Marco Antônio Arruda, MD, PhD · Neuropsychiatric Disorders Stuttering 2.0 (1.3-3.0) Arch Pediatr Adolesc Med. 2010;164(4):358-62 OR (95%CI) Learning Disability Sleep Disorder Epilepsy

Marco Antônio Arruda, MD, PhD Childhood and Adolescence Neurology

IHS Child and Adolescent Standing Committee Glia Institute Ribeirão Preto

São Paulo, Brazil [email protected]

“Additional ailment in a patient with a particular index disease”

Feinsten, AR

Guidetti, Arruda & Özge in Headache and Comorbidities in Childhood and Adolescence

2017

Comorbidity refers to the nonrandom association between two or among several disorders

headache OR migraine AND comorb* AND (child* OR adolescen* OR infant* OR pediatr*)

Identification n = 644

Screening n = 67

Eligibility n = 27

Included n = 23

Populational samples [n = 27] Clinical samples [n = 30] Review [n = 10]

Children and Adolescents Populational samples

ICHD 2 or 3 Primary headaches

ICD 10 coded diseases

Somatic Disorders OR (95%CI)

Int Forum Allergy Rhinol. 2016;6(3):322-7

Acta Paediatr. 2017;106(6):967-972

J Child Neurol. 2009 May ; 24(5): 536–543

Celiac Disease

Migraine

2.3 (2.1-2.5)

Allergic rhinitis Asthma

Headache

1.5 (1.2-1.9) 1.7 (1.3-2.1)

children

Celiac Disease

Migraine

2.3 (2.1-2.5)

Allergic rhinitis Asthma

Headache

1.5 (1.2-1.9)

1.4 (1.2-1.6)

Overweight Obesity

1.6 (1.4–2.2)

1.4 (1.1-1.6)

TTH CDH

2.0 (1.04–3.7)

1.5 (1.4-1.6)

Eczema

2 (1.2-3.2)

Anemia

Somatic Disorders

Risk Factors Vascular Disease

BMI C-reactive protein Homocysteine Serum/RBC folate

1.2-1.3 (1.1–1.6)

OR (95%CI)

Arch Pediatr Adolesc Med. 2010;164(4):358-62

Pediatrics. 2013;132:e9–16 Neurology. 2010;75:712–7 Int Forum Allergy Rhinol. 2016;6(3):322-7

Acta Paediatr. 2017;106(6):967-972

J Child Neurol. 2009 May ; 24(5): 536–543

J Allergy Clin Immunol. 2016; 137(2): 492–499.e5

1.7 (1.3-2.1)

2.0 (1.04-3.9)

TTH

3.2 (1.7–6.2)

Neuropsychiatric Disorders

4.5 (2.7–7.2)

Epilepsy

Excluding: 1.4.4 Migraine aura-triggered seizure 7.6.1 Hemicrania epiléptica 7.6.2 Postictal headache

J Pediatr. 2012 Aug;161(2):308-13

OR (95%CI)

Migraine Headache J Headache Pain (2010) 11:235–240

Childhood Occipital Epilepsy (Gastaut type)


Panayiotopoulos Syndrome

Childhood Epilepsy with Centrotemporal Spikes

Juvenile Myoclonic Epilepsy

Neurology 2012;79:468–473

Childs Nerv Syst (2011) 27:1419–1423

OR (95%CI)

Epilepsy

Migraine Headache J Headache Pain (2010) 11:235–240 J Pediatr. 2012 Aug;161(2):308-13

Epilepsia, 47(10):1674–1681, 2006

Excluding: 1.4.4 Migraine aura-triggered seizure 7.6.1 Hemicrania epiléptica 7.6.2 Postictal headache


Sleep Disorder

Bruxism 2.4 (1.7-3.3)

Sleep Talking 2.3 (1.7-3.0)

Somnambulism 3.4 (2.2-5.1)

Persistent Nightmare 2.3 (1.3-3.9)

