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Psychological Aspects of Illness • • • • Emotions Behaviors Cognitive States Psychiatric Disorders Relevance for Physicians • Diagnosis • Treatment • Screening for Psychiatric Disorders Role of Psychological Factors in Diagnosis and Treatment • History - Symptom Reporting • Physical Exam – Blood Drawing – Other Diagnostic Procedures • Treatment – Compliance vs. Non-Compliance Emotional Responses to Illness • • • • • Anxiety - Fear - Panic Sadness - Despair - Hopelessness Irritability - Anger - Rage Passivity - Helplessness Relief - Happiness - Mania Problematic Behaviors in Response to Illness • Withdrawal - Social Isolation - School Refusal • Oppositional Behavior - Tantrums Aggression • Head-banging - Self-Mutilation - Suicide • Attention-Seeking Behaviors Potential Cognitive Changes in Physical Illness • • • • Impairments in Intellectual Functioning Attentional and Learning Problems Slowed or Racing Thoughts Hallucinations and Delusions Potential Responses to Chronic Illness • • • • • Denial Why Me? or Why My Child? Guilt Feeling of Being “Different” Fears of Disfigurement, Disability, Death Physical Illness as Risk Factor for Psychiatric Disorder • Psychiatric Disorders found in 20% or more of medically ill children • High Rates of psychiatric disorders in children with CNS impairments (ie., epilepsy, AIDS, Brain Tumors, Head Injuries) Approaches to Understanding Psychological Responses • Need for Conceptual Framework • Awareness of Risk and Protective Factors • Applications to Patient Care Conceptual Frameworks • Biopsychosocial Model • Developmental Models • Applications of Developmental Concepts Biopsychosocial Model: A Systems Approach to Disease • Biological Component - anatomical, biochemical and molecular substrates • Psychological Component - emotions, motivations, cognition • Social Component - Family, School, Community, including Medical System Developmental Approach: Basic Tenets • Development occurs as a continuous series of interactions between the child’s biological endowment and the environment • The child’s understanding of and psychological response to medical illness is contingent on his or her developmental level and environmental experiences Potential Effects of Illness on Development • Regression from previous levels of mastery • Delay in Achievement of Developmental Landmarks - Emotional, Social, Motoric, Linguistic, Academic • Acceleration of Cognitive Understanding of Illness and Death • Neglect or Excessive Attention to Somatic Concerns Cognitive Development: Piaget • • • • Sensorimotor Stage (Birth to 2 Years) Pre-operational Stage (2 to 7 years) Concrete Operations (7 to 11 years) Formal Operations (11 years through adolescence) Applications of Developmental Concepts • Regression • Children’s Understanding of Illness and Death • Adolescents’ Sense of Invincibility Regression • Return to developmentally earlier mode of functioning - emotional, behavioral, cognitive, linguistic or motoric • Example: a 12 year old boy insists that his mother feed him and sleep in his room after he returns home from a hospitalization for a broken leg sustained in a bicycle accident Cognitive Understanding of Illness • Pre-operational Stage: “Immanent Justice” illness as punishment • Concrete Operations (Early): “Contagion” • Concrete Operations (Late) and Formal Operations: Growing Understanding of Disease Mechanisms and Etiological Complexity Understanding of Illness: Examples • A 3 year old boy states that he has asthma attacks because he is “bad” – (concept of “immanent justice”) • A 6 year old girl states that she “caught” diabetes from her sister (contagion) • A 12 year old boy with diabetes describes the role of the pancreas and insulin in regulating blood levels of glucose Concepts of Death and Dying • Below Age 5: Fears of Abandonment, Lack of Awareness of Irreversibility • Ages 5 to 10: Confusion, Focus on body parts • Ages 10 to 15: Reality, Despair Concepts of Death and Dying: Examples • A 3 year old girl asks who will “take care” of her if she dies • A 6 year old boy wonders who he will be able to “eat ice cream” with in his grave • A 13 year old boy with osteosarcoma asks why he has to go to school since he is “going to die anyway” Mediating Factors in Emotional Response to Illness • • • • • • Child Characteristics Illness Characteristics Family School Community Health Care System Mediating Factors: Child Characteristics • • • • • Age Sex Developmental Level Temperament Previous Experiences Mediating Factors: Illness Characteristics • • • • • • Acute vs. Chronic Systemic vs. Local Disability Disfigurement Pain Restrictions on Activity • • • • Etiology Age at Onset Diagnosis Prognosis Mediating Factors: Family • • • • • Family Structure: Intact vs. Fragmented Socio-economic Status Family Members’ Previous Experiences Supportive Capacity for Collaboration with Treating Staff Mediating Factors: Other Environmental Variables • School • Peers • Health Care System Mediating Factors: Treatment Variables • • • • Short vs. Long-Term Invasive vs. Non-invasive Frequency Need for Hospitalization - Single vs. Multiple • CNS Effects • Other Side Effects Insulin-Dependent Diabetes Mellitus (Juvenile Diabetes) • Affects about 1 in 600 children below age 12 in North America • 11,000 - 12,000 new cases per year • 7 million people with Diabetes Mellitus in U.S.; 5 - 10% have IDDM IDDM: Management Issues • Need for Daily Monitoring and Treatment • Effects on Broad Range of Activities (Diet, Exercise, School, Social Situations) • Risk of Acute Crises (Seizures, DKA) • Uncertainty about long-term outcome IDDM: Cognitive Factors • Risk of Neurocognitive Impairments from Hypo- and Hyper-Glycemia and Seizures • Age of Onset and Duration • Role of Cognitive Understanding by Parents and Child to Disease Management and Control IDDM: Emotional & Behavioral Problems • Symptoms of Depression and Anxiety at time of diagnosis • Impairment in Self Esteem • Non-compliance with daily management regimen • Involvement in High-Risk Activities in Adolescence IDDM: Management Approach • Parent Education regarding the disorder • Child Education appropriate to age and developmental level • Involvement of School Staff • Psychotherapy and family counseling when indicated • Peer Support Groups - Local and National – American Diabetic Association – Juvenile Diabetes Foundation Emotional Aspects of Physical Disease: Management Summary • Assess child, family, environment • Know Illness Characteristics - onset, course, treatment side effects, prognosis • Identify Risk and Protective Factors • Formulate Developmentally Appropriate Plan for Child and Family