Adolescent Health Care: A Practical Guide
Fatigue and the Chronic Fatigue Syndrome
The complaint of fatigue is common among adolescents. In studies of teenagers, up to 70% indicate that they are sleepy during the day (Hansen et al., 2005). In most instances, fatigue in adolescence is due to a deficit in hours of sleep. Accordingly, most adolescents sleep more on weekends, when they have time for catch-up, than they do during the week, when they are usually scheduled with multiple activities. In some instances, however, fatigue can be due to medical or psychological causes. The key to the evaluation of the adolescent with fatigue is to distinguish those cases that need merely reassurance and perhaps a change in schedule, from those who require further management for organic or psychiatric disorders or who are exhibiting signs and symptoms of the chronic fatigue syndrome (CFS).
Causes of Fatigue
Adolescent Sleep Patterns
The most common cause for fatigue in adolescents is insufficient sleep. Recent studies have demonstrated the following:
- Total sleep duration decreases from a mean of 10.1 hours at 9 years of age to a mean of 8.1 hours at 16 years (Iglowstein et al., 2003).
- Adolescents sleep as much as 2 hours less per night on weekdays during the school year than during the summer; weekend sleep is an average of 30 minutes more per night during the school year (Hansen et al., 2005).
- Fifteen percent of adolescents report falling asleep in the car or bus on the way to school; 25% report falling asleep on the way home (Lee et al., 1999).
- As adolescence progresses, bedtimes get later on both school days and nonschool days; wake-up times on weekends and holidays also get later (Millman, 2005).
In adolescents, psychological causes are responsible for most cases of fatigue that is unrelated to too little sleep and/or too much activity. Psychological causes of fatigue include:
- Stressful situations
- Other psychiatric disorders
Organic causes of fatigue are infrequent during adolescence, but the differential diagnosis is very broad. Fatigue may result from any of the following:
- Medications, illicit drugs, and poisonings
- Antihistamines, sedatives
- Alcohol, drug use
- Other medications (including antidepressants and other psychotropic medications)
- Heavy metal intoxication
- Infectious diseases
- Mononucleosis (see Chapter 29)
- Hepatitis (see Chapter 30)
- Influenza, mycoplasma (see Chapter 29)
- Cytomegalovirus, parvovirus infections
- Chronic infectious diseases, for example, human immunodeficiency virus (HIV), tuberculosis, Lyme disease, brucellosis
- Bacterial endocarditis
- Parasitic infections
- Endocrine disorders
- Hypothyroidism, hyperthyroidism (see Chapter 9)
- Diabetes mellitus, hypoglycemia
- Addison disease, Cushing syndrome
- Hypopituitarism, hypoparathyroidism
- Systemic illness
- Connective tissue diseases
- Congenital heart disease
- Inflammatory bowel disease
- Renal failure
- Liver failure
Although still relatively uncommon, sleep disorders are increasingly being recognized as a cause of fatigue and/or daytime sleepiness in adolescents. Included in this category are those with:
- Insomnia—Defined as decreased sleep quality and/or quantity due to trouble falling asleep and/or maintaining sleep. Insomnia can be:
- A symptom of an underlying medical or psychological disorder
- Due to no readily apparent cause, referred to as psychophysiological insomnia
- Part of a delayed sleep phase syndrome (DSPS), “a circadian based disorder in which an individual's internal circadian pacemaker is not in synchrony with internal or environmental time.” DSPS is thought to occur in up to 7% of adolescents (Millman, 2005).
- Obstructive sleep apnea (also referred to as sleep disordered breathing, SDB) occurs in up to 1% to 3% of adolescents (Millman, 2005).
