The relationship between physical and mental health in children and adolescents
Julia Gledhill
M. Elena Garralda
Introduction
The link between physical and psychological disorder in children and adolescents is well established. Children with chronic illness are at increased risk of emotional and behavioural disorders. In addition, repeated presentations with physical symptoms may represent underlying psychological distress or psychiatric disorder.
Because of the inextricable links between young people and the family in which they live, it is inappropriate to consider symptoms in an index child in isolation. The effects of symptomatology on family functioning, parent, and sibling relationships should be considered. This may have important aetiological and prognostic significance.
Associations between physical and psychological symptoms
There are various ways in which physical and psychological disorders are related; these are summarized in Table 9.3.4.1.
In this chapter we shall consider the following:
The psychiatric consequences of physical illness
Helping the dying child and his or her family
The effects of psychiatric disorder on the course and outcome of physical illness
Aspects of assessment and treatment intervention
Somatization and somatoform disorders, with a particular focus on recurrent abdominal pain, dissociative/conversion disorder, and chronic fatigue syndrome
Table 9.3.4.1 Associations between physical and psychological symptoms | ||||||||||
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Psychiatric aspects of chronic physical illness
Chronic physical illness and the risk of psychiatric disorder
Chronic physical illness in children, defined as disorders that last at least 1 year and are associated with persistent or recurrent handicap, affects about 4 per cent of children in Western countries.(1) This encompasses a broad spectrum of disorders including more common problems such as eczema, asthma, diabetes, epilepsy, and less prevalent conditions such as cystic fibrosis and cancer. Many children successfully adapt to living with a chronic illness, but it can be associated with a number of different types of stresses for children and their families.
The stress of chronic illness may operate at several levels. In addition to the presence of the illness itself, diagnostic and treatment procedures may be painful or have undesirable side-effects— changes in physical appearance such as alopecia, scars, and obesity may lead to difficulties in peer relationships. The demands of treatment such as dietary restrictions in diabetes may be difficult. The illness, together with hospital attendance for treatment, may lead to a considerable interruption to schooling as well as a reduced ability to participate in leisure activities and socialize with peers.
Although the majority of children and families successfully adapt to these stresses, children with chronic physical illness have a slightly increased risk for the development of associated psychiatric disorders. Specific factors related to the child and the illness have been shown to contribute to the likelihood of developing psychiatric disturbance and to influence the nature of the psychiatric disorder that develops (Table 9.3.4.2).(2)
(a) Nature of the physical disorder
Much of the increased prevalence of psychiatric disorder in children with chronic physical illness is accounted for by those with disorders affecting the brain, especially when epilepsy is involved.(3) They have a three-fold increased risk of psychiatric disorder over general population rates. The risk in young people with a chronic physical illness that does not involve the brain is considerably lower and only slightly increased over general population expectations.(3) The excess of psychopathology in children with brain anomalies may be attributable to the direct effects of organic pathology on behaviour, or may be mediated by the greater physical disability that frequently accompanies brain damage. Associated intellectual impairment may also be an important contributory factor.
Table 9.3.4.2 Factors related to the risk of psychiatric disorder and the form of its presentation | |||||||
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Whilst this dichotomy between disorders involving and not involving the brain is useful, there is little specificity in the behavioural pattern that may be attributable to intracerebral pathology. As a possible exception, children with brain dysfunction such as epilepsy or cerebral palsy may be more likely to exhibit externalizing disorders such as hyperactivity.(3) Psychiatric disorders in this group of children may be persistent, with 70 per cent still experiencing difficulties at 4-year follow-up. Overactivity, restlessness, and inattention are the best predictors of persistence.
For conditions not affecting the brain, the development of psychiatric disorder seems most likely to be linked with the accumulation of generic stress factors and family changes common to living with a chronic illness. These include life stresses such as hospitalization and daily difficulties such as specific dietary requirements and disruption of family routines.(4) A broad spectrum of psychiatric presentations are associated and these are not specific to the nature of the underlying disease processes. Children with non-neurological physical illnesses are more prone to developing emotional symptoms and eating anomalies as opposed to antisocial behaviour. Eating anomalies may arise from an emphasis on diet and a concern about poor appetite in the families of many children with chronic illnesses. Maternal anxiety may focus on feeding, especially in preschool children. The specificity of the relationship with emotional disorders is of interest. Physical illness in the child can generate family and social stresses and changes that are known risk factors for the development of emotional disorders in children. This includes mood disorders in parents and overinvolved and overprotective parenting.(2)
(b) Stage of the illness
Disorder at the time of initial diagnosis is not uncommon and is frequently short lived. In one study, 36 per cent of 8- to 13-year-olds with newly diagnosed insulin-dependent diabetes mellitus developed an adjustment disorder (most commonly dominated by depressive symptoms) within the first 3 months of diagnosis; 50 per cent had recovered within 2 months.(5) Similarly, in patients with chronic renal failure, psychological problems were reported in 60 per cent of children at the time of starting dialysis. One year later, after stabilization of their physical condition, the prevalence of disturbance was reduced to 21 per cent.(6) It is very likely therefore that in many children with chronic physical illness, psychiatric disorders are most frequently transitory adjustment disorders to stressful times in the illness.
