Parliamentary Debate: Kids being taken into care by medics who refuse to believe ME is real

Press Release: January 25, 2019, John Siddle, ME Association (UK).

Children with the devastating illness ME face the threat of being taken into care because medics refuse to accept their disease is real, parliament was today told.

ME – myalgic encephalomyelitis – is a cruel disease affecting a quarter of a million people in the UK who are being “failed” in a “national disgrace”.

While classed as a neurological disease, the stigmatised condition is still considered wrongly by some health professionals to be psychological. It means that often patients struggle to get the support they so desperately need.

ME manifests as activity-induced muscle fatigue, post-exertional malaise, problems with cognitive function, widespread muscle pain, unrefreshing sleep and ongoing flu-like symptoms.

In the debate today – the first in 20 years on ME – the House of Commons was told how one in five children with the disease are being threatened with the prospect of being forced into care.

MP Carol Monaghan, who brought today’s motion, led calls for more funding for research and better medical training to help support patients.

She said: “There is currently no cure for ME and many with the condition experience inadequate care and support.

“But there are an estimated quarter of a million people in the UK suffering from ME, and currently we are letting these people down.

“The cause of the disease is unknown, but many patients report that it developed after a viral infection such as flu or glandular fever.

“Many adults cannot maintain employment or relationships with family and friends, while children frequently fall behind in school. The ignorance surrounding the condition makes it harder to access benefits with DWP assessors often deciding the sufferer is fit for work.”

Several quality of life research studies have shown that the level of disability in ME can be just as great than many other serious medical conditions, including cancer and multiple sclerosis.

While some people with ME do improve over the course of time, it is only a small minority that return to full normal health. And the disease is indiscriminate, affecting both sexes, all ages and all races.

Mrs Monaghan, (SNP, Glasgow North West) added:

“Some with severe ME spend their days in darkened rooms, unable even to watch TV or listen to music.  Even touch is intolerable. Many are tube fed. For these individuals, ME is a life sentence, but a life spent existing, not living.

“This condition is largely unknown because those affected are often hidden away. I commend the ME community for lobbying so successfully to ensure so many members are here today.

“Leading up to this debate, I have been asked repeatedly what I hope to achieve. Ultimately what I want, and what the ME community wants, is better treatment and care for those with ME.”

Child protection proceedings

The debate was told how one in five families caring for a child with the devastating disease ME have been referred for child protection proceedings.

The Commons told how an eight-year-old – Girl B – was almost taken from her family by social services after medics said her condition was psychological.

Mrs Monaghan continued: “B’s parents were warned that if they did not fully comply, child protection proceeding would be initiated. Social services specified graded exercise, despite being warned of the dangers. As a result, B deteriorated rapidly until she became wheelchair bound. “

Under threat of court action, the girl’s parents were then forced to take her to a children’s hospital and threatened with the prospect of their daughter being taken into foster care.

Mrs Monaghan continued: “B was in constant pain, unable to sit upright, with her head hanging down the side, crying in distress.

“This continued for five months and her parents were threatened that if B didn’t progress, she’d be transferred to a psychiatric unit or placed in foster care.”

It was only when the girl’s parents sought the intervention of the secretary of state, that the girl was allowed home and removed from the ‘at risk’ register.

Suspension of controversial therapies

Ms Monaghan, who also called for the suspension of controversial Graded Exercise Therapy and Cognitive Behaviour Therapy as recommended treatment programmes, added: “A firm diagnosis of ME protects the child from these proceedings but unfortunately paediatricians are often reluctant to give this – simply because they do not understand the condition – which leaves the child open to social service intervention.

“This is a national disgrace and needs urgent action. Children who are already blighted by ME must not be subjected to this trauma.”

Improving medical education

Steve Brine, parliamentary under-secretary for health, responded to the debate, saying that, “The Government do not for one-minute underestimate ME.”

“We know that the condition has a devastating impact,” adding, “we cannot for one minute begin to understand what it must be like to suffer from this condition.”

