Mental Disorders and Psychological Stress
James C. Harris
Symptoms are signals that something is wrong with the child, and these might indicate a biologic syndrome or disease. On the other hand, symptoms may point to a psychological disorder in the child, or they may be the child’s way of responding to an abnormal situation at home or school. Physical or psychological symptoms may interfere with development by preventing a child from participating in age-appropriate activities, and these symptoms may have secondary effects that must be addressed in a comprehensive treatment program.
The concept of a mental disorder indicates an impairment in psychosocial adaptation occasioned by psychological distress and suffering or disability. It is not the expected response to a particular event, but rather the expression of behavioral, psychological, or biologic dysfunction. In assessing a child for a mental disorder, the physician must remember that the presenting symptoms may have multiple meanings to the child and family.
An assessment of symptoms leads to the diagnosis of those problems or syndromes that may be dealt with in pediatric practice or referred for treatment to other professionals. To make this diagnostic assessment, the current psychiatric classification follows a multiaxial system, sequentially addressing the clinical psychiatric syndrome, the presence of intellectual disability or abnormal personality traits, the occurrence of a general medical condition, and psychosocial and environmental problems that may affect diagnosis, treatment, and prognosis. It also provides for a global assessment rating of overall function. The revised Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), system does not include mixed diagnostic categories (i.e., mixed emotional and behavioral disorder), but The International Classification of Diseases, Tenth Edition, does. Both classification systems should be consulted. The DSM-IV-TR (2000) classification has a section on disorders usually first diagnosed during infancy, childhood, or adolescence. A primary care version, the Diagnostic and Statistical Manual for Primary Care (1996), is available and should be utilized regularly. Because this chapter discusses some of the more severe forms of
psychiatric and behavior disorders, the revised DSM-IV-TR criteria are reproduced. This chapter considers stress and illness and posttramatic stress disorder.
psychiatric and behavior disorders, the revised DSM-IV-TR criteria are reproduced. This chapter considers stress and illness and posttramatic stress disorder.
PSYCHOLOGICAL FACTORS AFFECTING MEDICAL CONDITIONS
Psychological factors contribute to the maintenance, exacerbation, and sometimes the initiation of a general medical condition or illness. The DSM-IV-TR uses the diagnostic term “psychological factors affecting medical condition” rather than the terms psychosomatic or somatopsychic that have been used to emphasize this association in the past. It is more useful to avoid these older terms and to describe specifically the multiple, concurrent conditions or problems with which the child and family present. Psychological factors might include a mental disorder such as anxiety, temperamental attributes, personality traits, or coping style; maladaptive behaviors; stress-related responses; the personal meanings of the illness; and the associated psychosocial circumstances that may influence treatment compliance.
These interacting circumstances, psychological symptoms, and individual responses to illness do not represent a unitary causality or a hypothetical entity called psychosomatic. The parents’ and child’s interpretations and experiences of the illness make each case unique and add to the richness of the encounter between physician and patient. The psychological response to illness can affect the child’s motivation to participate in a treatment program designed to facilitate recovery and can affect the parents’ attitudes in supporting that recovery. Symptoms may be maintained if the “sick role” has become a habitual one. Although the reasons for the original symptoms may be resolved, the interpersonal response to the illness may continue to maintain the symptoms.
Clinical presentations are affected by general psychological factors related to being acutely ill and to factors related to chronic physical illness. The clinical presentation also is affected by life events, including chronic stress in the family, the parents’ attitudes and interpersonal behavior toward the child, attitudes toward hospitalization, and behavior following discharge. Finally, the motivation to recover must be considered. Among the specific disorders that have significant potential for psychological complications are asthma, heart disease, cystic fibrosis, epilepsy, gastrointestinal disease, diabetes mellitus, short stature, and malignancies.
For example, a 7-year-old boy is seen frequently in the emergency department because of asthma. His symptoms respond quickly to symptomatic treatment on each visit, yet his mother returns with her son to the emergency department each week, complaining about his asthma. When she is asked whether his symptoms remind her of any past experience with illness in her life, she begins to talk movingly about her father’s death from emphysema that complicated black-lung disease. She had nursed her father through his final illness while pregnant with this boy, who bears a striking physical resemblance to his grandfather and who is named after him. When her son wheezes she becomes terrified, remembering her father’s terminal illness, and brings the child to the emergency department. The resolution of her bereavement is the essential ingredient in the treatment of the boy’s asthma, and when her bereavement resolves, the frequent emergency department visits end.
Important considerations in treatment are the parents’ concerns about the cause of the illness, their need for explanations, their understanding of the meaning of laboratory test results, their rejection or overly protective attitudes toward the child, and their understanding of the use of medication. Each illness has its own psychosocial context. Some issues that may require additional psychological support are anxiety about the child not being able to breathe in asthma, the experience of helplessness about when a seizure will occur, the frustration with encopresis, the fear of coma in diabetes, and the uncertainty about recovery in cystic fibrosis. For the child, excessive restrictions imposed by the parent during illness may influence personality development.
