The relationship between physical and mental health in children and adolescents

Julia Gledhill and M. Elena Garralda

Introduction

Associations,,, between,,, ph.y.s,i.c.a.!..,a.n.d„ psych,o„lo„gical,„symp,toms

Psychiatric, ,,a.s.pects„of, chronic, physical, illness chronic,physica|„i.|lness„,and,, th,e„,risk,, MpsychJatric, „disorder

Management

Prognosis,, ofpsychiatric, disorder, „inchildren „with,, chronic., physical,, ,illn,ess

Problemsof, children,,, and, Ma,d1ol1escen,ts„with,„s,ensory,, „impairment Assessment

Ihenatureof, ,psiychiatric„disoirders„,in1, „the,, hearing,, „impaired Assessment, „of„the„yisM,alMly„impaired„ child The„nature„of, ,ps.ychlatri.c,.diso.Ed.s.rs„l„n., „the,, visually, „impaired

Intervention Care of the dying child

The,, effects of, psychiatric „disorder on „the cpurse„and„ outcome, of,physical„illness Somatization and somatoform disorders

Disorders.,, presenting, with,, functional physical symptoms. ,3.n.d,„somatiza.tion Aches, „a„nd„pains,„and,spmatpfprm„pain, „disorder Dissociatiye/sconyersion,, disorder Chronic,fatigue, ,sy,nd„rpm£,,in,SMras.h.£Ma,, ,in„|C.D-10

Treatment,, pffunctional, symptoms, „and „somatoform,, ,d.is.o.rd.e.rs., „in„c,hild,ren, „an,d,„a,dolescen,ts,i„, research,, ,eyid,ence

C.o.nclu.ding„rema.rks

Chapter,, References Introduction

The link between physical and psychological disorder in children and adolescents is well established. Children with chronic illness are at increased risk of emotional and behavioural disorders. (!> In addition, repeated presentations with physical symptoms may represent underlying psychological distress or psychiatric disorder, for example recurrent abdominal pain in school-age children signifying emotional disorder.

Because of the inextricable links between young people and the family in which they live, it is inappropriate to consider symptoms in an index child in isolation. The effects of symptomatology on family functioning and parent and sibling relationships should be considered. This may have important aetiological and prognostic significance.

Associations between physical and psychological symptoms

There are various ways in which physical and psychological disorders are related and these are summarized in Table !..

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Table 1 Associations between physical and psychological symptoms

Table 1 Associations between physical and psychological symptoms

In this chapter we shall consider the following.

• The psychiatric consequences of physical illness, with a particular focus on the characteristics of physical disorders associated with an increased vulnerability to psychiatric sequelae. Examples of specific diseases will be used to illustrate this, and the effects on the individual child and his or her family will be described.

• The influence of sensory impairment on psychological functioning.

• Helping the dying child and his or her family.

• The effects of psychiatric disorder on the course and outcome of physical illness.

• Aspects of assessment and treatment intervention.

• Somatization and somatoform disorders, with a particular focus on recurrent abdominal pain, dissociative/conversion disorder, and chronic fatigue syndrome. Psychiatric aspects of chronic physical illness

Chronic physical illness and the risk of psychiatric disorder

Chronic physical illness in children, defined as disorders which last at least 1 year and are associated with persistent or recurrent handicap, affects about 4 per cent of children in Western countries.(2) This encompasses a broad spectrum of disorders including more common problems such as eczema, asthma, diabetes, and epilepsy, but also less prevalent conditions such as cystic fibrosis and cancer. Many children successfully adapt to living with a chronic illness, but chronic illness can be associated with a number of different types of stresses for children and their families.

The stress of chronic illness may operate at several levels. In addition to the presence of the illness itself, diagnostic and treatment procedures may be painful or have undesirable side-effects—changes in physical appearance such as alopecia, scars, and obesity may lead to difficulties in peer relationships. The demands of treatment such as dietary restrictions in diabetes may be difficult. The illness, together with hospital attendance for treatment, may lead to a considerable interruption to schooling as well as a reduced ability to participate in leisure activities and to socialize with peers.