OR (95%CI)

Epilepsy

Migraine Headache Neurology 2012;79:468–473

Childs Nerv Syst (2011) 27:1419–1423

J Headache Pain (2010) 11:235–240 J Pediatr. 2012 Aug;161(2):308-13

Epilepsia, 47(10):1674–1681, 2006

Pediatr Neurol 2010;43:420-424

Neuropsychiatric Disorders Learning Disability

1.4 (1.1-1.8)

OR (95%CI)

Sleep Disorder

Epilepsy

Migraine Headache J Child Neurol. 2009; 24(5): 536–543 Pediatr Neurol 2010;43:420-424

Neurology 2012;79:468–473

Childs Nerv Syst (2011) 27:1419–1423


Epilepsia, 47(10):1674–1681, 2006

Neuropsychiatric Disorders Stuttering

2.0 (1.3-3.0)

Arch Pediatr Adolesc Med. 2010;164(4):358-62

OR (95%CI) Learning Disability

Sleep Disorder

Epilepsy

Migraine Headache J Child Neurol. 2009; 24(5): 536–543 Pediatr Neurol 2010;43:420-424

Neurology 2012;79:468–473

Childs Nerv Syst (2011) 27:1419–1423


Epilepsia, 47(10):1674–1681, 2006

Neuropsychiatric Disorders OR (95%CI)

Anxious Depressed

5.8 (3.0-11.3)

3.0 (2.7-3.5)

Cephalalgia. 2012 Nov;32(15):1093-100 Headache. 2015 Feb;55 Suppl 1:39-50

Stuttering Learning Disability

Sleep Disorder

Epilepsy

Migraine Headache Arch Pediatr Adolesc Med. 2010;164(4):358-62 J Child Neurol. 2009; 24(5): 536–543 Pediatr Neurol 2010;43:420-424

Neurology 2012;79:468–473

Childs Nerv Syst (2011) 27:1419–1423


Epilepsia, 47(10):1674–1681, 2006


TTH

1.3 (1.1-1.6)

3.0 (1.4–6.8)

Anxious Depressed


Sleep Disorder

Epilepsy

Migraine Headache Cephalalgia. 2012 Nov;32(15):1093-100 Headache. 2015 Feb;55 Suppl 1:39-50

Arch Pediatr Adolesc Med. 2010;164(4):358-62 J Child Neurol. 2009; 24(5): 536–543 Pediatr Neurol 2010;43:420-424

Neurology 2012;79:468–473

Childs Nerv Syst (2011) 27:1419–1423


Epilepsia, 47(10):1674–1681, 2006

Migraine in children: psychiatric comorbidities

Anxious & Depressive symptoms

Somatic symptoms

Laurell et al. (2005)

Antilla et al. (2004)

Galli et al. (2007)

Vannatta et al. (2008)

Arruda et al. (2011) Populational

Clinical

Virtanen et al. (2004)

Arruda et al. (2015)

Mazzone et al. (2006)

Galli et al. (2007)

Vannatta et al. (2008)

Samples

Blaauw et al. (2014)

Arruda et al. (2012)


TTH

Anxious Depressed


Sleep Disorder

Epilepsy

Migraine Headache Cephalalgia. 2012 Nov;32(15):1093-100 Headache. 2015 Feb;55 Suppl 1:39-50


Neurology 2012;79:468–473

Childs Nerv Syst (2011) 27:1419–1423


Epilepsia, 47(10):1674–1681, 2006

Somatic

?