Developmentally, adaptation to the illness is an ongoing saga at home and at school, as the child’s psychological experience and comments by others influence day-to-day activities. Yet, most children with acute or chronic illnesses maintain their self-confidence and make full use of psychosocial support.
STRESS AND ILLNESS
This section focuses on those factors that relate to the stress of illness and factors that facilitate recovery. The presence of psychosocial variables and the ways in which they might influence susceptibility, rather than cause disease, are an essential consideration. This approach requires an evaluation of the circumstances that led to the consultation, as well as to the specific presentation of symptoms. The child, in the unique context of his temperament, genetic background, family life, and community experience, is the patient. Both the symptom itself and how it is experienced must be appreciated. The physician should address the external environmental conditions at home and at school, along with the child’s response to them, the risk factors that may lead to vulnerability to illness, nutrition and genetic predispositions, the family’s and child’s perception of the illness and how it affects their views of themselves, the child’s temperament, the child’s developmental level and the expected behavioral response to illness at that level, and the difficulty of relinquishing the dependence inherent in assuming the role of patient. All these factors are important in an initial assessment aimed at facilitating recovery.
Resilience to Stress
Historically, we have moved from a general emphasis on the effects of adverse life experience on behavior and symptoms to the specific kinds of life experiences that are most likely to lead to disorders. It is important to note that all children do not succumb to illness or become symptomatic when they are subjected to stress. In a study conducted by Rutter, more than half of the children were resilient to the effects of external circumstances on their behavior or somatic symptoms. However, risk factors do interact with developmental stages (e.g., an experience may be stressful and elicit a greater physiologic response in a younger child than in an older one).
In the psychiatric classification system, psychosocial stressors as well as protective factors should be considered. Psychosocial stressors are grouped together on Axis IV in the following categories: problems with primary support group (e.g., death of family member, health problems, divorce); problems related to the social environment (e.g., death of friend, living alone); educational problems (academic problems, peer problems); occupational problems; housing problems; economic problems; problems with access to health care services; problems related to interaction with the legal system and crime; and other psychosocial and environmental problems (e.g., exposure to disasters). To understand vulnerability and resilience to stress, individual differences in how potential stressors are experienced must be taken into account, and it is necessary to note that what is initially stressful may have strengthened the patient for later exposure to similar events. Experiences may be sensitizing or strengthening, depending on a variety of
factors. Although the experience may be ultimately strengthening, it is not experienced initially as positive by the child. The effect may be evident as protective only when new exposures to stress occur. For example, individual differences exist in separation experiences in younger children as compared with older ones. To be strengthening, early experience with separation must occur in the context of affectionate support and hopefulness, which may modify the effect of later stressors. On the other hand, early separation may be sensitizing; instead of developing resilience, some children may have exaggerated symptoms when the stress of separation recurs.
factors. Although the experience may be ultimately strengthening, it is not experienced initially as positive by the child. The effect may be evident as protective only when new exposures to stress occur. For example, individual differences exist in separation experiences in younger children as compared with older ones. To be strengthening, early experience with separation must occur in the context of affectionate support and hopefulness, which may modify the effect of later stressors. On the other hand, early separation may be sensitizing; instead of developing resilience, some children may have exaggerated symptoms when the stress of separation recurs.
An important preventive approach to separation and hospital stress is the hospital-based Child Life program, which provides anticipatory programming to prepare and strengthen the child for hospitalization and provides a normalized setting during the hospital stay. Social support is an important protective factor, and a particularly important element is a confiding relationship with one person, usually a parent. The parent’s style of interaction; psychological availability; and how, when, and to what degree he or she expresses emotion in the child’s presence may be critical factors in the child’s psychosocial development.
To understand the child’s response to stress, several issues must be considered. The timing of the event, the child’s developmental level, and the degree of cognitive development all are important. Young children apparently are not as responsive to separation stress in the first months of life, before developing selective parental attachment. After that time, an interpersonal bond is demonstrated by the child’s response to reunion after separation from the parent.
To appraise events cognitively as stressful, the child must attribute personal meaning to them. The child’s experience of self-efficacy also influences the response to the stress. The ability to develop strategies for controlling the environment is a psychologicalally protective element. Of importance are the kinds or patterns of stress that are experienced, individual differences in responsiveness, previous interpersonal experiences outside the home, self-esteem and self-efficacy, opportunities to control the situation, availability of intimate relationships, and developmental strategies to cope. The ability to appraise a new situation is a cognitive landmark. A child’s ability to act rather than react is important to gauge. A child can respond with feelings of self-esteem and self-efficacy if she is secure in affection and achievement and has had positive experiences appropriate for her temperament. These interpersonal abilities are very important when the child is threatened or alarmed.
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