In families facing pediatric CKD, parents commonly report experiencing increased levels of anxiety and depression (Brownbridge and Fielding 1991; Friedman 2006; Norman et al. 2004). The development of ESRD, with the possible need for dialysis or transplant surgery, is particularly stressful. At this juncture, frequent multidisciplinary assessments are necessary to determine the most appropriate time at which to initiate dialysis based on the child's physical and metabolic status. These assessments must also include an evaluation of the patient's home environment, including the family's financial resources and social supports. Peritoneal dialysis or hemodialysis may have a significant effect on a family's organization and structure (de Paula et al. 2008). Families assume a significant burden of care and responsibility, such as the need to rearrange schedules, alter vacation plans, and in some cases change career goals, to ensure optimal care for their child. Issues related to treatment nonadherence, potential graft loss, and medical complications become critical (Friedman 2006). Mortality rates among youngsters requiring renal replacement therapy are substantially higher than those among children without ESRD. In an Australia/New Zealand study of children and adolescents with ESRD, mortality rates were 30 times higher in pediatric patients undergoing renal replacement therapy than in Australian children in the general population, and rates were more than 4 times higher in children who were receiving dialysis than in those who had received renal transplants (McDonald and Craig 2004).

In a qualitative study of 31 Turkish parents of children being treated by hemodialysis, Cimete (2002) used focus group interviews to determine common family stressors and coping strategies. Parents reported ongoing anxiety about the possibility of their children's death and distress related to developmental delays and physical limitations that interfered with peers and education. Parents also reported guilt related to the need to restrict their children's fluid and food intake. They also expressed concern about healthy siblings who themselves expressed feelings of worry, neglect, and jealousy. Effective coping strategies endorsed by the parents included prayer, sharing feelings with spouses or others in the same situation, viewing things in a positive manner, and asking for help.

Fukunishi and Kudo (1995) administered the Family Environment Scale to mothers of children with ESRD. They found that scores on the Independence and Achievement Orientation subscales were significantly lower in the families of children who were receiving dialysis than in families of healthy controls. The authors postulated that children's physical dependence on their mothers during CAPD therapy and the mothers' tendency to be overprotective toward their children might explain some of the study's findings. The burden of CAPD was thought to restrict the ability of children to engage in other appropriate social activities. The authors further hypothesized that strong dependence on mothers may have led CAPD children to develop symptoms of separation anxiety.

Family functioning has been shown to have a significant impact on the physical and emotional care of youngsters with CKD. In a study of 41 families of children with kidney disease (including 15 children with steroid-sensitive nephritic syndrome, 12 children with CKD, and 14 kidney transplant recipients), Soliday et al. (2001) found that family conflict was associated with increases in externalizing symptoms and higher numbers of prescribed medications in the children with kidney disease. By contrast, family cohesion was associated with lower rates of hospitalization. In addition, a nontradi-tional family structure (e.g., single-parent families, blended families, families with biological parent and unrelated partner) was associated with a higher number of prescribed overall medications.

In a study of 41 families with children with renal disease and 34 families with healthy children, Soli-day et al. (2000) demonstrated that family environment predicted not only the behavior of children but also the level of stress experienced by parents of ill and healthy children. Regardless of the children's health status, family cohesion and encouragement to express emotions directly predicted better outcomes in terms of child behavior and parenting stress. Higher family conflict had the opposite effect. The data indicated that children with CKD respond in a manner similar to that of healthy controls and that an appropriate family environment may actually buffer the effects of illness-related stress.

Garralda et al. (1988) reported similar findings in that they noted a higher incidence of child psychiatric problems when parents reported increased stress and less access to emotional support. Of note in this study, children with psychiatric disturbances were also less likely to be adherent with their renal medications. Soliday et al. (2001) concluded that it is prudent for clinicians to address significant family conflict in order to optimize physical and emotional outcomes.

Parenting Teens Special Report

Parenting Teens Special Report

Top Parenting Teenagers Tips. Everyone warns us about the terrible twos, but a toddler does not match the strife caused once children hit the terrible teens. Your precious children change from idolizing your every move to leaving you in the dust.

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