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.
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.
Developmental stages in chronically ill children and adolescents
|Stage of development
|Effects of chronic illness||Child’s perception of illness25|
(0 - 1 y)
[trust vs mistrust]
|• 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|
(2 - 3 y)
[autonomy vs shame and doubt]
• Motor and language development may be delayed
• Parental reluctance to set limits
• Bladder and bowel function may be affected
|Little capacity to understand illness|
(3 - 5 y)
[initiative vs guilt]
• Parental overprotection, regression possible
• Initiative may be discouraged
|Illness can be seen as a punishment for bad behavior|
(6 - 12 y)
[industry vs inferiority]
• 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
(13 - 19 y)
[identity vs role confusion]
• 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
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.