Low prevalence of behavioural and emotional problems among Swiss paediatric patients with inflammatory bowel disease
- Denise Herzog1,
- Markus A Landolt2,3,
- Patrick Buehr4,
- Klaas Heyland4,
- Daniela Rogler4,
- Rebekka Koller4,
- Vanessa Rueger4,
- Valérie Pittet5,
- Andreas Nydegger6,
- Johannes Spalinger7,
- Michela Schäppi8,
- Susanne Schibli9,
- Christian P Braegger3,4,
- and the Swiss IBD Cohort Study Group
- 1Division of Paediatric Gastroenterology, Canton Hospital of Fribourg, Fribourg, Switzerland
- 2Department of Psychosomatics and Psychiatry, University Children's Hospital Zurich, Zurich, Switzerland
- 3Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
- 4Division of Gastroenterology and Nutrition, University Children's Hospital Zurich, Zurich, Switzerland
- 5Institute of Social and Preventive Medicine, University Hospital of Lausanne, Lausanne, Switzerland
- 6Division of Gastroenterology, University Children's Hospital of Lausanne, Lausanne Switzerland
- 7Division of Gastroenterology, Children's Hospital of Lucerne, Lucerne, Switzerland
- 8Division of Gastroenterology, University Children's Hospital of Geneva, Geneva, Switzerland
- 9Division of Gastroenterology, University Children's Hospital of Bern, Bern, Switzerland
- Correspondence to Dr Christian P Braegger, Division of Gastroenterology and Nutrition, University Children's Hospital, Steinwiesstrasse 75, Zurich CH-8032, Switzerland;
- Received 6 July 2012
- Revised 20 September 2012
- Accepted 24 September 2012
- Published Online First 19 October 2012
Objectives Whether behavioural and emotional maladjustment is more prevalent in children with inflammatory bowel disease (IBD) than in healthy controls remains controversial. The aim of this study was to assess paediatric IBD patients for problems with emotional and behavioural adjustment and to examine associations with clinical and demographic variables.
Methods Data from paediatric patients with IBD enrolled in the Swiss IBD Cohort Study and the results of both the parent-rated Strengths and Difficulties Questionnaire (SDQ) and the self-reported Child Depression Inventory (CDI) were analysed. Of the 148 registered patients, 126 had at least one questionnaire completed and were included.
Results The mean age of 71 patients with Crohn's disease (44 males, 27 females) was 13.4 years, and 12.8 years for the 55 patients with ulcerative or indeterminate colitis. The mean duration of disease was 1.2 and 2.7 years, respectively. The total score of the SDQ was abnormal in 11.4% of cases compared to 10% in the normal population. Abnormal sub-scores were found in 20.2% of subjects for the domain of emotional problems and in 17.1% for problems with peers. The total CDI T score indicated a significantly lower prevalence of clinical depression in IBD patients than in normal youth. No correlation between the total SDQ scores or the CDI T scores and gender, type or duration of IBD, inflammatory markers or disease scores was found.
Conclusions The prevalence of problems with behavioural and emotional adjustment among Swiss paediatric IBD patients is low and comparable to that of the normal population.
What is already known on this topic
Children and adolescents with inflammatory bowel disease are at risk for emotional and behavioural maladjustment and the development of psychiatric disorders.
Studies of the prevalence of psychosocial maladjustment and the development of psychiatric disorders have reported conflicting results.
What this study adds
The prevalence of emotional and behavioural maladjustment in Swiss children with inactive or mild inflammatory bowel disease (IBD) is not higher than in healthy youth.
The prevalence of clinical depression is significantly lower in IBD patients than in healthy youth.
Parents and patients dispute the prevalence of emotional problems, so both should provide information.
Paediatric patients with inflammatory bowel disease (IBD) often have self- and parent-reported emotional and behavioural difficulties.1–13 A recent meta-analysis of the results of research on the psychosocial consequences of this disorder concluded that the rates of maladjustment were higher in IBD patients than in healthy controls.11
To date, no such data are available in Switzerland. We hypothesised that disturbances of psychosocial adjustment would occur more frequently in paediatric IBD patients than in healthy youth. The aims of this study were, first, to determine the rates of behavioural and emotional problems and, second, to examine IBD-related determinants.