- Most commonly caused by enlarged tonsils and adenoids
- Increasingly being reported in obese adolescents
- Can also be due to retrognathia or nasal obstruction
- Other sleep disorders, which are uncommon but which can occasionally be seen in adolescents include the following:
- Idiopathic hypersomnia
- “Periodic leg movements during sleep”
- “Restless leg syndrome”
Chronic Fatigue Syndrome
CFS is a poorly understood and often controversial diagnosis that is seen mostly in adults but has increasingly been reported in adolescents. It involves chronic and debilitating fatigue seen in association with other symptoms. Details of this syndrome, as seen in adolescents, are as follows:
The Centers for Disease Control and Prevention has developed a working definition of CFS (Fukuda et al., 1994):
- Fatigue of at least 6 months duration
- Limits the individual to 50% of premorbid activity levels
- May be persistent or recurrent
- No other cause found to account for the fatigue
- Additional symptoms (four or more are required to meet the criteria for CFS)
- Recurrent pharyngitis
- Tender lymph nodes
- New-onset headaches
- Impaired memory or concentration
- Joint pains
- Muscle pains
- Nonrefreshing sleep
- Postexertion fatigue
Studies in adults and adolescents have shown the following:
Patients often have many symptoms of CFS simultaneously. One study of 59 children and adolescents showed the following symptoms (Krilov et al., 1998):
No specific etiology has been determined to be the cause of the CFS. Many possibilities have been considered. It is likely that the underlying cause may be a combination of factors, including an acute infectious illness that acts as a precipitant, a background of psychological distress, and an underlying physiological vulnerability (in the cardiovascular, neurological, endocrine, and/or immune systems). It is also likely that no two individuals with CFS have exactly the same relative ratio in the combination of underlying factors. Etiologies that have been considered include the following:
- Several infectious diseases, most notably Epstein-Barr virus (EBV) infection and influenza, can serve as the precipitant for the onset of CFS. In other parts of the world, other viral infections have been implicated as triggers for CFS.
- Any acute illnesses can cause an exacerbation of symptoms during the course of the syndrome.
- No specific infectious agent has been found to account for continuation of the symptoms.
- Cardiovascular system
- Orthostatic symptoms are common in patients with CFS (Stewart et al., 1999a).
- Tilt-table testing is often positive in patients with CFS.
- Underlying cardiovascular instability, in those with a tendency toward hypotension, may be a factor in the cause of CFS.
- Endocrine system
- Decreased hypothalamic-pituitary-adrenal axis function has been suspected as an etiology in CFS but never clearly documented (McKenzie et al., 1998).
- No other endocrine disorders have been consistently demonstrated in CFS.
- Headaches and impaired cognition are prominent symptoms in many patients with CFS.
- Computed tomography (CT) scans and magnetic resonance imaging (MRI) do not show abnormalities in patients with CFS.
- No other reproducible neurological abnormalities have been found to be a cause of CFS.
- Immune function
- Studies have shown in vitroabnormalities in lymphocyte function and cytokine production in CFS (Conti et al., 1998).
- Reproducible abnormalities and opportunistic infections have not been found.
- Treatment with immunoglobulins and other immune modulators have not shown clear benefits in CFS.
- A history of depression is found in many adults with CFS; depression may create a psychological vulnerability necessary for the onset of CFS.
- Depression may be one physiological consequence of changes in the brain that occur in CFS.
- Depression may be a natural reaction to feeling ill and fatigued for a long time.
- Some have suggested that CFS is merely an alternate expression of depression.
- There is substantial overlap in the symptoms of CFS and depression leading to the possibility that some patients with depression will be misdiagnosed as having CFS and vice versa.
- Other psychological variables
- Separation anxiety and/or school phobia may be a factor in some children and adolescents with CFS.
- Some have considered CFS to be in the realm of conversion reaction.
- Psychosomatic symptoms may be found premorbidly in some children and adolescents with CFS.
Evaluation of Fatigue
Evaluation of the adolescent with a complaint of fatigue is aimed at distinguishing those who are merely not getting enough sleep from those who may have a specific disorder of sleep or other psychological or medical causes. A complete history and thorough physical examination, selected laboratory tests, and occasionally other studies, are performed.
