1.Overview and definition

Orthostatic dysregulation (OD) is characterized by symptoms such as headaches, dizziness, and fatigue upon standing. It results from impaired autonomic regulation of the circulatory system, such as blood pressure and heart rate. OD commonly develops during adolescence, and symptoms are often more severe in the morning, which potentially interferes with school activities. Severe OD can lead to school refusal or social withdrawal, resulting in significant challenges in social reintegration.

OD affects approximately 10% of junior high school students, including mild cases, making it a common condition in children. It is implicated in 30%–40% of school refusal cases, highlighting the need for support from families and schools. Appropriate management requires severity-based treatment from the onset, along with environmental adjustments at home and in school settings.

Causes of OD include (1) impaired autonomic compensatory mechanisms to regulate circulatory changes upon standing, (2) insufficient or excessive sympathetic nervous system activity, (3) insufficient fluid intake, (4) psychosocial stress (symptoms worsen owing to the pressure of having to attend school despite physical discomfort), and (5) decreased daily activity (muscle weakness and impaired autonomic function → excessive blood pooling in the lower body → deconditioning leading to reduced cardiac output and cerebral blood flow further exacerbates symptoms).

2.Symptoms

OD symptoms include headache, lightheadedness upon standing, dizziness, difficulty waking in the morning, fatigue, decreased appetite, and fainting. Symptoms tend to be more severe in the morning and milder in the afternoon. They also worsen when standing or sitting and improve when lying down. A characteristic feature is sensitivity to atmospheric pressure changes, such as before rain. Nighttime wakefulness prevents sleep, leading to delayed waking. Severe cases can result in a reversed day-to-night sleep pattern.

3.Diagnostic steps

 1) OD is suspected if ≥3 of the following symptoms are present, or if ≥2 symptoms are severe: lightheadedness, fainting, malaise, difficulty waking up in the morning, headache, abdominal pain, palpitations, feeling worse in the morning and recovering in the afternoon, loss of appetite, motion sickness, or poor complexion.

 2) Underlying conditions such as iron deficiency anemia, heart disease, neurological disorders (such as epilepsy), or endocrine disorders (such as thyroid diseases) are ruled out.

 3) The new orthostatic test is conducted to determine the OD subtype: instantaneous orthostatic hypotension, postural tachycardia syndrome, vasovagal syncope, delayed orthostatic hypotension. In recent years, new subtypes such as cerebral hypoperfusion and hyper-response have been reported; however, special equipment is required for diagnosis.

 4) Severity is assessed based on both new orthostatic test results and daily living conditions.

 5) Psychosocial involvement is assessed using the “OD as a psychosomatic disorder” checklist (refer to guidelines).

4.Treatment

Treatment includes the following based on physical severity and the presence of psychosocial involvement:

1) Patient education

Many children feel anxious because they do not understand the cause of their symptoms. Conversely, many family members tend to view OD symptoms as psychological or emotional issues, often interpreting them negatively, such as thinking the child is lazy. This becomes a psychological stressor for the child, which worsens OD symptoms via the autonomic nervous system.

Carefully explaining to both the parents and children that OD is a physical illness can reduce their anxiety.

 2) Nonpharmacological treatment

These included standing up slowly while keeping the head down, not standing for more than 1–2 min, crossing legs even for short periods, aiming for 1.5–2 L of fluid intake per day and adding 3 g of salt to usual diet, walking for approximately 30 min daily to prevent muscle weakness, and maintaining a regular daily rhythm, such as going to bed early and waking up early.

3) Contact with school personnel

This involves enhancing school staff’s understanding of OD and establishing support systems for children with OD.

4) Medications

Medications (such as midodrine) can be prescribed after nonpharmacological therapies. However, medication alone is ineffective.

5) Environmental modification

To prevent children from being harmed by misunderstanding and becoming isolated due to distrust, awareness and understanding of OD among families and schools is essential.

6) Psychotherapy

Listening to the child’s distress over physical symptoms, anxiety about academic performance, and hurt feelings caused by negative reactions and other’s lack of understanding and acceptance fosters a sense of being understood and promotes the development of trust.

In mild cases without impairment of daily life, appropriate treatment typically leads to improvement within 2–3 months. Conversely, severe cases involving prolonged school absence require 2–3 years or longer for social reintegration.

5.Comorbid conditions

1) Physical conditions such as headaches (migraine and tension-type headache), functional gastrointestinal disorders (nausea, abdominal pain, constipation, and diarrhea related to gastrointestinal motility), and sleep disorders (difficulty falling asleep, difficulty waking in the morning, and reversed sleep–wake cycles).

2) Psychological/behavioral aspects, such reduced concentration and cognitive function owing to decreased cerebral blood flow, neurodevelopmental disorders, anxiety disorders, depression, internet gaming disorder, and school refusal.

YOSHIDA, Seiji

Yoshida children’s clinic for body and mind