Medical Overview

JRA, also referred to as juvenile idiopathic arthritis, is the most frequent connective tissue disease of childhood (Olson 2003). The etiology of JRA is unknown but may include a combination of factors such as environment (e.g., infection, trauma, stress), autoimmunity, and immunogenetics (Drotar 2006). Diagnostic criteria for JRA include an age of onset of younger than 16 years of age, arthritis of one or more joints, and a duration of disease greater than or equal to 6 weeks other conditions...

Polycystic Ovary Syndrome

A common endocrine disorder in adolescent girls and women with concomitant hyperandrogenism and insulin insensitivity is polycystic ovary syndrome (PCOS). Features of PCOS include obesity, hirsutism, acne, and amenorrhea (Himelein and Thatcher 2006). Additionally, infertility frequently results from PCOS and is thought to be a stressor that contributes to reduced quality of life and increased depressive symptoms for women and girls (Trent et al. 2003 Weiner et al. 2004). However, compared with...

References

Aldridge MD How do families adjust to having a child with chronic kidney failure A systematic review. Nephrol Nurs J 35 157-162, 2008 Ardissino G, Dacco V, Testa S, et al Epidemiology of chronic renal failure in children data from the ItalKid project. Pediatrics 111(4 Pt 1) e382-e387, 2003 Bakr A, Amr M, Sarhan A, et al Psychiatric disorders in children with chronic renal failure. Pediatr Nephrol 22 128-131, 2007 Brownbridge G, Fielding DM Psychosocial adjustment to end-stage renal failure...

Substance Induced Anxiety Disorder

Anxiety may be induced by a variety of substances or medications, either as a direct effect of a substance or as a withdrawal reaction (see Table 7-7). Corticosteroids, anticholinergic medications, beta-adrenergic agonists, and asthma medications are all potential causes of anxiety, particularly if the medication has recently been started or the dosage has changed (see Table 7-8). Table 7-9 serves as a reference for how anxiety disorders relate to the specific DSM-IV-TR specifiers of substance...

Vocal Cord Dysfunction

VCD is most often misdiagnosed as asthma and therefore ineffectively treated with asthma medications. First described by Christopher et al. (1983), VCD was recognized when patients presenting with asthma-like symptoms did not respond to the standard asthma therapies. The syndrome of VCD manifests with asthma-like signs and symptoms but is distinct from asthma in that the pathophysiology involves paradoxical vocal cord closure during inspiration (the obstruction being outside of the chest), in...

Correlates of Psychosocial Adjustment

Among health conditions that do not involve the brain, such as heart disease and asthma, few differences have been found with regard to child psychosocial adjustment (E.C. Perrin et al. 1993). Findings Figure 2-2. R. J. Thompson's (1985) stress and coping model of adjustment. Source. Reprinted from Wallander JL, Thompson RJ, Alriksson-Schmidt A Psychosocial Adjustment of Children With Chronic Physical Conditions, in Handbook of Pediatric Psychology, 3rd Edition. Edited by Roberts MC. New York,...

Bulimia Nervosa and Binge Eating Disorder

Bulimia nervosa has a prevalence of between 1 and 2 in adolescent and young adult women, with clinically significant bulimic binge eating behaviors (eating disorder not otherwise specified or binge-eating disorder) in an additional 2 -3 (Fairburn and Be-glin 1990 Fairburn et al. 2000 Flament et al. 1995 Hoek and van Hoeken 2003). The two primary features of bulimia nervosa are 1) overvaluation of body weight and shape and 2) a pattern of eating consisting of extreme dieting punctuated by...

Neurobiological Factors

A number of neurotransmitters and appetite-related neuropeptides have been identified as being abnormal in patients with eating disorders. Serotonin has been the neurotransmitter most commonly targeted for investigation, because the 5-hydroxytryptamine (5-HT) systems are known to be involved in disorders of mood, obsessiveness, appetite regulation, and impulse control. Although patients with anorexia nervosa have been found to have low levels of 5-HT metabolites in their cerebrospinal fluid and...

