Chronic Fatigue Syndrome in Childhood and Adolescence

  • Teruhisa Miike
  • David S. Bell


Chronic fatigue syndrome (CFS) in children and adolescents is a complex clinical condition with severe morbidity. It is common, with up to 8% of children and adolescents experiencing fatigue for more than 1 month, and nearly 2% having a CFS-like illness. The hallmark of the condition is activity limitation due to fatigue/exhaustion, and a pattern of somatic symptoms, including headache, sore throat, lymph node tenderness, cognitive difficulties, abdominal pain, and muscle and joint pain. While this pattern may be similar to adult CFS, the expression of these symptoms may differ because of developmental factors and identity formation. A physical examination typically demonstrates minor abnormalities only despite the sometimes marked activity limitation. Routine laboratory studies are similar to those carried out for adult CFS. New research demonstrating abnormalities with cerebral blood flow and tilt-table testing link pediatric CFS with pediatric orthostatic intolerance.

Treatment begins with extensive support in nutrition, education, and social and psychosocial domains, along with symptom reduction, particularly in the areas of pain and sleep. Overall the prognosis is favorable for the majority of children and adolescents with CFS, but complete recovery is rare. It is probable that 20% of pediatric CFS cases evolve into a chronic, lifelong disability.

Research areas include the relation of infection to the development of the syndrome, the differences in symptom patterns in younger children, immunological abnormalities, and blood flow abnormalities, particularly cerebral blood flow. Increased medical-provider education is essential for early recognition and treatment of the condition.