Child Behavior Checklist (CBCL)

4-18 y

Cephalalgia. 2012 Nov;32(15):1093-100

Curr Opin Neurol 2015, 28:261–264

CBCL Somatic domain

Feels dizzy or lightheaded Overtired without good reason Physical problems without known medical cause:

• Aches or pains (not stomach or headaches) • Headaches • Nausea, feels sick • Problems with eyes (not if corrected by glasses) • Rashes or other skin problems • Stomachaches • Vomiting, throwing up

Curr Opin Neurol 2015, 28:261–264

124 teachers 87 cities 18 states

5 national regions Target sample: 8,196

Final sample: 6,841 5 to 18 years-old

Urban and rural areas

National Phase

MTA SNAP IV Headache Questionnaire

MTA SNAP IV School Performance

Questionnaire

Assessment

Headache. 2015 Feb;55 Suppl 1:39-50


ADHD

3.8 (2.5-5.9)

J Atten Disord. 2017 Jun 1 [Epub ahead of print]

Anxious Depressed


Sleep Disorder

Epilepsy

Migraine Headache

TTH



Neurology 2012;79:468–473 Epilepsia, 47(10):1674–1681, 2006

Childs Nerv Syst (2011) 27:1419–1423



CM

7.3 (3.5-15.5)

ADHD

Anxious Depressed


Sleep Disorder

Epilepsy

Migraine Headache

TTH J Atten Disord. 2017 Jun 1 [Epub ahead of print]




Childs Nerv Syst (2011) 27:1419–1423



CM

7.3 (3.5-15.5)

ADHD

Anxious Depressed


Sleep Disorder

Epilepsy

Migraine Headache

TTH J Atten Disord. 2017 Jun 1 [Epub ahead of print]




Childs Nerv Syst (2011) 27:1419–1423


3.8 (2.5-5.9)

3.0 (1.4–6.8)

5.8 (3.0-11.3)

2.0 (1.3-3.0)

1.4 (1.1-1.8)

2.0 (1.04-3.9) 3.2 (1.7–6.2)

4.5 (2.7–7.2)

The important role of clinical studies on comorbidity

Pros

Populational

Clinical

Avoiding Berkson’s bias

Strengthen findings from pop studies

Samples

Estimates of risk factors

Prevalence and incidence rates

Better monitoring of comorbidity pattern and course

Rare or uncommon disorders

Better therapeutic interventions

Migraine Overall TTH Overall

Withdrawn ns ns

Somatic Frequency Gender, Age & Frequency

Anxious-Depressed Frequency & Race Gender & Frequency

Social Frequency Age

Thought ns Race

Attention Frequency & Income ns

Rule-breaking ns Gender

Aggressive Frequency Gender

Internalizing Frequency Gender & Frequency

Externalizing Income, Gender & Frequency Gender

Total Income & Frequency ns

Cephalalgia. 2012 Nov;32(15):1093-100

Headache. 2015 Feb;55 Suppl 1:39-50

Multivariate Analyses of Determinants of an Abnormal SDQ Total Difficulties Score Causing Impact in the Life of Children With Episodic Migraine and Episodic Tension-Type Headache

n.s.: age, race, city density, national region where a child lives, income class, and prenatal exposure to alcohol

J Atten Disord. 2017 Jun 1 [Epub ahead of print]

Episodic Migraine p Odds Ratio

for predictors

95% C.I.

Lower Upper

Gender

male vs. female .004 2.58 1.36 4.88

Prenatal exposure

to tobacco .025 2.03 1.09 3.77

Below vs. average plus above

average school performance .000 8.10 4.11 15.99

Frequency of headache attacks

5-9 vs. 1-4

+9 vs. 1-4

.000

.000 5.27 2.47 11.22

.000 11.72 5.40 25.41

Poor school performance

Prenatal exposure to tobacco

Nausea, photo & phonophobia

High frequency of attacks

Higher Risk

Psychiatric Comorbidity

Vincenzo Guidetti Marcelo E. Bigal Renato Arruda

Documents

Marco Antônio Arruda, MD, PhD · Neuropsychiatric Disorders Stuttering 2.0 (1.3-3.0) Arch Pediatr Adolesc Med. 2010;164(4):358-62 OR (95%CI) Learning Disability Sleep Disorder Epilepsy