Biofeedback

In biofeedback, a computer is paired with controlled breathing, relaxation, or hypnotic techniques. The computer generates a visual or auditory indicator of the child's muscle tension, peripheral skin temperature, or anal control, allowing the child to have external validation of the physiological changes he or she has produced using the techniques. Biofeedback also enhances the child's sense of mastery and control. It has been successfully used with children as young as age 6 years.

Impact and Sequelae of Cancer

Treatments of pediatric cancer include surgery, chemotherapy, radiation, and various combinations of these elements, depending on the histology and stage of the malignancy (Ludwig 2008). All of these treatments have the immediate impact of being strange and often frightening for pediatric patients and their families. Most treatment protocols also involve discomfort or pain, removal from familiar environments, and interference with usual developmental tasks, such as school and peer...

Eating Disorders in Children With Diabetes

An additional and somewhat unique concern in children and adolescents with diabetes is the occurrence of disordered eating. Such disordered eating is believed to be the result of both the focus that the treatment of diabetes places on dietary intake and the fact that treatment modalities often result in weight gain. However, some controversy exists regarding the prevalence of disordered eating in individuals with type 1 diabetes. Some studies have found no significant increase in diagnoses of...

Cognitive Changes in Children With Type 1 Diabetes

Evidence suggests that children with type 1 diabetes may experience a wide range of cognitive difficulties associated with their disease. A number of studies document that these children are at risk for learning disabilities and may experience difficulties with attention, processing speed, long-term memory, and executive functioning (e.g., McCarthy et al. 2003 Rovet and Alvarez 1997 Schoenle et al. 2002). As a result, academic problems may emerge, particularly for those children who have...

Psychosocial Interventions for Children With Type 1 Diabetes and Their Parents

Over the past three decades, a variety of psychosocial and behavioral interventions have been utilized in the context of type 1 diabetes (for comprehensive reviews of such interventions, see Delamater 2007 Hampson et al. 2000 Winkley et al. 2006). These interventions have tended to fall into one of four overlapping categories 1) patient family education and teaching of self-management skills 2) improvement of adherence to medical regimens 3) psychosocial interventions for children and 4)...

Child and Parental Adjustment to Type 2 Diabetes

Research on parent and child adjustment to type 2 diabetes is scant, especially considering the rising incidence of the disease (Naughton et al. 2008). One area of research has focused on health-related quality of life (HRQOL). Quality of life is thought to be an important factor in adjustment to the illness and has consequently been increasingly studied in patients with diabetes (e.g., de Wit et al. 2007). For instance, Pediatric Quality of Life Inventory scores were used to compare 91...

Interventions for Children With Type 2 Diabetes and Their Parents

Limited research has been conducted on interventions for children and adolescents with type 2 diabetes. Indeed, the majority of research has been conducted with adults. However, given the connection between obesity and type 2 diabetes, preventive interventions for children and adolescents are becoming more common. These interventions focus on increasing dietary knowledge and promoting physical activity to help reduce the likelihood of type 2 diabetes. For example, a 1-year school-based...

Adherence Issues in Diabetes Care

A comprehensive review of treatment adherence in diabetes is beyond the scope of this chapter however, the tremendous importance of compliance with the complex medical regimen warrants a brief discussion (for additional information on adherence issues, see Delamater 2000 and Chapter 13, Treat ment Adherence, in this volume). As mentioned previously, diabetes adherence is a multifaceted construct, and children with diabetes face multiple task demands in regard to a complex treatment of a chronic...

Stressful Life Events

Stressful life events, including childhood trauma, have been associated with the development of som-atization later in life (Campo and Fritsch 1994). Chronic stressors can have an effect on the body's stress response systems, such as the hypothalamic-pituitary-adrenal (HPA) axis. Although elevations of cortisol may be associated with acute stress, prolonged exposure to stress can suppress the HPA axis, resulting in the lowered cortisol levels that are associated with somatic complaints (Lackner...

Adrenal insufficiency

Adrenal insufficiency refers to impaired secretion of cortisol with or without impaired secretion of aldo-sterone. Adrenal insufficiency can result from disorders of the adrenal cortex (primary adrenal insufficiency) or of the hypothalamus or pituitary (secondary adrenal insufficiency) (see Figure 19-2). Symptoms of adrenal insufficiency include weakness, abdominal pain, and hyperpigmentation. Chronic primary adrenal insufficiency, or Addison's disease, usually results from autoimmune...

