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Article |

Adolescent Chronic Fatigue Syndrome:  A Follow-up Study FREE

Stefan M. van Geelen, MPhil; Rob J. Bakker, MD; Wietse Kuis, PhD, MD; Elise M. van de Putte, PhD, MD
[+] Author Affiliations

Author Affiliations: Department of Pediatrics, University Medical Center Utrecht, Utrecht, the Netherlands.


Arch Pediatr Adolesc Med. 2010;164(9):810-814. doi:10.1001/archpediatrics.2010.145.
Text Size: A A A
Published online

Objective  To describe the symptomatic and educational long-term outcomes, health care use, and risk factors of nonrecovery in adolescent chronic fatigue syndrome (CFS).

Design  Follow-up study.

Setting  Academic pediatric hospital.

Participants  Sixty adolescents with CFS.

Interventions  Regular care.

Outcome Measures  The Checklist Individual Strength, Child Health Questionnaire, and a general questionnaire regarding further symptoms, school attendance, work attendance, and treatment.

Results  Complete measurements were returned for 54 adolescents (90%). At initial assessment, their mean (SD) age was 16.0 (1.5) years and 20.4% were male. The mean follow-up duration was 2.2 years. At follow-up, the mean (SD) age was 18.2 (1.5) years; 28 adolescents (51.9%) had nearly complete improvement of symptoms but 26 (48.1%) did not experience improvement. Adolescents who attended school (n = 41) had missed an average of 33% of classes during the last month. The rest (n = 13) had worked an average of 38.7% of a full-time job during the last month. A total of 66.7% of subjects were treated by a physiotherapist, 38.9% were clinically treated in rehabilitation, 48.1% had received psychological support, and 53.7% had used alternative treatment.

Conclusions  About half of the adolescents had recovered from CFS at follow-up. The other half was still severely fatigued and physically impaired. Health care use had been high, and school and work attendance were low. Older age at inclusion was a risk factor, and pain, poor mental health, self-esteem, and general health perception at outcome were associated with an unfavorable outcome. Future research should focus on customizing existing treatment and studying additional treatment options.

Chronic fatigue syndrome (CFS) in adolescence is a heterogeneous and medically unexplained condition.1 No laboratory tests for adolescent CFS are available.2 Its main symptom is functionally disabling fatigue, severely affecting young patients' lives.3 Like in adult CFS, the most commonly used criteria in adolescent CFS are the English Oxford4 and the US Centers for Disease Control and Prevention (CDC)5 criteria. The Oxford criteria are considered somewhat less restrictive.6 The prevalence of adolescent CFS has been estimated to be 1.3% to 4.4% in British and US populations.7,8 Estimations of the prevalence of adolescent CFS in other populations are sometimes lower.9 The incidence of adolescent CFS is estimated at 0.5%,10 and the female to male ratio is estimated at 4:1.11 Randomized controlled treatment trials for adolescent CFS have been rare but there is growing support for a positive effect of cognitive behavioral therapy.12,13

There have only been a few follow-up studies that described the outcome of adolescent CFS after regular care, applying either Oxford or CDC criteria for CFS. In Table 1, the main studies of the prognosis of adolescent CFS are presented. About one-third to one-half of the patients in the studies described still experienced severe fatigue, physical impairment, and little improvement at follow-up. At present, the largest cohort described in a follow-up study of pediatric CFS included 35 patients. Most studies so far have used the Oxford criteria for CFS, and there is only 1 follow-up study that has used the 1994 CDC criteria for CFS. However, all diagnoses in these studies were made retrospectively. Furthermore, most studies had a disproportionately high percentage of male participants and a wide age range. In this study, the outcomes of 54 adolescents who fulfilled the 1994 CDC criteria for CFS are described.

