DSM-IV-TR Diagnostic Criteria
There is evidence from the history, physical examination, or laboratory findings that the psychiatric disorder is caused by the direct physiological consequences of a general medical condition.
The disturbance is not better accounted for by another mental disorder
The disturbance does not occur exclusively during the course of delirium
(Adapted, with permission, for Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000, Washington, DC: American Psychiatric Association.)
The factors that affect a child's response to chronic illness can be classified as follows: (1) factors in the child, (2) factors in the family, (3) factors related to chronic disease in general, and (4) factors related to specific diseases.
The child's age at the onset of a disease affects his or her psychological reaction. Preschool children are affected by hospitalization if they are separated from their parents. School-aged children are affected by being cut off from their peers and education and by forced immobility. Adolescents are particularly affected if the disease affects their body image or their capacity to relate to peers, especially if heterosexual relationships are interrupted or precluded.
The child's beliefs about the cause, nature, or prognosis of the illness may be inaccurate and interfere with coping. Children with oppositional defiant disorder may transfer their behavior to the medical condition, becoming noncompliant with treatment. This can be a serious problem, for example, in juvenile diabetes, hemophilia, or epilepsy. Other preexisting psychiatric disorders can interfere with coping. Illness can aggravate psychiatric disorders such as anxiety, depression, or disruptive disorders.
Parents should receive a full explanation of the cause, nature, treatment, and prognosis of the disease. They may have a false, unhelpful sense of responsibility for the illness, particularly if they are carriers of what proves to be a genetic disease. Some parents react initially with denial. Others react by becoming overprotective, by having unrealistic expectations for improvement, by withdrawing, or by rejecting and abandoning the child. Latent tensions between the parents can be aggravated and, at times, separation or divorce precipitated.
Parents with preexisting psychiatric illness, particularly affective disorder, borderline personality disorder, or substance abuse, are likely to have particular difficulty and to need special support. Significant is the quality of the attachment experiences the parents have been able to provide for the child as an infant, before the onset of the disease. If, because of parental inadequacy or extremes of infant temperament or both, the child experienced insecure or disorganized attachment, his or her adaptation to illness may be compromised.
The psychological health of siblings may be overlooked as a result of parental preoccupation with the physically ill child. Siblings may experience deprivation of attention, causing sadness and withdrawal or resentment and acting-out.
Factors Related to Chronic Disease in General
Parents find it particularly difficult to cope when the diagnosis is unclear. Similarly, a disease with a hopeless prognosis, such as metastatic osteosarcoma, puts severe stress on the family system. Some chronic diseases (e.g., sickle cell anemia) have intermittent episodes, causing the child and parents to be hypervigilant. Diseases that affect the child's physical appearance or for which the treatment is disfiguring (e.g., the cushingoid appearance caused by corticosteroid treatment) are particularly problematic for adolescents who may become noncompliant with treatment. Diseases that cause severe pain or require invasive treatment (e.g., intravenous chemotherapy for cancer) are also likely to produce adverse psychological reactions. Some treatments can have adverse neurocognitive effects (e.g., cranial irradiation for leukemia).
Attacks of asthma can be triggered by a variety of allergic, infectious, physiologic, or psychological factors. Severely asthmatic children are at markedly increased risk of psychological disorder, particularly depression. Affective disorder and family dysfunction increase the risk of a fatal asthmatic attack. The use of corticosteroids and the limitations on activity caused by chronic asthma can impede academic and social functioning.
Individuals with cystic fibrosis, a chronic genetic disease, are now surviving into their 30s. Almost all the males are sterile. Pregnancy in women with cystic fibrosis carries a severe risk. One study identified one third of the children with this disease as emotionally disturbed. Eating disorders are more common in adolescents with cystic fibrosis. Family dysfunction and disease severity increase the risk of psychological disorder.
Juvenile-Onset Diabetes Mellitus
Family dysfunction predicts poor diabetic control. About 18% of diabetic adults exhibit emotional disturbance, usually depression or anxiety; and about 50% of severely diabetic adults are so affected. About 36% of children with diabetes are depressed or otherwise disturbed. Fear of hypoglycemia or ketosis, resistance to dietary restrictions, tampering with insulin dosage, and even suicide attempts by insulin overdose have been reported. Poor diabetic control is associated with reading problems and with psychiatric disorder in the child or parent.
Despite improved survival statistics, many children with leukemia exhibit the “Damocles” syndrome, the sense of living on borrowed time, not knowing when a fatal relapse will occur. Bone marrow biopsies, repeated hospitalizations, and chemotherapy can be frightening experiences. Cranial irradiation and intrathecal methotrexate can cause neurocognitive deficits.
