SOCIAL, EMOTIONAL, AND BEHAVIORAL FUNCTIONING OF CHILDREN EXPOSED TO MEDICAL TRAUMA: A THEORY OF...
Transcript of SOCIAL, EMOTIONAL, AND BEHAVIORAL FUNCTIONING OF CHILDREN EXPOSED TO MEDICAL TRAUMA: A THEORY OF...
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SOCIAL, EMOTIONAL, AND BEHAVIORAL FUNCTIONING OF
CHILDREN EXPOSED TO MEDICAL TRAUMA: A THEORY OF HARDINESS
Robert B. Noll, Ph.D.
Director, Child Development Unit
Medical Director for Behavioral Health
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ACKNOWLEDGEMENTS
• Vannatta, Gerhardt, Sheeber, Zeller, Reiter-Purtill
• Staff--UC Friendship Study
• Dahl, Szigethy, Rofey, Finder
• National Institute of Health
• American Cancer Society
• National Arthritis Foundation
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RESEARCH RATIONALE
• Improve clinical care
• Theory – Stress and trauma
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STRESSFUL/TRAUMATIC LIFE EVENTS
• Random versus non-random
• Uncontrollable versus controllable
GREATEST HARM
• Uncontrollable, randomly occurring stressful/traumatic life events
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IMPACT ON CHILDREN
• Social functioning
• Emotional well being
• Externalizing behavior (acting out)
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IMPACT ON PARENTS AND FAMILIES
• Parental mental health
• Child-rearing
• Family functioning
– Time management
– Siblings
• Economic issues
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STRESS / TRAUMA MODEL
Evolutionary Behavioral Health
Illness Parameters
•Trauma to the CNS
Family Parameters
•Extreme Family Deprivation
ChildDysfunction
Childhood Chronic Illness
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METHODOLOGY PROBLEMS
• Comparison groups
• Sampling
• Contextual factors
• Source of information
• Lack of longitudinal data
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SELECTION CRITERIA FOR COMPARISONS
• Classmate at school
• Race
• Gender
• Closest date of birth
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FAMILY DEMOGRAPHIC VARIABLES
• Family social prestige
• Family income
• Age of parents
• Number of children living at home
• Education of parents
• Marital status
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CHILD DEMOGRAPHIC VARIABLES
• Age
• Gender
• Race
• IQ
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PRIMARY DIMENSIONS OF SOCIAL FUNCTIONING
• What is the child like?
• Is the child liked?
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REVISED CLASS PLAYWhat is the child like?
1. Popular/Leader
2. Prosocial
3. Aggressive/Disruptive
4. Sensitive/Isolated
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ILLNESS ROLES
Someone who is sick a lot
Someone who misses a lot of school
Someone who is tired a lot
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SOCIAL ACCEPTANCE Is the child liked?
Three Best Friends
– Number of nominations
– Reciprocated friendships
Like Rating Scale
– Overall social acceptance
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CHILDREN’S EMOTIONAL WELL-BEING
CHILDREN’S REPORT (objective and projective)
– depression/anxiety
– loneliness
– self concept
PARENT’S REPORT
– depression/anxiety
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EVALUATION OF CHILD FUNCTIONING
• PERSPECTIVE OF MEDICAL CHART
• PERSPECTIVE OF OTHERS– teachers
– peers
– parents (mothers and fathers)
• PERSPECTIVE OF SELF– questionnaires
– projectives
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DATA ANALYSIS
• Comparison of group means
• Disease severity
• Age and gender as moderatorsmoderators
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GENERAL SELECTION CRITERIA
• 8-15 years of age
• No full time special education
• Treated at CCHMC
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CHILDREN WITH CHRONIC ILLNESS
• Neurofibromatosis (Type 1)
• Cancer (no primary CNS involvement)
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NF1
• 72 identified (medical records)
• 66 located and agreed to participate
• 60 schools participated
• 54 children with NF and 53 COMPs participate in home-based assessment
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NF1: DISEASE SEVERITY
• Overall medical severity
• Visibility/cosmetic involvement
• Neurologic involvement