Mr Brine said nobody with ME should ever “be fobbed off by the medical profession.” He said that before the debate he had spoken with the chair of the Royal College of GPs – Prof. Helen Stokes-Lampard – and will organise a future discussion on improving medical education and awareness.

“The NICE guidance is clear on a number of important points. There is no one form of treatment to suit every patient; that is self-evident. The needs and preferences of patients should absolutely be taken into account. Doctors should explain that no single strategy will be successful for all patients, which is a hallmark of this condition.

“In common with people receiving any NHS care, ME patients have the absolute right to refuse or withdraw from any part of their treatment; nobody is making this happen. Those with severe symptoms may require access to a wider range of support, managed by a specialist.”

Research funding

On the subject of research funding for ME, Mr Brine said that it wasn’t the Governments responsibility to allocate specific funding, and that the problem lay with the quality of research applications.

He said, “The truth is – sometimes it is a hard and inconvenient truth to hear—there have not been good enough research proposals in the ME space, partly because of the stigma and partly because of the division in the medical community. We need people to come forward with good research proposals in this space; that can only be advantageous.”

In closing, Mrs Monaghan replied that, “On the question of medical research, I am sure that many researchers will have heard what he said. However, it is notable that although there is some excellent biomedical research going on just now, it is being funded by charities, and not by the Government. The Government need to take this seriously.”

The ME Association

The ME Association is at the forefront of improving access to care, treatment and research and removing the disease’s stigma.

Despite being recognised by the World Health Organisation as a neurological disease, and a report from the Chief Medical Officer of Health calling for more research and a network of hospital-based clinics, many doctors still don’t know how to diagnose and manage ME/CFS and lack or research means that we still don’t have any effective forms of treatment.

Dr Charles Shepherd, the charity’s medical adviser, added: “There are major problems with both undergraduate and postgraduate medical education on ME.

“Undergraduate education on ME is inadequate, or even non-existent, in many medical schools.  So, doctors are qualifying knowing little or nothing about the diagnosis or management of ME and without ever seeing a patient with ME. This is particularly so in medical schools where there is nobody carrying out research, or a clinician seeing patients with ME.

“Continuing lack of medical education means that many doctors in primary care/general practice are then unsure about how to make a diagnosis (leading to a late or misdiagnosis) and/or being unable to provide guidance on even basic aspects of management.

“This is a completely unacceptable situation for a disease that is twice as common as multiple sclerosis and where a new report has estimated that is costing the UK economy around £3.5 billion in lost taxes, healthcare and benefit costs.”

The motion was passed unanimously:

“That this House calls on the Government to provide increased funding for biomedical research into the diagnosis and treatment of ME, supports the suspension of Graded Exercise Therapy and Cognitive Behaviour Therapy as means of treatment, supports updated training of GPs and medical professionals to ensure they are equipped with clear guidance on diagnosis of ME and appropriate management advice to reflect international consensus on best practice, and is concerned about the current trends of subjecting ME families to unjustified child protection procedures.”


Comment on the Debate

Dr Charles Shepherd, Hon. Medical Adviser, ME Association

“Overall, I thought it was an excellent debate and although the House of Commons chamber looked rather empty at times, it is quite an achievement to get around 40 MPs to attend a backbench chamber debate for 90 minutes at the end of Thursday afternoon – when most are heading home to their constituencies.

“Carol Monaghan made an excellent opening speech which was followed by shorter speeches from over 20 MPs.

“MPs from all political parties made very similar points covering all the key concerns that have been put to them by the Forward ME Group in our briefing document – lack of medical education, need for biomedical research, NICE recommendations on CBT and GET, the PACE trial etc.

“Most MPs also referred to personal issues that had been raised by their constituents – some of which very clearly illustrated the need for an urgent change of attitude by some sections of the medical profession.

“A number of MPs made very thoughtful contributions (e.g. Nicky Morgan, Ben Lake, David Drew, Dr Phillipa Whitford) and others spoke with real passion (e.g. Stephen Pound).