Although the majority of individual children and families successfully adapt to these stresses, children with chronic physical illness have a slightly increased risk for the development of associated psychiatric disorders.(1) Specific factors related to the child and the illness have been shown to contribute to the likelihood of developing psychiatric disturbance and to influence the nature of the psychiatric disorder that develops ( T§b!e.2) (3)

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Table 2 Factors related to the risk of psychiatric disorder and the form of its presentation

Nature of the physical disorder

Much of the increased prevalence of psychiatric disorder in children with a chronic physical illness is accounted for by those with disorders affecting the brain, especially when epilepsy is involved.^ These children have a threefold increased risk of psychiatric disorder over general population rates. By comparison, the risk in young people with a chronic physical illness that does not involve the brain is considerably lower and only slightly increased over general population expectations/4» The excess of psychopathology in children with brain anomalies may either be attributable to the direct effects of organic pathology on behaviour, or it may be mediated by the greater physical disability that frequently accompanies brain damage. Associated intellectual impairment may also be an important contributory factor.

Whilst this dichotomy between disorders involving and not involving the brain is useful, there is little specificity in the behavioural pattern that may be attributable to intracerebral pathology. As a possible exception, children with brain dysfunction such as epilepsy or cerebral palsy may be more likely to exhibit externalizing disorders such as hyperactivity.(4) Psychiatric disorders in this group of children may be persistent, with 70 per cent still experiencing difficulties at 4-year follow-up. Overactivity, restlessness, and inattention were the best predictors of persistent psychiatric disorder. (6)

For conditions not affecting the brain, the development of psychiatric disorder seems most likely to be intimately linked with the accumulation of generic stress factors and family changes common to living with a chronic illness. These include life stresses such as hospitalization as well as daily difficulties such as specific dietary requirements and a disruption of family routines.(7) A broad spectrum of psychiatric presentations may be associated that are not specific to the nature of the underlying disease processes. Children with non-neurological physical illnesses may be more prone to developing emotional symptoms and eating anomalies as opposed to antisocial behaviour. Eating anomalies may be understood as arising from an emphasis on diet and a concern about poor appetite in the families of many children with chronic illnesses. Maternal anxiety may focus on feeding, especially in preschool children. The specificity of the relationship with emotional disorders is also of interest. Physical illness in the child can generate family and social stresses and changes known to be risk factors for the development of emotional disorders in children. This includes mood disorders in parents and overinvolved and overprotective parenting. (3>

Stage of the illness

The stage of the illness is associated with different psychological risks. Disorder at the time of initial diagnosis is not uncommon and is frequently short lived. In one study, 36 per cent of 8- to 13-year-olds with newly diagnosed insulin-dependent diabetes mellitus developed an adjustment disorder (most commonly dominated by depressive symptoms) within the first 3 months of diagnosis. However, 50 per cent had recovered within 2 months.(8) Similarly, in patients with chronic renal failure, psychological problems were reported in 60 per cent of children at the time of starting dialysis. One year later, after stabilization of their physical condition, the prevalence of disturbance was reduced to 21 per cent.(9) It is very likely therefore that in many children with chronic physical illness, psychiatric disorders are most frequently transitory adjustment disorders to stressful times in the illness.

Severity of illness/degree of life threat

More severe physical disorders and those constituting a greater degree of life threat have been associated with a higher risk of psychiatric disturbance. (1,!!) In a study of children with endstage chronic renal failure, those with more severe disorders (on hospital haemodialysis) had more psychiatric disorder than those not yet requiring dialysis/.10 Diabetic children and adolescents with a history of hospitalization for ketoacidosis in the previous year were more likely to exhibit psychiatric disorder than a control group of outpatients with insulin-dependent diabetes mellitus who had not been admitted to hospital for diabetic ketoacidosis during the preceding 12 months.(!2) However, the link between illness severity and the risk of psychosocial impairment may vary with the setting in which it is examined. Less severe physical impairment, for example, has been shown to be associated with a higher risk of behavioural problems, specifically in the school setting. (1. ^J Teachers may be less aware of the presence of an underlying physical disorder in this group who have less visible physical signs, and may make less allowance for these children than for those with a more overt disorder.