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RCP: TEACHER NOMINATIONS
-1-0.8-0.6-0.4-0.2
00.20.40.60.8
1
Popular-Leader Prosocial
Aggressive-Disruptive
Sensitive-Isolated
NF
COMP
* ** **
**p < .01; *p < .05
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RCP ILLNESS ROLES: PEERS
-1-0.8-0.6-0.4-0.2
00.20.40.60.8
1
Sick a lotMisses a lot of
school Tired a lot
NF
COMP
*** ******
***p < .001
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RCP: PEER NOMINATIONS
-1-0.8-0.6-0.4-0.2
00.20.40.60.8
1
Popular-Leader Prosocial
Aggressive-Disruptive
Sensitive-Isolated
NF
COMP
**
***
** p < .01; ***p < .001
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SOCIAL ACCEPTANCE: NF1
-1-0.8-0.6-0.4-0.2
00.20.40.60.8
1
Three BestFriends
ReciprocatedFriendships Like Rating
NF
COMP
*******
**p < .01; ***p < .001
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DEPRESSION AND LONELINESS
0
5
10
15
20
25
30
35
Depression Loneliness
NF
COMP
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SELF PERCEPTIONS
1
1.5
2
2.5
3
3.5
4
Scholastic Social Athletic
NF
COMP
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SELF PERCEPTIONS
1
1.5
2
2.5
3
3.5
4
Physical Behavior Global SelfWorth
NF
COMP
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MOTHER REPORTS
45
50
55
60
65
70
Total BehaviorProblems
Externalizing Internalizing
NF
COMP
*p < .05; **p < .01
***
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FATHER REPORTS
45
50
55
60
65
70
Total BehaviorProblems
Externalizing Internalizing
NF
COMP
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DISEASE SEVERITY: NF1
OVERALL MEDICAL SEVERITYOVERALL MEDICAL SEVERITY
• Sick a lot (peers)
• Attention (mothers and fathers)
VISIBILITY/COSMETIC INVOLVEMENTVISIBILITY/COSMETIC INVOLVEMENT
• RA rating
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NEUROLOGIC DISEASE SEVERITY:
PEER REPORTS
• Social behavior
– Popular-Leader [r = -.32]
– Sensitive-Isolated [r = .28]
• Social acceptance– Reciprocated friendships [r = -.28]
– Like Ratings [r = -.32]
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NEUROLOGIC DISEASE SEVERITY:
PARENT REPORTS• Externalizing symptoms (M & F)
• Attention (M)
• Rhythmicity (M & F)
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NEUROLOGIC DISEASE SEVERITY: CHILD REPORTS
• Depression [r = .43]
• Self concept: Behavior [r = .30]
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CONCLUSIONS: CHILDREN WITH NF
• Social functioning
• Emotional well being
• Behavior (acting out)
• DISEASE SEVERITY
– Major role: Neurological severity
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SELECTION CRITERIA: CANCER
• No primary CNS involvement
• On chemotherapy
– 11 months since diagnosis
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DISEASE STATUS
PRIMARY DISEASE– leukemias
– lymphomas
– solid tumors
# OF PATIENTS• 34
• 21
• 17
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CHILDHOOD CANCER: ILLNESS SEVERITY
• Protocols
• Response to treatment
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RCP: TEACHER NOMINATIONS
-1-0.8-0.6-0.4-0.2
00.20.40.60.8
1
Sociability-Leadership
Aggressive-Disruptive
Sensitive-Isolated
CANCER
COMP
**
**
**p < .01
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RCP ILLNESS ROLES: PEERS
-1-0.8-0.6-0.4-0.2
00.20.40.60.8
1
Sick a lotMisses a lot of
school Tired a lot
CANCER
COMP
*** ***
***
***p < .001
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RCP: PEER NOMINATIONS
-1-0.8-0.6-0.4-0.2
00.20.40.60.8
1
Sociability-Leadership
Aggressive-Disruptive
Sensitive-Isolated
CANCER
COMP
**
**p < .01
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SOCIAL ACCEPTANCE: CANCER
-1-0.8-0.6-0.4-0.2
00.20.40.60.8
1
Three BestFriends
ReciprocatedFriendships Like Rating
CANCER
COMP
*
*p < .05
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SOCIAL ACCEPTANCE: NF1
-1-0.8-0.6-0.4-0.2
00.20.40.60.8
1
Three BestFriends
ReciprocatedFriendships Like Rating
NF
COMP
*******
**p < .01; ***p < .001
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DEPRESSION AND LONELINESS
0
5
10
15
20
25
30
35
Depression Loneliness
CANCER
COMP
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SELF PERCEPTIONS
1
1.5
2
2.5
3
3.5
4
Scholastic Social Athletic
CANCER
COMP
**
**p < .01
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SELF PERCEPTIONS
