Depression, self-esteem, and life events in adolescents with chronic diseases

Behavioral adjustment in children with asthma: a meta-analysis

This study is a meta-analytic review of the behavioral adjustment of children and adolescents with asthma. Of 78 studies initially reviewed, 26 studies (encompassing 28 data sets), reflecting data on nearly 5,000 children with asthma (mean age = 8.4 years; 40% female), met criteria for inclusion. Effect size estimates were calculated across studies using standard methods. Separate effect sizes were calculated for internalizing and externalizing behavioral problems, degrees of asthma severity, and differences in control group used (i.e., sample controls or normative data). Results indicate that children with asthma have more behavioral difficulties than do healthy children, with the effect for internalizing behaviors being greater than that for externalizing behaviors (d(mn) = .73 vs .40). Increased asthma severity was associated with greater behavioral difficulties. Results did not differ by comparison group (healthy controls vs normative data). The findings suggest that patients with asthma, particularly children with severe asthma, should be considered at higher risk for behavioral difficulties that may necessitate psychosocial intervention.

Depression in Asthma: Prevalence and Clinical Implications

BACKGROUND: Asthma and depression are both common illnesses. Data suggest that the prevalence of asthma and asthma-related morbidity and mortality has increased in the past 2 decades. Asthma has long been considered an illness in which mood and emotions contribute to symptom exacerbation. Therefore, we reviewed the recent literature on depression in persons with asthma. DATA SOURCES: The MEDLINE (1966-1999) and PSYCHINFO (1967-1999) databases were used to find English-language articles on asthma and depression. Search terms included asthma, depression, dysthymia, and mood. DATA SYNTHESIS: This literature suggests depressive symptoms are more common in asthma patients than in the general population and perhaps even more common than in some other general medical conditions. Depression may be associated with asthma morbidity and mortality. Limited data suggest the older tricyclic antidepressants may improve both depression and asthma symptoms. However, no studies have examined the use of second-generation antidepressants in asthma patients. CONCLUSION: Depressive symptoms are common in asthma patients. However, the prevalence of depressive disorders in this population is not well determined. Future studies should focus on determining the prevalence of major depressive disorder in this population and the effect of antidepressants on mood and asthma symptoms.

Depression and asthma in children

Genetic vulnerability, allergic sensitivity, immunological compromise, and psychological stressors all contribute to the onset and severity of asthma. When depression decreases compliance and worsens prognosis, caring for an asthmatic child becomes even more problematic. Early intervention to address comorbid depressive disorders increases compliance, improves outcome, and allows a child to continue to appropriately to meet developmental expectations. In cases of severe asthma, treatment of depression may also decrease mortality.

Factors associated with repeat suicide attempts among adolescents

OBJECTIVE

To determine potential risk factors associated with repeat suicide attempts among adolescents.

METHOD

Retrospective medical record review of all patients aged 13-20 years who presented to the emergency department at an inner city tertiary hospital after attempted suicide between 1994 and 1996. Subjects were identified using the International Classification of Diseases (ICD-9) codes E950.0 to E959.9 for attempted suicide. Study variables included demographic parameters, chronic medical conditions/illnesses, psychiatric and substance abuse disorders, history of sexual abuse and previous and subsequent suicide attempts. Variables univariately associated with repetition at p < 0.25 were entered into a multiple regression analysis.

RESULTS

Eighty seven per cent of patients presented with a drug overdose. Seventy-six per cent of all subjects attempted suicide in the context of a dispute or relationship break-up. At least one psychiatric disorder was present in 76% of subjects at the index attempt. The most frequently diagnosed disorders were depression (45.5%) and drug (34%) and alcohol abuse (27%). Variables predicting repetition within 12 months were drug (OR = 3.891, p = 0.02) and alcohol abuse (OR = 3.56, p = 0.05), non-affective psychotic disorders (OR = 3.81, p = 0.04), and chronic medical conditions/illness (OR = 3.29, p = 0.03). A history of sexual abuse was almost significant (OR = 3.03, p = 0.06).

CONCLUSIONS

Adolescents most likely to re-attempt suicide with 12 months present with either substance abuse, non-affective psychotic disorders, chronic medical conditions, or a history of sexual abuse. All adolescents with a possible suicide attempt should receive a comprehensive mental health and psychosocial assessment. Closer scrutiny of the role of chronic illnesses and sexual abuse in both future research and clinical management is urged. A broad based, multidisciplinary intervention approach is recommended.