Psychosocial risk and intrafamilial protective factors

When a physically ill child develops psychological symptoms, these are frequently attributed by families and professionals to the presence of the physical illness and its stresses. It is, however, important not to neglect consideration of other predisposing factors within the child, for example genetic vulnerability, temperamental characteristics, problems in the family such as marital disharmony, lack of open communication, maternal mental illness, and problems within the broader social environment such as bullying at school and poor peer relationships. These factors are likely to contribute to child psychopathology in ill as well as in healthy children. Conversely, protective factors such as secure parent-child attachments, increased family social support in response to the physical diagnosis, as well as sensitive paediatric management of hospitalizations and stressful medical procedures may reduce the risk of developing psychiatric disorder.

Age (developmental stage)

Manifestations of psychological distress in ill children are likely to vary with the child's developmental stage. Preschool children have fewer cognitive resources to cope with discomfort and stressful medical procedures and are particularly likely to rely on maternal support and distraction to cope with illness. Between 4 and 7 years of age, children frequently believe that illness has been caused by something bad they have done and that they should be punished. (7) Clinginess to parents, fearfulness, sleep difficulty, and oppositional-defiant behaviour may be specially common in preschool children. (!4) The need for repeated painful procedures, for example with cancer chemotherapy, may lead to the development of specific needle phobia.

For school-age children, school life is a key aspect of their adjustment to illness. Return to school after cancer chemotherapy can be associated with the development of school phobia, loneliness, and social isolation in some children. School absence and having to catch up with school work, teasing or even bullying, especially of children who look different, may also occur and contribute to lowered self-esteem and the risk of affective disturbance. Cognitive development in adolescence means that this group of young people have a greater understanding of the implications of their illness and of the realities of death; depression will be expected to occur more frequently in this age group. Adolescents may also begin to challenge and experiment with their treatment; they may fail to come to outpatient appointments or attend erratically. There may also be a decline in compliance with medical advice and adherence to treatment regimens. (7) For example, diabetics may not follow recommended dietary advice and may show reduced attention to their insulin regimen and monitoring of blood sugars leading to poorer diabetic control.

The way in which psychiatric disorder presents may influence its perceived significance to health professionals and the likelihood of psychiatric referral. On the whole, presentations with behavioural disturbances such as screaming, struggling, panicking, or a failure to comply with treatment are more likely to precipitate referral by general practitioners or paediatricians than internalizing disorders such as depression, which may be regarded as an 'understandable' response to being so unwell.

Effects on parents and siblings

Whilst most families successfully adjust to the presence of a child with a chronic illness in the family, this may act as a risk factor for psychological disorder. The incidence of marital break-up is not increased, but there are reports of increased marital distress. (15> In parallel with the heightened short-term psychological difficulties found in ill children immediately following diagnosis, (16) a similar temporal pattern of disorder has been reported for parents and siblings. (1Z18) Most research on parents has focused on mothers, who often undertake the practicalities of caring for a sick child. They may need to stop work themselves, leading to increased social isolation and a reduction in extrafamilial support. (1Z> Fathers and mothers often cope very differently with the diagnosis; mothers tend to react by emotional release, whereas fathers are more likely to withdraw and concentrate on practicalities. (1Z> Higher rates of maternal psychiatric treatment and negative affect have been found in families with a chronically ill child. (19) Siblings may resent both the extra attention their ill brother or sister is receiving and repeated separations from parents during periods of hospitalization. Their psychological adjustment is related to the degree of functional impairment and recent physical health of their ill sibling/18 the extent to which family life is disrupted by the illness, and the psychosocial support available. The need for improved communication with healthy siblings has been shown/1.8

One disorder which highlights the complexities of interaction between living with a chronic illness and its effect on different family members is AIDS. Vertical transmission from an infected mother to her unborn child is the most rapidly increasing source of paediatric HIV infection. (20) Maternal antibodies in the baby's serum may delay the diagnosis. This may lead to disruption of attachment and bonding. (21> Parents have to cope with feelings of guilt and, in cases of iatrogenic transmission, with anger towards the hospital, which may interfere with ongoing physical and psychological care. In addition, families are faced with an uncertain prognosis as well as having to negotiate the stigma and consequent social isolation that frequently accompany the diagnosis. Episodes of parent and child physical ill health may coincide and an ill mother will have greater difficulty in providing for the emotional needs of her child. Healthy siblings may not be told the diagnosis even though they may become suspicious and more aware of the stigma attached to them. As with all chronic illness, the manifestations of psychological ill health are varied. Supportive families in which feelings can be openly expressed are more able to mediate the impact of illness.

