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Essential Issues in Pediatric Psychosomatic Medicine

Essential Issues in Pediatric Psychosomatic Medicine

With the advent of new treatments
for medical diseases
such as cancer, asthma, HIV
infection, and cystic fibrosis, more children
and adolescents are living with
chronic illness than ever before. Seventy
years ago, persons with cystic fibrosis
survived an average of 5 years, while
currently the life expectancy for patients
with cystic fibrosis is more than 30
years.1 For children with cancer, the 5-year survival rate has improved dramatically
to 79% for the period of 1995 to
2000.2 Increased survival, however, has
brought new morbidities.3 Children
with chronic illnesses are more likely
to have emotional, behavioral, and
psychiatric symptoms than healthy
children4 and may be psychologically
affected or traumatized by medical
treatment.

Pediatric psychosomatic medicine,
also called pediatric consultation-liaison
psychiatry, investigates the psychiatric
issues affecting medically ill
youths in the context of their development,
cognition, communication, familial
interactions, and pharmacokinetic
dynamics. With the recent addition of
psychosomatic medicine as a subspecialty
field of psychiatry,5 the field of
pediatric psychosomatics has become
an increasingly active area of clinical
care and research.

Pediatric consultation-liaison psychiatrists,
in collaboration with pediatricians,
are called on to assess chronically
ill children and adolescents for psychiatric
illness, to address nonadherence,
to investigate unexplained physical
symptoms, and to attend to psychosocial
stressors. Three aspects of psychiatric
consultation in the medically and
surgically ill that are specific to working
with young patients are:

  • An awareness of the cognitive and
    emotional developmental levels of
    the patient.
  • An appreciation of the essential role
    of the family.
  • A focus on facilitating coping and
    adjustment to illness, rather than
    concentrating on psychopathology,
    in order to encourage an optimal
    developmental trajectory.

Cognitive and emotional development

Clinicians need a basic knowledge of
normal physical, motor, language,
cognitive, sexual, and emotional development in chronically ill children
in order to distinguish normal
responses to stress from detrimental
responses. Understanding a child's
cognitive abilities to process information
is essential when communicating
with him or her about his or
her disease (Table 1).

While children generally pass
through similar stages of cognitive
development, clinicians cannot assume
that chronologic age is equivalent to
mental age. Children with medical
illness may not mature at the same rate
as healthy children because of delayed
neurocognitive development, disruptions
in education, and limited social
experiences. For example, a 15-year
old chronically ill adolescent may function
at the level of an elementary
school-aged child. Similarly, consultations
for adults who have childhoodonset
chronic illnesses should inquire
into early hospital and medical experiences
to provide a fuller understanding
of the current level of development.

Table 1
Developmental stages in chronically ill children and adolescents
Stage of development
[Erikson stages]

(Piaget stages)
  Effects of chronic illness   Child's perception of illness25
Infancy
(0 - 1 y)
[trust vs mistrust]
(sensorimotor)
• Illness may decrease infant's access to environment

• Parental separation, guilt, anger, and grief may interfere with attachment

• Difficulty with trust and possible sense of helplessness
Little capacity to understand illness
Toddler
(2 - 3 y)
[autonomy vs shame and doubt]
(sensorimotor/
preoperational)
• Motor and language development may be delayed

• Parental reluctance to set limits

• Bladder and bowel function may be affected
Little capacity to understand illness
Preschooler
(3 - 5 y)
[initiative vs guilt]
(preoperational)
• Parental overprotection, regression possible

• Initiative may be discouraged
Illness can be seen as a punishment for bad behavior
School-aged child
(6 - 12 y)
[industry vs inferiority]
(concrete operational)
• Possible alienation from peers

• Fewer social interactions because of illness

• Parents may limit social activities using
illness as an excuse

• Illness may hamper normal development of self-esteem and sense of mastery

• Illness causation is seen as temporal proximity as well as bad behavior

• Older children may understand illness as a result of contact with germs

• Child may understand the internalization of a disease within the body and may also understand role in disease treatment
Adolescent
(13 - 19 y)
[identity vs role confusion]
(formal operational)
• Adolescents may be concerned about appearance and medication side effects

• Potential risk-taking behavior, eg, drugs,unprotected sex

• Noncompliance with medical regimen
• Greater understanding of the body
processes in disease

• Greater comprehension of the mind-body connection

Role of the family

Consideration of the genetic and environmental
contributions of the family
is a critical aspect of comprehensive
psychiatric consultation. Recently, a
functional genetic polymorphism was
shown to moderate the effects of stressful
life events on the incidence of
depression.6 Parents are also the legal
year and
financial decision makers in caring
for their children and can even choose
whether to inform a child of his or her
diagnosis. Feelings of depression, anxiety,
helplessness, and distress are not
limited to the patient. Siblings are often
affected, especially in cases of tissue
donation.7Chronic illness can positively
or negatively change familial dynamics8;
psychotherapy or family-focused
interventions may be indicated for
adjustment difficulties.

Focus on adjustment

The hospital or clinic environment can
be distressing or traumatic for the
acutely or chronically ill child. Injections,
procedures, and surgeries can
be particularly stressful experiences
for children. Interventions should be
used whenever possible to reduce
discomfort for these patients.9 Pain
from both medical conditions and treatments
can provoke anxiety and affect
later pain sensitivities and neurologic
development.10 Posttraumatic stress
disorder is a risk from traumatic injury
or intense hospital experiences such as
transplantations. Identifying and easing
potentially traumatic situations may decrease the child's stress and improve
medical outcomes.11

Children with cancer or asthma
The psychological effects of specific
medical conditions, such as cancer and
asthma, have been the focus of scientific
inquiry. Pediatric cancer patients
have rates of depression similar to those
of the general pediatric population,12
which may be a consequence, in part,
of the use of avoidant coping styles by
medically ill children.13 Interventions such as cognitive-behavioral techniques
and use of topical anesthetics and sedation
before and during invasive cancer
treatments have been shown to decrease
anxiety, distress, and pain for pediatric
cancer patients.

The most common pediatric chronic
illness is asthma, which has been associated
with psychiatric problems in
both children and parents. More than
one third of children with asthma have
anxiety disorders, while increased
severity of illness is associated with
increased psychosocial problems.
Parenting difficulties with 3-week-old
infants have been associated with subsequent
onset of asthma at ages 3 and 6
years, even controlling for socioeconomic
differences.14 Both family therapy
and pharmacologic treatments for
anxiety and depression have been useful
in treating children with asthma.

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