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