1. Psychological Aspects of Illness Emotions Behaviors Cognitive States Psychiatric Disorders

2. Relevance for Physicians Diagnosis Treatment Screening for Psychiatric Disorders

3. Role of Psychological Factors in Diagnosis and Treatment History - Symptom Reporting Physical Exam –Blood Drawing –Other Diagnostic Procedures Treatment –Compliance vs. Non-Compliance

4. Emotional Responses to Illness Anxiety - Fear - Panic Sadness - Despair - Hopelessness Irritability - Anger - Rage Passivity - Helplessness Relief - Happiness - Mania

5. Problematic Behaviors in Response to Illness Withdrawal - Social Isolation - School Refusal Oppositional Behavior - Tantrums - Aggression Head-banging - Self-Mutilation - Suicide Attention-Seeking Behaviors

6. Potential Cognitive Changes in Physical Illness Impairments in Intellectual Functioning Attentional and Learning Problems Slowed or Racing Thoughts Hallucinations and Delusions

7. Potential Responses to Chronic Illness Denial Why Me? or Why My Child? Guilt Feeling of Being “Different” Fears of Disfigurement, Disability, Death

8. 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)

9. Approaches to Understanding Psychological Responses Need for Conceptual Framework Awareness of Risk and Protective Factors Applications to Patient Care

10. Conceptual Frameworks Biopsychosocial Model Developmental Models Applications of Developmental Concepts

11. 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

12. 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

13. 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

14. 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)

15. Applications of Developmental Concepts Regression Children’s Understanding of Illness and Death Adolescents’ Sense of Invincibility

16. 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

17. 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

18. 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

19. 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

20. 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”

21. Mediating Factors in Emotional Response to Illness Child Characteristics Illness Characteristics Family School Community Health Care System

22. Mediating Factors: Child Characteristics Age Sex Developmental Level Temperament Previous Experiences

23. Mediating Factors: Illness Characteristics Acute vs. Chronic Systemic vs. Local Disability Disfigurement Pain Restrictions on Activity Etiology Age at Onset Diagnosis Prognosis

24. Mediating Factors: Family Family Structure: Intact vs. Fragmented Socio-economic Status Family Members’ Previous Experiences Supportive Capacity for Collaboration with Treating Staff

25. Mediating Factors: Other Environmental Variables School Peers Health Care System

26. Mediating Factors: Treatment Variables Short vs. Long-Term Invasive vs. Non-invasive Frequency Need for Hospitalization - Single vs. Multiple CNS Effects Other Side Effects

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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