Emotional Aspects of Physical Illness in Children and Adolescents

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Emotional Aspects of Physical Illness in
Children and Adolescents
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Overview

• Scope of Topic
• Relevance for Physicians
• Spectrum of Emotional Responses to Illness
• Conceptual Framework
• Mediating Factors
• Psychological Aspects of Selected Illnesses
• Guidelines for Evaluation and Management

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Scope of Topic

• Acute Minor Illnesses and Injuries Universal
  Childhood Experiences
• Chronic Physical Illnesses 10 to 15 of children
  will experience before age 18
• Emotional-psychological aspects are present
  across all age groups and illnesses

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Psychological Aspects of Illness

• Emotions
• Behaviors
• Cognitive States
• Psychiatric Disorders

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Relevance for Physicians

• Diagnosis
• Treatment
• Screening for Psychiatric Disorders

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Role of Psychological Factors in Diagnosis and
Treatment

• History - Symptom Reporting
• Physical Exam
• Blood Drawing
• Other Diagnostic Procedures
• Treatment
• Compliance vs. Non-Compliance

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Emotional Responses to Illness

• Anxiety - Fear - Panic
• Sadness - Despair - Hopelessness
• Irritability - Anger - Rage
• Passivity - Helplessness
• Relief - Happiness - Mania

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Problematic Behaviors in Response to Illness

• Withdrawal - Social Isolation - School Refusal
• Oppositional Behavior - Tantrums - Aggression
• Head-banging - Self-Mutilation - Suicide
• Attention-Seeking Behaviors

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Potential Cognitive Changes in Physical Illness

• Impairments in Intellectual Functioning
• Attentional and Learning Problems
• Slowed or Racing Thoughts
• Hallucinations and Delusions

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Potential Responses toChronic Illness

• Denial
• Why Me? or Why My Child?
• Guilt
• Feeling of Being Different
• Fears of Disfigurement, Disability, Death

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Physical Illness as Risk Factor for Psychiatric
Disorder

• Psychiatric Disorders found in 20 or more of
  medically ill children
• High Rates of psychiatric disorders in children
  with CNS impairments (ie., epilepsy, AIDS, Brain
  Tumors, Head Injuries)

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Constructive Responses to Physical Illness

• Courage
• Acceptance
• Adaptation
• Mastery

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Approaches to Understanding Psychological
Responses

• Need for Conceptual Framework
• Awareness of Risk and Protective Factors
• Applications to Patient Care

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Conceptual Frameworks

• Biopsychosocial Model
• Developmental Models
• Applications of Developmental Concepts

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Biopsychosocial Model A Systems Approach to
Disease

• Biological Component - anatomical, biochemical
  and molecular substrates
• Psychological Component - emotions, motivations,
  cognition
• Social Component - Family, School, Community,
  including Medical System

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Developmental Approach Basic Tenets

• Development occurs as a continuous series of
  interactions between the childs biological
  endowment and the environment
• The childs understanding of and psychological
  response to medical illness is contingent on his
  or her developmental level and environmental
  experiences

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Potential Effects of Illnesson Development

• Regression from previous levels of mastery
• Delay in Achievement of Developmental Landmarks -
  Emotional, Social, Motoric, Linguistic, Academic
• Acceleration of Cognitive Understanding of
  Illness and Death
• Neglect or Excessive Attention to Somatic Concerns

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Cognitive Development Piaget

• Sensorimotor Stage (Birth to 2 Years)
• Pre-operational Stage (2 to 7 years)
• Concrete Operations (7 to 11 years)
• Formal Operations (11 years through adolescence)

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Applications of Developmental Concepts

• Regression
• Childrens Understanding of Illness and Death
• Adolescents Sense of Invincibility

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Regression

• Return to developmentally earlier mode of
  functioning - emotional, behavioral, cognitive,
  linguistic or motoric
• Example a 12 year old boy insists that his
  mother feed him and sleep in his room after he
  returns home from a hospitalization for a broken
  leg sustained in a bicycle accident

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Cognitive Understanding of Illness

• Pre-operational Stage Immanent Justice -
  illness as punishment
• Concrete Operations (Early) Contagion
• Concrete Operations (Late) and Formal
  Operations Growing Understanding of Disease
  Mechanisms and Etiological Complexity

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Understanding of Illness Examples

• A 3 year old boy states that he has asthma
  attacks because he is bad
• (concept of immanent justice)
• A 6 year old girl states that she caught
  diabetes from her sister (contagion)
• A 12 year old boy with diabetes describes the
  role of the pancreas and insulin in regulating
  blood levels of glucose

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Concepts of Death and Dying

• Below Age 5 Fears of Abandonment, Lack of
  Awareness of Irreversibility
• Ages 5 to 10 Confusion, Focus on body parts
• Ages 10 to 15 Reality, Despair

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Concepts of Death and Dying Examples

• A 3 year old girl asks who will take care of
  her if she dies
• A 6 year old boy wonders who he will be able to
  eat ice cream with in his grave
• A 13 year old boy with osteosarcoma asks why he
  has to go to school since he is going to die
  anyway