Table Graphic Jump LocationTable 1. Follow-up Studies of Adolescent Chronic Fatigue Syndromea
PARTICIPANTS

All participating adolescents had first visited a general practitioner before being referred to a general pediatrician in a nonacademic setting. Subsequently, they were referred to the academic pediatric hospital. Seventy-four adolescents who had previously participated in a number of research studies of adolescent CFS21,22 were considered for inclusion. At initial examination, these adolescents were assessed for CFS, and the diagnosis, in accordance with the 1994 CDC criteria, was either made or confirmed by a specialized academic pediatrician. Although they had been clinically diagnosed with CFS, 14 of the 74 adolescents (18.9%) were not eligible for participation in this follow-up study because their initial scores on the subjective fatigue subscale of the Checklist Individual Strength (CIS-20) were below cutoff (see “Primary Outcome Measures” section). Questionnaires were sent to the remaining 60 adolescents. All questionnaires were filled out at home. The duration of the follow-up was defined as the time between the initial research examinations at the academic pediatric hospital and the present study's assessments. The study was approved by the ethical committee of the hospital, and informed consent was obtained from all participating adolescents and their parents.

PRIMARY OUTCOME MEASURES

Fatigue was assessed using the subjective fatigue subscale of the CIS-20.23 This scale measures experience of fatigue and consists of 8 items; scores range from 8, no fatigue, to 56, extremely fatigued. It is a reliable, validated assessment measure with good internal consistency (Cronbach α = .9312). The CIS-20 has previously been used in research into adolescent CFS.22 Various cutoff scores (range, 35.7-40) for recovery on this measure have been used.12,24 In this study, the cutoff on the subscale was set at 40 (mean plus 2 SD of the subjective fatigue distribution in healthy adolescents24) to dichotomize the outcomes as improved (score <40) or not improved (score ≥40).

Functional impairment was measured using the physical role functioning subscale of the Child Health Questionnaire–Child Form (CHQ-CF87).25 This scale measures limitations in school work and daily activities as a result of physical health and consists of 3 items; scores range from 0, severe limitations due to physical problems, to 100, no limitations due to physical problems. It is a reliable, validated assessment measure with good internal consistency (Cronbach α = .8626). The CHQ-CF87 has previously been used in research regarding adolescent CFS.23 Cutoff scores for recovery on the physical role functioning subscale of the CHQ-CF87 have not yet been set for adolescent CFS. However, on the physical functioning subscale of the Short-Form General Health Survey27 (also ranging from 0, maximal physical limitation, to 100, ability to do all activities, and previously used in adolescent CFS), a cutoff of 65 has been used.12 In this study, the cutoff for the physical role functioning subscale of the CHQ-CF87 was correspondingly set at 65 to dichotomize outcomes as improved (score >65) or not improved (score ≤65). A classification of nearly complete improvement required a score of less than 40 on the subjective fatigue subscale of the CIS-20 combined with a score greater than 65 on the physical role functioning subscale of the CHQ-CF87.

SECONDARY OUTCOME MEASURES

In addition to the physical role functioning subscale of the CHQ-CF87, we used the emotional role functioning subscale, which measures limitations in school work and daily activities as a result of emotional problems such as worry or sorrow (Cronbach α = .9026); the behavioral role functioning subscale, which measures limitations in school work and daily activities as a result of behavioral problems (Cronbach α = .7126); the bodily pain subscale, which measures the severity and frequency of bodily pain (Cronbach α = .8526); the general behavior subscale, which measures the exhibition of aggressive, delinquent, and immature behavior (Cronbach α = .7926); the mental health subscale, which measures a diversity of positive and negative feelings (Cronbach α = .8626); the self-esteem subscale, which measures satisfaction with abilities, looks, family/peer relations, and life overall (Cronbach α = .8926); and the general health perceptions subscale, which measures beliefs concerning health (Cronbach α = .7726). This was done to cover additional physical and psychosocial domains at outcome.

In a further general questionnaire, the participants were asked to indicate (yes/no) the regular presence during the last month of 8 symptoms according to the 1994 CDC criteria (self-reported impairment in memory or concentration, sore throat, tender cervical or lymph nodes, muscle pain, multijoint pain, headache, unrefreshing sleep, postexertional malaise lasting 24 hours or more). School attendance was measured as the percentage of classes the adolescent had attended at school during the last month compared with the school schedule of classmates. If the participants no longer attended school, work attendance was calculated as the percentage of a fulltime job (38 hours) the adolescent had worked during the last month. Finally, participants were asked to estimate the total number of therapeutic visits they had (if any) with physiotherapists, psychologists, and alternative health care suppliers in the follow-up period and (if applicable) to estimate the months they had spent in clinical rehabilitation.