In HIV encephalopathy, the neurologic disease progresses in parallel with the immunodeficiency. The disease follows one of three courses: subacute progressive, plateau type, or static. Subacute encephalopathy is associated with gradual deterioration and loss of function including motor impairment, apathy, loss of facial expression, emotional lability, and loss of concentration. In some patients the disease plateaus for months before the patient finally deteriorates. Other patients exhibit neurocognitive defects that do not progress.
HIV infection acquired from the mother is usually associated with an environment of social deprivation. Parental guilt is a common accompaniment. Infection caused by contaminated transfusions (e.g., in hemophilia) often provokes parental rage against the source of the contamination. The psychiatrist's task is to keep the child in the mainstream as long as possible, help the family deal with guilt and anger, and prepare the child for the required hospitalization and medical procedures.
When parents are apprised that their child is blind or deaf, they often experience grief. If they become depressed, the child may be affected by relative deprivation of attention. Both blind and deaf children are affected by the difficulty their parents have in establishing joint reference and shared attention (i.e., for parent and child to focus their attention, together, on an object). The prelinguistic games characteristic of normal children and their parents may be replaced by manual gestures.
Hearing adults and children have difficulty making social contact with deaf children. Blind children tend to be even more socially isolated. Although deaf children have been described as egocentric and impulsive, and blind children as introverted and dependent, it is not clear that these generalities are valid.
Blind children exhibit delayed acquisition of classification and conservation skills. Deaf children are slow to conserve; however, many deaf adolescents are capable of formal cognitive operations. Reading and writing are delayed in both groups. There is fierce controversy over whether oral methods or sign language should be used in teaching the deaf, whether oral language should be combined with signing, and whether deaf children should be mainstreamed into schools.
The prevalence of psychiatric disorder among the deaf has been estimated as 2.5–3 times that of those with normal hearing. Increased rates of psychiatric disorder have been found among students who attend residential schools for the deaf. Hearing-impaired children are at risk of physical and sexual abuse. The prevalence of psychiatric disorder among the visually impaired is less certain. One study estimated a prevalence rate of 45% (including 18.6% with mental retardation). There may be an association between retrolental fibroplasia and autism.
Most children with cerebral palsy have three or more disabilities (e.g., cognitive defect, epilepsy, communication disorders, sensory impairment, orthopedic disorders, psychiatric disorder). Between 50% and 75% are mentally retarded. The prevalence of psychiatric disorder is 3–5 times as high as in control groups, but there is no typical psychiatric disorder. Children with organic brain dysfunction are more likely to develop psychiatric disorder. By the age of 4 years, children with cerebral palsy become aware that they are different from their peers, and they become increasingly aware of social rejection and limited prospects. Only 10% marry. By adolescence, their difficulties in forming social relationships and attaining independence are likely to have caused depression, anxiety, lack of confidence, low self-esteem, and in some adolescents, attacks of rage.
Epilepsy carries an increased risk of psychiatric disorder (e.g., depression, anxiety, conduct disorder, suicide). The risk is increased if other neurologic abnormalities are present. Epileptic adolescents are particularly affected by the stigma attached to having seizures in public. Phenytoin and phenobarbitone, which are used as anticonvulsants, can dull intellectual performance. There is controversy over the assertion that epilepsy is associated with violent behavior. One study showed that patients with temporal lobe epilepsy had an 85% prevalence of psychiatric disorder, particularly catastrophic rage and hyperkinesis. Another study suggested that the rate of psychiatric disorder in patients with temporal lobe epilepsy is no higher than in patients with other forms of epilepsy. About 10% of children with temporal lobe epilepsy develop a psychotic illness in adolescence or adulthood.
Fritz GK: Common clinical problems in pediatric consultation. In: Fritz GK, et al. (eds).Child and Adolescent Mental Health Consultation in Hospitals, Schools, and Courts. Washington, DC: American Psychiatric Press, 1993, pp. 47–66.
Ryan RM,Sundheim STPV,Voeller KKS: Medical diseases. In: Coffey CE,Brumback RA (eds).Textbook of Pediatric Neuropsychiatry. Washington, DC: American Psychiatric Press, 1998, pp. 1223–1274.
Williams DT,Pleak RR,Hanesian H: Neurological disorders. In: Lewis M (ed).Child and Adolescent Psychiatry, 3rd edn. Philadelphia: Lippincott Williams & Wilkins, 2002, pp. 755–766.
Whitaker AH,Birmaher B,Williams D: Traumatic and infectious brain injury in children. In: Lewis M (ed).Child and Adolescent Psychiatry, 3rd edn. Philadelphia: Lippincott Williams & Wilkins, 2002, pp. 431–447.