Prevalence of DSM IV anxiety and affective disorders in a pediatric population of asthmatic children and adolescents

A series of 82 children and adolescents with moderate and severe persistent asthma was studied. Their psychopathological problems were compared to those of 82 healthy subjects, matched for age, sex and socio-economic status. The patients completed the Child Depression Inventory, an inventory of fears and anxiety (ECAP) and the Coopersmith Self Esteem Inventory. Parents of asthmatic children filled in the Child Behavior Check List to assess their social competence. The patients were examined with the revised Kiddie Schedule for Affective Disorders and Schizophrenia. There were more anxiety symptoms in the asthmatic group than in the control group. Asthmatics were not significantly more depressed than controls and their self-esteem was as good. We found 29 anxiety disorders, four affective disorders and four disruptive behavior disorders. Generalized anxiety disorder was the main diagnosis (n=24). The asthmatic subgroup presenting anxiety and affective disorders had poorer self esteem, fewer activities and worse social competence than other asthmatics and controls. Adolescents did not seem to have more emotional disturbances than younger patients. Girls did not have more DSM IV anxiety or affective disorders than boys.

Factors associated with self-concept in children with asthma

PURPOSE

To investigate the relationship of demographic asthma, family, and child factors with self-concept in children with asthma.

METHODS

Data were collected twice approximately 4 years apart from both the affected children and their mothers (N = 134) via interviews and self-report questionnaire.

FINDINGS

Children who demonstrated more negative attitudes toward their illness, had less satisfaction with family relationships, and used more negative coping behaviors had the poorest self-concepts. Over time, the greatest improvement in self-concept occurred in children whose attitudes and satisfaction with family relationships improved and whose use of negative coping behaviors decreased.

CONCLUSIONS

Results suggest that some children with asthma, especially girls with severe asthma, appear to be at risk for poor self-concept.

Prevalence of DSM-IV disorders in children and adolescents with asthma versus diabetes

OBJECTIVE

To evaluate the relationships between asthma and type and incidence of psychiatric problems in a pediatric population.

METHODS

A series of 93 children and adolescents with asthma presenting during a 1-year period to a pediatric pneumology and allergy service was studied. Their psychopathological problems were compared with those of 93 children with insulin-dependent diabetes mellitus (IDDM). Various questionnaires were completed by the patients: the Child Depression Inventory (CDI), the State-Trait Anxiety Inventory for Children (STAIC), and the Coopersmith Self-Esteem Inventory (SEI). Their parents were administered the Child Behavior Checklist (CBCL). The patients were examined using the revised Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS-R).

RESULTS

There were more symptoms in the asthma group than in the IDDM group, as indicated by total CBCL scores, internalization and externalization CBCL subscores, and the STAIC scores. Asthma was often associated with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) psychiatric disorders. We found 30 anxiety disorders, 5 affective disorders, and 6 disruptive behaviour disorders. Asthmatic children did not seem to be more depressed than the IDDM group, and their self-esteem, overall, was good. However, the asthma subgroup presenting with psychiatric disorders had poorer self-esteem and social competence. Adolescents did not seem to suffer more psychiatric disturbances than did younger patients. Girls did not suffer more psychiatric disturbances than did boys.

CONCLUSION

Asthma appears to be associated both with higher overall incidence of psychiatric problems than in IDDM and with particular categories of psychiatric problems. In particular, the problems include anxiety disorders, internalizing symptoms, and disruptive behaviours.

Quality of life in inflammatory bowel disease: background and definitions

Defining and measuring quality of life is a relatively new dimension of health care for many clinicians. The traditional method of evaluating clinical status and response to treatment has been to look at disease-specific symptoms, global assessments (e.g., impressions of the good, better, or worse condition of a patient), days missed at school, and a variety of disease activity scores. These impressions and techniques may or may not reflect how patients are functioning day to day and how they feel about the illness. To address these issues, health-related quality of life questionnaires have been developed to measure the functional effect of an illness and its treatment on a patient, as perceived by the patient. There are four broad domains that are considered part of a health-related quality-of-life questionnaire: 1) physical and occupational function, 2) psychologic state, 3) social interaction, and 4) somatic sensation. In the case of children, the perception of parents or caretakers may be added to complete the picture. Significant social and psychiatric problems have been described in children with IBD, including absenteeism from school, depression, suicide, and major disruption of family patterns. To understand fully the impact of inflammatory bowel disease and its treatment on patient and family function requires one or more quality-of-life instruments that are sensitive to the full range of symptoms, growth and development, and response (including side effects) to many new therapies.

Depression in pediatric chronic illness. A diathesis-stress model

Depression in pediatric chronic illness has been receiving increasing attention in recent years. Studies to date have typically focused on characteristics of illness as the major determinants of the development of depression, but characteristics of the child have received less attention. This review suggests that a diathesis-stress model can be a fruitful heuristic that would incorporate illness characteristics and attributes of the child and environmental effects in an overall framework to guide future research and treatment.