Evidence Based Treatments

Although findings from the meta-analysis by LeBo-vidge et al. (2003) suggest that youth with JRA may be at increased risk for overall adjustment problems, little systematic research has focused on explicitly improving psychosocial adjustment among youth with JRA. In fact, few studies have examined interventions for parents and caregivers of youth with JRA (Hagglund et al. 1996 Ireys et al. 1996 Turner et al. 2001). Ireys et al. (1996) conducted a randomized clinical trial in which mothers of...

Psychosocial Adjustment

Management issues for the mental health specialist consulting on these cases are acute and chronic. Presentation is based on both the location of the tumor and the age of the patient. Psychiatric morbidity is high among survivors of malignant pediatric brain tumors. These patients are exposed to surgery, radiation, and chemotherapeutic agents that cause acute and chronic effects on the brain and CNS. Patients may develop endocrinopathies, growth abnormalities, intellectual decline,...

Congenital Hypothyroidism

The hypothalamic-pituitary-thyroid axis is active by midgestation and mature by birth. Prior to midges-tation, fetal development relies on maternal thyroid hormones (Greenspan and Gardner 2004). Congenital hypothyroidism occurs in approximately 1 of 4,000 live births and is usually due to thyroid dysgenesis or deficits in thyroid hormone production. Congenital hypothyroidism is one of the most common causes of mental retardation however, because maternal thyroid hormones transfer across the...

Concluding Comments

Anxiety is a particularly common experience in the medical setting for pediatric patients and their family members. When assessing and treating pediatric anxiety in these settings, the clinician needs to consider the context in which the symptoms present and the environment in which symptoms are maintained due to the strong degree of overlap between symptoms of anxiety and certain medical disorders. Anxiety symptoms may be present as part of a primary or preexisting psychological disorder, as a...

Bone Marrow Transplantation

The term bone marrow transplantation, although still commonly used, is actually a misnomer. The term refers to a process in which a patient is treated with such intensity of chemotherapy and total body irradiation that the ability of the bone marrow to create blood cells is destroyed. This treatment is referred to as conditioning (Mori et al. 2008). The patient is then rescued with an infusion of hematopoietic (blood-making) cells. The infusion is done using an intravenous drip no surgery or...

Cognitive Behavioral Approaches

Cognitive-behavioral techniques not only have direct effects on symptoms but also promote self-efficacy by increasing the child's ability to self-manage symptoms. Although parents may need an initial explanation so as to understand how the techniques can alter physiological function to provide symptom relief, parents are often pleased to have their children learn skills that can work synergistically with Table 9-4. Clinical interview topics Description of pain Location, quality, intensity,...

Normal Development and Feeding

Conceptualization of feeding problems requires an understanding of normal feeding development and of how problems can arise. The complex and dynamic process of feeding involves a sequence of hierarchical steps (e.g., accepting, chewing, propelling, swallowing). Feeding difficulties can occur at any point along this continuum, and the complexity involved during the earliest stages of feeding development may serve as the root of feeding issues (Drewett and Young 1998 Patel et al. 2002). For...

Clinical Features

Although any body part or aspect of physical appearance may be a source of concern and several body parts may be involved simultaneously, concerns generally focus on the patient's face or head (e.g., size or shape of the nose, eyes, lips, teeth, or other facial features thinning hair excessive facial hair acne wrinkles scars). Individuals may spend hours per day checking their appearance, engage in excessive grooming or exercising to minimize or erase the defect, and or become housebound. BDD...

Acquired Juvenile Hypothyroidism

Hypothyroidism occurs in either sex from infancy through adulthood but most commonly presents during pubertal development in girls (LaFranchi 1992). In pediatric populations, acquired hypothy-roidism typically results from autoimmune destruction of the thyroid gland. Classic symptoms of acquired hypothyroidism include poor growth, weight gain, poor concentration, depression, and fatigue. Similar to congenital hypothyroidism, acquired hy-pothyroidism is treated with levothyroxine (Fisher and...