Chronic Fatigue Syndrome Activity Limitation Chronic Fatigue Syndrome Patient Orthostatic Intolerance Symptom Pattern 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Tomoda A, Miike T, Yamada E, Honda H, Moroi T, Ogawa M, Ohtani Y, Morishita S (2000) Chronic fatigue syndrome in childhood. Brain Dev 22:60–64PubMedCrossRefGoogle Scholar
  2. 2.
    Bell DS (1995) Chronic fatigue syndrome in children and adolescents: a review. Focus Opinion: Pediatrics 1:412–420Google Scholar
  3. 3.
    Rowe KS, Rowe KJ (2002) Symptom patterns of children and adolescents with chronic fatigue syndrome. In: Singh NN, Ollendick TH, Singh AN (eds) International perspectives on child and adolescent mental health, vol 2. Elsevier Science, Oxford, pp 395–421Google Scholar
  4. 4.
    Oleske JM, Palumbo D, Sterling J, Evans TL (2002) CFS in children and adolescents. In: John JF, Oleske JM (eds) A consensus manual for the primary care and management of chronic fatigue syndrome. Academy of Medicine of New Jersey, Lawrenceville, pp 51–56Google Scholar
  5. 5.
    Smith MS, Carter BD (2003) Chronic fatigue syndrome in adolescence. In: Jason LA, Fennell PA, Taylor RR (eds) Handbook of chronic fatigue syndrome. Wiley, New York, pp 693–712Google Scholar
  6. 6.
    Jordan KM, Landis DA, Downey MC, Osterman SL, Thurm AE, Jason LA (1998) Chronic fatigue syndrome in children and adolescents: a review. J Adolescent Health 22:4–18CrossRefGoogle Scholar
  7. 7.
    Arav-Boger R, Spirer Z (1995) Chronic fatigue syndrome: pediatric aspects. Isr J Med Sci 31:330–334PubMedGoogle Scholar
  8. 8.
    Tomoda A, Jhodoi T, Miike T (2001) Chronic fatigue syndrome and abnormal biological rhythms in school children. J Chronic Fatigue Syndrome 8:29–37CrossRefGoogle Scholar
  9. 9.
    Buskila D, Press J, Gedalia A, Klein M, Neuman L, Boehm R, Sukenik S (1993) Assessment of nonarticular tenderness and prevalence of fibromyalgia in children. J Rheumatol 20:368–370PubMedGoogle Scholar
  10. 10.
    Kulig JW (1991) Chronic fatigue syndrome and fibromyalgia in adolescence. Adolescence Med: State Art Rev 2:473–484Google Scholar
  11. 11.
    Bell D, Bell K, Cheney P (1994) Primary juvenile fibromyalgia syndrome and chronic fatigue syndrome in adolescents. Clin Inf Dis 18(Suppl 1):S21–S23Google Scholar
  12. 12.
    Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A, and the International Chronic Fatigue Syndrome Study Group (1994) The chronic fatigue syndrome: A comprehensive approach to its definition and study. Ann Intern Med 121:953–959PubMedGoogle Scholar
  13. 13.
    Carruthers B, Jain AK, De Meirlier KL, Peterson DL, Klimas NG, Lerner AM, Bested AC, Flor-Henry P, Joshi P, Powles ACP, van de Sande M (2003) Myalgic encephalomyelitis/chronic fatigue syndrome: clinical working case definition, diagnostic and treatment protocols. J Chronic Fatigue Syndrome 11:1–12Google Scholar
  14. 14.
    Sharpe MC, Archard LC, Banatuala JE, Borysecwicz LK, Clare AW, David A, Edwards RH, Hawton KE, Lambert HP, Lane R (1991) A report. Chronic fatigue syndrome: guidelines for research. J R Soc Med 84:118–121PubMedGoogle Scholar
  15. 15.
    Reeves WC, Lloyd A, Vernon SD, Klimas NG, Jason LA, Bleijenberg G, Evengard B, White PD, Nisenmbaum R, Unger ER (2003) Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution. BMC Health Services Research 3:25. PubMedCrossRefGoogle Scholar
  16. 16.
    De Jong IWAM, Prins JB, Fiselier THJW, Weemaes CMR, Meijer-Van Den Bergh EMM, Bleijenberg G (1997) Chronic fatigue syndrome in youngsters. (Het chronisch vermoeidheidssyndroom bij jongeren.) Ned Tijdschr Geneeskd [Dutch J Med] 141:1513–1516PubMedGoogle Scholar
  17. 17.
    Sigurdsson B, Sigurjonsson J, Sigurdsson J, Thorkelsson J, Gudmundsson KA (1950) Disease epidemic in Iceland simulating poliomyelitis. Am J Hyg 52:222–238PubMedGoogle Scholar
  18. 18.
    Bell DS (1992) Children with ME/CFIDS: overview and review of the literature. In: Hyde B, Goldstein J, Levine P (eds) Myalgic encephalomyelitis. Nightingale Research Foundation, Ottawa, pp 209–218Google Scholar