Adolescents' perspectives of chronic illness: "it's hard"

An exploratory, qualitative study with tenets from grounded theory was used to elicit detailed descriptions of adolescents' chronic illness experiences. The philosophy of symbolic interactionism guided this study. Understanding the adolescents' experiences included exploring adolescents' perspectives of the following: (1) what it is like to have a chronic illness, and (2) how they deal with having a chronic illness. A sample of 23 adolescents, 13 to 16 years of age, and diagnosed with either diabetes, asthma, arthritis, Crohn's disease, or ulcerative colitis participated. Data collection involved the adolescents participating in open-ended interviews. The constant comparative method was used to analyze all data from the interviews. The findings revealed that having a chronic illness made life more difficult for the adolescents. Adolescents experience extra effort, restriction, pain, and additional worries because of having a chronic illness. However, adolescents also clearly had ways to help them deal with their illness. These strategies and recommendations for practice and future research are discussed.

Self-reported allergy-related symptoms and psychological morbidity in primary care

OBJECTIVE

To examine the relationship between allergy-related symptoms, food intolerance and psychological distress in primary care.

METHODS

Two thousand three hundred and thirty two adults in five General Practices in the South of England completed questionnaires regarding allergy-related symptoms and psychological symptoms, but no association was demonstrated between a history of diagnosed or treated asthma, eczema or hay fever and psychological morbidity. Cases of food intolerance had lower levels of psychological distress than expected compared to hospital samples. Current, but not past wheezing and eczema, was associated with an excess of life stresses in the previous six months.

CONCLUSIONS

The association between psychological distress and the label of food allergy/intolerance found in specialist care does not extend to primary care.

Health professionals caring for chronically ill adolescents: adolescents' perspectives

PURPOSE

To describe chronically ill adolescents' perceptions of how health professionals can best care for chronically ill adolescents.

DESIGN

A qualitative study with tenets from grounded theory, including theoretical sampling and the constant comparison of data.

SETTING

Participants' homes of private hospital offices.

PARTICIPANTS

Twenty-three adolescents, 13 to 16 years of age, who were diagnosed with either diabetes, asthma, arthritis, Crohn's disease, or ulcerative colitis.

MAIN OUTCOME MEASURES

Open-ended, in-depth interview method.

RESULTS

Eight themes emerged: (1) treat me like a person; (2) try to understand; (3) don't treat me differently; (4) give me some encouragement; (5) don't force me; (6) give me options; (7) have a sense of humor; and (8) know what you are doing.

CONCLUSIONS

Health professionals need to adopt an overall approach described as careful maneuvering when caring for adolescents with chronic illness. This approach involves the health professional having sound knowledge and the ability to guide adolescents confidently and sensitively in the management of their illness.

The adolescent with sickle cell anemia

Adolescence is a time of intense change and turmoil. Helping patients with sickle cell disease have a smooth transition from the pediatric to adult health care environment is an important and meaningful experience. Facilitating the patient's transition, however, takes time and effort. Pediatricians must compile accurate medical summaries transmitting the details and nuances of the patient's history and care. Effort must be expended to ensure that details related to alloimmunization are not omitted. The pediatrician must be careful that the transfer does not create feelings of rejection and abandonment in the patient and the family. Physicians accepting the patient in transfer must devote time to educating and counseling the new patient. A relationship of trust and respect must be built. The physician should work with the patient to explore feelings of distrust and to uncover any concerns and fears, which should be dealt with proactively to avoid major conflicts later. Working closely with the adolescent patient can have many rewards, including helping the patient through a difficult period of adjustment. Helping the patient negotiate this difficult period can have many positive consequences. It is essential that both the pediatrician and internist work closely with the patient and family during the transfer process. Failure to do so can have disastrous consequences. When the collaboration is successful, however, the rewards for patients, families, and providers are great.

Chronic illness and emotional distress in adolescence

OBJECTIVE

The purpose of this study was to investigate emotional distress and suicidal ideation among adolescents with and without chronic illness.

METHODS

Two groups were compared from the Barcelona Adolescent Health Survey (3,129 students aged 14-19 years) data base. The index group included 162 adolescents with chronic conditions (100 females and 62 males) including those with asthma, diabetes, seizures, or cancer. No differences in prevalence of emotional distress or suicidal ideation were found among the four categories of disease. The control group included 865 subjects (383 females and 482 males). No age differences were evident between the index and control groups. Chi-square and Student's t-test were used for intergroup comparisons, with the criterion value set at p < .01 to reduce the probability of type I error. Analyses were conducted separately by gender.

RESULTS

Compared with controls, a significantly greater proportion of females with chronic illness reported emotional problems, feeling in a bad mood, feeling sad, believing nothing amused them, having suicidal thoughts, expressing depressive symptomatology, and having personal problems needing professional help. In contrast, no significant group differences were found for males. No gender differences were found regarding recent contact with a mental health specialist.