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Mediating Factors in Emotional Response to
Illness

• Child Characteristics
• Illness Characteristics
• Family
• School
• Community
• Health Care System

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Mediating Factors Child Characteristics

• Age
• Sex
• Developmental Level
• Temperament
• Previous Experiences

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Mediating Factors Illness Characteristics

• Acute vs. Chronic
• Systemic vs. Local
• Disability
• Disfigurement
• Pain
• Restrictions on Activity

• Etiology
• Age at Onset
• Diagnosis
• Prognosis

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Mediating Factors Family

• Family Structure Intact vs. Fragmented
• Socio-economic Status
• Family Members Previous Experiences
• Supportive
• Capacity for Collaboration with Treating Staff

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Mediating Factors Other Environmental Variables

• School
• Peers
• Health Care System

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Mediating Factors Treatment Variables

• Short vs. Long-Term
• Invasive vs. Non-invasive
• Frequency
• Need for Hospitalization - Single vs. Multiple
• CNS Effects
• Other Side Effects

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Psychological Aspects of Selected Chronic
Illnesses

• Asthma
• Juvenile Diabetes
• Pediatric HIV Infection

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Asthma

• Most prevalent chronic illness in childhood
• 5 of American children
• No.1 cause of school absenteeism due to chronic
  illness
• 10 million missed days/year
• 3 million ER visits/year
• 500,00 hospitalizations
• 6000 deaths

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Asthma Emotional Factors

• Multi-factorial etiology
• Role of Stressors Familial/Environmental
• Reactions of Child and Parents to Restrictions on
  Childs Activity Level
• Frightening quality of asthma attacks
• Fear of Death
• Symptoms of Depression and Anxiety Common in
  Asthmatics

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Asthma Treatment

• Pharmacologic, Environmental, Psychological
  Components
• High Rates of Treatment Non-compliance

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Psychological Factors in Asthma Pharmacologic
Side Effects

• Theophylline Variable, with potential effects on
  learning and behavior
• Steroids Cushingnoid Appearance, Mood Swings,
  Psychosis

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Insulin-Dependent Diabetes Mellitus (Juvenile
Diabetes)

• Affects about 1 in 600 children below age 12 in
  North America
• 11,000 - 12,000 new cases per year
• 7 million people with Diabetes Mellitus in U.S.
  5 - 10 have IDDM

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IDDM Management Issues

• Need for Daily Monitoring and Treatment
• Effects on Broad Range of Activities (Diet,
  Exercise, School, Social Situations)
• Risk of Acute Crises (Seizures, DKA)
• Uncertainty about long-term outcome

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IDDM Cognitive Factors

• Risk of Neurocognitive Impairments from Hypo- and
  Hyper-Glycemia and Seizures
• Age of Onset and Duration
• Role of Cognitive Understanding by Parents and
  Child to Disease Management and Control

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IDDM Emotional Behavioral Problems

• Symptoms of Depression and Anxiety at time of
  diagnosis
• Impairment in Self Esteem
• Non-compliance with daily management regimen
• Involvement in High-Risk Activities in Adolescence

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IDDM Management Approach

• Parent Education regarding the disorder
• Child Education appropriate to age and
  developmental level
• Involvement of School Staff
• Psychotherapy and family counseling when
  indicated
• Peer Support Groups - Local and National
• American Diabetic Association
• Juvenile Diabetes Foundation

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Pediatric HIV Infection

• Worldwide over 500,000 children died of AIDS in
  1998
• 590,000 children under age 15 newly infected with
  AIDS in 1998 worldwide
• 8280 children and 3302 adolescents with AIDS in
  US in 1998
• Most new pediatric HIV cases are due to perinatal
  transmission - gestation, labor, delivery,
  breast-feeding

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Pediatric HIV Infection Cognitive Effects

• 20 - 50 of children with HIV have CNS disease
• 10 of children with HIV have progressive
  encephalopathy
• CNS disease more common in younger children
  (under age 3)
• Children with HIV are at increased risk for other
  causes of cognitive impairment

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Pediatric HIV Emotional Behavioral Problems

• Apathy
• Flat Affect
• Anxiety
• Depression
• Aggression - spitting, biting

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Pediatric HIV Special Considerations

• Child may have lost 1 or both parents to AIDS
• Grief over parental loss may be compounded by
  multiple foster care and institutional placements
  and high degree of stigmatization associated with
  HIV
• Disclosure may lead to ostracism and interference
  in school and social activities

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Pediatric HIV Management Issues

• Complicated Treatment Regimens
• Sexual Activities and Other High Risk Behaviors
  in Adolescents
• Fear of Disability and Death
• Confidentiality

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Emotional Aspects of Physical Disease Management
Summary

• Assess child, family, environment
• Know Illness Characteristics - onset, course,
  treatment side effects, prognosis
• Identify Risk and Protective Factors
• Formulate Developmentally Appropriate Plan for
  Child and Family