Psychological Symptoms

As I stand in the night the fear approaches I stand strong and face it with all I have It tears and beats down on me I stand my ground and face whatever it comes at me with It reaches to the darkest part of my soul It flows through me and never seems to go away It comes right back But I stand my ground For the hopes of the end and of something better I stand strong for the things that help me fight it In the end it does not end but I still stand strong Into the night I stand bold till the end But then there is another journey ahead Another challenge to face I will face sadness, humiliation, opinion, pain, disgrace, and choice as they tear me apart. The medicine from friendship, family, love, and life experiences heal me. —Derick Mount, whose osteosarcoma was diagnosed at age 12. (12/3/1986–8/17/2005)

When a child faces a chronic or life-threatening illness, families immediately inherit myriad challenges. First and foremost, the family is thrust into living with uncertainty. Concerns about the child's health status are accompanied by additional stresses, including parental ability to maintain employment with associated financial implications; the child's ability to negotiate school and maintain relationships; and the ongoing negotiation of other difficult events or traumas that occur in everyday life. Worry and sadness are natural psychological reactions in this context. However, when should clinicians be concerned that these responses, secondary to the illness or treatment, are becoming pathologic in and of themselves? When do worry and sadness translate into anxiety and depression?

Symptoms such as anxiety and depressed mood are evaluated on a continuum ( Fig. 26-1 ). In general, increasing frequency of a symptom, lasting longer than two continuous weeks, and the presence of significant impairment in functioning or the expressed desire for death should alert clinicians to pursue an in-depth mental health assessment to explore the need for specific psychological intervention. Such assessments must take into account the cultural background of the family, because psychological symptoms may be either minimized or emphasized in certain cultural contexts.

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Spectrum of clinical concerns.

There are particular junctures in the illness where strong psychological reactions may be expected. The diagnosis of a life-threatening illness such as cancer and the subsequent aggressive treatment may be disruptive, frightening, and potentially traumatic for children and their families. Anxiety or depression may emerge at multiple stages of illness: during and immediately after diagnosis and treatment from the uncertainty of outcome, as well as during survivorship, treatment for relapses and end-of-life care, and when worries appear about how death might affect the family. Hospitalization may create more anxiety in children under the age of 5 years or in those who already had difficulty separating from caregivers. Just thinking about chemotherapy or hospital smells may trigger feelings of anxiety. Youth, particularly adolescents, are concerned about the effects the illness and treatment may have on their appearance. Additionally, the further a child gets from a normal routine, the more anxiety-inducing it may be to try to re-enter his or her previous life with school, family, and friends. Anxiety, depression, post-traumatic stress, disordered sleep, and adequate pain control must all be addressed for optimal care to be provided.