The history is geared toward evaluating the adolescents' sleep patterns and activity levels; looking for evidence of medical, psychological, or sleep disorders; and determining whether a diagnosis of CFS may apply:
- Sleep patterns and activity levels
- Hours of sleep at night, naps during the day
- Time going to sleep, time arising
- Difficulty falling asleep, waking up during the night
- Patterns on weekdays, patterns on weekends
- School schedule, out-of-school schedule
- Alcohol use, illicit drug use
- Dietary patterns, caffeine intake
- Medical history
- Past medical history, review of systems
- Medications: over the counter, prescription
- History of fever, weight loss, night sweats
- Symptoms consistent with endocrinopathy, infection, or neoplastic process
- Snoring in patient or family, unexplained leg movements
- Psychological history
- Relationships with family and friends
- School performance and attitude
- Evidence of depression and/or anxiety
- Signs of stress at home or in school
- Psychiatric disorders in patient or family
- Acting out behaviors, social withdrawal
- Criteria for diagnosis of CFS
- Fatigue persists for >6 months
- Activity is limited to <50% of premorbid levels
- Accompanying symptoms present
- No other cause of fatigue
- Fatigue on exertion, nonrefreshing sleep
Fatigue associated with nonorganic causes is usually accompanied by normal physical examination results. Important areas to examine include the following:
- General appearance: Evidence of chronic illness
- Height, weight, and body mass index (BMI)
- Lymph nodes: Evidence of adenopathy
- Thyroid gland: Presence of goiter
- Cardiac: Evidence of abnormal heart murmur
- Abdomen: Hepatosplenomegaly
- Extremities: Evidence of arthritis, rash
- Sexual maturity rating: Puberty advancement normal or not
- Mental status examination to identify abnormalities in mood, intellectual function, memory, and personality—in particular, signs of depression or anxiety
Laboratory Testing and Other Studies
- Screening tests: Most adolescents with fatigue will have to undergo baseline screening tests consisting of:
- Complete blood count, erythrocyte sedimentation rate
- Comprehensive metabolic panel (electrolytes, liver, kidneys)
- T4and thyrotropin (TSH)
- Mononucleosis testing (Monospot/heterophile ± EBV titers)
- Additional tests: As called for, based on the history and physical examination, other tests may include:
- Tuberculosis testing (purified protein derivative [PPD])
- Electrocardiogram (ECG), chest x-ray
- Sinus x-rays
- HIV testing
- Antinuclear antibody (ANA)/rheumatoid factor (RF)
- Cortisol level
- Lyme titers (in endemic areas or with a positive travel history)
- Other studies
- Sleep studies (polysomnography) may be performed in a sleep laboratory if a sleep disorder is suspected.
- Tilt-table testing may be considered in those with orthostatic symptoms, especially in CFS. However, caution is required in interpreting tilt-table testing because positive results are frequent in adolescence and are nonspecific.
- Neurological studies (MRI or CT of the brain) may be necessary in those with headaches or other accompanying symptoms.
General Causes of Fatigue
Guiding and managing the adolescent with fatigue follows directly from determination of the cause of the fatigue:
- Adolescent sleep patterns
- Reassurance that there are no medical or psychological problems may be provided.
- Guidance regarding more appropriate sleep patterns and day time schedules may be offered.
- Changing school start times are being considered in some local and national discussions.
- Medical and psychological causes
- Patients with mononucleosis are encouraged to return to school as soon as they are able and they should not participate in contact sports to avoid the potential of splenic rupture (see Chapter 29).
- Appropriate treatment is provided to those with other medical causes of fatigue.
- Psychological treatment is provided to those with stress, depression, anxiety, or other psychological disorders.
- Sleep disorders
- Guidance on changing sleeping patterns is provided to those with the DSPS (Table 35.1). Both the 1-day and 1-week plans require significant motivation to be successful.
- Use of melatonin and/or bright lights have been studied for the treatment of DSPS, but results are inconsistent, these approaches must be used with caution, they are not yet widely accepted, and effects do not appear to be long lasting (Millman, 2005).
- Sleep studies may be performed in those with suspected sleep disorders.
