broadly measures neuropsychological abilities related to executive functioning and learning, was administered to parents of 118 children and adolescents referred for psychological testing at a pediatric psychology clinic; 85 teachers also completed LEAF scales to assess reliability across different raters and settings. Scores on neuropsychological tests of executive functioning and academic achievement were abstracted from charts. Psychometric analyses of the LEAF scale demonstrated satisfactory internal consistency, parent-teacher inter-rater reliability in the small to large effect size range, and test–retest reliability in the large effect size range, similar to values for other executive functioning checklists. Correlations between corresponding subscales on the LEAF and other behavior checklists were large, while most correlations with neuropsychological tests of executive functioning and achievement were significant but in the small to medium range. Results support the utility of the LEAF as a reliable and valid questionnaire-based assessment of delays and disturbances in executive functioning and learning. Applications and advantages of the LEAF and other questionnaire measures of executive functioning in clinical neuropsychology settings are discussed.

Association between irritability and bias in attention orienting to threat in children and adolescents.

Irritability, a frequent complaint in children with psychiatric disorders, reflects increased predisposition to anger. Preliminary work in pediatric clinical samples links irritability to attention bias to threat, and the current study examines this association in a large population-based sample. We studied 1,872 children (ages 6-14) using the Development and Well-Being Assessment (DAWBA), Childhood Behavior Checklist (CBCL), and dot-probe tasks. Irritability was defined using CBCL items that assessed temper tantrums and hot temper. The dot-probe task assessed attention biases for threat-related (angry face) stimuli. Multiple regression analysis was used to assess specificity of associations to irritability when adjusting for demographic variables and co-occurring psychiatric traits. Propensity score matching analysis was used to increase causal inference when matching for demographic variables and co-occurring psychiatric traits. Irritability was associated with increased attention bias toward threat-related cues. Multiple regression analysis suggests associations between irritability and threat bias are independent from demographic variables, anxiety, and externalizing traits (attention-deficit/hyperactivity, conduct, and headstrong/hurtful), but not from broad internalizing symptoms. Propensity score matching analysis indicated that this association was found for irritable versus nonirritable groups matched on demographic and co-occurring traits including internalizing symptoms. Irritability in children is associated with biased attention toward threatening information. This finding, if replicated, warrants further investigation to examine the extent to which it contributes to chronic irritability and to explore possible treatment implications.

C-47Does Attention Negatively Impact Performance on the Test of Memory Malingering Among a Pediatric ADHD Clinical Sample?

C-47Does Attention Negatively Impact Performance on the Test of Memory Malingering Among a Pediatric ADHD Clinical Sample?

Association Between Widespread Pain Scores and Functional Impairment and Health-Related Quality of Life in Clinical Samples of Children.

Pain involving several body regions generally represents nervous system pathophysiology shifting from predominantly peripheral to more central. In adults, higher widespread pain scores are clinically meaningful and confer risk for poor response to treatment. It is unknown whether widespread pain is similarly important in children. To address this gap, we conducted an observational study examining 1) associations between widespread pain and functional impairment and health-related quality of life (HRQOL) in clinical pediatric samples, and 2) associations among sociodemographic factors and pain catastrophizing with widespread pain scores. Participants were 166 children aged 10 to 18years from 3 samples (acute pain, presurgery, chronic pain). Children self-reported pain intensity, pain catastrophizing, functional impairment, and HRQOL. Children indicated pain locations on a body diagram, which was coded using the American College of Rheumatology definition of widespread pain. Results revealed higher widespread pain scores were associated with greater functional impairment with routine activities (F=3.15, P=.02) and poorer HRQOL (F=3.29, P=.02), adjusting for pain intensity, study group, and demographic characteristics. Older age (B = .11, P=.02), and Hispanic ethnicity (B=.67, P=.04) were associated with higher widespread pain scores. Findings support incorporating evaluation of widespread pain into pediatric pain assessment. Future research is needed to examine the longitudinal effect of widespread pain on children's treatment outcomes. This article examines the association between widespread pain scores and functional impairment and HRQOL in community and clinical samples of children. Assessment of the spatial distribution of the pain experience provides unique information that may identify children at risk for poorer health.

Eating disorder examination: Factor structure and norms in a clinical female pediatric eating disorder sample.

