Mental Health Challenges in Treating Seriously Ill Children and Adolescents

1. Mental Health Challenges in Treating Seriously Ill Children and Adolescents Paula K. Rauch M.D. Chief, Child Psychiatry Consultation Service Massachusetts General Hospital prauch@partners.orgwww.mghpact.org

2. This Presentation • Primary psychiatric illness in the medically ill child • Psychosomatic illness • Non adherence • Some factors with specific pediatric illnesses • Time for questions

3. Primary Psychiatric Illness • Psychiatric conditions are under diagnosed in children and under diagnosed in the medically ill population. Sick children are doubly under diagnosed. • It is not “normal” for the seriously ill child to be depressed and anxious. • Diagnosed psychiatric illness in a medically ill child should be treated.

4. Assessing for Depression • Ask the child: Are you depressed? • Ask the parents: Is your child depressed? • Is the child similar at home? • Non adherence does not equal depression • Psychosomatic symptoms do not mean a child is depressed

5. Depression • SSRI’s are widely used with medically ill children including children with cancer, cystic fibrosis, and inflammatory bowel disease. • Bupropion or mood stabilizers may be a good choice for the child on steroids. • Sometimes a stimulant may be a good choice

6. Assessing for Anxiety • Ask about the pattern of the anxiety • Pre-procedure • Chronic • Night before scheduled admission • Are parents allaying or increasing anxiety • Help parents learn ways to help • Help parents identify negative behaviors • Treating anxiety will decrease pain

7. Preventative Measures • Be honest with the child about medical interventions • Keep the playroom and the child’s room as procedure free zones • Be very active about pain management • Learn what has helped or worsened the child’s coping in the past • Explain the purpose of procedures • Remind children the goal is to get them home

8. Behavioral Interventions • Distraction • Breathing • Imagery • Hypnosis • Consider doing some interventions with parent and child together

9. Anxiety • Short acting benzodiazepines may be used to treat anticipatory anxiety associated with procedures. • Short acting benzodiazepines may be helpful for difficulty falling asleep the day before admission or during short hospital stays. • Some children are disinhibited by benzos.

10. Anxiety • Generalized anxiety in the hospital setting may respond to low dose long acting benzodiazepine. • Pre existing anxiety disorders may respond to SSRI’s. • Anxiety expressed as agitated behavior in the young child may respond to clonidine or in the older child an atypical antipsychotic.

11. Assessing for Attention Disorders • Get pre morbid history • Pre existing ADHD may emerge as problematic behavior during a hospitalization or may not • Behavior that interferes with optimal medical care should be treated • Older children may report that they need medication to focus and thus cope better

12. ADHD • Stimulants are widely used for children with major medical illnesses and ADHD. • Stimulants may be helpful for children with ADHD following traumatic brain injury or neurosurgery. • Blood pressure and appetite should be attended to in illnesses in which these side effects of stimulants may be significant.

13. Assessing for Psychosomatic Illness • Every illness has a psychological overlay • Approach every condition with med/psych • Do not wait until all tests are negative to introduce the psychological support • Some ways to talk about psychological component • Use examples with cancer and diabetes • Use a coaching model • Frame uncertainty in ways that encourage returning to functioning

14. A Psychosomatic Presentation • Often emerges at a developmental point where expectations have increased • Parent and child can imagine how successful the child would be if not for the medical symptoms • It can seem noble to be dependent and sick • Form of regression and connection with parent

15. Psychosomatic Illness • The child should be assessed for undiagnosed depression, anxiety, or ADHD • There may be treatable psychiatric illness in the parent. • It may be helpful to wean the child off unnecessary medications. • Parents need to be ready for change

16. Assessing Non Adherence • The child/teenagers perspective is important • The parent’s perspective is also key • Review the care plan within the daily life of the child and parents • Walk me through a day in your life • What do your friends think or say • How does this schedule cause problems for you Build good habits before adolescence

17. Non Adherence • Assess for undiagnosed psychiatric illness. • Anxiety or depression may be a significant component of non adherence. • ADHD in the child or the parent may be contributory. • Side effects may lead to non adherence • Chaotic family life or cognitive limits may be a factor

18. Chronic Illness • Each illness has its own challenges • Age of onset • Demands of daily medical regimen • Risks of non adherence • Age when symptoms worsen and the child becomes functionally impaired • End of Life (EoL) care

19. Asthma • Very variable presentations • Often early onset • Often associated with food allergies • Acute onset of shortness of breath is anxiety provoking: Anxiety management • Home allergens problematic in many families: Reactive not proactive

20. Diabetes • Onset anytime in childhood • Long term and acute consequences • Insulin shots are anxiety provoking • Dietary changes are challenging • Adherence measures in hemoglobin test often cause parent-teen conflict • Non adherence can be acutely lethal

21. Inflammatory Bowel Disease • Embarrassing symptoms • Sometimes a familial component • Steroid use affects appearance and mood stability • Body image issues common (colostomy) • Difficult choices with newer medications with potential risks

22. Cystic Fibrosis • Often early diagnosis • Impairment emerges in adolescence • Genetics may lead to parental guilt • May be only sibling or have affected siblings • Variable presentation • Non adherence often not acutely detected

23. Cancers • Acute onset at any age • Often seen as the scariest diagnosis • Associated with some “nobility” • Many untimely deaths • Enormous anxiety in the parents • Variability in maintaining peer group • Coping with recurrence and EoL

24. Palliative Care • Treat depression at the end of life as you would at other times. • Treat anxiety aggressively. • Attend to pain. • Attend to sleeplessness. • Chronic fatigue may respond to a stimulant.

25. Summary • Psychiatric conditions can be and should be diagnosed and treated in the medically ill child. • Behavior that prevents essential medical treatment must be treated. • Anxiety and depression represent a significant portion of the morbidity associated with medical illness in children.

26. Summary • Every medical illness in childhood should be approached with a combined medical and psychological approach. • Pediatricians need psychologically trained colleagues who understand their practice patterns and the natural history of the diseases they treat in order to be most useful.