STATISTICAL ANALYSIS

All statistical analyses were performed using SPSS version 16.0 (SPSS Inc, Chicago, Illinois). On the outcome variables, group means and standard deviations were calculated. Potential risk factors (eg, sex, age, severity of fatigue at inclusion, duration of follow-up) were quantified with odds ratios using logistic regression with outcome (recovered vs not recovered) as the dependent variable. The significance level was set at P < .05 (2-tailed tests).

Complete data for 54 (90%) adolescents were returned. At first inclusion, their mean (SD) age was 16.0 (1.5) years, all were white, 20.4% were male, and their mean (SD) score on the subjective fatigue subscale of the CIS-20 was 49.4 (5.1). Onset had been gradual in 27 (50%) cases, following “flulike illness” in 22 cases (40.7%) and acute (ie, sudden onset without preceding flulike symptoms) in 5 cases (9.3%). At follow-up, the mean (SD) age was 18.2 (1.5) years. There were no significant differences between responders and nonresponders in sex, age, or fatigue severity. The mean (SD) follow-up duration was 2.2 (1.6) years but the symptoms in most cases had existed substantially in the years prior to initial assessment. During this time, 43 adolescents (79.6%) had not received any other diagnosis, 3 (5.6%) were diagnosed with celiac disease, 3 (5.6%) had lactose intolerance, 2 (3.7%) had metabolic disorder, 1 (1.9%) had hypermobility syndrome, 1 (1.9%) had major depressive disorder, and 1 (1.9%) had anxiety disorder.

Table 2 shows the scores on the primary outcome measures of the 54 adolescents for whom complete measurements were returned. At follow-up, 28 adolescents (51.9%) had a score of less than 40 on the subjective fatigue subscale of the CIS-20 and a score greater than 65 on the physical role functioning subscale of the CHQ-CF87, indicating that they had a nearly complete improvement of CFS at follow-up.

Table 3 shows the scores on the secondary outcome measures. The mean scores on the behavioral role functioning, emotional role functioning, and general behavior subscales of the CHQ-CF87 were generally good. However, the mean scores on the mental health and self-esteem subscales of the CHQ-CF87 were unfavorable (approximately 1 SD below the mean scores in a healthy young population26); the mean scores on the bodily pain and general health perceptions subscales of the CHQ-CF87 were particularly low (respectively, about 1.5 and 2 SD below the mean scores in a healthy young population26).

Table 4 shows school attendance, work attendance, and therapeutic contacts for the 54 adolescents for whom complete measurements were returned. At follow-up, the participants who still attended school had, on average, missed approximately one-third of regular classes during the last month. For a previously described cohort of 167 healthy adolescents, this percentage was only 12.5%.21 In the Netherlands, it is common to start a full-time job after finishing school. However, participants who no longer attended school had worked only an average of approximately one-third of a full-time job during the last month. The variety and frequency of therapeutic health care use had been considerable between initial assessment and follow-up.

Table Graphic Jump LocationTable 4. School Attendance, Work Attendance, and Health Care Use at Follow-up

Only a higher age at initial inclusion was found to be a risk factor for nonrecovery of CFS at follow-up (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.06-2.39; P = .03). Sex, severity of fatigue at inclusion, type of onset, other diagnoses, health care use (psychological treatment, physiotherapy, rehabilitation, or alternative treatment), and length of time between inclusion and follow-up were not associated with outcome. At follow-up, a high amount of reported CDC CFS symptoms (OR, 1.62; 95% CI, 1.19-2.22; P = .002) and a low score on the mental health (OR, 0.95; 95% CI, 0.90-0.99; P = .01), self esteem (OR, 0.94; 95% CI, 0.90-0.99; P = .01), bodily pain (OR, 0.93; 95% CI, 0.93-0.99; P = .002), and general health perceptions (OR, 0.92; 95% CI, 0.84-0.96; P < .001) subscales of the CHQ-CF87 were associated with nonrecovery.

The outcome of unexplained pediatric chronic fatigue (ie, not diagnosed as CFS) is mostly positive.28,29 It is generally thought that the prognosis for adolescent CFS is also relatively good.1,2 In this study it was found that, although about half of the participating adolescents had nearly complete improvement, the other half were still severely fatigued, had impaired physical functioning, and would probably still fulfill 1994 CDC criteria for CFS at follow-up.

