Impact of Complicated Medical Problems in Children on Behavioral Health
Children with complicated medical problems are at significantly increased risk for behavioral health problems, and their parents also experience higher rates of mental health issues, including depression, anxiety, and stress.
Effects on Children's Behavioral Health
Increased Risk for Mental Health Problems
- Children with chronic health conditions have a 1.44-1.55 times higher risk of behavioral problems compared to healthy children, independent of sociodemographic variables 1
- Children with certain medical conditions (e.g., asthma, recurrent abdominal pain, sickle cell anemia) may be at greater risk for depressive symptoms than those with other conditions (e.g., cancer, cystic fibrosis, diabetes mellitus) 2
- In children with type 1 diabetes, the presence of other health problems is a predictor of increased risk for difficulties with diabetes management 3
Types of Behavioral Health Problems
- Children with chronic medical conditions show higher rates of internalizing problems, particularly:
- Social withdrawal
- Anxiety
- Somatic complaints
- Depressive symptoms 3
- Externalizing problems, most commonly attention deficits and hyperactivity, are also identified in adolescents with chronic conditions 3
- Children with complex congenital heart disease may experience impairments in social cognition, limiting their ability to form healthy relationships 3
Long-term Impacts into Adulthood
- Without timely treatment, mental disorders experienced by young children can impair learning ability and relationships, causing lifelong complications 4
- Young adults with congenital heart disease may experience poor adjustment in vocational, social, and domestic environments, as well as psychological distress 3
- The prevalence of comorbid psychiatric disorders is 3-4 times higher among adults with neurocognitive impairment than in the general population 3
Effects on Parents' Behavioral Health
Prevalence of Parental Mental Health Issues
- Parental distress has been reported in 30-80% of parents of children with congenital heart disease and appears not to be related to the severity of the condition 5
- Parents of children with special health care needs (CSHCN) have higher rates of poor physical and emotional health and depression 3
Specific Mental Health Problems in Parents
- Parents, especially mothers, are at risk of:
- Psychological distress
- Anxiety
- Depression
- Somatization
- Hopelessness
- Posttraumatic stress symptoms 5
- Family stress, marital problems, and sleep deprivation are common occurrences when caregiving is left to an unsupported family 3
Contributing Factors to Parental Stress
- Care coordination and navigating complex, fragmented healthcare systems are major stressors for parents 3
- Due to nursing shortages, unfilled nursing shifts at home become the parent's responsibility, leading to increased burden 3
- Families often experience financial stress, missed work, and parental unemployment due to caregiving responsibilities 3
- Personal knowledge of acute and chronic complications of a child's condition may result in anxiety and/or depression in parents 3
Risk Factors and Predictors
Child-Related Factors
- Presence of multiple health problems 3
- Poor school attendance 3
- Learning disabilities 3
- Pre-existing emotional and behavioral disorders 3
Family-Related Factors
- Single-parent home 3
- Chronic physical or mental health problems in a parent or close family member (including substance abuse) 3
- Recent major life change for the parent (e.g., loss of job, death in family) 3
- Lack of adequate health insurance 3
- Complex childcare arrangements 3
- Health/cultural/religious beliefs that make it difficult to follow treatment plans 3
Barriers to Mental Health Care
- 45.8% of children with mental disorders report not receiving mental health services when needed 4
- Primary reasons for not receiving needed healthcare include:
- Problems getting an appointment (72.1%)
- Issues related to cost (39.3%)
- Services not being available in the area (38.5%) 4
- Poor experiences with healthcare providers are consistently associated with not receiving needed mental health services 4
Recommendations for Clinical Practice
Assessment and Screening
- Assess both risk factors and strengths of the child and family at the time of diagnosis 3
- During routine medical checkups, medical professionals should ask about parental stress, family functioning, and psychosocial functioning of the child 5
- Early identification of mental health issues is critical as behavior patterns tend to become established or "track" over time and are difficult to change 3
Support for Self-Management
- Support self-management in children with complex chronic conditions, which improves health outcomes not only by improving adherence to treatment but also by building capacity to navigate challenges 3
- Recognize that self-management in pediatrics is really shared management between the youth and parent(s)/caregiver(s) 3
- Design care to address self-management for pediatric patients, including assessment of skills, collaborative goal setting, and promotion of competence and eventual autonomy 3
Psychosocial Interventions
- Provide early psychosocial interventions to alleviate stress and reduce children's emotional and behavioral problems 5
- Aim interventions at improving coping and enhancing parenting 5
- When needed, ensure adequate psychosocial care is provided 5
- Counsel families to avoid overprotection and unnecessary restriction of a child or adolescent with chronic conditions 3
Care Coordination
- Establish a Medical Home for children with complex medical needs to reduce travel logistics and trouble with coordination of medical care 3
- Clearly delineate the specific roles and responsibilities of primary care and subspecialty physicians and their teams 3
- Ensure comprehensive care coordination to reduce family stress 3
By addressing both the child's medical needs and the family's psychosocial needs, healthcare providers can help mitigate the behavioral health impacts of complicated medical problems on both children and their parents.