Nonadherence with treatment, another common reason for a psychosomatic consultation request, can range from 11% to 93% in pediatric patients. It adversely affects treatment response, increases the need for additional prescriptions, and may extend the course of illness.15Factors such as age, culture, patient and family characteristics, and dosage and means of administration of medication can all affect adherence. Furthermore, child psychopathology such as oppositional defiant disorder has been associated with a higher rate of nonadherence with medical regimens.16 Thus, multiple factors need to be considered when evaluating nonadherence.
Psychiatric disordersMany of the psychiatric disorders seen in adult psychosomatic medicine practice are also seen in practices involving children and adolescents, although research on the prevalence of specific conditions is sparse. Delirium is relatively common and has a similar presentation to that seen in adults. Certain symptoms, such as disorientation and psychosis, appear to be less common or more difficult to assess in pediatric patients, while delirium associated with organic causes, including medication toxicity, infection, and metabolic imbalances, is comparable in prevalence to adult delirium.17 Strategies for treating delirium include reorienting the child through reassurance, use of familiar objects, and clocks and calendars (when age appropriate) in the hospital room. When pharmacologic treatment is indicated, typical and atypical antipsychotic medications are used.17
Other psychiatric conditions that may be encountered in chronically ill children include depression, anxiety, somatization, and illness falsification. Assessing psychiatric illness is often difficult because of physical symptoms that interfere with diagnostic measures; this can lead to both overdiagnosis and underdiagnosis. Depression appears to be similarly prevalent in chronically ill and healthy children; in children with chronic illness, it can lead to complications in medical outcomes and increased disability.18
Somatization can occur when a child learns that reporting physical symptoms garners more attention than reporting emotional distress.19 Illness falsification, though rare in children, may manifest as factitious fevers, self-induced rashes, or deliberately manipulated insulin levels.20 Somatization, illness falsification, and Munchausen syndrome by proxy (illness falsification by caretaker) can all lead to unneeded treatment and, in extreme cases, death. Management of these disorders requires a clear understanding of the delicate interplay between biologic, psychological, and social factors that affect psychiatric symptoms.
Use of psychotropic medicationPsychotropic medications for symptoms as well as syndromes can be quite helpful in improving the quality of life of many patients. The prevalence of psychotropic use in the general pediatric population is estimated to be around 6%,21 but the prevalence of psychotropic medication use in medically ill children is not well documented. Table 2 shows psychotropic medications with their FDA approval status for use in children and adolescents.
|
Table 2 Psychotropic medications with FDA approval status
for use in children and adolescents |
|||||||
| Class | Medications | FDA labeled for use in children | |||||
| Anti- depressants |
Amitriptyline (generic) | 12 y and older, for depression, polyneuropathy | |||||
| Bupropion (Wellbutrin, Zyban) | No | ||||||
| Citalopram (Celexa) | No | ||||||
| Desipramine (Norpramin, generic) | No | ||||||
| Doxepine (Adepin, Sinequan, generic) | 12 y and older, for mixed anxiety and depressive disorder | ||||||
| Escitalopram (Lexapro) | No | ||||||
| Fluoxetine (Prozac, generic) | 7 - 17 y, for depression, OCD | ||||||
| Fluvoxamine (Luvox) | 8 y and older, for OCD | ||||||
| Mirtazapine(Drug information on mirtazapine) (Remeron) | No | ||||||
| Nortriptyline (Pamelor, generic) | No | ||||||
| Sertraline (Zoloft) | 6 - 17 y, for OCD | ||||||
| Paroxetine (Paxil, generic) | No | ||||||
| Trazodone (Desyrel) | No | ||||||
| Venlafaxine (Effexor) | No | ||||||
| Anxiolytics | Alprazolam (Xanax, generic) |
No | |||||
| Clonazepam (Klonopin, generic) | Up to 10 y, or 30 kg, for epilepsy | ||||||
| Lorazepam (Ativan, generic) | 12 y and older, for insomnia (oral), anesthesia premedication (oral) | ||||||
| Mood stabilizers | Carbamazepine (Tegretol, generic) | 12 y and older, for depression, polyneuropathy | |||||
| Gabapentin (Neurontin) | 3 - 12 y, for partial seizures | ||||||
| Lamotrigine (Lamictal) | 2 y and older, for partial seizures | ||||||
| Lithium (Eskalith, generic) | 12 y and older, for bipolar disorder | ||||||
| Oxcarbazepine (Trileptal) | 4 - 16 y, for epilepsy | ||||||
| Valproate (Depakote, Depacon, generic) | 10 y and older, for migraine prophylaxis, epilepsy | ||||||