The cohort of adolescents who participated in this study is the largest described in any follow-up after regular care. The diagnosis of CFS was established according to the 1994 CDC criteria at initial examination, the female to male ratio was in accordance with research findings, the mean age of participants did not have a wide range, and a strict cut-off score on a validated measure of adolescent CFS was used to qualify subjects for inclusion. However, the CHQ-CF87 was not used at inclusion. Therefore, potential predictors of outcome were limited. Furthermore, while all questionnaires were validated for this age group and no adolescents indicated that they had difficulty with completion, the answering of questionnaires at home might not ensure complete confidentiality without parental influence.

In previous studies, few risk factors for adolescent CFS have been identified.30 As in our study, older age at diagnosis has been found to imply an increased risk of prolonged adolescent CFS.3,10 The high levels of school nonattendance are in concordance with the literature.13 The use of health care services in adolescent CFS was high and comparable with recent studies.32,33 While no specific form of health care was associated with a better outcome, almost all adolescents had received some kind of treatment, and it is difficult to estimate what the outcome would have been had this not been the case. Although some of the participating adolescents had received cognitive behavioral therapy as part of routine psychological support, this also did not result in a superior outcome. This is consistent with findings that the results of cognitive behavioral therapy for CFS are generally superior within, rather than outside, the confines of randomized controlled trials.34 The percentage of adolescents who had not recovered from CFS at follow-up in this study was somewhat higher than in previous studies and more like the outcome rates in adult CFS.35 This might be owing to the strict use of 1994 CDC criteria for CFS, the use of a cutoff score for eligibility, and a higher age of participants at inclusion. In addition, the diagnosis of CFS in the adolescents who participated in this study was established (or confirmed) in a tertiary academic hospital setting and might represent a particularly impaired cohort.

Despite intensive health care use, a substantial proportion of adolescent patients with CFS remain severely fatigued and physically impaired. This is associated with considerable pain and poor mental health, self-esteem, and general health, and greatly affects school and work attendance. Therefore, future research into adolescent CFS should not only focus on recognizing patient characteristics for a favorable outcome but should also be directed toward further customizing existing treatment and studying additional interventions for patients who do not benefit from established treatment options.36,37

Correspondence: Stefan M. van Geelen, MPhil, Department of Pediatrics, University Medical Center Utrecht, Room KE.04.133.1, Lundlaan 6, 3584 EA Utrecht, the Netherlands (s.m.vangeelen@umcutrecht.nl).

Accepted for Publication: February 4, 2010.

Author Contributions: Mr van Geelen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: van Geelen, Bakker, Kuis, and van de Putte. Acquisition of data: van Geelen, Kuis, and van de Putte. Analysis and interpretation of data: van Geelen, Bakker, and van de Putte. Drafting of the manuscript: van Geelen. Critical revision of the manuscript for important intellectual content: van Geelen, Bakker, Kuis, and van de Putte. Statistical analysis: van Geelen and Bakker. Obtained funding: van Geelen and Kuis. Study supervision: Kuis and van de Putte.

Financial Disclosure: None reported.

Funding/Support: This study was supported by grant 400-03-469 from the Netherlands Organization for Scientific Research (Mr van Geelen).