  19. 19.
    Parish J (1974) Epidemic neuromyasthenia: a reappraisal. J Int Res Commun Med Sci 2:22–26Google Scholar
  20. 20.
    Acheson ED (1959) The clinical syndrome variously called benign myalgic encephalomyelitis, Iceland disease, and epidemic neuromyasthenia. Am J Med 26:569–595PubMedCrossRefGoogle Scholar
  21. 21.
    Bell K, Cookfair D, Bell D, Reese P, Cooper L (1991) Risk factors associated with chronic fatigue syndrome in a cluster of pediatric cases. Rev Inf Dis 13(Suppl 1):S32–38Google Scholar
  22. 22.
    Bell D, Bell K (1989) Chronic fatigue syndrome in childhood: relation to Epstein-Barr virus. In: Ablashi D (ed) Epstein-Barr virus and human disease. Humana Press, Rome, pp 412–417Google Scholar
  23. 23.
    Bell D, Bell K (1988) The post-infectious chronic fatigue syndrome: diagnosis in childhood (Letter). Ann Intern Med 109:167Google Scholar
  24. 24.
    Vernon SD, Whistler T, Cameron B, Hickie I, Reeves W, Lloyd A (2006) Preliminary evidence of mitochondrial dysfunction associated with post-infectious fatigue after acute infection with Epstein-Barr virus. BMC Infect Dis 6
  25. 25.
    Jordan KM, Ayers PM, Jahn SC, Taylor KK, Huang CF, Richman J, Jason LA (2000) Prevalence of fatigue and chronic fatigue syndrome-like illness in children and adolescents. J Chronic Fatigue Syndrome 6:3–21CrossRefGoogle Scholar
  26. 26.
    Mears CJ, Taylor RR, Jordan KM, Binns HJ, Pediatric Research Group (2004) Sociodemographic and symptom correlates of fatigue in an adolescent primary care sample. J Adolescent Health 35:528–533Google Scholar
  27. 27.
    Lloyd AR, Hickie I, Boughton CR, Spencer O, Wakefield D (1990) Prevalence of chronic fatigue syndrome in an Australian population. Med J Austr 153:522–528Google Scholar
  28. 28.
    Dobbins JG, Randall B, Reyes M, Steele L, Livens EA, Reeves WC (1997) The prevalence of chronic fatiguing illnesses among adolescents in the United States. J Chronic Fatigue Syndrome 3:15–27CrossRefGoogle Scholar
  29. 29.
    Dowsett EG, Colby J (1997) Long-term sickness absence due to ME/CFS in UK schools: an epidemiological study with medical and educational implications. J Chronic Fatigue Syndrome 3:29–42CrossRefGoogle Scholar
  30. 30.
    Jones JF, Nisenbaum R, Solomon L, Reyes M, Reeves WC (2004) Chronic fatigue syndrome and other fatiguing illnesses in adolescents: A population-based study. J Adolescent Health 35:34–40Google Scholar
  31. 31.
    Farmer A, Fowler T, Scourfield J, Thapar A (2004) Prevalence of chronic fatigue in children and adolescents. Br J Psychiatr 184:477–481CrossRefGoogle Scholar
  32. 32.
    Komaroff AL, Buchwald D (1991) Symptoms and signs of chronic fatigue syndrome. J Rev Infect Dis 13(Suppl 1):S8–S11Google Scholar
  33. 33.
    Jason L, King CP, Frankenberry EL, Jordan KM, Tyron WW, Rademaker F, Huang CF (1999) Chronic fatigue syndrome: assessing symptoms and activity level. J Clin Psychol 55: 411–424PubMedCrossRefGoogle Scholar
  34. 34.
    Smith MS, Mitchell J, Corey L, Gold D, McCauley EA, Glover D, Tenover F (1991) Chronic fatigue in adolescents. Pediatrics 88:195–202PubMedGoogle Scholar
  35. 35.
    Walford GA, Nelson WM, McCluskey DR (1993) Fatigue, depression, and social adjustment in chronic fatigue syndrome. Arch Dis Child 68:384–388PubMedCrossRefGoogle Scholar
  36. 36.
    Carter BD, Edwards JF, Kronenberger WG, Michalczyk L, Marshall GS (1995) Case control study of chronic fatigue in pediatric patients. Pediatrics 95:179–186PubMedGoogle Scholar
  37. 37.
    Saidi G, Haines L (2006) The management of children with chronic fatigue syndrome-like illness in primary care: a cross-sectional study. Br J Gen Pract 56:43–47PubMedGoogle Scholar
  38. 38.
    Gunn WJ, Connell DB, Randall B (1993) Epidemiology of chronic fatigue syndrome: the centers for disease control study. In: Bock G, Whelan J (eds) Chronic fatigue syndrome. Wiley, New York, pp 83–101CrossRefGoogle Scholar
  39. 39.
    Jordan KM, Kolak AM, Jason LA (1997) Research with children and adolescents with chronic fatigue syndrome: methodologies, designs, and special considerations. J Chronic Fatigue Syndrome 3:3–13CrossRefGoogle Scholar
