The relationship between children's treatment-related behaviour problems, age and clinical status in cystic fibrosis

Procedural anxiety among children and adolescents with cystic fibrosis and their parents

BACKGROUND

Procedural anxiety involves acute distress around medical procedures and may lead to avoidance or resistance behaviors that interfere with effective cystic fibrosis (CF) care and health outcomes. While individuals with CF commonly endure uncomfortable and/or distressing medical procedures, procedural anxiety among children and adolescents with CF has received little research attention. This study investigated the prevalence and correlates of procedural anxiety among individuals with CF aged 6-18 and their parents.

METHOD

Eighty-nine parents of children with CF completed surveys examining child procedural anxiety, anxiety, and health behaviors (including treatment adherence); and parent vicarious procedural anxiety.

RESULTS

Seventy-five percent of participants rated at least one CF-related procedure as "extremely" anxiety-inducing for their child. Parental vicarious procedural anxiety was reported in 80.9% of participants. Procedural anxiety significantly correlated with child anxiety, treatment-resistive behaviors, and parent-vicarious procedural anxiety. Procedural anxiety was associated with younger age and frequency of distressing procedures, but not with forced expiratory volume in 1 s, body mass index, hospitalizations, or exposure to general anesthesia.

CONCLUSION

Procedural anxiety is common among children, adolescents, and caregivers, and is associated with child anxiety and treatment resistance, emphasizing the importance of screening and interventions for procedural anxiety as part of routine CF care from early childhood. Implications for screening and intervention are discussed.

Eating disorders and body image in cystic fibrosis

Eating disorders and disturbed body image have been reported in individuals with cystic fibrosis (CF) and may contribute to poor weight gain, reduced lung function and increased mortality. CF individuals often look and feel different from their peers and bear the additional burden of body-altering side effects of treatment. As a result, the impact of disorders such as binge eating, anorexia nervosa, and bulimia nervosa may adversely affect the social, emotional, and physical development of those with CF.

Multiple risk factors may contribute to the development of an eating disorder in CF. Growth failure is affected by the physical impairments of CF, including pancreatic insufficiency, high energy demands, respiratory infections, and delayed and stunted growth and puberty. Psychological factors, such as CF associated depression and anxiety, intense focus on BMI, lack of control in a chronic disease, and preoccupation with morbidity and mortality, likely further contribute. Exercise inefficiency, secondary to poor lung function, low BMI and pulmonary exacerbations, and the potential for medication manipulation are also additional risk factors.

The intense scrutiny around BMI may lead to a poor relationship with food, including disordered eating habits, abnormal mealtime behaviors, and stressful caregiver-patient interactions regarding meals. This further contributes to a discrepancy between ideal CF nutritional standards and the reality of the challenges of appropriate daily energy intake for an individual with CF.

It is imperative that CF providers are equipped to identify potential eating disorders and disturbed body image in their CF patients. Improved screening and monitoring practices should be developed and implemented, with multidisciplinary support from all CF care team members, including dietitians, mental health professionals, and social workers, to best support holistic care and optimize outcomes. Increased attention to these concerns may help reduce CF related morbidity and mortality.

Impact of Cystic Fibrosis on Unaffected Siblings: A Systematic Review

OBJECTIVE

To conduct a systematic review of the evidence to determine the impact of cystic fibrosis (CF) on unaffected siblings.

STUDY DESIGN

We searched MEDLINE (Ovid interface, from 1946); EMBASE (Ovid interface, from 1946); CINAHL (EBSCO interface); Academic Search Complete (EBSCO interface); Psych Info (EBSCO interface); ProQuest Theses' and Dissertation's (ProQuest); British Index of Nursing (ProQuest); Web of Science (ISI, Web of Knowledge portal); PubMed (PubMed NCBI); BASE (Bielefeld Academic Research Engine); Scopus; EThOS (e-theses online service); Open Grey; and Cochrane Library. Contents pages of the Journal of Cystic Fibrosis, June 2002-April 2017 were hand searched to identify further eligible studies. Reference lists of eligible articles and relevant review papers were screened. Inclusion criteria were full studies published after 1989 in English focusing on the impact of cystic fibrosis on unaffected siblings.