Patel  MXSmith  DGChalder  TWessely  S Chronic fatigue syndrome in children: a cross-sectional survey. Arch Dis Child 2003;88 (10) 894- 898
PubMed
Smith  MS Adolescent chronic fatigue syndrome. Arch Pediatr Adolesc Med 2004;158 (3) 207- 208
PubMed
Chalder  TGoodman  RWessely  SHotopf  MMeltzer  H Epidemiology of chronic fatigue syndrome and self reported myalgic encephalomyelitis in 5-15 year olds: cross sectional study. BMJ 2003;327 (7416) 654- 655
PubMed
Sharpe  MCArchard  LCBanatvala  JE  et al.  A report: chronic fatigue syndrome: guidelines for research. J R Soc Med 1991;84 (2) 118- 121
PubMed
Fukuda  KStraus  SEHickie  ISharpe  MCDobbins  JGKomaroff  A The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994;121 (12) 953- 959
PubMed
Eminson  DM Medically unexplained symptoms in children and adolescents. Clin Psychol Rev 2007;27 (7) 855- 871
PubMed
Farmer  AFowler  TScourfield  JThapar  A Prevalence of chronic disabling fatigue in children and adolescents. Br J Psychiatry 2004;184477- 481
PubMed
Mears  CJTaylor  RRJordan  KMBinns  HJ Sociodemographic and symptom correlates of fatigue in an adolescent primary care sample. J Adolesc Health 2004;35 (6) 528e.21- 26
PubMed
de Jong  LWPrins  JBFiselier  TJWeemaes  CMMeijer-Van den Bergh  EMBleijenberg  G Chronic fatigue syndrome in young persons [in Dutch]. Ned Tijdschr Geneeskd 1997;141 (31) 1513- 1516
PubMed
Rimes  KAGoodman  RHotopf  MWessely  SMeltzer  HChalder  T Incidence, prognosis, and risk factors for fatigue and chronic fatigue syndrome in adolescents: a prospective community study. Pediatrics 2007;119 (3) e603- e609
PubMed
Jordan  KMLandis  DADowney  MCOsterman  SLThurm  AEJason  LA Chronic fatigue syndrome in children and adolescents: a review. J Adolesc Health 1998;22 (1) 4- 18
PubMed
Stulemeijer  MDe Jong  LWFiselier  TJHoogveld  SWBleijenberg  G Cognitive behaviour therapy for adolescents with chronic fatigue syndrome: a randomized controlled trial [published online ahead of print December 7, 2004]. BMJ 2005;330 (7481) 14
PubMed
Knoop  HStulemeijer  MDe Jong  LWFiselier  TJBleijenberg  G Efficacy of cognitive behavioral therapy for adolescents with chronic fatigue syndrome: a long-term follow-up of a randomized controlled trial. Pediatrics 2008;121 (3) e619- e625
PubMed
Smith  MSMitchell  JCorey  L  et al.  Chronic fatigue in adolescents. Pediatrics 1991;88 (2) 195- 202
PubMed
Rangel  LGarralda  MELevin  MRoberts  H The course of severe chronic fatigue syndrome in childhood. J R Soc Med 2000;93 (3) 129- 134
PubMed
Bell  DSJordan  KRobinson  M Thirteen-year follow-up of children and adolescents with chronic fatigue syndrome. Pediatrics 2001;107 (5) 994- 998
PubMed
Gill  ACDosen  AZiegler  JB Chronic fatigue syndrome in adolescence: a follow-up study. Arch Pediatr Adolesc Med 2004;158 (3) 225- 229
PubMed
Sankey  AHill  CMBrown  JQuinn  LFletcher  A A follow-up study of chronic fatigue syndrome in children and adolescents: symptom persistence and school absenteeism. Clin Child Psychol Psychiatry 2006;11 (1) 126- 138
PubMed
Holmes  GPKaplan  JEGantz  NM  et al.  Chronic fatigue syndrome: a working case definition. Ann Intern Med 1988;108 (3) 387- 389
PubMed