- Use of continuous positive airway pressure (CPAP) and/or orthodontic appliances at night, may help some adolescents with obstructive sleep apnea syndromes.
Chronic Fatigue Syndrome
No specific treatment has been found to shorten the course of CFS in adolescents; however, certain management approaches can help adolescents and their families cope better with the illness and decrease morbidity associated with CFS. They include the following:
- Explanation and reassurance
- Provide a detailed explanation of CFS (including etiology and management, course and outcome).
- Reassure patients and families that symptoms are real and generally improve with time.
- Guide families on minimizing “doctor shopping,” unnecessary testing, and unproven therapies.
- Do not turn CFS into a chronic illness with secondary problems and secondary gain.
- Emphasize that the prognosis for adolescent CFS has generally been shown to be substantially better than the prognosis for adult CFS.
- Symptomatic treatment
- Antidepressant medication may be used to decrease symptoms of depression in CFS but studies do not show that they change the course or outcome of the illness.
- Anti-inflammatory medications can be used for treatment of symptoms; medications for sleep should be used sparingly.
- Patients with neurally mediated hypotension and/or a positive tilt-test result may benefit from medication—an α-agonist or β-blocker, fludrocortisone, or an increase in salt and water intake.
- Multiple vitamins, minerals, herbs, and supplements have been tried in patients with CFS without definitive benefits.
- Lifestyle changes and coping skills
- Many adolescents with CFS require home tutoring or partial school programs to function educationally.
- Studies have shown graded exercise programs to be beneficial in some adolescents with CFS (Viner et al., 2004).
- Patients and families need to develop realistic expectations while an adolescent is experiencing the symptoms of CFS.
- Psychological management
- Studies have shown cognitive-behavioral therapy to provide benefit for some adolescents with CFS (Whiting et al., 2000).
- Individual and/or family therapy may also be helpful (Krilov and Fisher, 2002).
- Self-help groups may be more appropriate for adults than for adolescents.
- Follow-up care
- Follow-up visits are provided (every 3–6 weeks) to monitor physical symptoms and psychological issues and to provide on-going guidance and reassurance.
- Although adolescents with CFS generally improve over time, exacerbations may be caused by intercurrent illness, a change in schedule or stressful situations.
- Studies have shown that more than 80% of adolescents with CFS have significant improvement within 1 to 3 years of onset of illness; this contrasts with adults who generally have a longer course and worse prognosis (Krilov et al., 1998).
http://www.cdc.gov/ncidod/diseases/cfs/index.htm. The CDC Web site for CFS.
http://www.cfids.org. Chronic Fatigue and Immune Dysfunction Syndrome Association of America has information for patients and families. To receive information, call its resource line at 704-365-2343, or send e-mail at email@example.com.
http://www.niaid.nih.gov/publications/cfs.htm. NIH state of the art consultation.
References and Additional Readings
Bates DW, Buchwald D, Lee J. Clinical laboratory test findings in patients with chronic fatigue syndrome. Arch Intern Med 1995;155:97.
Bates DW, Schmitt W, Buchwald D, et al. Prevalence of fatigue and chronic fatigue syndrome in a primary care practice. Arch Intern Med 1993;153:2759.
Blacker CVR, Greenwood DT, Wesnes KA, et al. Effect of galantamine hydrobromide in chronic fatigue syndrome. A randomized controlled trial. JAMA 2004;292:1204.
Carter BD, Edwards JF, Kronenberger WG, et al. Case control study of chronic fatigue in pediatric patients. Pediatrics 1995;95:179.
Cho WK, Stollerma GIL. Chronic fatigue syndrome. Hosp Pract 1992;27:221.
Conti F, Pittoni V, Sacerdote P, et al. Decreased immuno-reactive beta-endorphin in mononuclear leucocytes from patients with chronic fatigue syndrome. Clin Exp Rheumatol1998;16:729.
Czeisler CA, Richardson GS, Coleman RM, et al. Chronotherapy: resetting the circadian clocks of patients with delayed sleep phase insomnia. Sleep 1981;4:1.
