Adolescents Ages 1318 Years

Adolescents also experience feelings of sadness, anger, and loss as a result of their conditions (Donovan 1989). Chronic medical problems may affect an adolescent's functioning in new normative roles, impacting areas of his or her life such as dating. As a result, some adolescents may begin to be seen by their peers as loners. These adolescents may fear death and may withdraw from their environment, leading to further isolation. Parents may become increasingly concerned about an adolescent's psychosocial adjustment but may be fatigued by their challenging parenting role. Separation issues can be as complex and confusing for parents as they are for adolescents, and some parents may feel torn and ambivalent about letting go. This ambivalence can impact the extent to which the adolescent separates and engages with his or her peer group.

History of Illness and Medical Experiences

Few studies have examined the relationship between illness duration and adjustment in children with chronic illnesses. Some investigators have reported that children with chronic illnesses that require strict disease management, such as juvenile diabetes, perceive their illness as increasingly difficult to manage over time (Kovacs et al. 1990). Additionally, age at illness onset may play a role; one study found that boys with early-onset diabetes had more behavior problems than either girls with early-onset diabetes or youngsters of either gender with late-onset diabetes (Rovet et al. 1987). Age at onset may not be related to self-reported distress, suggesting a complex relationship between illness experience and adaptation (Kovacs et al. 1990).

Temperament

Temperamental difficulties have been found to predict poor behavioral and emotional adjustment in children with chronic medical illnesses. Two studies have found a relationship between dimensions such as activity level, reactivity, behavioral difficulty, and distractibility on the one hand and mother-reported behavior problems on the other (Lavigne et al. 1988; Wallander et al. 1988). Notably, both populations included in these studies had illnesses characterized by central nervous system impairment (i.e., spina bifida and cerebral palsy), which may affect findings regarding psychological functioning, given the apparent importance of whether or not the brain is involved in a child's chronic condition.

Interactions With Parents, Family Environment, and Parental Mental Health

Maternal depression and anxiety play important roles in child adjustment to chronic illnesses and child behavior during procedures (Wallander and Thompson 1995). One reason for the interest in assessing parental distress is that it has potential effects not only on the child's adjustment but also on the accuracy of the parent's reporting of the child's adjustment (R.J. Thompson et al. 1993). In studies of depressed mothers of children with a range of chronic conditions (e.g., diabetes, mental retardation, cystic fibrosis), mothers with depression reported more behavior problems in their children than did nondepressed mothers (Walker et al.

1989). However, the depressed mothers' reports still bore a significant relationship to the level of child adjustment, suggesting that the reports were influenced both by the mother's emotional state and by the child's behavior.

Maternal anxiety plays an important role in mother-reported behavior problems and in child-reported psychiatric symptoms. One longitudinal study of children with cystic fibrosis found this to be the case even after controlling for demographic parameters (R.J. Thompson et al. 1992). The same study also found that at follow-up, maternal anxiety played a role in increases in child self-reported psychiatric symptoms when baseline child psychological functioning was controlled for (R.J. Thompson et al. 1994). A parallel study of children with sickle cell anemia yielded some but not all of the same findings (R.J. Thompson et al. 1993).

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