  40. 40.
    Van Hoof E, Maertens M (2002) No, I am not lazy! A guide for adolescents with CFS/ME and their primary caregivers. (Neen, ik ben niet lui! Een gids voor jongeren met CVS/ME en hun opvoeders.) VUB Press, BrusselsGoogle Scholar
  41. 41.
    Miike T, Tomoda A, Jhodoi T, Iwatani N, Mabe H (2004). Learning and memorization impairment in childhood chronic fatigue syndrome manifesting as school phobia in Japan. Brain Dev 26:442–447PubMedCrossRefGoogle Scholar
  42. 42.
    Tomoda A, Miike T, Honda T, Fukuda K, Kai Y, Nabeshima M, Takahashi M (1995) Singlephoton emission computed tomography for cerebral blood flow in school phobias. Curr Ther Res 56:1088–1093CrossRefGoogle Scholar
  43. 43.
    Furusawa M, Morishita S, Kira M, Takahashi M, Tomoda A, Miike T, Arai N (1998) Evaluation of school refusal with localized proton MR spectroscopy. Asia Ocean J Radiol 3:170–174Google Scholar
  44. 44.
    de Lange F, Kalkman JS, Bleijenberg G, Hagoort P, Werf SP, van der Meer JW, Toni I (2004) Neural correlates of the chronic fatigue syndrome: an fMRI study. Brain 127:1948–1957PubMedCrossRefGoogle Scholar
  45. 45.
    Lange G, Streffner J, Cook D, Bly B, Christodoulou C, Liu W, De Luca J, Natelson BH (2005) Objective evidence of cognitive complaints in chronic fatigue syndrome: a BOLD fMRI study of verbal working memory. NeuroImage 26:513–524PubMedCrossRefGoogle Scholar
  46. 46.
    Barron DF, Cohen BA, Geraghty MT, Violand R, Rowe PC (2002) Joint hypermobility is more common in children with chronic fatigue syndrome than in healthy controls. J Pediatr 141:421–425PubMedCrossRefGoogle Scholar
  47. 47.
    Rowe PC, Barron DF, Calkins H, Maumenee IH, Tong PY, Geraghty MT (1999) Orthostatic intolerance and chronic fatigue syndrome associated with Ehlers-Danlos syndrome. J Pediatr 135:494–499PubMedCrossRefGoogle Scholar
  48. 48.
    van de Putte EM, Uiterwaal CSPM, Bots ML, Kuis W, Kimpen JLL, Engelbert RHH (2005) Is chronic fatigue syndrome a connective tissue disorder? A cross-sectional study in adolescents. Pediatrics 115:e415–e422PubMedCrossRefGoogle Scholar
  49. 49.
    Spence V, Stewart J (2004) Standing up for ME. Biologist 51:65–70Google Scholar
  50. 50.
    Yamaguchi H, Tanaka H, Adachi K, Mino M (1996) Beat-to-beat blood pressure and heart rate responses to active standing in Japanese children. ACTA Paediatr 85:577–583PubMedCrossRefGoogle Scholar
  51. 51.
    Rowe P, Bou-Holaigh I, Kan J, Calkins H (1995) Is neurally mediated hypotension an unrecognized cause of chronic fatigue? Lancet 345:623–625PubMedCrossRefGoogle Scholar
  52. 52.
    Stewart JM, Gewitz MH, Weldon A, Munoz J (1999) Patterns of orthostatic intolerance: the orthostatic tachycardia syndrome and adolescent chronic fatigue. J Pediatr 135:218–225PubMedCrossRefGoogle Scholar
  53. 53.
    Tanaka H, Yamaguchi H, Matushima R, Tamai H (1999) Instantaneous orthostatic hypotension in children and adolescents: A new entity of orthostatic intolerance. Pediatr Res 46:691–696PubMedCrossRefGoogle Scholar
  54. 54.
    Iwatani N, Miike T, Kai Y, Kodama M, Mabe H, Tomoda A, Fukuda K, Jhodoi T (1997) Gluco-regulatory disorders in school refusal students. Clin Endocrinol 47:273–278CrossRefGoogle Scholar
  55. 55.
    Itoh Y, Fukunaga Y, Igarashi T, Imai T, Yoshida J, Tsuchiya M, Fujino O, Murakami M, Yamamoto M (1998) Autoimmunity in chronic fatigue syndrome in children. Jpn J Rheumatol 8:429–437CrossRefGoogle Scholar
  56. 56.
    Yoshiuchi K, Farkas J, Natelson BH (2006) Patients with chronic fatigue syndrome have reduced absolute cortical blood flow. Clin Physiol Funct Imaging 26:83–86PubMedCrossRefGoogle Scholar
  57. 57.
    Bou-Holaigh I, Rowe P, Kan J, Calkins H (1995) The relationship between neurally mediated hypotension and the chronic fatigue syndrome. JAMA 274:961–967CrossRefGoogle Scholar
  58. 58.
