Essential Issues in Pediatric Psychosomatic Medicine

With the advent of new treatmentsfor medical diseasessuch as cancer, asthma, HIVinfection, and cystic fibrosis, more childrenand adolescents are living withchronic illness than ever before. Seventyyears ago, persons with cystic fibrosissurvived an average of 5 years, whilecurrently the life expectancy for patientswith cystic fibrosis is more than 30years.¹ For children with cancer, the 5-year survival rate has improved dramaticallyto 79% for the period of 1995 to2000.² Increased survival, however, hasbrought new morbidities.³ Childrenwith chronic illnesses are more likelyto have emotional, behavioral, andpsychiatric symptoms than healthychildren⁴ and may be psychologicallyaffected or traumatized by medicaltreatment.

Pediatric psychosomatic medicine,also called pediatric consultation-liaisonpsychiatry, investigates the psychiatricissues affecting medically illyouths in the context of their development,cognition, communication, familialinteractions, and pharmacokineticdynamics. With the recent addition ofpsychosomatic medicine as a subspecialtyfield of psychiatry,⁵ the field ofpediatric psychosomatics has becomean increasingly active area of clinicalcare and research.

Pediatric consultation-liaison psychiatrists,in collaboration with pediatricians,are called on to assess chronicallyill children and adolescents for psychiatricillness, to address nonadherence,to investigate unexplained physicalsymptoms, and to attend to psychosocialstressors. Three aspects of psychiatricconsultation in the medically andsurgically ill that are specific to workingwith young patients are:

• An awareness of the cognitive andemotional developmental levels ofthe patient.
• An appreciation of the essential roleof the family.
• A focus on facilitating coping andadjustment to illness, rather thanconcentrating on psychopathology,in order to encourage an optimaldevelopmental trajectory.Cognitive and emotional development

Clinicians need a basic knowledge ofnormal physical, motor, language,cognitive, sexual, and emotional development in chronically ill childrenin order to distinguish normalresponses to stress from detrimentalresponses. Understanding a child'scognitive abilities to process informationis essential when communicatingwith him or her about his orher disease (Table 1).

While children generally passthrough similar stages of cognitivedevelopment, clinicians cannot assumethat chronologic age is equivalent tomental age. Children with medicalillness may not mature at the same rateas healthy children because of delayedneurocognitive development, disruptionsin education, and limited socialexperiences. For example, a 15-year old chronically ill adolescent may functionat the level of an elementaryschool-aged child. Similarly, consultationsfor adults who have childhoodonsetchronic illnesses should inquireinto early hospital and medical experiencesto provide a fuller understandingof the current level of development.

• Role of the family

Consideration of the genetic and environmentalcontributions of the familyis a critical aspect of comprehensivepsychiatric consultation. Recently, afunctional genetic polymorphism wasshown to moderate the effects of stressfullife events on the incidence ofdepression.⁶ Parents are also the legalyear andfinancial decision makers in caringfor their children and can even choosewhether to inform a child of his or herdiagnosis. Feelings of depression, anxiety,helplessness, and distress are notlimited to the patient. Siblings are oftenaffected, especially in cases of tissuedonation.⁷Chronic illness can positivelyor negatively change familial dynamics⁸;psychotherapy or family-focusedinterventions may be indicated foradjustment difficulties.

Focus on adjustment

The hospital or clinic environment canbe distressing or traumatic for theacutely or chronically ill child. Injections,procedures, and surgeries canbe particularly stressful experiencesfor children. Interventions should beused whenever possible to reducediscomfort for these patients.⁹ Painfrom both medical conditions and treatmentscan provoke anxiety and affectlater pain sensitivities and neurologicdevelopment.¹⁰ Posttraumatic stressdisorder is a risk from traumatic injuryor intense hospital experiences such astransplantations. Identifying and easingpotentially traumatic situations may decrease the child's stress and improvemedical outcomes.¹¹

Children with cancer or asthmaThe psychological effects of specificmedical conditions, such as cancer andasthma, have been the focus of scientificinquiry. Pediatric cancer patientshave rates of depression similar to thoseof the general pediatric population,¹²which may be a consequence, in part,of the use of avoidant coping styles bymedically ill children.¹³ Interventions such as cognitive-behavioral techniquesand use of topical anesthetics and sedationbefore and during invasive cancertreatments have been shown to decreaseanxiety, distress, and pain for pediatriccancer patients.

The most common pediatric chronicillness is asthma, which has been associatedwith psychiatric problems inboth children and parents. More thanone third of children with asthma haveanxiety disorders, while increasedseverity of illness is associated withincreased psychosocial problems.Parenting difficulties with 3-week-oldinfants have been associated with subsequentonset of asthma at ages 3 and 6years, even controlling for socioeconomicdifferences.¹⁴ Both family therapyand pharmacologic treatments foranxiety and depression have been usefulin treating children with asthma.