Effects of Stress and Depression on Asthma

The effect of emotional distress on asthma has been controversial over the years. Although emotional compromise has an effect on adherence to appropriate medical management, robust evidence also indicates that direct psychobiological pathways and mechanisms link stress and emotions with disease activity (Chen and Miller 2007 B.D. Miller and Wood 2003 G.E. Miller and Chen 2006 Wright et al. 1998). Evidence links negative family emotional climate to child depression, emotional triggering of...

Depression as a Continuum

Psychological adjustment problems are common for youngsters affected by physical conditions however, many of the psychological symptoms that are recognized by the pediatrician or assessed by the mental health clinician do not meet threshold criteria for a DSM-IV-TR diagnosis (Bennett 1994). Evidence strongly suggests that these subthreshold symptoms of depression may impact outcome and should be a focus of intervention (Oguz et al. 2002 Todaro et al. 2000). In a study of 159 children ages 4-16...

Parental Adjustment to Type 1 Diabetes

Although the majority of parents of children with type 1 diabetes adapt well, a subset of parents reports clinically significant psychological distress following initial diagnosis and throughout the course of their child's illness (e.g., Kovacs et al. 1990 Parker et al. 1994). Increased maternal psychological distress (e.g., symptoms of anxiety, somatiza-tion, anger, suspiciousness, depression, dysphoria) has been observed immediately following diagnosis. Parents of children with chronic...

Neuropsychiatric Manifestations

Neuropsychiatric sequelae of pediatric SLE occur due to disease involvement in the central and periph eral nervous systems. Prevalence rates of neuropsy-chiatric manifestations vary widely and range from 20 to 95 these variable rates may be due to lack of standard definitions in the literature and to the frequency of lupus-associated headaches (Benseler and Silverman 2007). Common neuropsychiatric sequelae include headaches, psychiatric manifestations (e.g., anxiety disorders, mood disorders,...

Child Adjustment to Type 1 Diabetes

A considerable amount of research has been conducted over the past three decades that examines youth adjustment to type 1 diabetes. Collectively, the extant research suggests that many of these children are well adjusted across multiple domains of emotional and behavioral functioning (e.g., Dela-mater 2007 Jacobson et al. 1997 Johnson 1980). At the same time, a consistent subset of youth with type 1 diabetes appears to be at risk for developing significant adjustment difficulties, particularly...

Mood Disorders in Specific Physical Illnesses

Depression co-occurring with physical illness worsens the prognosis of many general medical conditions. The presence of depression is associated with higher morbidity and mortality rates in many adult physical illnesses (Evans et al. 2005a). In this section, we briefly review specific illness conditions for Table 6-10. Confounding overlaps between DSM-IV-TR symptoms of depression and symptoms of physical illness and or its treatment Table 6-10. Confounding overlaps between DSM-IV-TR symptoms of...

Renal Disease

Renal insufficiency results from a functional loss of nephrons. Although generally transient and reversible as in acute renal failure, the loss may be permanent and lead to dialysis in chronic renal failure. Table 30-1. Medication use in hepatic disease Impact of hepatic disease on drug dosing Potential drug effect on liver function Antidepressants that are metabolized by phase I hepatic oxidative metabolism require an approximately 50 dosage reduction. Doses of bupropion should not exceed 75...

Refeeding and Nutrition

Managing meals and eating behaviors during an inpatient medical admission presents many challenges. Unlike specialized units, general medical or psychiatric units often do not have an established treatment program for patients with eating disorders. To complicate matters further, patients admitted for medical complications of their malnutrition may be at significant risk for refeeding syndrome (Katzman 2005). To effectively minimize such risks, staff need to closely monitor the patient's fluids...

Precocious Puberty

Precocious Puberty Pediatrics

Normal pubertal development requires activation of the hypothalamic-pituitary-gonadal axis (see Figure 19-3). In girls, the first sign of puberty is typically breast development, occurring between ages 8 and 13 years, followed by the appearance of pubic hair and menarche. In boys, the first sign of puberty is usually testicular enlargement, occurring between ages 9 and 14 years, followed by the appearance of pubic hair and penile growth. Generally speaking, pediatricians and pediatric...