“And while ministerial responses tend to be disappointing when it comes to actual action, I think that Steve Brine, Minister for Health, had clearly got the message about education, lack of biomedical research, bad management etc and that he will be talking to his advisers and colleagues about the points that were being made.

“One specific ministerial action, which is clearly going to happen, is a meeting with the President of the Royal College of General Practitioners to discuss GP education – which can obviously follow up the work that the Forward Group have been doing with the RCGP.

“So, a big thank you to Carol for securing this debate; thanks to all the MPs who turned up and spoke, and thanks to everyone who wrote to their MP to ask them to attend.

List of MPs who took part in the debate – in order of speaking:

1.      Carol Monaghan – SNP – Glasgow NW 2.      Ben Lake – Plaid Cymru – Ceredigion
3.      Sir David Amess – Con – Basildon 4.      Liz Twist – Lab – Blaydon
5.      Adrian Bailey – Lab – West Bromwich 6.      Nick Symonds – Lab – Torteen (Wales)
7.      Nicky Morgan – Con – Loughborough 8.      Liz McInnes – Lab – Haywd & Middleton
9.      Kevin Foster – Con – Torbay 10.   Patricia Gibson – SNP – Ayrshire & Arran
11.   Emma Lewell-Buck – Lab – South Shields 12.   Darren Jones – Lab – Bristol North West
13.   David Drew – Lab – Stroud 14.   Mohammed Yasin – Lab – Bedford
15.   Stephen Kerr – Con – Stirling 16.   Jim Shannon – DUP – Strangford
17.   Kelvin Hopkins – Ind – Luton North 18.   Dr Phillipa Whitford – SNP Health
19.   Stephen Pound – Lab – Ealing North 20.   Sharon Hodgson – Shadow Health
21.   Karen Lee – Lab – Lincoln 22.   Steve Brine – Health Minister
23.   Carol Monaghan – Concluding remarks

A number of other MPs – Justine Greening, Con, Putney, Julian Lewis, Con, New Forest East, Paula Sherrif, Lab, Dewsbury – made interventions. NB:  There were other MPs in the chamber for all or part of the debate but did not take part. See Hansard Volume 653.

Defining the minimally clinically important difference of the SF-36 physical function subscale for paediatric CFS/ME: triangulation using three different methods

Abstract:

BACKGROUND: Defining the minimally clinically important difference (MCID) is important for the design and analysis of clinical trials and ensures that findings are clinically meaningful. Studies in adult populations have investigated the MCID of The Short Form 36 physical function sub-scale (SF-36-PFS). However, to our knowledge no studies have defined the MCID of the SF-36-PFS in a paediatric population. We aimed to triangulate findings from distribution, anchor and qualitative methods to identify the MCID of the SF-36-PFS for children and adolescents with CFS/ME.

METHODS: Quantitative methods: We analysed routinely-collected data from a specialist paediatric CFS/ME service in South-West England using: 1) the anchor method, based on Clinical Global Impression (CGI) outcomes at 6 months’ follow-up; 2) the distribution method, based on the standard deviation of baseline SF-36-PFS scores. Qualitative methods: Young people (aged 12-17 years) and parents were asked to complete the SF-36-PFS, marking each question twice: once for where they would currently rate themselves/their child and a second time to show what they felt would be the smallest amount of change for them/their child to feel treatment had made a difference. Semi-structured interviews were designed to explore what factors were deemed important to patients and to what extent an improvement was considered satisfactory. We thematically analysed qualitative interviews from 21 children and their parents.

RESULTS: Quantitative results: Six-month follow-up data were available for 198 children with a mean age of 14 years. Most were female (74%, 146/198) and 95% gave their ethnicity as “White British”. Half the standard deviation of the baseline SF-36-PFS scores was 11.0. “A little better” on the CGI equated to a mean difference on the SF-36-PFS from baseline to 6-month follow-up of 9.0. Qualitative results: Twenty-one children with CFS/ME participated: 16 females (76.2%) with a mean age of 14.4 years. Twenty mothers and two fathers were also interviewed. The median minimal improvement in the SF-36-PFS was 10. Participants indicated that small changes in physical function can lead to important improvements in valued social and family function. Patients and parents were positive about improvement even in the presence of persisting symptoms. Triangulation: The MCID based on the mean score from the three methods was 10.

