Childhood Health Research Paper

There are several reasons for establishing child health psychology as a separate discipline from that of adults. First, children’s understanding of health, and the causes and implications of illness, differ from those of adults. Second, children’s health is important both for understanding the current health of the child and in terms of implications for adult health. Children who adopt unhealthy lifestyles tend to become adults with unhealthy lifestyles. Third, diseases that affect children may have different implications for daily life compared with conditions that affect adults. Thus, children with diabetes need insulin on a daily basis, whereas many adults may be treated by diet or medication alone. Untreated, cancer in children is rapidly fatal, but may be more chronic in adults. Fourth, the impact of childhood illness is not restricted to the individual but affects the whole family. Parents, and doctors, make decisions on behalf of children, often with little clear understanding of the child’s preferences.

Child health psychology is concerned with the relationship between psychological and physical well- being. The scope of child health psychology is generally considered to include the following:

(a) psychosocial contributions to outcomes in pediatric conditions;

(b) assessment and treatment of behavioral and emotional consequences of disease;

(c) role of psychology in health care settings;

(d) promotion of health and health-related behaviors;

(e) prevention of illness and injury among children and adolescents; and

(f) training.

In reviewing the achievements of child health psychology, this initial conceptualization has been followed, though it is immediately apparent that some areas have been the focus of much greater research activity than others.

1. Psychosocial Contributions To Outcomes In Pediatric Conditions

It has been argued that chronic illness challenges the child’s normal development by limiting opportunities, restricting play and activities, the attainment of autonomy, and potentially compromising family and peer relationships. These effects may differ specifically as a function of the child’s age. For infants, chronic illness is most likely to affect parent–child relationships, restrict mobility, or limit opportunities to socialize with peers. Separation from parents is a key issue. For older children, the impact will have a more direct effect in terms of reduced schooling, compromised peer relationships, more time with adults, concerns about body image, and awareness of vulnerability and possible death. Cancer in adolescence may extend a period of dependency on parents and reduce opportunities to establish close interpersonal relationships with the opposite sex.

Clinically, the study of how development proceeds despite such adversity is justified in terms of increasing our understanding of normal development, offering insights where problems occur and improving clinical services. The identification of protective factors, such as parenting, is also important. In some cases, family variables may be better indicators of outcome than illness predictors. Thus, Carlson-Green et al. (1995) studied 63 children who had been treated for a brain tumor. The best predictors of children’s behavior problems were family and demographic variables, while the best predictors of achievement were illness and demographic variables. The implications are that outcome following traumatic illness and treatment may be very much influenced by positive family variables. Identification of factors that moderate outcomes is of central interest in child health psychology.

2. Assessment And Treatment Of Behavioral And Emotional Consequences Of Disease

Measurement of psychosocial adjustment has been central to research in this area. In that a central task of childhood is to develop toward an autonomous, healthy, and well-functioning adult, adjustment has been defined in developmental-normative terms. ‘Good adjustment, then, is reflected as behavior that is age-appropriate, normative and healthy, and that follows a trajectory toward positive adult functioning. Maladjustment is mainly evidenced in behavior that is inappropriate for the particular age, especially when this behavior is qualitatively pathological or clinical in nature’ (Wallander and Thompson 1995 pp. 125–6).

While the basic question concerning how illness and treatment affects the child’s normal development is a very real one, the issue of measurement is complex. Standardized measures that capture the kind of experiences described so graphically by parents in interview studies are not available.

Measurement of adjustment has often been based on parents’ reports and most commonly is assessed using the Child Behavior Checklist (Achenbach 1991). This measure has come under considerable criticism, not least because it lacks sensitivity for work with sick children (Perrin et al. 1991). Many of the items assess somatic symptoms. As a consequence, children with cancer (or any physical illness) inevitably have higher scores than healthy children.

Improvements in the management of a number of life threatening conditions, for example, cancer and cystic fibrosis, have led to increased survival. However, this has been achieved at the cost of often daily, frequently painful, and certainly intrusive treatment regimens, which may continue for many years. Survival alone is therefore no longer perceived to be an adequate outcome measure. A central concern must be the extent to which treatment compromises quality of life (QoL). This change in emphasis has necessitated the development of alternative means of assessing treatment outcomes. Clinicians and researchers have therefore turned to measures of QoL to provide a more comprehensive account of individual patient experience as well as information on which to base decisions about service provision. Acceptance of this broader perspective on outcomes has led to a recognition of the need to identify methods of medical management, which impose fewer restrictions on quality of life.

Quality of life is a difficult concept to define and an even more difficult one to measure. Critical to most definitions is the notion that an individual’s perception of their QoL is unique, and it therefore follows that efforts must be made to elicit information directly from the individual. Proxy ratings, as provided by caregivers, are useful, but not a substitute for an individual’s own information.

Only some 3 percent of trials in pediatric oncology include a measure of QoL. There are few examples of their use in intervention studies (Kazak et al. 1996). To a large extent, this can be attributed to reticence on the part of clinicians to use the measures. Objections are generally based on perceptions of poor psychometric properties. In addition, many measures lack face validity; they do not appear to tap issues of relevance to the children under study. Many measures are criticized as too long, too repetitive, or simply inappropriate.

