Pediatric Psychology:Coping with Medical Stressors

Melissa SternPSY 4930November 21, 2006

Medical Stressors

InjectionsBlood draws (venipunctures)Other painful/uncomfortable procedures: Chemotherapy Lumbar punctures

HospitalizationChronic Illness

How common are medical stressors?

By the age of 5=10 preventative injections5 million medical procedures/yr2 million children < 15 are hospitalized/yr.12.6 million children have a chronic illness

What affects a child’s ability to cope?

Developmental factors Age Cognitive maturity Emotional maturity

Coping style Sensitizers vs. repressors Primary vs. secondary coping Changes over time

Family variablesIllness/Treatment characteristics

Developmental Considerations

Infancy/Toddlerhood Separation from parents Interfere with development of attachment,

interpersonal trust, self-regulation Show most severe reactions:

Inconsolable crying Apprehension Somatic complaints Regression

May delay social development Noncompliant and oppositional behavior

Limit setting

Developmental Considerations

Middle Childhood Most affected in academic or peer

contexts Medical treatments may affect cognition Frequent school absences Bullying

Cognitive considerations Rule-oriented thinking may promote

adherence (e.g., a belief that recovery results from strict adherence)

Developmental Considerations

Adolescence Adolescent concerns may interfere

with appropriate coping Developing autonomy Peer and romantic relationship Self-consciousness about appearance

Adherence decreases Cognitive maturity can be protective

Sophisticated coping strategies

Understanding of Illness

Preoperational Stage Thinking is based on naïve perception (e.g.,

seeing is believing) Believe that illness is caused by external

events, objects, or people Cold is caused by trees or happens when

someone stands near you May understand the idea of contagion, but

do not understand the process Causes and consequences are confused

Understanding of Illness

Concrete Operations Period Understand contamination—something

harmful causes illness Later, can understand internalization

(swallowing or breathing can affect the inside of the body)

Invisible objects (e.g., germs) cause illness

Understand that an object causes illness because of it’s qualities

Understanding of Illness

Formal Operations Period Understand that illness may be

caused by physiological or psychological states

Understand abstract concepts (e.g., poor nutrition)

However, their understanding of illness is often overestimated—concrete thinking still predominates

Understanding of Pain

Infants & Toddlers In the past, newborns were thought not to

experience pain In infants, pain responses are global,

diffuse, and prolonged By 6-8 months, infants display anticipatory

fear and avoidance behavior By age 2, response to pain is localized,

expressions of anger, or appeals for aid are more common

Understanding of Pain

Preschool Period Pain is viewed as an unpleasant

physical entity caused by external events

Coping is mostly passive: Rely on medicine or parents for relief

Understanding of Pain

Middle Childhood Pain is a feeling Can differentiate pain based on intensity,

quality, or duration Physical and psychological causes are

recognized, but not integrated Children may initiate coping responses:

Exercising or talking with friends Level of understanding is related to type of

pain Injections vs. Headaches

Understanding of Pain

Adolescence Cognitively sophisticated

explanations of pain and it’s causes (e.g., using metaphors)

Understand that both physiological causes and psychological causes can occur simultaneously

Understand the adaptive purpose of pain

Coping Styles

Coping: “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of a person”Research in this area has been divided into coping during anticipation/ preparation phase and the encounter itself

Coping Styles: Anticipation Phase

Sensitizers: Cope with stressor by gathering information and becoming familiar with the upcoming encounterRepressors: Turn away from the stressor using denial or distraction

Coping Styles:Anticipation Phase

Primary control: Coping style that involves attempts to modify external conditionsSecondary control: Style that attempts to modify internal events (oneself)

Secondary is most effective with uncontrollable stressorsPrimary is best with controllable stressors

Interventions to Promote Coping

Primary goals Encourage positive relationships Emotional support Age appropriate information

Types of Interventions Education, Modeling, Coping Skills

Training

Coping Interventions

Educational interventions Include using dolls to explain procedures,

written materials for parents, videotapes Have been shown to be efficacious with a

variety of medical procedures Fewer distress behaviors Higher parental satisfaction Less parental anxiety

Developmentally appropriate information is crucial

Coping Intervention

Modeling interventions Based on social learning theory Involve an educational component

and a modeling component Model may be a peer (live or videotaped),

doll, or puppet Model is shown to engage in positive

coping skills Participant modeling vs. Symbolic

modeling

Coping Interventions

Coping skills training May include both education and

modeling, but focuses on teaching coping techniques

Coping strategies taught include Relaxation, imagery, distraction

Other considerations

Children undergoing repeated medical procedures do not respond as well to interventions Post-traumatic reactions

Behavioral techniques may be used to reduce anxiety Operant techniques, systematic

desensitization

Other considerations

Mixed results regarding parental participation Parental presence is usually helpful,

unless the parent is anxious Usually is most helpful during

preparation for medical procedures

Health Policy

Less than half of surveyed hospitals used preparation-focused interventions (e.g., education, modeling, or coping skills)Most use narrative preparation, tours, play therapy, or printed material These have not been supported

empirically

Family Variables & Coping

Family variables are important to consider when children undergo medical stressorsFamily and individual characteristics are more important than disease characteristicsFamily variables influence child coping through: Parent coaching Modeling Home environment

Family Environment

Adaptability, Cohesion, Communication, ConflictFamily flexibility may promote positive copingLow cohesion may promote avoidant copingHigh family competence (problem solving together) was related to better coping

Parent Mental Health

Relationship between parent mental health and child illness is bidirectional More parents of children with chronic

illnesses seek psychological services Maternal anxiety, distress, etc. can

negatively impact the management of child’s illness

Factors that influence parents mental health can also impact the child Social support

Dimensions of Chronic Illness

DurationAge of OnsetLimitation of ActivitiesVisibilityExpected SurvivalMobilityPhysiological Functioning

CognitionEmotional/SocialSensory FunctioningCommunicationCourseUncertaintyStigmaPain

Happy Thanksgiving!!