CONCLUSIONS: Converging evidence indicates future studies in paediatric CFS/ME should use an MCID of 10 on the SF-36-PFS.

Source: Brigden A, Parslow RM, Gaunt D, Collin SM, Jones A, Crawley E. Defining the minimally clinically important difference of the SF-36 physical function subscale for paediatric CFS/ME: triangulation using three different methods. Health Qual Life Outcomes. 2018 Oct 19;16(1):202. doi: 10.1186/s12955-018-1028-2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194701/ (Full article)

Pediatric chronic fatigue syndrome: current perspectives

Abstract:

Pediatric chronic fatigue syndrome is an important illness as it is relatively common and also very disabling with a wide range of impacts on the child, the family, and health care systems. It is a complicated illness but the majority of children get better with specialist treatment. This literature review provides an update on the epidemiology of chronic fatigue syndrome/myalgic encephalomyelitis, including factors associated with it, and discusses the current evidence for treatment.

Source: Esther Crawley. Pediatric chronic fatigue syndrome: current perspectives. Dove Press. 29 March 2018 Volume 2018:9 Pages 27—33 https://www.dovepress.com/pediatric-chronic-fatigue-syndrome-current-perspectives-peer-reviewed-article-PHMT (You can download a PDF file of the full article.)

Investigating the effectiveness and cost-effectiveness of FITNET-NHS (Fatigue In Teenagers on the interNET in the NHS) compared to Activity Management to treat paediatric chronic fatigue syndrome (CFS)/myalgic encephalomyelitis (ME): protocol for a randomised controlled trial

Abstract:

BACKGROUND: Paediatric chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) is a relatively common and disabling condition. The National Institute for Health and Clinical Excellence (NICE) recommends Cognitive Behavioural Therapy (CBT) as a treatment option for paediatric CFS/ME because there is good evidence that it is effective. Despite this, most young people in the UK are unable to access local specialist CBT for CFS/ME. A randomised controlled trial (RCT) showed FITNET was effective in the Netherlands but we do not know if it is effective in the National Health Service (NHS) or if it is cost-effective. This trial will investigate whether FITNET-NHS is clinically effective and cost-effective in the NHS.

METHODS: Seven hundred and thirty-four paediatric patients (aged 11-17 years) with CFS/ ME will be randomised (1:1) to receive either FITNET-NHS (online CBT) or Activity Management (delivered via video call). The internal pilot study will use integrated qualitative methods to examine the feasibility of recruitment and the acceptability of treatment. The full trial will assess whether FITNET-NHS is clinically effective and cost-effective. The primary outcome is disability at 6 months, measured using the SF-36-PFS (Physical Function Scale) questionnaire. Cost-effectiveness is measured via cost-utility analysis from an NHS perspective. Secondary subgroup analysis will investigate the effectiveness of FITNET-NHS in those with co-morbid mood disorders.

DISCUSSION: If FITNET-NHS is found to be feasible and acceptable (internal pilot) and effective and cost-effective (full trial), its provision by the NHS has the potential to deliver substantial health gains for the large number of young people suffering from CFS/ME but unable to access treatment because there is no local specialist service. This trial will provide further evidence evaluating the delivery of online CBT to young people with chronic conditions.

TRIAL REGISTRATION: ISRCTN registry, registration number: ISRCTN18020851 . Registered on 4 August 2016.