RESULTS

In total, 13 papers, 4 PhD theses and 1 MSc thesis were included in the review. Four themes were identified; family functioning, psychosocial impact, knowledge of CF, and condition-specific differences.

CONCLUSIONS

Most studies are old and may not accurately represent the impact of CF on unaffected siblings following changes to health care provision including newborn bloodspot screening and the advent of CF transmembrane regulator modulator therapies. Further work is needed directly with siblings rather than using mothers as proxies to determine effect of age, sex, and disease trajectory on unaffected siblings' experiences.

The natural history and predictors of persistent problem behaviours in cystic fibrosis: a multicentre, prospective study

BACKGROUND

In cystic fibrosis (CF), problems with sleep, eating/mealtime behaviours, physiotherapy adherence and parental mental health issues are common, yet their natural history and the extent of service use to address them are unknown.

OBJECTIVE

Follow up the 2007 cohort to determine: (1) prevalence of child sleep, eating/mealtime behaviours, physiotherapy adherence, and externalising/internalising problem behaviours and primary caregiver mental health status after a 3-year period; (2) natural history of child behaviours; (3) potentially modifiable predictors of persistent problems; and (4) service use for behaviours.

DESIGN

Prospective cohort.

SETTING

Royal Children's Hospital, Monash Medical Centre and Sydney Children's Hospital (Australia) CF clinics.

PARTICIPANTS

Caregivers, of children aged 3-8 years, who completed the baseline questionnaire.

MAIN OUTCOME MEASURES

Child sleep, eating/mealtime behaviours, adherence with therapy and externalising and internalising behaviours.

PREDICTORS

parenting style (low warmth), caregiver mental health status and sleep quality at baseline.

RESULTS

102 of 116 (88%) families participated. The prevalence of sleep and eating/mealtime problems at follow-up was similar to baseline. The prevalence of caregiver mental health symptoms remained higher than the community data. 71 out of 102 (70%) of the children experienced at least one persistent behaviour problem. Caregiver mental health difficulties predicted persistent child moderate to severe sleep problems (adjusted OR 6.5, 95% CI 1.2 to 36.2, p=0.03) and their persistently poor adherence to the physiotherapy regimen (adjusted OR 3.5, 95% CI 1.3 to 9.2, p=0.01).

CONCLUSIONS

Child problem behaviours are common in children with CF, persist and are often predicted by the mental health of the parent. Routine surveillance for and management of child problem behaviours are recommended.

A qualitative study of physiotherapy education for parents of toddlers with cystic fibrosis

BACKGROUND

Education and daily physiotherapy are often highlighted as difficult and stressful tasks for parents of young children with cystic fibrosis. This study aimed to identify factors that impair the delivery and retention of physiotherapy education for parents of these children and factors that impair effective physiotherapy treatment in the home environment.

METHODS

A focus group of physiotherapists and six semi-structured interviews of parents with children with cystic fibrosis were conducted. The qualitative method of Grounded Theory was used to analyse the information and develop key themes.

RESULTS

Major emergent themes were 'transitions', 'psychological distress' and 'connectedness'. Factors influencing the effectiveness of parental physiotherapy education include the large volumes of information, appropriateness of educational resources and timing of education. Factors influencing home physiotherapy management for toddlers include mastering techniques, the transition from infant to toddler and time management.

CONCLUSION

Physiotherapy education and management were key causes of psychological distress for parents. This research suggests that significant targeted development of educational resources is warranted, in conjunction with dedicated and ongoing formal psychosocial support for parents.