Management

In the absence of supportive rigorous treatment research in this area, the most important tenet of the psychological care of children with physical illness is based on good clinical practice. It calls for clear and consistent communication between paediatricians and child psychiatrists and their multidisciplinary teams. This allows early detection and intervention for psychological disorder.

Child psychiatrists frequently work closely with paediatric colleagues to assist in identifying young people at risk for psychiatric disorder, to provide assessment and treatment when indicated, and to give support and advice with regard to diagnosis and management. Many paediatric units have regular weekly psychosocial ward rounds where professionals both from within the hospital and from the community—representing paediatrics, child and adolescent psychiatry teams, social work, and education—can meet to discuss the progress of the child from each perspective.

A full psychiatric assessment involving the child and the family will be carried out in referred cases. This needs to be preceded by a careful explanation to families from paediatric colleagues about the reasons why a psychiatric consultation has been sought.

Important information about premorbid concerns and the child's level of functioning may be obtained from schools, social workers, and other professionals involved with the family. Parental permission should be sought to communicate with the school.

Specific psychiatric diagnoses should be treated appropriately. Children may develop acute confusional disorders associated with intracerebral infection or febrile illness. Manipulation of the ward environment to ensure that clear differentiation is established between night and day, familiar toys are nearby, close family are in attendance, and developmentally appropriate explanations are given to the child about where they are and what is happening may help considerably. If, despite this, behaviour is too difficult for staff to safely manage and is interfering with treatment, sedative medication may be needed and should be discussed with paediatricians.

Children with adjustment disorders may be helped by psychological interventions. It is essential to understand fully the illness stresses that have led to the psychological reactions by discussion with paediatric staff as well as with parents and children. Management may include ways of decreasing existing stresses or helping individuals to adjust to them. Possible interventions include general supportive counselling, individual therapy using cognitive behavioural interventions to deal with specific situations or problems, and family therapy.

When there is a chronically ill child in the family, parents often find it difficult to maintain the usual boundaries within the family. Disciplining an ill child may lead to feelings of parental guilt. This may lead to increasing anxiety for children who exhibit increasingly oppositional behaviour in an effort to test the boundary limits. Discussion regarding parenting techniques in the context of these feelings may be helpful in redressing this balance. Parents also tend to increase their protective responses to ill children and show more overinvolved parenting. If this is excessive it may impede the child's development, but to a modest degree it may be helpful and advantageous for the child's development.

Systematic desensitization together with relaxation and distraction techniques may be used to treat a specific needle phobia. However, this needs to be carried out in collaboration with ward staff and taking due account of associated psychopathology, for example oppositional behaviour, a generalized anxiety state, or an adjustment reaction. Treatment of the associated problems can often obviate the need for direct phobic treatment. When indicated, the latter's success is likely to be dependent on external changes that reduce anticipatory anxiety. These might include minimizing the time this child needs to wait for treatment and ensuring that more experienced members of the medical team are responsible for cannula insertion.

Generalized symptoms of anxiety are not uncommon in parents and children and may be manifested in different ways, for example a young child may resume bedwetting, a school-age child may become intensely distressed by parental separation, adolescents may experience difficulties sleeping, and anxious parents may become agitated with ward staff. Regular explanations from staff about the child's condition and treatment may help to alleviate this anxiety. Communication difficulties within the family may contribute to anxiety and be helped by family meetings where difficulties can be shared. Relaxation and distraction techniques together with cognitive behavioural interventions may also be of benefit. If symptoms are intense and interfering with physical treatment, anxiolytic medication may be indicated.

Antidepressant medication may be considered for children and adolescents with a depressive episode. The choice of medication should be discussed with the medical team to minimize drug interactions and side-effects that may exacerbate the physical condition of the patient.

Treating children with severe illness who may be receiving distressing and painful treatment can arouse intense emotions in the most experienced of paediatric staff. Regular meetings with the mental health professionals may help them to process some of these feelings and prevent them from interfering with patient care.

Prognosis of psychiatric disorder in children with chronic physical illness

Many of the psychological difficulties experienced by chronically ill children are short lived and do not continue into adult life. Persistence of disorder is related to the severity of childhood symptoms(22) (the more severe being more likely to last), persistence of physical symptoms into adulthood, (23> and to the presence of physical disorder affecting the brain (TabJeJ).

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