Source: Baos S, Brigden A, Anderson E, Hollingworth W, Price S, Mills N, Beasant L, Gaunt D, Garfield K, Metcalfe C, Parslow R, Downing H, Kessler D, Macleod J, Stallard P, Knoop H, Van de Putte E, Nijhof  S, Bleijenberg G, Crawley E. Investigating the effectiveness and cost-effectiveness of FITNET-NHS (Fatigue In Teenagers on the interNET in the NHS) compared to Activity Management to treat paediatric chronic fatigue syndrome (CFS)/myalgic encephalomyelitis (ME): protocol for a randomised controlled trial. Trials. 2018 Feb 22;19(1):136. doi: 10.1186/s13063-018-2500-3. https://www.ncbi.nlm.nih.gov/pubmed/29471861

Note: Update published December 19, 2019. https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-019-3895-1

Cognition In Young People With ME/CFS

By Dr R. Vallings

One of the main reasons that young people with ME/CFS struggle with school is associated with cognition. Mental confusion, memory problems and difficulties with concentration are all described and may relate to abnormal neurological pathology, sluggish cerebral circulation and generalised fatigue.

Cognitive effort leads to fatigue in the same way that exercise will lead to muscle fatigue and post-exertional malaise. Headaches are frequently a prominent and persistent symptom, and they too will interfere with the student’s cognitive ability. There can be aggravation of symptoms associated with trying to focus and learn from a computer screen. Many will describe visual symptoms with blurring of text or eye fatigue.

A noisy classroom situation may not be conducive to mental effort, and students are often moving from room to room carrying heavy books, this all adding to the burden which the illness poses.

The young person may have problems with sleep, waking feeling unrefreshed, and again cognitive effort may thus be limited. He/she may arrive at school feeling already exhausted due to lack of restorative sleep and having to get up early, and then issues such as travelling, and the anxiety associated with what may lie ahead that day.

Too much exercise, standing for long periods, heat and poor nutrition can all compromise cognition. The student will be motivated to keep up with peers, and push him/herself mentally, physically and socially beyond the comfort zone, and suffer the consequences cognitively.

The teacher may have minimal understanding of the illness and its sequelae, and even the efforts of parents to explain can be brushed aside as “fussiness”. Attention span may be very short and the labels of laziness, attention deficit or learning disorders can be appended inappropriately.

Those with ME/CFS are usually highly motivated to achieve and will be disappointed by failures and lack of encouragement. Ridicule is often reported.

Parents and medical personnel need to communicate with the teachers to enhance their understanding of ME/CFS. To ensure that the student has the best possible opportunities to achieve appropriate education and a feeling of success. This will mean allowing the student to work at their own pace with adequate rest periods.

Management of the Cognitive Difficulties by the Primary Care Physician

Once a firm diagnosis has been made, the young person will feel relieved that there is an explanation for their problems, particularly those experienced by attempts to participate in regular schooling.

Parents need to be involved in this discussion, which should be addressed principally to the patient, so that he/she is also involved in decision making, and feels part of the team approach. Only the young person knows how they feel, and should be encouraged to verbalise their fears and needs. Teenagers will often need opportunity for discussion without a parent present.

Many young people fear getting behind their peers academically. There is a fear of never being able to catch up and consequently losing friends who move on. There needs to be encouragement to participate in ongoing education, however minimally, but without undue pressure.

This may mean limited attendance at school, or if available, correspondence education or home-schooling. The student can then work at their own pace. They should be encouraged to work for short periods with adequate rest periods, recognising when they are ready to rest. Some sort of structure for the days is helpful.

This may be difficult, if at home with parents needing to work. Particular difficulties need to be discussed, such as aggravation from computer screens, and difficulty focusing on written text (sometimes a ruler placed across the page can help with maintaining focus). Aggravating factors such as noise, bright lights, temperature and unpleasant odours may need to be adjusted. Snacks and drinks need to be available and allowed.

If well enough, some gentle outdoor exercise during breaks between cognitive effort should be suggested, and for younger children playing with siblings or friends after school or at weekends should be encouraged.

Focus on symptom control is important, and this may be achieved with attention to sleep difficulties and efficient pain management. Learning good relaxation strategies with the use of music, visualisation, and teaching self hypnosis all have a role. Having their own private space means that these things are more likely to be done, and rest will be undisturbed. Regular snacking with plenty of salt can help overcome symptoms associated with orthostatic intolerance.