• Treatment nonadherence

Nonadherence with treatment, anothercommon reason for a psychosomaticconsultation request, can range from11% to 93% in pediatric patients. Itadversely affects treatment response,increases the need for additional prescriptions,and may extend the courseof illness.¹⁵Factors such as age, culture,patient and family characteristics, anddosage and means of administration ofmedication can all affect adherence.Furthermore, child psychopathologysuch as oppositional defiant disorderhas been associated with a higherrate of nonadherence with medicalregimens.¹⁶ Thus, multiple factors needto be considered when evaluatingnonadherence.

• Psychiatric disorders

Many of the psychiatric disorders seenin adult psychosomatic medicine practiceare also seen in practices involvingchildren and adolescents, althoughresearch on the prevalence of specificconditions is sparse. Delirium is relativelycommon and has a similar presentationto that seen in adults. Certainsymptoms, such as disorientation andpsychosis, appear to be less commonor more difficult to assess in pediatricpatients, while delirium associated withorganic causes, including medicationtoxicity, infection, and metabolic imbalances,is comparable in prevalence to adult delirium.¹⁷ Strategies for treatingdelirium include reorienting the childthrough reassurance, use of familiarobjects, and clocks and calendars (whenage appropriate) in the hospital room.When pharmacologic treatment is indicated,typical and atypical antipsychoticmedications are used.¹⁷

Other psychiatric conditions thatmay be encountered in chronically illchildren include depression, anxiety,somatization, and illness falsification.Assessing psychiatric illness is oftendifficult because of physical symptomsthat interfere with diagnostic measures;this can lead to both overdiagnosis andunderdiagnosis. Depression appears tobe similarly prevalent in chronically illand healthy children; in children withchronic illness, it can lead to complicationsin medical outcomes andincreased disability.¹⁸

Somatization can occur when a childlearns that reporting physical symptomsgarners more attention than reportingemotional distress.¹⁹ Illness falsification,though rare in children, may manifestas factitious fevers, self-inducedrashes, or deliberately manipulatedinsulin levels.²⁰ Somatization, illnessfalsification, and Munchausen syndromeby proxy (illness falsificationby caretaker) can all lead to unneededtreatment and, in extreme cases, death.Management of these disorders requiresa clear understanding of the delicateinterplay between biologic, psychological,and social factors that affect psychiatricsymptoms.

• Use of psychotropic medication

Psychotropic medications for symptomsas well as syndromes can be quitehelpful in improving the quality of lifeof many patients. The prevalence of psychotropic use in the general pediatricpopulation is estimated to be around6%,²¹ but the prevalence of psychotropicmedication use in medically ill childrenis not well documented. Table 2 showspsychotropic medications with theirFDA approval status for use in childrenand adolescents.

Terminal illness

Terminal illness and the death of a childis a sad and inevitable aspect of pediatrichospital consultation that provokessignificant anxiety in the patient, family,and caregivers. Informing a child thathe or she is going to die is difficult, butparents rarely regret sharing this informationwith the child.²² Children indifferent developmental stages havediffering conceptions or misunderstandingsof death and may be helped by frank conversations with family orby play therapy facilitated by pediatricpsychosomatic medicine specialists.Comfort is another important issue atthe end of life; parents have reportedthat at the end of life, their child had agreat deal of suffering from pain, dyspnea,or fatigue and had "no fun."²³ Psychiatristscan provide treatment for adying child while also offering supportto the family and hospital staff.

• Conclusion

With evolving innovations in medicaltechnology and rapid advances in neuroscienceand molecular genetics, acomprehensive and integrative fieldsuch as pediatric psychosomatic medicinecan only be expected to expand.Recent research on cytokine-inducedsickness behavior²⁴ and the periodicidentification of novel genetic markersin patients with chronic diseases providenew information that may help in thedevelopment of future treatments.

Clinicians providing psychiatric caremust always remain vigilant in understandinghow these treatments are experiencedby children and their families.Early identification of psychiatric symptomatologywill enhance outcomes inat-risk children. Appropriate diagnosisof mental disorders, prompt psychiatrictreatment, and recognition of normaldevelopmental processes in childrenand adolescents are critical aspects ofcaring for the whole child.

Terminal illness

Terminal illness and the death of a childis a sad and inevitable aspect of pediatrichospital consultation that provokessignificant anxiety in the patient, family,and caregivers. Informing a child thathe or she is going to die is difficult, butparents rarely regret sharing this informationwith the child.²² Children indifferent developmental stages havediffering conceptions or misunderstandingsof death and may be helped by frank conversations with family orby play therapy facilitated by pediatricpsychosomatic medicine specialists.Comfort is another important issue atthe end of life; parents have reportedthat at the end of life, their child had agreat deal of suffering from pain, dyspnea,or fatigue and had "no fun."²³ Psychiatristscan provide treatment for adying child while also offering supportto the family and hospital staff.

• Conclusion

With evolving innovations in medicaltechnology and rapid advances in neuroscienceand molecular genetics, acomprehensive and integrative fieldsuch as pediatric psychosomatic medicinecan only be expected to expand.Recent research on cytokine-inducedsickness behavior²⁴ and the periodicidentification of novel genetic markersin patients with chronic diseases providenew information that may help in thedevelopment of future treatments.