The factor structure of the eating disorder examination (EDE) has never been tested in a clinical pediatric sample, and no normative data exist. The factor structure of an adapted EDE was examined in a clinical sample of 665 females aged 9-17 years with anorexia nervosa spectrum (70%), bulimia nervosa spectrum (12%), purging disorder (3%), and unspecified feeding and eating disorders (15%). The original four-factor model was a good fit in a confirmatory factor analysis as well a higher order model with three dimensions of restraint, eating concern, and combined weight concern/shape concern. Normative data are reported for clinicians to identify the percentiles in which their patients' score. The findings support dimensions of restraint, eating concern, weight concern, and shape concern in a clinical pediatric sample. This supports the factorial validity of the EDE, and the norms may assist clinicians to evaluate symptoms in females under 18 years.

A cultivation-independent PCR-RFLP assay targeting oprF gene for detection and identification of Pseudomonas spp. in samples from fibrocystic pediatric patients

Species-specific genetic markers are crucial to develop faithful and sensitive molecular methods for the detection and identification of Pseudomonas aeruginosa (Pa). We have previously set up a PCR-RFLP protocol targeting oprF, the gene encoding the genus-specific outer membrane porin F, whose strong conservation and marked sequence diversity allowed detection and differentiation of environmental isolates (Agaras et al., 2012). Here, we evaluated the ability of the PCR-RFLP assay to genotype clinical isolates previously identified as Pa by conventional microbiological methods within a collection of 62 presumptive Pa isolates from different pediatric clinical samples and different sections of the Hospital de Niños “Sor María Ludovica” from La Plata, Argentina. All isolates, but one, gave an oprF amplicon consistent with that from reference Pa strains. The sequence of the smaller-sized amplicon revealed that the isolate was in fact a mendocina Pseudomonas strain. The oprF RFLP pattern generated with TaqI or HaeIII nucleases matched those of reference Pa strains for 59 isolates (96%). The other two Pa isolates (4%) revealed a different RFLP pattern based on HaeIII digestion, although oprF sequencing confirmed that Pa identification was correct. We next tested the effectiveness of the PCR-RFLP to detect pseudomonads on clinical samples of pediatric fibrocystic patients directly without sample cultivation. The expected amplicon and its cognate RFLP profile were obtained for all samples in which Pa was previously detected by cultivation-dependent methods. Altogether, these results provide the basis for the application of the oprF PCR-RFLP protocol to directly detect and identify Pa and other non-Pa pseudomonads in fibrocystic clinical samples.

(500) The role of perceived injustice in chronic pain in a clinical pediatric sample

(500) The role of perceived injustice in chronic pain in a clinical pediatric sample

Rapid genotyping of human rotavirus using SYBR green real-time reverse transcription-polymerase chain reaction with melting curve analysis.

To develop a real-time reverse transcription-polymerase chain reaction (RT-PCR) assay to genotype rotavirus (G and P) in Alberta from January 2012 to June 2013. We developed and validated a different approach to perform rotavirus G and P genotyping using a two-step SYBR green RT-PCR (rt-gPCR) by selecting genotype-specific primers of published conventional RT nested PCR (cnRT-PCR) assay and optimizing the amplification conditions. cDNA was first synthesized from total RNA with SuperScript™ II reverse transcriptase kit followed by amplication step using monoplex SYBR green real-time PCR. After the PCR reaction, melting curve analysis was used to determine specific genotype. Sixteen samples previously genotyped using cnRT-PCR were tested using the new assay and the genotyping results were compared as sensitivity analysis. Assay specificity was evaluated by testing other gastroenteritis viruses with the new assay. The amplicon size of each available genotype was determined by gel-electrophoresis and DNA sequences were obtained using Sanger-sequencing method. After validation and optimization, the new assay was used to genotype 122 pediatric clinical stool samples previously tested positive for rotavirus using electron microscopy between January 2012 and June 2013. The new rt-gPCR assay was validated and optimized. The assay detected G1 to G4, G9, G12 and P[4] and P[8] that were available as positive controls in our laboratory. A single and clear peak of melting curve was generated for each of specific G and P genotypes with a Tm ranging from 80 °C to 82 °C. The sensitivity of rt-gPCR was comparable to cnRT-PCR with 100% correlation of the 16 samples with known G and P genotypes. No cross reaction was found with other gastroenteritis viruses. Using the new rt-gPCR assay, genotypes were obtained for 121 of the 122 pediatric clinical samples tested positive for rotavirus: G1P[8] (42.6%), G2P[4] (4.9%), G3P[8] (10.7%), G9P[8] (10.7%), G9P[4] (6.6%), G12P[8] (23.0%), and unknown GP[8] (0.8%). For the first time, G12 rotavirus strains were found in Alberta and G12 was the second most common genotype during the study period. Gel electrophoresis of all the genotypes showed expected amplicon size for each genotype. The sequence data of the two G12 samples along with other genotypes were blasted in NCBI BLAST or analyzed with Rota C Genotyping tool (http://rotac.regatools.be/). All genotyping results were confirmed to be correct. rt-gPCR is a useful tool for the genotyping and characterization of rotavirus. Monitoring of rotavirus genotypes is important for the identification of emerging strains and ongoing evaluation of rotavirus vaccination programs.

