Chapter 47. Psychological Reactions to Acute & Chronic Systemic Illness in Pediatric Patients

Regression is a normal reaction to acute physical illness. Physically ill children become more dependent, clinging, and demanding. Younger children may revert to bedwetting and immature speech. Preschool children may interpret the illness as a punishment for something they have done.

Younger children react to hospitalization with protest, if they are separated from, and perceive they have been abandoned by, their parents. Depression and detachment occur subsequently. These serious sequelae can be averted if a parent can stay with the child and help with daily care. Because all modern pediatric hospitals encourage parents to do so, the long-term effects of traumatic separation are seldom seen today.

Adolescents are most affected by acute illness if they see it as shameful, if they are immobilized, or if they have fantastic ideas about the cause or nature of the illness (e.g., that it was caused by masturbation).

Pain complicates adaptation to acute illness. A child's coping can be enhanced if a familiar person is present during a painful procedure; if the procedure is explained ahead of time (e.g., in play); if the medical attendant is truthful, calm, and efficient; and if appropriate reassurance and praise is offered by the physician and the parents after the procedure. If the child does break down emotionally during the procedure, the medical attendant or team must studiously avoid showing irritation or provoking guilt.

Younger children sometimes react to acute burn trauma with dissociation, and delirium may occur as a result of associated fever or tissue breakdown. Badly burned children are subsequently immobilized and exposed to repeated painful procedures (e.g., changes of dressing) and to plastic surgery, which may be required for years. The effect of disfigurement on self-esteem is discussed later in this chapter.

Delirium

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with a reduced ability to focus, sustain, or shift attention.

2. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established or evolving dementia.

3. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.

4. There is evidence from the history, physical examination, or laboratory findings that the delirium is caused by the direct physiological consequences of (1) a general medical condition; (2) substance intoxication; or (3) substance withdrawal.

(Adapted, with permission, for Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000, Washington, DC: American Psychiatric Association.)

General Considerations

Delirium is an acute or subacute, fluctuating, reversible derangement of cerebral metabolism, characterized by (1) impairment of attention, thinking, awareness, orientation, and memory, (2) illusions and hallucinations, and (3) reversal of the sleep–wake cycle. In children, delirium is most often encountered in infectious illness (particularly with fever), trauma (particularly in relation to burns or after cardiotomy), hypoxia, metabolic disturbance (e.g., acidosis, hepatic failure, renal failure), endocrinopathy (e.g., hypoglycemia), or intoxication (e.g., with drugs, pesticides, or heavy metals). In adolescents, withdrawal from illicit drugs or alcohol must be considered.

Clinical Findings

The full diagnostic evaluation of delirium requires physical and neurologic examination; a mental status examination; screening investigations (e.g., blood chemistry, blood count, urinalysis, toxicology screen, blood gases, electrocardiogram, chest X-ray); and discretionary investigations (e.g., electroencephalogram, computed tomography scan, lumbar puncture, specialized blood chemistries) directed by the clinician's diagnostic hypotheses. See Chapter 14 for a more detailed discussion of delirium.

Treatment

The treatment of delirium is directed at the cause. The child psychiatrist is likely to be called on to diagnose it, especially when the cognitive impairment is subtle and delirium has been mistaken for functional psychosis. Agitation can be alleviated with oral or intramuscular haloperidol, with the addition of small doses of lorazepam, if required. Good nursing and the presence of a parent can help to calm the patient.

Complications/Adverse Outcomes of Treatment

Managing disruptive behavior, particularly agitation and combative behavior, is the most challenging aspect of delirium therapy. If this is mismanaged, serious injuries can result.

Prognosis

The prognosis of delirium is dependent on its cause and the ability of the treatment team to prevent future episodes.

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. 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.

2. The disturbance is not better accounted for by another mental disorder

3. 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.)

General Considerations

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.

Factors in the Child

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.

Factors in the Family

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).

Specific Diseases or Conditions

Asthma

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.

Cystic Fibrosis

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.

Leukemia

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.

HIV Encephalopathy

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.

Sensory Impairment

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.

Cerebral Palsy

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

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.