Medication such as very low-dose tricyclics or melatonin to help with sleep may be useful. Some young people benefit from use of stimulants such as methylphenidate, but there is a risk of a false sense of wellbeing, leading to overdoing things. If the child is depressed or unduly anxious, this should be addressed and there should be opportunity to talk things through privately with a trusted professional, who has understanding of this illness.

The young person needs to understand the issues that can aggravate cognition, such as overdoing things mentally and physically, learning m to pace carefully, and avoiding situations which have proved detrimental. Planning time carefully and incorporating rewards can all help to ensure a better outcome.

Attention to achieving a regular body clock will mean that a good routine that fits in with family and school is possible. Standing for long periods, getting overheated or dehydrated and not eating adequately should all be avoided.

Above all there needs to be a sense of achievement, (however small), progress and normality if at all possible. Only the young person him/herself know how they really feel, and gaining a sense of control over this illness, rather than letting the illness control them entirely will achieve a growing sense of personal achievement and freedom from stress.

Reprinted with permission from Meeting Place – Autumn 2016 – Number 123: The official quarterly journal of ANZEMS Inc.

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Diagnosis and Management in Young People: A Primer

Abstract:

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex disease that affects children and adolescents as well as adults. The etiology has not been established. While many pediatricians and other health-care providers are aware of ME/CFS, they often lack essential knowledge that is necessary for diagnosis and treatment. Many young patients experience symptoms for years before receiving a diagnosis.

This primer, written by the International Writing Group for Pediatric ME/CFS, provides information necessary to understand, diagnose, and manage the symptoms of ME/CFS in children and adolescents. ME/CFS is characterized by overwhelming fatigue with a substantial loss of physical and mental stamina. Cardinal features are malaise and a worsening of symptoms following minimal physical or mental exertion. These post-exertional symptoms can persist for hours, days, or weeks and are not relieved by rest or sleep.

Other symptoms include cognitive problems, unrefreshing or disturbed sleep, generalized or localized pain, lightheadedness, and additional symptoms in multiple organ systems. While some young patients can attend school, on a full or part-time basis, many others are wheelchair dependent, housebound, or bedbound.

Prevalence estimates for pediatric ME/CFS vary from 0.1 to 0.5%. Because there is no diagnostic test for ME/CFS, diagnosis is purely clinical, based on the history and the exclusion of other fatiguing illnesses by physical examination and medical testing. Co-existing medical conditions including orthostatic intolerance (OI) are common.

Successful management is based on determining the optimum balance of rest and activity to help prevent post-exertional symptom worsening. Medications are helpful to treat pain, insomnia, OI and other symptoms. The published literature on ME/CFS and specifically that describing the diagnosis and management of pediatric ME/CFS is very limited. Where published studies are lacking, recommendations are based on the clinical observations and practices of the authors.

Source: Rowe PC, Underhill RA, Friedman KJ, Gurwitt A, Medow MS, Schwartz MS, Speight N, Stewart JM, Vallings R, Rowe KS. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Diagnosis and Management in Young People: A Primer. Front Pediatr. 2017 Jun 19;5:121. doi: 10.3389/fped.2017.00121. eCollection 2017. http://journal.frontiersin.org/article/10.3389/fped.2017.00121/full

Children’s experiences of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME): a systematic review and meta-ethnography of qualitative studies

Abstract:

OBJECTIVE: To synthesis the qualitative studies of children’s experiences of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME).

DESIGN: Systematic review and meta-ethnography.

BACKGROUND: CFS/ME is an important disabling illness, with uncertain cause and prognosis. As a result, children with CFS/ME can find themselves living with greater uncertainty and stigma, exacerbating the impact of the condition. There is a growing body of qualitative research in CFS/ME, yet there has been no attempt to systematically synthesis the studies involving children.