1
1.5
2
2.5
3
3.5
4
Physical Behavior Global SelfWorth
CANCER
COMP
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MOTHER REPORTS
45
50
55
60
65
70
Total BehaviorProblems
Externalizing Internalizing
CANCER
COMP
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FATHER REPORTS
45
50
55
60
65
70
Total BehaviorProblems
Externalizing Internalizing
CANCER
COMP
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DISEASE SEVERITY: CANCER
• Peer reports: Aggressive-Disruptive
• Peer reports: Like Ratings
• Teacher reports: Sensitive-Isolated
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CONCLUSIONS: Children with Cancer on Chemotherapy
• Social functioning
• Emotional well being
• Behavior (acting out)
• Disease severity
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DEPRESSION AND YOUTH WITH CANCER
• 2 recent review papers
– DeJong & Fombonne, 2006
– Noll & Kupst, 2007
• Cross sectional/longitudinal: Modest levels of depression regardless of methodology or reporting source
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ADDITIONAL COMPLETED WORK
CROSS SECTIONAL
• Sickle cell disease (2 studies)
• Hemophilia (3 site investigation)
• Juvenile rheumatoid arthritis
• Juvenile migraines
• Siblings of children with SCD (Hgb SS)
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ADDITIONAL COMPLETED WORK
LONGITUDINAL
2 year classroom follow ups
– Cancer
– Juvenile rheumatoid arthritis
– Sickle cell disease
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ADDITIONAL WORK COMPLETED
NEUROLOGIC INVOLVEMENT
• Bone marrow transplant survivors
• Brain tumor survivors
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18 YEAR OLD FOLLOW UPS
• Cancer (N = 51)• Sickle Cell Disease (N = 42)• Juvenile Rheumatoid Arthritis (N = 29)
• Comparison Peers (N = 132)
• 79% of eligible young adults (CI)
• 83% of eligible comparisons
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YOUNG ADULT EMOTIONAL WELL-BEING
• YOUTH REPORT -PTSD
-Depression/anxiety
-Self concept
• PARENT’S REPORT– PTSD
– Depression/anxiety
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Depression // Dissociative Symptoms
0
5
10
15
20
Depression A-DES
CHRONIC ILLNESS
COMP
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MOOD
0
10
20
30
40
50
TMD DEP-DEJ TEN-ANX
CHRONIC ILLNESS
COMP
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SELF PERCEPTIONS: 18 Y/O FOLLOW UP
1
1.5
2
2.5
3
3.5
4
Scholastic Social Athletic
CHRONIC ILLNESS
COMP
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SELF PERCEPTIONS: 18 Y/O FOLLOW UP
1
1.5
2
2.5
3
3.5
4
Physical Behavior Global SelfWorth
CHRONIC ILLNESS
COMP
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K-SADS-E (current)
0
2
4
6
8
10
Depression Anxiety
CHRONIC ILLNESS
COMP
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K-SADS-E (lifetime)
0
2
4
6
8
10
Depression Anxiety
CHRONIC ILLNESS
COMP
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Internalizing Symptoms: Parent Report at Age 18
45
50
55
60
65
70
Int-Mother Int-Father
C I
COMP
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Percentage of High School Students Who Felt Sad or
Hopeless, 1999 – 2007
1 No significant change over time
National Youth Risk Behavior Surveys, 1999 – 2007
28.3 28.3 28.5128.528.6
0
20
40
60
80
100
1999 2001 2003 2005 2007
Pe
rce
nt
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Percentage of High School Students Who Seriously Considered Attempting
Suicide, 1991 – 2007
1 Decreased 1991-2007, p < .05
National Youth Risk Behavior Surveys, 1991 – 2007
29.024.1 24.1
20.5 19.314.5116.916.919.0
0
20
40
60
80
100
1991 1993 1995 1997 1999 2001 2003 2005 2007
Pe
rce
nt
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Percentage of High School Students Who Attempted
Suicide,* 1991 – 2007
* One or more times during the 12 months before the survey.1 No change 1991-2001, decreased 2001-2007, p < .05
National Youth Risk Behavior Surveys, 1991 – 2007
7.3 8.6 8.7 7.7 8.3 6.918.48.58.8
0
20
40
60
80
100
1991 1993 1995 1997 1999 2001 2003 2005 2007
Pe
rce
nt
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CONCLUSIONS: YOUNG ADULTS AND CHRONIC ILLNESS
• Depression
• Anxiety
• Post traumatic stress
– Symptoms
– Disorder
• Self concept
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IF HARDINESS IS TYPICAL?WHY?