Using behavioral interventions to assist with routine procedures in children with cystic fibrosis

Routine cystic fibrosis (CF) medical care includes invasive procedures that may be difficult for young children and adolescents to tolerate because of anxiety, concern with health status, or unfamiliarity with the performed tasks. A growing body of pediatric psychology literature suggests that behavior therapy can effectively increase patient cooperation with stressful medical procedures such as tracheostomy care and needle sticks. Throat cultures are obtained at least quarterly in the outpatient setting or more frequently if a CF patient develops respiratory symptoms. Obtaining a throat culture from an anxious and uncooperative child poses a significant challenge for physicians, since the child may demonstrate emotional distress and avoidant behavior that disrupts efficient specimen collection during a routine clinic visit. The use of behavioral interventions, such as relaxation exercises, diaphragmatic breathing, differential reinforcement, gradual exposure, and systematic desensitization, is beneficial in addressing this commonly encountered problem in CF care. This case series describes the implementation of a behavioral therapy protocol utilizing two interventions, gradual exposure and systematic desensitization, in two young CF patients for the treatment of behavioral distress with routine throat cultures. The behavioral interventions were simple and transferred easily from mock procedures to actual specimen collection. Moreover, these cases highlight the important roles of the pediatric psychology staff on a comprehensive multidisciplinary CF care team to improve patient cooperation with routine clinic procedures and the medical treatment regimen overall.

Adherence and psychopathology in children and adolescents with cystic fibrosis

BACKGROUND

The striking increase in the lifespan of individuals with cystic fibrosis (CF) has largely been attributed to the dramatic improvements in treatment regimens. These treatments are time intensive and may interfere with healthy development and family function. The objective of this study was to investigate the association between psychopathology and treatment adherence in children and adolescents with CF.

METHODS

Structured psychiatric interviews were performed on 52 patients with CF. Additional information on family function and youth behaviors were also collected. Youth and parent reports of adherence to the CF treatments were obtained and compared with the CF teams' records.

RESULTS

The mean overall adherence to the CF teams' recommendations was 77-81% for the child and parent reports, respectively. Children with anxiety disorders and families who were more cohesive showed significantly higher rates of adherence to the CF treatments. In addition, children in families with a balance of structure and flexibility also report higher levels of adherence to the CF treatments.

CONCLUSIONS

Anxiety disorders in children with CF may be associated with increased adherence to the numerous CF treatment regimens. In addition, family patterns that are cohesive and balanced are better able to incorporate the CF treatments into family life.

Treatment demands and differential treatment of patients with cystic fibrosis and their siblings: patient, parent and sibling accounts

Cystic fibrosis (CF) is a progressive disease with no known cure. Advances in diagnosis and treatment have resulted in patients living longer and thus families live with the illness for longer. Treatments are becoming increasingly demanding and are largely performed in the family home. Mothers are often reported to experience greater stress and poorer adjustment than mothers of well children or population norms. Patients and siblings are also reported to display adjustment difficulties. Siblings have rarely been included in research designs. This qualitative study investigates the impact of CF and treatment on eight patients, eight mothers, one father and eight siblings. A family systems perspective was adopted. Each individual was interviewed independently using semistructured interviews. Patients and siblings were aged between 9 and 21 years. Qualitative analyses revealed high levels of non-adherence (intentional and unintentional) and parental involvement in treatment, minimal involvement of siblings, and preferential treatment towards patients. Demanding treatment, coupled with the progressive nature of CF, promote high levels of parental involvement for younger children as well as older teenagers, often due to attempted or actual non-adherence. Siblings may receive less attention while patients' needs take priority. Future development of a measure of adherence suitable for children and adolescents should take into account different motivations for non-adherence, particularly regarding the level of personal control over adherence to treatment. In addition, the potential impact of having a brother or sister with CF should not be underestimated and the needs of siblings should not go unnoticed.

Routine stresses in caring for a child with cystic fibrosis

Difficulties experienced by mothers caring for a child with cystic fibrosis were assessed. Difficulties were categorized as: (1) developmental, which included tasks generic to all families (bedtimes, socialization, siblings and communication with others); and (2) illness, which were especially pertinent to the care of the child with cystic fibrosis (mealtimes, physiotherapy and home-based medical care). Age differences were found in stresses associated with developmental routines, with mothers of younger children reporting more difficulties. With regard to illness routines, more difficulties were reported for children in better health (higher Shwachman scores). The data suggest that parents experience increasing difficulties in implementing home-based medical care where the child is in better health. Clinic staff need to be more aware of these difficulties and target information to parents appropriately.