Dale JK, Strauas SE. The chronic fatigue syndrome: considerations relevant to children and adolescents. Adv Pediatr Infect Dis 1992;7:63.
Demitrack MA. Chronic fatigue syndrome and fibromyalgia: dilemmas in diagnosis and clinical management. Psychiatr Clin North Am 1998;21:71.
Epstein KR. The chronically fatigued patient. Med Clin North Am 1995;79:315.
Evengard B, Schacterie RS, Komaroff AL. Chronic fatigue syndrome: new insights and old ignorance. J Intern Med 1999;246:455.
Feder HM, Dworkin PH, Orkin C. Outcome of 48 pediatric patients with chronic fatigue: a clinical experience. Arch Fam Med 1994;3:1049.
Forsyth LM, Preuss HG, MacDowell AL, et al. Therapeutic effects of oral NADH on the symptoms of patients with chronic fatigue syndrome. Ann Allergy Asthma Immunol1999;82:185.
Fukuda K, Straus SE, Hickie I, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994;121:953.
Gill AC, Dosen A, Ziegler JB. Chronic fatigue syndrome in adolescents: a follow-up study. Arch Pediatr Adolesc Med 2004;158:225.
Goodnick PJ, Sandoval R. Psychotropic treatment of chronic fatigue syndrome and related disorders. J Clin Psychiatry 1993;54:13.
Guilleminault C, Lee JH, Chan A. Pediatric obstructive sleep apnea syndrome. Arch Pediatr Adolesc Med 2005;159:775.
Haines LC, Saidi G, Cooke RW. Prevalence of severe fatigue in primary care. Arch Dis Child 2005;90(4):367.
Hansen M, Janssen I, Zee P, et al. The impact of school daily schedule on adolescent sleep. Pediatrics 2005;115:1555.
Iglowstein I, Jenni OG, Molinari L, et al. Sleep duration from infancy to adolescence: reference values and generational trends. Pediatrics 2003;111:302.
Jain S, DeLisa J. Chronic fatigue syndrome: a literature review from a psychiatric perspective. Am J Phys Med Rehabil 1998;77(2):160.
Jason LA, Jordan KM, Richman JA, et al. A community-based study in prolonged fatigue and chronic fatigue. J Health Psychol 1999;4:9.
Jordan K, Landis D, Downey M, et al. Chronic fatigue syndrome in children and adolescents: a review. J Adolesc Health 1998;22:4.
Krilov LR, Fisher M. Chronic fatigue syndrome in youth: maybe not so chronic after all. Contemp Pediatr 2002;19:61.
Krilov L, Fisher M, Friedman S, et al. Course and outcome of chronic fatigue in children and adolescents. Pediatrics 1998;102:360.
Lee KA, McEnany G, Weekes D. Gender differences in sleep patterns for early adolescents. J Adolesc Health 1999;24:16.
Marshall GS. Report of a workshop on the epidemiology, natural history, and pathogenesis of chronic fatigue syndrome in adolescents. J Pediatr 1999;134:395.
McKenzie R, O'Fallen A, Dale J, et al. Low dose hydrocortisone for treatment of chronic fatigue syndrome. JAMA 1998;280:1061.
Melnick A. When an adolescent is tired all the time. Consultant 1981;July:150.
Mercer PW, Merritt SL, Cowell JM. Differences in reported sleep need among adolescents. J Adol Health 1998;23:259.
Millman RP. Working Group on Sleepiness in Adolescents/Young Adults, American Academy of Pediatrics Committee on Adolescence. Excessive sleepiness in adolescents and young adults: causes, consequences, and treatment strategies. Pediatrics 2005;115:1774.
Morehouse RL, Flanigan M, MacDonald DD, et al. Depression and short REM latency in subjects with chronic fatigue syndrome. Psychosom Med 1998;60:347.
Natelson BH. Chronic fatigue syndrome. JAMA 2001;285:2557.