Sample and questionnaires
Data of patients up to 16 years of age were retrieved from the Swiss IBD Cohort Study database.14 The Pediatric Crohn's Disease Activity Index15 ,16 and the Pediatric Ulcerative Colitis Activity Index were calculated.17 ,18 The parent-rated Strengths and Difficulties Questionnaire (SDQ), validated for children aged 6–16 years, addresses emotional, behavioural, hyperkinetic and peer problems with four subscales and strengths (pro-social behaviour) with a fifth, resulting in 25 items, each with scores ranging from 0 to 2.19–23 The self-rated Children's Depression Inventory (CDI), validated for youth aged 8–17 years,24 addresses negative mood, ineffectiveness, negative self-esteem, interpersonal problems and anhedonia, resulting in 26 items, each with scores ranging from 0 to 2.24–26
Of the 148 paediatric patients entered into the database (81 boys, mean age 12.9±3.3 years, 80 Crohn's disease, 60 ulcerative colitis, 8 indeterminate colitis), 22 were excluded because neither the SDQ nor the CDI had been completed. Of the 126 patients included in the final analysis, 79 (62.7%) had inactive and 34 (27%) mild disease, 122 were born in Switzerland, 4 were born in another European country, and 72 had both questionnaires completed. The characteristics of the 126 patients are displayed in table 1.
Descriptive statistics were conducted to summarise frequencies, non-parametric tests and contingency tables to compare proportions and groups, and Pearson's correlation coefficient to assess for the strength of associations. A statistical significance level of p<0.05 was chosen.
The results of the 88 SDQ (43 boys) and the 110 CDI (62 boys) are displayed in table 2. For associations between the SDQ total score or sub-scores, or the CDI T scores and disease-related variables, see table 3.
This study analysed information about the behavioural and emotional adjustment of patients with IBD obtained from two sources: parents and patients. The most important result is that both sources achieved normal global scores, indicating that maladjustment is not more prevalent in children with inactive or mildly active IBD. The SDQ sub-score analysis revealed a high rate of parent-rated emotional problems, contrasting with a low rate indicated by the self-rated CDI. As described earlier,27 this discrepancy may reflect more of a parental preoccupation than a real prevalence of emotional problems.
The SDQ and the Child Behaviour Checklist (CBCL) are comparable questionnaires.28 ,29 Studies using the CBCL and including patients with low disease activity yielded comparable results.5 ,7 ,11 ,12 ,27 ,30–32 The same is true for the CDI: studies including patients with low disease activity11 ,12 ,30 ,32 yielded low rates, and studies including patients with active disease reported higher rates of depressive symptoms.5 ,10 ,33–35 In fact, a decreasing prevalence of emotional problems with the achievement of disease remission was described earlier.5 There are several limitations to these results. First, despite the use of short questionnaires, only 72 patients (48.6% of the whole cohort of 148) completed both, thereby conferring a certain amount of uncertainty to our results. Second, measuring the psychological adjustment of children with IBD using the general population as control subjects can be challenging, especially because the sensitivity of the SDQ regarding the detection of IBD-related consequences is not defined. A similar concern applies to the CDI. Third, the appropriateness of German norms for our sample can be questioned. Nevertheless, because France, Germany and Switzerland are neighbouring central European countries, major cross-cultural bias seems unlikely. Finally, there may be some concerns regarding our correlational findings because the chance of falsely significant results increases when more comparisons are performed on the same set of data.
Funding This study was supported by a research grant from the Swiss National Science Foundation, grant 3347CO-108792/1 (Swiss IBD Cohort).
Contributors MAL and CPB: conception and design of the study; CPB, PB, KH, DR, RK, VR, AN, JS, MTC and SS: data collection; DH, VP and MAL: data analysis and statistical analysis; DH, MAL and CPB: interpretation of the data; DH: drafting and finalising of the manuscript. CPB is the guarantor of the paper.
Competing interests None.
Ethics Approval This study was approved by the Ethikkommission der Gesundheitsdirektion des Kantons Zürich.
Provenance and peer review Not commissioned; externally peer reviewed.