Adaptation to Illness

David J. Schonfeld and Ellen C. Perrin

Children frequently experience minor illnesses; during their first year alone, children experience an average of five to seven respiratory or gastrointestinal illnesses. Many children also have a long-term illness that may be associated with restrictions in daily activities; physical disabilities; and repetitive, often painful, treatments and hospitalizations. Estimates of the prevalence of chronic illness range from 17% to 20% of children, with estimates even higher if less serious conditions are included. Approximately 2% of children from birth to 21 years of age have a chronic condition that is severe enough to significantly alter their daily lives; approximately 200 children per 10,000 require intensive care hospitalization each year.¹

Illnesses and their treatment are predictably upsetting experiences for children and their families. They represent potential stressors that can interfere with normal development, but they also provide an opportunity for mastery, which can enhance self-esteem and promote development. It is important to appreciate how children of various ages typically interpret and react to physical illness and its treatment to identify ways of minimizing the negative impact of such experiences and of maximizing their positive potential.² This section reviews the developmental process by which children come to understand physical illness and its treatment; children’s reactions to acute and chronic illness; children’s normal reactions to the treatment process, including medical procedures and hospitalization; and guidelines for assisting children to understand and cope with illness and treatment.

CHILDREN’S UNDERSTANDING OF ILLNESS AND ITS TREATMENT

Children develop an increasingly sophisticated understanding of physical illness and its treatment as the result of both biological maturation and the accumulation of relevant experiences.³ Developmental theorists (such as Piaget) describe important qualitative differences in the basic ways that children at different developmental stages see, interpret, and come to understand various phenomena, including physical illness and its treatment.⁴ Effective support and assistance during the illness is enhanced by an appreciation of this developmental process.⁵

Very young children often rely on magical thinking and phenomenistic explanations and may attribute the cause of illness to immanent justice, the belief that good is naturally rewarded and misdeeds are punished. This leads to a child believing illness is caused from personal guilt or causes guilt in others. Children may persist in using immanent justice explanations if they have had less personal experience with illness and if more adequate explanations have not been provided. Children as young as 4 years old can respond to educational efforts to improve their understanding both of specific diseases and of illness in general.⁶

As young children develop a more accurate understanding about the causes of illness, the concept of contagion appears in their explanations of illness. Initially, such explanations are often overextended to include even noninfectious conditions. By about 9 or 10 years of age, children believe that germs must be internalized to cause illness, but they usually cannot elaborate on the process or mechanism by which illness results. By 12 or 13 years of age, children begin to appreciate the complicated interactions between host and agent in disease causation and recovery from illness. Frequently, it is not until adolescence that children can associate apparently unrelated symptoms (eg, sore throat and a rash) or different stages of an illness with a single disease process. During adolescence, children develop a better understanding of physiology, enabling them to appreciate the rationale underlying many common treatments, such as the use of insulin in diabetes or bronchodilators for asthma.

Young children may fail to accurately report symptoms of physical illness, because they do not understand the processes of bodily functioning or illness causality. They may not understand the relationship of symptoms to a disease process (eg, that dizziness or headache might be symptoms of hypoglycemia). Magical thinking and egocentrism may lead children to conclude that they can deal with symptoms on their own, without reporting them to adults. In addition, immanent justice beliefs may encourage the withholding of information out of shame or fear of punishment. In frustration, parents, and even health care providers, may unwittingly reinforce maladaptive views of treatment as a form of punishment by “threatening” the child with worsening health or invasive procedures (eg, “If you don’t take your asthma medicine, your wheezing will get worse and you’ll have to go to the hospital and get a shot”). While such strategies might yield short-term compliance with treatment regimens, they fail to help a child reach a better understanding of underlying health concepts or the rationale for treatment. These issues are particularly relevant for children with a chronic medical condition, who are often asked to identify and report subtle symptoms (eg, shortness of breath) that may result in unpleasant or painful treatments.

Less is known about how children come to understand the cause of psychological conditions. Children younger than 10 or 11 years of age appear to attribute the causes of psychological symptoms to genetic and perinatal difficulties, while older children more often impute social and intrafamilial difficulties.⁷ Children less than 10 years of age who do not have a psychological condition tend to believe that psychological symptoms are intentional and under volitional control, at least in part.⁸

CHILDREN’S REACTIONS TO ACUTE ILLNESS

Many factors, such as those listed in Table 99-1, may influence children’s reactions to acute illness and its treatment. Influencing factors include those that are intrinsic to the child or related to the nature of the family support and the specific characteristics of the illness and the treatment process. The child’s understanding of the illness and its treatment becomes increasingly more important for children after 4 years of age. Systematically preparing children with specific information and developmentally appropriate explanations facilitates their psychological and physiological adjustment to illness, difficult procedures, and hospitalization. Preparation for a planned hospitalization enhances a child’s ability to cooperate with treatment and assists parents by decreasing their anxiety and improving their satisfaction with the treatment process.⁹ Some innovative programs have been developed to help parents and families cope more effectively with the stresses encountered when a child is hospitalized.^1,10 Educational interventions are also helpful for siblings of hospitalized children.¹¹

Table 99-1. Factors Affecting the Impact of Illness and Its Treatment

Stay updated, free articles. Join our Telegram channel

Join

Full access? Get Clinical Tree