Mental Health Evaluation

Although psychological or psychiatric treatment is not universally necessary, the mental health consultant's ability to identify "high-risk" children and intervene in a timely fashion is crucial. Ideally, the psychological status of each child admitted to palliative care should be evaluated to facilitate optimal care planning in the same way that medical and nursing assessments are carried out. Although sadness and anxiety are typical and expected reactions to prolonged illness and treatment, under sustained stress, such responses may progress to disabling clinical disorders that may ultimately necessitate psychotherapy and/or psychotropic medication; this is especially true for a child with preexisting vulnerabilities, including a prior psychiatric history in the child or a family member.

Although overemphasizing pathology in the child should be avoided, minimizing or failing to recognize important symptoms also presents risks. Unfortunately, both parents and clinicians often underestimate the degree of emotional distress experienced by pediatric populations with chronic illness. Differential diagnosis may be difficult for non-mental health providers because the normal emotions of sadness and grief overlap with the symptoms of clinical depression (e.g., crying, decreased appetite, difficulty sleeping, and decreased attention and concentration) (Kersun and Shemesh 2007; Shemesh et al. 2005). The mental health clinician, by assessing the severity of symptoms, particularly in terms of intensity and duration relative to the child's current reality, can determine whether psychotherapy is necessary or existing supportive services (e.g., child life,

As the illness progresses, the emphasis gradually shifts from curative to palliative treatment. Curative

Highly technical invasive treatments may be used both to prolong life and to improve quality alongside palliative care, each becoming dominant at different stages of the disease.

Palliative

No cure is possible, and care is palliative from the time of diagnosis.

At first it is not apparent that the illness is terminal, and palliative care starts suddenly once that realization dawns.

Figure 16-3. Curative and palliative care relationship.

Source. Reprinted from Joint Working Party on Palliative Care for Adolescents and Young Adults: Palliative Care for Young People Aged 13-24. Researched and written by Thornes R. Edited by Elston S. Bristol, UK, Association for Children with Life-Threatening or Terminal Conditions and Their Families, September 2001. Used with permission.

chaplaincy, ongoing relationships with physicians and nurses) would suffice.

Child mental health clinicians possess knowledge of normal psychological development that is essential for evaluating the impact of illness on a child, providing explanations in developmentally appropriate ways, and identifying appropriate interventions. Conceptions of death are thought to generally correspond with the progression through four sequential stages of cognitive development (Poltorak and Gla-zer 2006), as shown in Table 16-2, although children with a life-threatening illness often possess an advanced understanding of death relative to their healthy same-age peers (Bluebond-Langner 1996).

During infancy and toddlerhood, children hold little, if any, understanding of death; rather, death is equated with separation from caregivers. By preschool age, children develop an awareness of death; however, they are unlikely to recognize that death is universal, an inevitable outcome for all living things including themselves and loved ones (Poltorak and Glazer 2006). Lacking the concept of irreversibility, young children are also unlikely to understand the permanence of death. Thus, a young child of a deceased sibling may continue to ask days after his passing when her brother will be returning home. Additionally, preschoolers' limited understanding of cause and effect may lead them to wrongly infer causality, referred to as magical thinking. For example, young children may perceive themselves as responsible for negative events when such events have coincided closely in time with their own actions or thoughts. Within the context of psychotherapy, such beliefs can be explored and misconceptions clarified.

From approximately 6 to 12 years of age, children develop logical reasoning skills and are able to understand more objective causes of death. They also grasp that all functions of the living physical body cease to exist at the time of death. Children's fears of death remain primarily centered on the concrete fear of being separated from parents and other loved ones. By adolescence, abstract reasoning enables them to anticipate the future in a way that younger children cannot. The experience of death for the adolescent becomes more focused on existential issues related to an afterlife similar to that seen in adults.

Table 16-2. Development of the death concept

Stage

Age

Death concept

Sensorimotor

Birth to 2 years

No concept of death

Preoperational

2-6 years

Magical thinking

Concrete operational

6-12 years

Attainment of Universality Irreversibility Causality Nonfunctionality

Formal operational

12 years to adulthood

Increasingly abstract reasoning

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