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STRESS / TRAUMA MODEL
Evolutionary Behavioral Health
Illness Parameters
•Trauma to the CNS
Family Parameters
•Extreme Family Deprivation
ChildDysfunction
Childhood Chronic Illness
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DARWIN: ORIGIN OF THE SPECIES
• General evolutionary theory
• Evolution by natural selection
• Inclusive fit theory
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EVOLUTIONARY THEORY OF STRESS/TRAUMA: KEY FEATURES
• Specific hypotheses– Testable model
•
Developmental focus
• Role of coping or medications– Opportunities for behavioral
health
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WHY EVOLUTIONARY THEORY?
• Uniting topics across disciplines of
behavioral science
• Requires an understanding of the
function of behavior
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ATTACHMENT THEORY: STRANGER ANXIETY
• Cognitive
• Developmental
• Social
• Personality
• Clinical (psychiatry/psychology/DBP)
• Neuroscience
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FUNCTION OF THE BEHAVIORWHY DOES IT EXIST?
• Origins within ancestral conditions
– Humans as living fossils
• Adaptive significance
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DEVELOPMENTAL CONSIDERATIONS
• Adolescents take risks
• National Youth Risk Behavior Surveys, 1991 – 2007
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Leading Causes of Death Among Persons Aged 10 – 24 Years in the
United States, 2003
Suicide11%
Motor Vehicle Crashes
31%
Other Unintentional
I njuries14%
Other Causes29%
Homicide15%
National Youth Risk Behavior Surveys, 1991 – 2005
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Leading Causes of Death Among Persons Aged 25 Years and Older in the United
States, 2003
Cancer23%
Cardiovascular Disease
38%
Diabetes3%
Other Causes36%
National Youth Risk Behavior Surveys, 1991 – 2005
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CHILD/ADOLESCENT RISK TAKING BEHAVIORS
• Neurobiological development
• Risk taking
– What were you thinking?
• Protective effect—children and teens live in the moment
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OPPORTUNITIES FOR PEDIATRICS
• National Institute of Mental Health
• Framework for prevention science
– Universal
– Selective
– Targeted
National Institute of Mental Health. (1998). Priorities for prevention research. A national advisory council workgroup on mental health disorders prevention research. NIMH: Bethesda, MD.
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BEHAVIORAL HEALTH SERVICES
Empirically supported therapies
• Psychopharmacology
• Cognitive behavior therapies
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PEDIATRIC SUB-SPECIALTY CARE
Coping and Wellness Center (Szigethy—RO1; NIH Innovator Award)
Polycystic Ovary Syndrome (Rofey--K 12)
Objectives:– Improve physical health
– Reduce stigma
– Improve access
– Remove communication barriers
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PEDIATRIC PRIMARY CARE
Child & Family Counseling Center
– Partnership with CCP
– Empirically supported therapies
• Reduce stigma
• Improve access
• Eliminate communication barriers