METHODS: Studies exploring the experiences of children diagnosed with CFS/ME, published or unpublished, using qualitative methods were eligible. MEDLINE, EMBASE, PsycINFO and CINAHL databases were searched as well as grey literature, reference lists and contacting authors. Quality assessment was done independently using the Critical Appraisal Skills Programme (CASP) checklist. Studies were synthesised using techniques of meta-ethnography.

RESULTS: Ten studies involving 82 children with CFS/ME aged 8-18 were included. Our synthesis describes four third-order constructs within children’s experiences: (1) disruption and loss: physical, social and the self; (2) barriers to coping: suspension in uncertainty, problems with diagnosis and disbelief; (3) facilitators to coping: reducing uncertainty, credible illness narratives, diagnosis and supportive relationships and (4) hope, personal growth and recovery. CFS/ME introduces profound biographical disruption through its effects on children’s ability to socialise, perform school and therefore how they see their future. Unfamiliarity of the condition, problems with diagnosis and felt stigma prevent children from forming a new illness identity. Children adopt coping strategies such as building credible explanations for their illness.

CONCLUSIONS: Physical, social, emotional and self-dimensions of life should be included when treating and measuring outcomes from healthcare in paediatric CFS/ME. There is a need for greater recognition and diagnosis of childhood CFS/ME, specialist advice on activity management and improved communication between health and education providers to help children cope with their condition.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

 

Source: Parslow RM, Harris S, Broughton J, Alattas A, Crawley E, Haywood K, Shaw A. Children’s experiences of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME): a systematic review and meta-ethnography of qualitative studies. BMJ Open. 2017 Jan 13;7(1):e012633. doi: 10.1136/bmjopen-2016-012633. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5253584/ (Full article)

 

Low putamen activity associated with poor reward sensitivity in childhood chronic fatigue syndrome

Abstract:

Motivational signals influence a wide variety of cognitive processes and components of behavioral performance. Cognitive dysfunction in patients with childhood chronic fatigue syndrome (CCFS) may be closely associated with a low motivation to learn induced by impaired neural reward processing. However, the extent to which reward processing is impaired in CCFS patients is unclear.

The aim of the present functional magnetic resonance imaging (fMRI) study was to determine whether brain activity in regions related to reward sensitivity is impaired in CCFS patients. fMRI data were collected from 13 CCFS patients (mean age, 13.6 ± 1.0 years) and 13 healthy children and adolescents (HCA) (mean age, 13.7 ± 1.3 years) performing a monetary reward task. Neural activity in high- and low-monetary-reward conditions was compared between CCFS and HCA groups. Severity of fatigue and the reward obtained from learning in daily life were evaluated by questionnaires.

Activity of the putamen was lower in the CCFS group than in the HCA group in the low-reward condition, but not in the high-reward condition. Activity of the putamen in the low-reward condition in CCFS patients was negatively and positively correlated with severity of fatigue and the reward from learning in daily life, respectively.

We previously revealed that motivation to learn was correlated with striatal activity, particularly the neural activity in the putamen. This suggests that in CCFS patients low putamen activity, associated with altered dopaminergic function, decreases reward sensitivity and lowers motivation to learn.

 

Source: Mizuno K, Kawatani J, Tajima K, Sasaki AT, Yoneda T, Komi M, Hirai T, Tomoda A, Joudoi T, Watanabe Y. Low putamen activity associated with poor reward sensitivity in childhood chronic fatigue syndrome. Neuroimage Clin. 2016 Sep 26;12:600-606. eCollection 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5043413/ (Full article)

 

Comorbidities treated in primary care in children with chronic fatigue syndrome / myalgic encephalomyelitis: A nationwide registry linkage study from Norway

Abstract:

BACKGROUND: Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a complex condition. Causal factors are not established, although underlying psychological or immunological susceptibility has been proposed. We studied primary care diagnoses for children with CFS/ME, with children with another hospital diagnosis (type 1 diabetes mellitus [T1DM]) and the general child population as comparison groups.