Parents' goals for ADHD care in a clinical pediatric sample.

This report describes goals parents have for their children with attention deficit/hyperactivity disorder (ADHD) when coming for a pediatric visit. Data were collected from 441 parents of children presenting to either a primary care pediatric practice or a developmental behavioral pediatric practice. Parents were asked to report their top 1 or 2 goals for improvement for their children, and responses were coded into 17 categories. These categories were further grouped into 7 goal composites and examined in relation to demographic characteristics of the families, office type, and symptomology. Goals related to reducing symptoms of inattention were most common, but goals were heterogeneous in nature. Goals were meaningfully, but modestly, related to symptomology. In several instances, symptoms of comorbid conditions interacted with symptoms of ADHD in relation to specific goals being reported. Parents' goals extended beyond ADHD symptoms. Pediatricians need an array of resources to address parents' goals.

Cognitive predictors of verbal memory in a mixed clinical pediatric sample.

Verbal memory problems, along with other cognitive difficulties, are common in children diagnosed with neurological and/or psychological disorders. Historically, these “memory problems” have been poorly characterized and often present with a heterogeneous pattern of performance across memory processes, even within a specific diagnostic group. The current study examined archival neuropsychological data from a large mixed clinical pediatric sample in order to understand whether functioning in other cognitive areas (i.e., verbal knowledge, attention, working memory, executive functioning) may explain some of the performance variability seen across verbal memory tasks of the Children’s Memory Scale (CMS). Multivariate analyses revealed that among the cognitive functions examined, only verbal knowledge explained a significant amount of variance in overall verbal memory performance. Further univariate analyses examining the component processes of verbal memory indicated that verbal knowledge is specifically related to encoding, but not the retention or retrieval stages. Future research is needed to replicate these findings in other clinical samples, to examine whether verbal knowledge predicts performance on other verbal memory tasks and to explore whether these findings also hold true for visual memory tasks. Successful replication of the current study findings would indicate that interventions targeting verbal encoding deficits should include efforts to improve verbal knowledge.

Parent–child concordance in reporting of child eating disorder pathology as assessed by the eating disorder examination

The aim of this study was to examine parent-youth concordance in reporting of eating disorder pathology, as assessed by the Eating Disorder Examination (EDE) in a clinical pediatric sample. The sample comprised 619 parent-youth dyads of youth (8-18 years) presenting for treatment at a specialist eating disorder clinic. A cross-sectional correlational design was used to examine the association between parent and youth symptom reports. On the whole, parent-youth inter-rater agreement was poor to moderate. Agreement was acceptable for the presence of behavioral symptoms, with the exception of excessive exercise (PAK = 0.48-0.98). There was poor inter-rater agreement on frequency of behavioral symptoms, with parents providing lower estimates than youth (ICC = 0.07-0.52). Although we predicted that inter-rater agreement on cognitive symptoms would by higher with adolescents than children, both groups were discordant with parent reports. Younger children identified less severe eating disorder cognitions than parents and the opposite occurred for adolescents. An anorexia nervosa presentation and lower malnutrition were not associated with lower inter-rater agreement, as might have been expected through ego syntonicity. Youth with bulimia nervosa presentations reported significantly higher severity of cognitive symptoms and more frequent disordered eating behaviors compared with their parents. Results support the utility of parent-youth assessment via the EDE to obtain a wider clinical picture of eating disorder psychopathology in children and adolescents, particularly for younger children. Clinical implications pertinent to administration of the EDE and parent literacy regarding eating disorder symptoms are discussed.