Substance Induced Mood Disorder

Manic or depressive episodes may result from medications, alcohol or drugs of abuse, or toxic agents. DSM-IV-TR specifies that the mood disturbance, either manic or depressive, must have developed within 1 month of substance intoxication or withdrawal that the substance (or medication) must be etiologically related to the disturbance and that these clinical conclusions must be based on the medical history, physical examination, or laboratory findings (see Table 6-11). Alcohol, cannabis,...

Anxiety Disorder Due to a General Medical condition

Many medical conditions may result in symptoms of anxiety, and the consultant should consider this possibility if the history is not typical for a primary anxiety disorder or if anxiety symptoms are resistant to treatment (see Table 7-5). Medical etiologies are also more likely when physical symptoms of anxiety, such as shortness of breath, tachycardia, or tremor, are more marked. Anxiety that is secondary to a medical condition should be differentiated from co-morbid anxiety or anxiety that is...

Hormone Secreting Tumors

Pheochromocytoma is a rare disorder that can occur in both children and adults and is associated with catecholamine secretion from a tumor in the renal medulla. This secretion results in acute, episodic, or chronic symptoms of anxiety that are often associated with hypertension. Clinical symptoms include increased heart rate, increased blood pressure, myo-cardial contractility, and vasoconstriction. Patients may present with headache, sweating, palpitations, apprehension, and a sense of...

Acute Agitation

Acute agitation is a heightened state of anxiety, emotional arousal, and increased motor activity that occurs not uncommonly in the pediatric setting, for example, in states of acute intoxication, sedative withdrawal, and delirium, as well as in the context of emergency department evaluations or in patients with primary mood and psychotic disorders (Jibson 2007). Patients with organic brain syndromes or with cognitive impairments may also be at higher risk of such behaviors. In these...

Cognitive Behavioral Therapy

Cognitive-behavioral therapy (CBT) is a problem-oriented treatment that seeks to identify and modify maladaptive behavior and cognitions. It is based on the premise that patients and their families develop cognitive distortions (e.g., passive locus of control, learned helplessness) and or maladaptive behaviors (e.g., inactivity, poor self-soothing) that adversely affect their functioning (see Table 28-3). For example, the belief that important medical information is being withheld may lead a...

Congenital Heart Disease

Congenital heart disease (CHD) refers to a diverse grouping of heart defects, including acyanotic (left- to-right shunt) lesions, cyanotic (right-to-left shunt) lesions, and obstructive lesions (see Table 21-1). The clinical effects of these disorders can differ significantly between and within the diagnostic groupings. Whereas some children affected by CHD display only subtle symptomatology with few consequences, others can face reduced physical functioning, extended hospital stays, repeated...

Epidemiology

Asthma is the most common chronic illness facing children in the United States. The prevalence rates for pediatric asthma are at historically high levels (Moorman et al. 2007). Morbidity and mortality remain inexplicably elevated, despite the considerable advances in the pharmacological management of asthma this phenomenon is commonly referred to as a modern health paradox. Prevalence of childhood asthma ranges from 5 to 15 , depending on the country (International Study of Asthma and Allergies...

Health Related Quality of Life

Patients' health-related quality of life (HRQOL) varies depending on the stage of CKD, the need for dialysis, and whether or not patients are transplant recipients. In many studies, these groups are compared with each other, leading to variable findings. Much of the early HRQOL research was done using generic questionnaires. Goldstein et al. (2008), however, developed the Pediatric Quality of Life Inventory 3.0 ESRD Module to assess changes in HRQOL that are specific to CKD. Ruth et al. (2004)...

Pediatric Illness Falsification in the Child

Children are victimized by a variety of means, limited only by the perpetrator's imagination. They are subjected to unnecessary hospitalizations, tests, procedures, and treatments for disabilities that are physical, psychological, or educational (attention-deficit hyperactivity disorder ADHD and learning problems). Disease falsification includes symptom exaggeration and distortion false reports manipu Figure 12-1. The diagnoses that jointly constitute Munchausen by proxy. lation of medication,...