METHODS: All Norwegian children born 1992-2012 constituted the study sample. Children with CFS/ME (n = 1670) or T1DM (n = 4937) were identified in the Norwegian Patient Register (NPR) (2008-2014). Children without either diagnosis constituted the general child population comparison group (n = 1337508). We obtained information on primary care diagnoses from the Norwegian Directorate of Health. For each primary care diagnosis, the proportion and 99 % confidence interval (CI) within the three groups was calculated, adjusted for sex and age by direct standardization.

RESULTS: Children with CFS/ME were more often registered with a primary care diagnosis of weakness/general tiredness (89.9 % [99 % CI 88.0 to 91.8 %]) than children in either comparison group (T1DM: 14.5 % [99 % CI: 13.1 to 16.0 %], general child population: 11.1 % [99 % CI: 11.0 to 11.2 %]). Also, depressive disorder and anxiety disorder were more common in the CFS/ME group, as were migraine, muscle pain, and infections. In the 2 year period prior to the diagnoses, infectious mononucleosis was registered for 11.1 % (99 % CI 9.1 to 13.1 %) of children with CFS/ME and for 0.5 % (99 % CI (0.2 to 0.8 %) of children with T1DM. Of children with CFS/ME, 74.6 % (1292/1670) were registered with a prior primary care diagnosis of weakness / general tiredness. The time span from the first primary care diagnosis of weakness / general tiredness to the specialist health care diagnosis of CFS/ME was 1 year or longer for 47.8 %.

CONCLUSIONS: This large nationwide registry linkage study confirms that the clinical picture in CFS/ME is complex. Children with CFS/ME were frequently diagnosed with infections, supporting the hypothesis that infections may be involved in the causal pathway. The long time span often observed from the first diagnosis of weakness / general tiredness to the diagnosis of CFS/ME might indicate that the treatment of these patients is sometimes not optimal.

 

Source: Bakken IJ, Tveito K, Aaberg KM, Ghaderi S, Gunnes N, Trogstad L, Magnus P, Stoltenberg C, Håberg SE. Comorbidities treated in primary care in children with chronic fatigue syndrome / myalgic encephalomyelitis: A nationwide registry linkage study from Norway. BMC Fam Pract. 2016 Sep 2;17(1):128. doi: 10.1186/s12875-016-0527-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5010760/ (Full article)

 

Less efficient and costly processes of frontal cortex in childhood chronic fatigue syndrome

Abstract:

The ability to divide one’s attention deteriorates in patients with childhood chronic fatigue syndrome (CCFS). We conducted a study using a dual verbal task to assess allocation of attentional resources to two simultaneous activities (picking out vowels and reading for story comprehension) and functional magnetic resonance imaging.

Patients exhibited a much larger area of activation, recruiting additional frontal areas. The right middle frontal gyrus (MFG), which is included in the dorsolateral prefrontal cortex, of CCFS patients was specifically activated in both the single and dual tasks; this activation level was positively correlated with motivation scores for the tasks and accuracy of story comprehension.

In addition, in patients, the dorsal anterior cingulate gyrus (dACC) and left MFG were activated only in the dual task, and activation levels of the dACC and left MFG were positively associated with the motivation and fatigue scores, respectively.

Patients with CCFS exhibited a wider area of activated frontal regions related to attentional resources in order to increase their poorer task performance with massive mental effort. This is likely to be less efficient and costly in terms of energy requirements. It seems to be related to the pathophysiology of patients with CCFS and to cause a vicious cycle of further increases in fatigue.

 

Source: Mizuno K, Tanaka M, Tanabe HC, Joudoi T, Kawatani J, Shigihara Y, Tomoda A, Miike T, Imai-Matsumura K, Sadato N, Watanabe Y. Less efficient and costly processes of frontal cortex in childhood chronic fatigue syndrome. Neuroimage Clin. 2015 Sep 10;9:355-68. doi: 10.1016/j.nicl.2015.09.001. ECollection 2015. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4589845/ (Full article)