Bell  DSBell  KM Chronic fatigue syndrome: diagnostic criteria. Ann Intern Med 1988;109167
PubMed
van de Putte  EMUiterwaal  CSBots  MLKuis  WKimpen  JLEngelbert  RH Is chronic fatigue syndrome a connective tissue disorder? a cross-sectional study in adolescents. Pediatrics 2005;115 (4) e415- e422
PubMed
van de Putte  EMvan Doornen  LJEngelbert  RHKuis  WKimpen  JLUiterwaal  CS Mirrored symptoms in mother and child with chronic fatigue syndrome. Pediatrics 2006;117 (6) 2074- 2079
PubMed
Vercoulen  JHMMSwanink  CMAFennis  JFMGalama  JMDVan der Meer  JWMBleijenberg  G Dimensional assessment of chronic fatigue syndrome. J Psychosom Res 1994;38 (5) 383- 392
PubMed
van de Putte  EMEngelbert  RHKuis  WKimpen  JLUiterwaal  CS Alexithymia in adolescents with chronic fatigue syndrome. J Psychosom Res 2007;63 (4) 377- 380
PubMed
Landgraf  JM Measuring pediatric outcomes in applied clinical settings: an update about the child health questionnaire (CHQ). Qual Life Newslett MAPI Res Inst 1999;235- 6
Raat  HLandgraf  JMBonsel  GJGemke  RJBJEssink-Bot  ML Reliability and validity of the child health questionnaire-child form (CHQ-CF87) in a Dutch adolescent population. Qual Life Res 2002;11 (6) 575- 581
PubMed
Stewart  ALHays  RDWare  JE  Jr The MOS short form general health survey: reliability and validity in a patient population. Med Care 1988;26 (7) 724- 735
PubMed
Krilov  LRFisher  MFriedman  SBReitman  DMandel  FS Course and outcome of chronic fatigue in children and adolescents. Pediatrics 1998;102 (2 pt 1) 360- 366
PubMed
Feder  HM  JrDworkin  PHOrkin  C Outcome of 48 pediatric patients with chronic fatigue: a clinical experience. Arch Fam Med 1994;3 (12) 1049- 1055
PubMed
Hempel  SChambers  DBagnall  AMForbes  C Risk factors for chronic fatigue syndrome/myalgic encephalomyelitis: a systematic scoping review of multiple predictor studies. Psychol Med 2008;38 (7) 915- 926
PubMed
Garralda  MERangel  L Impairment and coping in children and adolescents with chronic fatigue syndrome: a comparative study with other paediatric disorders. J Child Psychol Psychiatry 2004;45 (3) 543- 552
PubMed
Scheeres  KWensing  MSeverens  HAdang  EBleijenberg  G Determinants of health care use in chronic fatigue syndrome patients: a cross-sectional study. J Psychosom Res 2008;65 (1) 39- 46
PubMed
Jason  LABenton  MCValentine  LJohnson  ATorres-Harding  S The economic impact of ME/CFS: individual and societal level costs [published online ahead of print April 8, 2008]. Dyn Med 2008;7610.1186/1476-5918-7-6
Quarmby  LRimes  KADeale  AWessely  SChalder  T Cognitive-behaviour therapy for chronic fatigue syndrome: comparison of outcomes within and outside the confines of a randomised controlled trial. Behav Res Ther 2007;45 (6) 1085- 1094
PubMed
Cairns  RHotopf  M A systematic review describing the prognosis of chronic fatigue syndrome. Occup Med 2005;5520- 3110.1093/occmed/kqi013
Whiting  PBagnall  AMSowden  AJCornell  JEMulrow  CDRamírez  G Interventions for the treatment and management of chronic fatigue syndrome: a systematic review. JAMA 2001;286 (11) 1360- 1368
PubMed
Van Houdenhove  BLuyten  P Customizing treatment of chronic fatigue syndrome and fibromyalgia: the role of perpetuating factors. Psychosomatics 2008;49 (6) 470- 477
PubMed