Clinicians providing psychiatric caremust always remain vigilant in understandinghow these treatments are experiencedby children and their families.Early identification of psychiatric symptomatologywill enhance outcomes inat-risk children. Appropriate diagnosisof mental disorders, prompt psychiatrictreatment, and recognition of normaldevelopmental processes in childrenand adolescents are critical aspects ofcaring for the whole child.

• Dr Pao is deputy clinical director, NationalInstitute of Mental Health (NIMH) ClinicalResearch Center, Bethesda, Md. Ms Ballard isa research associate at NIMH. Dr Raza is apsychiatry resident at NIMH. The authorshave no conflicts to disclose.

References:

References1. Cystic Fibrosis Foundation. 50 Years of progress,hope. Bethesda, Md. 2005. Available at: www.cff.org/UploadedFiles/news/news/50YearTimelineFinal.pdf [PDF].Accessed March 17, 2006.
2. Ries LAG, Eisner MP, Kosary CL, et al, eds. SEER Cancer Statistics Review, 1975-2002. National CancerInstitute; 2005. Available at: http://seer.cancer.gov/csr/1975_2002/. Accessed March 10, 2006.
3. American Academy of Pediatrics, Committee onPsychosocial Aspects of Child and Family Health.The new morbidity revisited: a renewed commitmentto the psychosocial aspects of pediatric care.Pediatrics. 2001;108:1227-1230.
4. Knapp PK, Harris ES, Consultation-liaison in childpsychiatry: a review of the past 10 years, part I: clinicalfindings. J Am Acad Child Adolesc Psychiatry.1998;37:17-25.
5. Gitlin DF, Levenson JL, Lyketsos CG. Psychosomaticmedicine: a new psychiatric subspecialty.Acad Psychiatry. 2004;28:4-11.
6. Caspi A, Sugden K, Moffitt TE, et al. Influence of lifestress on depression: moderation by a polymorphismin the 5-HTT gene. Science. 2003;301:386-389.
7. Sharpe D, Rossiter L. Siblings of children with achronic illness: a meta-analysis. J Pediatr Psychol.2002;27:699-710.
8. Wamboldt MZ, Wamboldt FS. Role of the familyin the onset and outcome of childhood disorders:selected research findings. J Am Acad Child AdolescPsychiatry. 2000;39:1212-1219.
9. Kain ZN, Caldwell-Andrews A, Wang SM.Psychological preparation of the parent and pediatricsurgical patient. Anesthesiol Clin North America.2002;20:29-44.
10. Fitzgerald M, Beggs S. The neurobiology of pain:developmental aspects. Neuroscientist. 2001;7:246-257.
11. National Child Traumatic Stress Network. MedicalEvents & Traumatic Stress in Children and Families.2005. Available at http://www.nctsnet.org/nccts/nav.do?pid=typ_mt. Accessed March 10, 2006.
12. Bennett DS. Depression among children withchronic medical problems: a meta-analysis. J PediatrPsychol. 1994;19:149-169.
13. Phipps S, Srivastava DK. Repressive adaptation inchildren with cancer. Health Psychol. 1997;16:521-528.
14. Klinnert MD, Nelson HS, Price MR, et al. Onsetand persistence of childhood asthma: predictors frominfancy. Pediatrics. 2001;108:E69.
15. Winnick S, Lucas DO, Hartman AL, Toll D. Howdo you improve compliance? Pediatrics. 2005;115:e718-e724.
16. Bernstein GA, Anderson LK, Hektner JM, RealmutoGM. Imipramine compliance in adolescents. J AmAcad Child Adolesc Psychiatry. 2000;39:284-291.
17. Turkel SB, Tavare CJ. Delirium in children andadolescents. J Neuropsychiatry Clin Neurosci. 2003;15:431-435.
18. Shemesh E, Bartell A, Newcorn JH. Assessmentand treatment of depression in medically ill children.Curr Psychiatry Rep. 2002;4:88-92.
19. Silber TJ, Pao M. Somatization disorders in childrenand adolescents. Pediatr Rev. 2003;24:255-64.
20. Libow JA. Child and adolescent illness falsification.Pediatrics. 2000;105:336-342.
21. Zito JM, Safer DJ, Dosreis S, et al. Psychotropicpractice patterns for youth: a 10 year perspective.Arch Pediatr Adolesc Med. 2003;157:17-25.
22. Kreicbergs U, Valdimarsdottir U, Onelov E, et al.Talking about death with children who have severemalignant disease. N Engl J Med. 2004;351:1175-1186.
23. Wolfe J, Grier HE, Klar N et al. Symptoms andsuffering at the end of life in children with cancer.N Engl J Med. 2000;342:326-333.
24. Konsman JP, Parnet P, Dantzer R. Cytokineinducedsickness behaviour: mechanisms and implications.Trends Neurosci. 2000;25:154-159.
25. Koopman HM, Baars RM, Chaplin J, ZwindermanKH. Illness through the eyes of the child: the developmentof children's understanding of the causes ofillness. Patient Educ Couns. 2004;55:363-370.