| Anti-psychotics | Aripiprazole (Abilify) | No | |||||
| Chlorpromazine (Thorazine) | 6 mo and older, for anxiety about presurgery 1 - 12 y, for behavioral syndrome Pediatric, for nausea and vomiting, tetanus |
||||||
| Droperidol (Inapsine) | 2 y and older, for prophylaxis of postoperative nausea and vomiting | ||||||
| Haloperidol (Haldol, generic) | 3 y and older, for delirium, Tourette syndrome, severe problematic behavior | ||||||
| Olanzapine (Zyprexa) | No | ||||||
| Quetiapine (Seroquel) | No | ||||||
| Risperidone (Risperdal) | No | ||||||
| Thioridazine (Mellaril, generic) | 2 y and older, for schizophrenia | ||||||
| Ziprasidone (Geodon) | No | ||||||
| Stimulants | Dextroamphetamine (Adderall, generic) | 3 y and older, for ADHD, narcolepsy | |||||
| Methylphenidate (Concerta, Ritalin, generic) | 6 y and older, for ADHD, narcolepsy | ||||||
| Other | Atomoxetine (Strattera) | 6 y and older, for ADHD | |||||
| Clonidine (Catapres) | Pediatric, for epidural for pain relief | ||||||
| Guanfacine (Tenex) Propranolol(Drug information on propranolol) (Inderal, |
12 y and older, for hypertension | ||||||
| Propranolol (Inderal, generic) | Pediatric, for hypertension | ||||||
| OCD, obsessive-compulsive disorder; ADHD, attention-deficit/hyperactivity disorder. | |||||||
Terminal illness
Terminal illness and the death of a child is a sad and inevitable aspect of pediatric hospital consultation that provokes significant anxiety in the patient, family, and caregivers. Informing a child that he or she is going to die is difficult, but parents rarely regret sharing this information with the child.22 Children in different developmental stages have differing conceptions or misunderstandings of death and may be helped by frank conversations with family or by play therapy facilitated by pediatric psychosomatic medicine specialists. Comfort is another important issue at the end of life; parents have reported that at the end of life, their child had a great deal of suffering from pain, dyspnea, or fatigue and had “no fun.”23 Psychiatrists can provide treatment for a dying child while also offering support to the family and hospital staff.
ConclusionWith evolving innovations in medical technology and rapid advances in neuroscience and molecular genetics, a comprehensive and integrative field such as pediatric psychosomatic medicine can only be expected to expand. Recent research on cytokine-induced sickness behavior24 and the periodic identification of novel genetic markers in patients with chronic diseases provide new information that may help in the development of future treatments.
Clinicians providing psychiatric care must always remain vigilant in understanding how these treatments are experienced by children and their families. Early identification of psychiatric symptomatology will enhance outcomes in at-risk children. Appropriate diagnosis of mental disorders, prompt psychiatric treatment, and recognition of normal developmental processes in children and adolescents are critical aspects of caring for the whole child.
Terminal illness
Terminal illness and the death of a child is a sad and inevitable aspect of pediatric hospital consultation that provokes significant anxiety in the patient, family, and caregivers. Informing a child that he or she is going to die is difficult, but parents rarely regret sharing this information with the child.22 Children in different developmental stages have differing conceptions or misunderstandings of death and may be helped by frank conversations with family or by play therapy facilitated by pediatric psychosomatic medicine specialists. Comfort is another important issue at the end of life; parents have reported that at the end of life, their child had a great deal of suffering from pain, dyspnea, or fatigue and had “no fun.”23 Psychiatrists can provide treatment for a dying child while also offering support to the family and hospital staff.
ConclusionWith evolving innovations in medical technology and rapid advances in neuroscience and molecular genetics, a comprehensive and integrative field such as pediatric psychosomatic medicine can only be expected to expand. Recent research on cytokine-induced sickness behavior24 and the periodic identification of novel genetic markers in patients with chronic diseases provide new information that may help in the development of future treatments.
Clinicians providing psychiatric care must always remain vigilant in understanding how these treatments are experienced by children and their families. Early identification of psychiatric symptomatology will enhance outcomes in at-risk children. Appropriate diagnosis of mental disorders, prompt psychiatric treatment, and recognition of normal developmental processes in children and adolescents are critical aspects of caring for the whole child.