CONCLUSIONS

Chronic illnesses were associated with substantive emotional distress and suicide ideation in females but not in males. Females with chronic conditions did not, however, seek mental health services more often than their non-chronically ill counterparts. This suggests serious shortcomings in identification of "at-risk" youth and effective outreach to this population.

Family stress and metabolic control in diabetes

The common clinical assumption that stress has a deleterious effect on metabolic control in insulin dependent diabetes mellitus (IDDM) has not been confirmed in children and adolescents. This cross sectional study of 43 children and adolescents with IDDM and their families examined the relations between family life stress, family social support, and metabolic control. High family life stress was found to be strongly correlated with HbA1c in the whole group (n = 43) and in children under 12 years (n = 27) when considered separately. Family social support was not found to be directly related to HbA1c, but was found to buffer the effects of family life stress. These findings support the hypotheses that family stress affects metabolic control in IDDM and that good social support buffers these deleterious effects.

Issues in adolescent asthma: what are the needs?

In the UK most children with asthma do not attend hospital clinics and continuity of care is provided by their general practitioner. However, those with severe asthma, most of whom will not grow out of their symptoms, need hospital-based care as well. As they progress through adolescence teenagers become increasingly uncomfortable in paediatric wards and outpatient clinics. They need clinics where they can meet the chest physician who will take on their care before they transfer to a clinic for adults (table 5). Adolescent asthmatic patients are a distinct group of patients with different treatment requirements from either paediatric or adult patients. It is important that physicians recognise adolescent needs and the importance of regular health checks, smoking, peer pressure, and the negotiation of treatment plans in this group of patients.

Emotional well-being among adolescents with and without chronic conditions

PURPOSE

To investigate whether adolescents with chronic conditions differ from adolescents without chronic conditions in several psychological outcomes. An additional purpose was to explore whether adolescents with chronic conditions differ as a function of the visibility of their conditions.

METHODS

By means of the Adolescent Health Survey, 1683 students (grades 7-12) with a variety of chronic conditions were compared with 1650 students without chronic conditions in regard to emotional well-being, worries and concerns, and body image. Differences in emotional well-being were examined as a function of perception of family connectedness. Comparisons were also made between adolescents with visible and invisible conditions.

RESULTS

Adolescents with chronic conditions had lower emotional well-being scores, worried more about dying soon and about school or future work, and had poorer body image. For students with and without chronic conditions, higher emotional well-being scores were significantly related to higher levels of family connectedness. The best explanatory variables of emotional well-being were body image, family connectedness, concerns about school and future work, having a disability, and worry about peer relationships, accounting together for 36% of the variance in the outcome variable. No differences were found between adolescents with visible and invisible conditions.

CONCLUSIONS

Although adolescents with chronic conditions do less well than adolescents without chronic conditions, having a disability is not the most influential factor on emotional well-being. Family connectedness is of fundamental importance for adolescents' emotional health.

The attitude of asthmatic and nonasthmatic adolescents toward gymnastic lessons at school

Questionnaires examining attitudes to physical activity and to gymnastic lessons at school were filled out by 37 asthmatic and 36 healthy adolescents. No significant differences were demonstrated between the two groups. The study suggests that if a positive approach to physical activity is associated with active involvement, attitudinal factors per se should not mitigate against active participation of asthmatic subjects in sports.

Body image in chronic illness--a reconceptualization

OBJECTIVE

Was to construct a classification system of the body image specifically relevant to patient experience of chronic physical disorder.

METHOD

To review both previous writings on body image and also data on psychosocial factors relevant to a variety of chronic illnesses. From this were derived four component parts of body image: comfort, competence, appearance and predictability. These are discussed in general and disease-specific terms.

RESULTS

Using this format, a classification system is offered. This is intended to be simple enough for routine clinical use and yet to offer some insight into body experience. An example is given.

CONCLUSION

Separating out the aspects of body image relevant to physical illness provides a clinically useful classification system. Further work is needed to determine its applicability as a research tool.

Self-perception of asthmatic children and modification through self-management programmes

To examine the influence of asthma on patients' self-perceptions, 48 children with light to moderate asthma and 41 healthy children were selected to complete Harter's Self-perception Profile for children. No differences between the groups were observed. Then, to assess the effects of a psychological asthma treatment programme on self-perception, 27 of the asthmatic children were selected and allocated to three groups of 9 patients. The first of these groups received an asthma self-management programme, the second received that programme plus training in progressive relaxation, and the third (as control) only standard pharmacological treatment. Immediately after intervention and at 6- and 12-mo. follow-ups subjects again completed Harter's profile on which no significant changes were observed.