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Emotional Aspects of Physical Illness in Children and Adolescents

Emotional Aspects of Physical Illness in Children and Adolescents. 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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Emotional Aspects of Physical Illness in Children and Adolescents

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  1. Emotional Aspects of Physical Illness in Children and Adolescents

  2. 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

  3. 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

  4. Psychological Aspects of Illness • Emotions • Behaviors • Cognitive States • Psychiatric Disorders

  5. Relevance for Physicians • Diagnosis • Treatment • Screening for Psychiatric Disorders

  6. Role of Psychological Factors in Diagnosis and Treatment • History - Symptom Reporting • Physical Exam • Blood Drawing • Other Diagnostic Procedures • Treatment • Compliance vs. Non-Compliance

  7. Emotional Responses to Illness • Anxiety - Fear - Panic • Sadness - Despair - Hopelessness • Irritability - Anger - Rage • Passivity - Helplessness • Relief - Happiness - Mania

  8. Problematic Behaviors in Response to Illness • Withdrawal - Social Isolation - School Refusal • Oppositional Behavior - Tantrums - Aggression • Head-banging - Self-Mutilation - Suicide • Attention-Seeking Behaviors

  9. Potential Cognitive Changes in Physical Illness • Impairments in Intellectual Functioning • Attentional and Learning Problems • Slowed or Racing Thoughts • Hallucinations and Delusions

  10. Potential Responses toChronic Illness • Denial • Why Me? or Why My Child? • Guilt • Feeling of Being “Different” • Fears of Disfigurement, Disability, Death

  11. 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)

  12. Constructive Responses to Physical Illness • Courage • Acceptance • Adaptation • Mastery

  13. Approaches to Understanding Psychological Responses • Need for Conceptual Framework • Awareness of Risk and Protective Factors • Applications to Patient Care

  14. Conceptual Frameworks • Biopsychosocial Model • Developmental Models • Applications of Developmental Concepts

  15. 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

  16. Developmental Approach: Basic Tenets • Development occurs as a continuous series of interactions between the child’s biological endowment and the environment • The child’s understanding of and psychological response to medical illness is contingent on his or her developmental level and environmental experiences

  17. 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

  18. 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)

  19. Applications of Developmental Concepts • Regression • Children’s Understanding of Illness and Death • Adolescents’ Sense of Invincibility

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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”

  25. Mediating Factors in Emotional Response to Illness • Child Characteristics • Illness Characteristics • Family • School • Community • Health Care System

  26. Mediating Factors: Child Characteristics • Age • Sex • Developmental Level • Temperament • Previous Experiences

  27. Acute vs. Chronic Systemic vs. Local Disability Disfigurement Pain Restrictions on Activity Etiology Age at Onset Diagnosis Prognosis Mediating Factors: Illness Characteristics

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

  29. Mediating Factors: Other Environmental Variables • School • Peers • Health Care System

  30. Mediating Factors: Treatment Variables • Short vs. Long-Term • Invasive vs. Non-invasive • Frequency • Need for Hospitalization - Single vs. Multiple • CNS Effects • Other Side Effects

  31. Psychological Aspects of Selected Chronic Illnesses • Asthma • Juvenile Diabetes • Pediatric HIV Infection

  32. 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

  33. Asthma: Emotional Factors • Multi-factorial etiology • Role of Stressors: Familial/Environmental • Reactions of Child and Parents to Restrictions on Child’s Activity Level • Frightening quality of asthma attacks • Fear of Death • Symptoms of Depression and Anxiety Common in Asthmatics

  34. Asthma: Treatment • Pharmacologic, Environmental, Psychological Components • High Rates of Treatment Non-compliance

  35. Psychological Factors in Asthma: Pharmacologic Side Effects • Theophylline: Variable, with potential effects on learning and behavior • Steroids: Cushingnoid Appearance, Mood Swings, Psychosis

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. Pediatric HIV: Emotional & Behavioral Problems • Apathy • Flat Affect • Anxiety • Depression • Aggression - spitting, biting

  44. 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

  45. Pediatric HIV: Management Issues • Complicated Treatment Regimens • Sexual Activities and Other High Risk Behaviors in Adolescents • Fear of Disability and Death • Confidentiality

  46. 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

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