Figures

Tables

Table Graphic Jump LocationTable 1. Follow-up Studies of Adolescent Chronic Fatigue Syndromea
Table Graphic Jump LocationTable 4. School Attendance, Work Attendance, and Health Care Use at Follow-up

References

Patel  MXSmith  DGChalder  TWessely  S Chronic fatigue syndrome in children: a cross-sectional survey. Arch Dis Child 2003;88 (10) 894- 898
PubMed
Smith  MS Adolescent chronic fatigue syndrome. Arch Pediatr Adolesc Med 2004;158 (3) 207- 208
PubMed
Chalder  TGoodman  RWessely  SHotopf  MMeltzer  H Epidemiology of chronic fatigue syndrome and self reported myalgic encephalomyelitis in 5-15 year olds: cross sectional study. BMJ 2003;327 (7416) 654- 655
PubMed
Sharpe  MCArchard  LCBanatvala  JE  et al.  A report: chronic fatigue syndrome: guidelines for research. J R Soc Med 1991;84 (2) 118- 121
PubMed
Fukuda  KStraus  SEHickie  ISharpe  MCDobbins  JGKomaroff  A The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994;121 (12) 953- 959
PubMed
Eminson  DM Medically unexplained symptoms in children and adolescents. Clin Psychol Rev 2007;27 (7) 855- 871
PubMed
Farmer  AFowler  TScourfield  JThapar  A Prevalence of chronic disabling fatigue in children and adolescents. Br J Psychiatry 2004;184477- 481
PubMed
Mears  CJTaylor  RRJordan  KMBinns  HJ Sociodemographic and symptom correlates of fatigue in an adolescent primary care sample. J Adolesc Health 2004;35 (6) 528e.21- 26
PubMed
de Jong  LWPrins  JBFiselier  TJWeemaes  CMMeijer-Van den Bergh  EMBleijenberg  G Chronic fatigue syndrome in young persons [in Dutch]. Ned Tijdschr Geneeskd 1997;141 (31) 1513- 1516
PubMed
Rimes  KAGoodman  RHotopf  MWessely  SMeltzer  HChalder  T Incidence, prognosis, and risk factors for fatigue and chronic fatigue syndrome in adolescents: a prospective community study. Pediatrics 2007;119 (3) e603- e609
PubMed
Jordan  KMLandis  DADowney  MCOsterman  SLThurm  AEJason  LA Chronic fatigue syndrome in children and adolescents: a review. J Adolesc Health 1998;22 (1) 4- 18
PubMed
Stulemeijer  MDe Jong  LWFiselier  TJHoogveld  SWBleijenberg  G Cognitive behaviour therapy for adolescents with chronic fatigue syndrome: a randomized controlled trial [published online ahead of print December 7, 2004]. BMJ 2005;330 (7481) 14
PubMed
Knoop  HStulemeijer  MDe Jong  LWFiselier  TJBleijenberg  G Efficacy of cognitive behavioral therapy for adolescents with chronic fatigue syndrome: a long-term follow-up of a randomized controlled trial. Pediatrics 2008;121 (3) e619- e625
PubMed
Smith  MSMitchell  JCorey  L  et al.  Chronic fatigue in adolescents. Pediatrics 1991;88 (2) 195- 202
PubMed
Rangel  LGarralda  MELevin  MRoberts  H The course of severe chronic fatigue syndrome in childhood. J R Soc Med 2000;93 (3) 129- 134
PubMed
Bell  DSJordan  KRobinson  M Thirteen-year follow-up of children and adolescents with chronic fatigue syndrome. Pediatrics 2001;107 (5) 994- 998
PubMed
Gill  ACDosen  AZiegler  JB Chronic fatigue syndrome in adolescence: a follow-up study. Arch Pediatr Adolesc Med 2004;158 (3) 225- 229
PubMed
Sankey  AHill  CMBrown  JQuinn  LFletcher  A A follow-up study of chronic fatigue syndrome in children and adolescents: symptom persistence and school absenteeism. Clin Child Psychol Psychiatry 2006;11 (1) 126- 138
PubMed
Holmes  GPKaplan  JEGantz  NM  et al.  Chronic fatigue syndrome: a working case definition. Ann Intern Med 1988;108 (3) 387- 389
PubMed
Bell  DSBell  KM Chronic fatigue syndrome: diagnostic criteria. Ann Intern Med 1988;109167
PubMed
van de Putte  EMUiterwaal  CSBots  MLKuis  WKimpen  JLEngelbert  RH Is chronic fatigue syndrome a connective tissue disorder? a cross-sectional study in adolescents. Pediatrics 2005;115 (4) e415- e422
PubMed
van de Putte  EMvan Doornen  LJEngelbert  RHKuis  WKimpen  JLUiterwaal  CS Mirrored symptoms in mother and child with chronic fatigue syndrome. Pediatrics 2006;117 (6) 2074- 2079
PubMed
Vercoulen  JHMMSwanink  CMAFennis  JFMGalama  JMDVan der Meer  JWMBleijenberg  G Dimensional assessment of chronic fatigue syndrome. J Psychosom Res 1994;38 (5) 383- 392
PubMed
van de Putte  EMEngelbert  RHKuis  WKimpen  JLUiterwaal  CS Alexithymia in adolescents with chronic fatigue syndrome. J Psychosom Res 2007;63 (4) 377- 380
PubMed
Landgraf  JM Measuring pediatric outcomes in applied clinical settings: an update about the child health questionnaire (CHQ). Qual Life Newslett MAPI Res Inst 1999;235- 6
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