(c) Severity of illness/degree of life threat
More severe physical disorders and those constituting a greater degree of life threat are associated with a higher risk of psychiatric disturbance. In children with end-stage chronic renal failure, those with more severe disorders (on hospital haemodialysis) have been found to have more psychiatric disorder than those not yet requiring dialysis.(7) More severely affected diabetic children and adolescents with a history of hospitalization for ketoacidosis in the previous year are more likely to exhibit psychiatric disorder than a control group of outpatients also with insulin-dependent diabetes mellitus.(8) Posttraumatic stress disorder (which by definition requires acknowledgement of perceived life threat), and high levels of post-traumatic stress symptoms have been found in children and parents up to a year after admission to Paediatric Intensive Care Units(9); (a much higher proportion than following admission to general paediatric wards), and up to 10 years after treatment for childhood cancer.(10)
The link between illness severity and risk of psychosocial impairment may vary with the setting in which it is examined. Less severe physical impairment has been shown to be associated with a higher risk of behavioural problems in the school setting.(7) Teachers may be less aware of the presence of an underlying physical disorder in this group who have less visible physical signs, and may make less allowance for these children than for those with a more overt disorder.
(d) Psychosocial risk and intrafamilial protective factors
When a physically ill child develops psychological symptoms, these are frequently attributed by families and professionals to the presence of the illness and its stresses. It is important not to neglect consideration of other predisposing factors (i) within the child, for example genetic vulnerability, temperamental characteristics, (ii) in the family such as marital disharmony, lack of open communication, maternal mental illness affecting parenting, and (iii) within the broader social environment such as bullying at school and poor peer relationships. These factors contribute to child psychopathology in ill as well as in healthy children. Conversely, protective factors such as secure parent–child attachments, increased family social support in response to the physical diagnosis, as well as sensitive paediatric management of hospitalizations and stressful medical procedures may reduce the risk of developing psychiatric disorder.
(e) Age (developmental stage)
Manifestations of psychological distress in ill children vary with each developmental stage. Preschool children have fewer cognitive resources to cope with discomfort and stressful medical procedures and are likely to rely on maternal support and distraction to cope with illness. Between 4 and 7 years of age, children may believe that illness has been caused by something bad they have done and that they should be punished.(4) Clinginess to parents, fearfulness, sleep difficulty, and oppositional–defiant behaviour are seen in preschool children. The need for repeated painful procedures, for example with cancer chemotherapy, can lead to the development of specific needle phobia.
For school-age children, school life is a key aspect of their adjustment to illness. Return to school after cancer chemotherapy can be associated with the development of school phobia, loneliness, and social isolation. School absence and having to catch up with school work, teasing, or even bullying, especially of children who look different, may also occur and contribute to lowered self-esteem and the risk of affective disturbance. Cognitive development in adolescence allows a greater understanding about the implications of chronic illness and the realities of death; depression occurs more frequently in this age group. Adolescents may begin to challenge and experiment with their treatment; they may fail to come to outpatient appointments or attend erratically. There may also be a decline in compliance with medical advice and adherence to treatment regimens.(4) For example, diabetics may not follow dietary advice or pay reduced attention to their insulin regimen and monitoring of blood sugars leading to poorer diabetic control. Adherence may be influenced by family factors; poorer metabolic control is associated with less family cohesion and a parenting style that is perceived as critical and negative.(11) Adolescents aged 13–18 years with diabetes and co-morbid internalizing disorders, and discharged from hospital, have been found to be at greater risk of readmission up to 2 years later. This relationship was not found for younger children, suggesting that greater parental control of diabetes management (as is usual for younger children) may ameliorate the potential for psychiatric disorder to affect treatment adherence.(12)
The way in which psychiatric disorder presents may influence its perceived significance to health professionals and the likelihood of psychiatric referral. Presentations with behavioural disturbances such as screaming, struggling, panicking, or a failure to comply with treatment are more likely to precipitate referral than internalizing disorders such as depression.
Effects on parents and siblings
Whilst most families successfully adjust to the presence of a child with chronic illness in the family, this may act as a risk factor for psychological disorder. The incidence of marital break-up is not increased, but there are reports of increased marital distress. Interparental conflict may not be directly expressed but instead diverted to excessive worry and focus on the illness, which can be very stressful for the child.(13) In parallel with the heightened short-term psychological difficulties found in ill children immediately following diagnosis, a similar temporal pattern of disorder has been reported for parents and siblings. Most research has focused on mothers, who often undertake the practicalities of caring for a sick child. They may need to stop work themselves, leading to increased social isolation and a reduction in extra-familial support.(14) Fathers and mothers often cope differently with the diagnosis; mothers tend to react by emotional release, whereas fathers are more likely to withdraw and concentrate on practicalities.(14) Higher rates of maternal psychiatric treatment and negative affect have been found in families with a chronically ill child. The risk of maternal depression is greater for mothers of children with chronic as compared with newly diagnosed epilepsy; the burden of illness may impede parenting capacity and contribute to the development or maintenance of psychopathology in the children.(13) Siblings may resent both the extra attention an ill brother or sister is receiving, and repeated separations from parents during periods of hospitalization. Their psychological adjustment is related to the degree of functional impairment(15) and recent physical health of their ill sibling, the extent to which family life is disrupted by the illness, and the psychosocial support available. The need for improved communication with healthy siblings has been identified.
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