Nisenbaum R, Reyes M, Mawle AC, et al. Factor analysis of unexplained fatigue and interrelated symptoms: overlap with criteria for chronic fatigue syndrome. Am J Epidemiol1998;148:72.
Peterson PK, Pheley A, Schroeppel J, et al. A preliminary placebo-controlled crossover trial of fludrocortisone for chronic fatigue syndrome. Arch Intern Med 1998;158:914.
Powell P, Bentall RP, Nye FJ, et al. Randomized controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome. Br Med J 2001;322:387.
Prins JB, van der Meer JW, Bleijenberg G. Chronic fatigue syndrome. Lancet 2006;367:346.
van de Putte EM, Uiterwaal CS, Bots ML, et al. Is chronic fatigue syndrome a connective tissue disorder? A cross-sectional study in adolescents. Pediatrics 2005;115(4):e415.
Rangel L, Garralda E, Levin M, et al. Personality in adolescents with chronic fatigue syndrome. Eur Child Adolesc Psychiatry 2000;9:39.
Reid S, Chalder T, Cleare A, et al. Chronic fatigue syndrome. Br Med J 2000;320:292.
Rowe PC. Orthostatic intolerance and chronic fatigue syndrome: new light on an old problem. J Pediatr 2002;140:387.
Rowe PC, Bou-Holaigah I, Kan JS, et al. Is neurally mediated hypotension an unrecognized cause of chronic fatigue? Lancet 1995;345:623.
Rowe PC, Calkins H, DeBusk K, et al. Fludrocortisone acetate to treat neurally mediated hypotension in chronic fatigue syndrome. JAMA 2001;285:52.
Ruffin MT, Cohen M. Evaluation and management of fatigue. Am Fam Physician 1994;50:625.
Sharpe M. Chronic fatigue syndrome. Psychiatr Clin North Am 1996;19:549.
Smith MS. Adolescent chronic fatigue syndrome. Arch Pediatr Adolesc Med 2004;158:207.
Smith MS, Mitchell J, Corey L, et al. Chronic fatigue in adolescents. Pediatrics 1991;88:195.
Stewart J, Gewitz M, Weldon A, et al. Orthostatic intolerance in adolescent chronic fatigue syndrome. Pediatrics 1999a;103:116.
Stewart J, Gewitz M, Weldon A, et al. Patterns of orthostatic intolerance: the orthostatic tachycardia syndrome and adolescent chronic fatigue. J Pediatr 1999;135:218.
Stones G, Fry A, Crawford C. Sleep abnormalities demonstrated by home polysomnography in teenagers with chronic fatigue syndrome. J Psychosam Res 1998;45:85.
Strauss SE. Pharmocotherapy of chronic fatigue syndrome: another gallant attempt. JAMA 2004;292:1234.
Tanaka H, Matsushima R, Tamai H, et al. Impaired postural cerebral hemodynamics in young patients with chronic fatigue with and without orthostatic intolerance. J Pediatr2002;140:412.
Tillet A, Glass S, Reeve A, et al. Provision of health and education services in school children with chronic fatigue syndrome. Ambul Child Health 2000;6:83.
Vercoulen JH, Swanink CM, Zitman FG, et al. Randomized, double-blind, placebo-controlled study of fluoxetine in chronic fatigue syndrome. Lancet 1996;347:858.
Vereker MI. Chronic fatigue syndrome: a joint pediatric-psychiatric approach. Arch Dis Child 1992;67:550.
Viner R, Gregorowski A, Wine C, et al. Outpatient rehabilitation treatment of chronic fatigue syndrome. Arch Dis Child 2004;89:615.
Whiting P, Bagnall A-M, Sowden AJ, et al. Interventions for the treatment and management of chronic fatigue syndrome: a systematic review. JAMA 2000;286:1360.
Wilson A, Hickie I, Lloyd A, et al. Longitudinal study of outcome of chronic fatigue syndrome. Br Med J 1994;308:756.
Wright JB, Beverley DW. Chronic fatigue syndrome. Arch Dis Child 1998;79:368.