    Stewart J, Weldon A, Arlievsky N, Li K, Munoz J (1998) Neurally mediated hypotension and autonomic dysfunction measured by heart rate variability during head-up tilt testing in children with chronic fatigue syndrome. Clin Autonom Res 8:221–230CrossRefGoogle Scholar
  59. 59.
    Stewart J (2001) Orthostatic intolerance: a review with application to the chronic fatigue syndrome. J Chronic Fatigue Syndrome 8:45–64CrossRefGoogle Scholar
  60. 60.
    Grubb B, Karas B (1999) Clinical disorders of the autonomic nervous system associated with orthostatic intolerance: an overview of classification, clinical evaluation and management. Pacing Clin Electrophysiol 22:798–810PubMedCrossRefGoogle Scholar
  61. 61.
    Rodriguez R, Snider K, Cornel G, Teixeira OHP (1999) Cerebral blood flow velocity during tilt-table test for pediatric syncope. Pediatrics 104:237–242PubMedCrossRefGoogle Scholar
  62. 62.
    Streeten D, Thomas D, Bell D (2000) The roles of orthostatic hypotension, orthostatic tachycardia, and subnormal erythrocyte volume in the pathogenesis of the chronic fatigue syndrome. Am J Med Sci 320:1–8PubMedCrossRefGoogle Scholar
  63. 63.
    Carter BD, Kronenberger WG, Edwards JF, Michalczyk L, Marshall GS (1996) Differential diagnosis of chronic fatigue in children: behavioral and emotional dimensions. J Dev Behav Pediatr 17:16–21PubMedCrossRefGoogle Scholar
  64. 64.
    Solnit AJ, Provence S, Schowalter M (1987) Psychological development: from health to illness. In: Rudolphe AM, Hoffman JIE (eds) Pediatrics, 18th edn. Appleton & Lange, Norwalk, pp 53–54Google Scholar
  65. 65.
    American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, Washington, DCGoogle Scholar
  66. 66.
    Johnson S, DeLuca J, Natelson B (1996) Assessing somatization disorder in the chronic fatigue syndrome. Psychosom Med 58:50–57PubMedGoogle Scholar
  67. 67.
    Knook L, Kavelaars A, Sinnema G, Kuis W, Heijnen C (2000) High nocturnal melatonin in adolescents with chronic fatigue syndrome. J Clin Endocrinol Metab 85:3690–3692PubMedCrossRefGoogle Scholar
  68. 68.
    Sankey A, Hill C, Brown J, Quinn L, Fletcher A (2006) A follow-up study of chronic fatigue syndrome in children and adolescents: symptom persistence and school absenteeism. Clin Child Psychol Psychiatr 11:126–138CrossRefGoogle Scholar
  69. 69.
    Stulemeijer M, de Jong L, Fiselier T, Hoogveld S, Bleijenberg G (2005) Cognitive behavior therapy for adolescents with chronic fatigue syndrome: randomized controlled trial. BMJ 330:14–25PubMedCrossRefGoogle Scholar
  70. 70.
    Richards J (2000) Chronic fatigue syndrome in children and adolescents: a review article. Clin Child Psychol Psychiatr 5:31–51CrossRefGoogle Scholar
  71. 71.
    Dale JK, Straus SE (1992) The chronic fatigue syndrome: considerations relevant to children and adolescents. Adv Pediatr Infect Dis 7:63–83PubMedGoogle Scholar
  72. 72.
    Gill AC, Dosen A, Ziegler JB (2004) Chronic fatigue syndrome in adolescents: a follow-up study. Arch Pediatr Adolescent Med 158:225–229CrossRefGoogle Scholar
  73. 73.
    Feder HM, Dworkin PH, Orkin C (1994) Outcome of 48 pediatric patients with chronic fatigue: a clinical experience. Arch Fam Med 3:1049–1055PubMedCrossRefGoogle Scholar
  74. 74.
    Marshall GS, Gesser RM, Yamanishi K, Starr SE (1991) Chronic fatigue in children: clinical features, Epstein-Barr virus, and human herpes virus 6 serology and long-term follow-up. Pediatr Inf Dis J 10:287–290Google Scholar
  75. 75.
    Krilov LR, Fisher M, Friedman SB, Reitman D, Mandel FS (1998) Course and outcome of chronic fatigue in children and adolescents. Pediatrics 102:360–366PubMedCrossRefGoogle Scholar
  76. 76.
    Bell D, Jordan K, Robinson M (2001) Thirteen-year follow-up of children and adolescents with chronic fatigue syndrome. Pediatrics 107:994–998PubMedCrossRefGoogle Scholar

Copyright information

© Springer 2008

Authors and Affiliations

  • Teruhisa Miike
    • 1
  • David S. Bell
    • 2
  1. 1.Faculty of Medical and Pharmaceutical SciencesKumamoto University Graduate SchoolKumamotoJapan
  2. 2.State University of New York at BuffaloLyndonvilleUSA

Personalised recommendations