It would be appropriate to conclude this section with some discussion of the increasing use of qualitative measures. These are preferred by some, while others acknowledge the need for qualitative measures in combination with the more conventional quantitative measures. Qualitative methods can be used in the development of quantitative measures, ensuring that the latter include issues of importance to the target population. Qualitative methods may also be the method of choice in situations involving sensitive issues or for work with very young or handicapped children (Eiser and Twamley 1999).

3. Intervention Programs

Interventions have been reported to facilitate return to school following long illness. Varni et al. (1993), for example, reported a social skills program to teach children returning to school following diagnosis with cancer how to deal with other children’s questions. A number of methods were used (e.g. role-play) to prepare children for teasing and allow them to develop the skills to know what to say and save face.

Other programs are aimed at improving self-care. Holzheimer et al. (1995), for example, used a teaching video, instruction booklet, and opportunities to rehearse the desired skills, and reported improved use of an inhaler in preschool children with asthma.

Efforts to treat procedure-related pain have been reported most frequently in pediatric oncology. Children with cancer undergo regular painful procedures (e.g., lumbar punctures and bone marrow aspirations). The earliest reports by Jay et al. (1986) described interventions based on cognitive behavior therapy, including breathing exercises and use of imagery. Filmed modeling has also been used. Although the early reports were often based on a small number of case studies, more recent work has involved randomized clinical trials. Kazak et al. (1996) reported that a combined physiological and psychological intervention was more successful than a physiological intervention alone.

Interventions for disease-related pain for children remain poorly developed, despite the very high levels of pain experienced by children with conditions such as cancer, arthritis, hemophilia, and sickle cell disease. Interventions need to target both disease-related pain and the child’s perceptions of pain. Walco et al. (1999) conclude that more work is needed which documents the emergence of pain experiences and coping over time. Interventions need to be based on a variety of approaches, and target the pain experience within a social and family context.

Schools based programs for children with headaches may be particularly successful. Larsson and Carlsson (1996) randomized 26 children aged 10–15 years with chronic tension type headache to a nurse administered relaxation training intervention or no treatment control. The five-week program involved twice weekly sessions, each lasting approximately 20 minutes. Headache activity was reduced in children in the intervention group at post-treatment and six-month follow-up compared with the no treatment controls.

4. The Promotion Of Health And Health-Related Behaviors

Drug and alcohol use among teenagers and adolescents usually occurs in group situations, and the use of such substances has been found to be strongly motivated by self-presentational desires such as the need for social approval and peer acceptance. Family factors, including parental modeling (often parents themselves are heavy users of the substance), and the family–child relationship, are key risk factors for subsequent substance use. In addition, peer relationships appear to be strongly related to the extent of alcohol and illicit drug use. Both types of substance abuse seem to be more common among those who report academic difficulty or poor adjustment at school. Other reasons for the illicit use of alcohol and drugs include the wish to convey autonomy or rebelliousness, and the reduction of anxiety in intergroup settings. Some may use alcohol or drugs if they feel unable to cope with the pressures associated with growing up; as a sort of temporary escape from school problems, social anxieties, or home difficulties.

5. Issues Relating To Training

The nature of much of the work with children involves collaboration with other professionals: clinicians, teachers, and social services. Issues of training particularly need to address the potential obstacles to successful collaboration. There is inevitably some friction between psychologists and pediatricians in the way in which they approach research and clinical issues concerned with chronically sick children. While both share some ideals about what should be done to help children with chronic conditions and their families, their training and experience does not necessarily mean that they share the same research agenda.

6. Future Directions

Increasing recognition of the closeness between physical and psychological health has contributed to an increasing visibility of psychological factors in pediatric medicine. So too have changes in treatment. In reality, caring for the child with chronic illness is not always about achieving a cure, but should be about enhancing the QoL. As such, there is pressure to include measures of QoL as an integral part of the evaluation of clinical trials. The development of disease-specific QoL scales means that health outcomes can now be considered from a more holistic point of view. QoL measures also have a role in evaluating innovative treatments. Children undergoing bone marrow transplants necessarily experience isolation, pain, and lengthy hospitalizations, and assessments of their QoL during treatment and after are essential.

Given the increasing costs of health care, it is critical that treatments are evaluated in terms of both physical and psychological well-being. Thus, evaluations of the success or otherwise of growth hormone therapy must not be based on height alone, but consideration also needs to be given to the child’s psychological wellbeing.

There remains scope for considerable improvements in measures available. Current work rarely draws on expertise in developmental psychology to direct the format or content of measures. There is an emerging literature documenting children’s language, memory, and emotional development, much of which could be used to guide new measures. It is also important that measures are based on a theoretical framework. In the past, theory has been sparse or embedded in a model of maladjustment. It is likely that theories of normal child development will prove more useful in the future. Despite the criticisms that can be made, there is no doubt that the establishment of a child health psychology in itself has done much to increase the profile of work with children. The difficulties involved may be considerable, but these also contribute to its attractiveness. That children have a unique perspective on life, despite the hardships of a serious illness, is without debate. From such a perspective, and for many people, work with children is therefore not only humbling, but intrinsically more satisfying, than work with other groups.

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