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Psychosocial Intervention in Children
After Cardio-thoracic Transplantation


ANDREA CABY, MD
Professor of Social Pediatrics
University of Emden/Leer
Faculty of Health and Social Sciences
Emden, Germany


andrea_caby@yahoo.de

FILIP CABY, MD
Head of Department
Child and Adolescent Psychiatry
Marienkrankenhaus Aschendorf
Papenburg, Germany


filip.caby@t-online.de



Psychosocial issues contribute greatly to the overall aspects of health and well being, yet they remain understudied, as well as psychosocial interventions underestimated in the course of a disease.

We hereby like to illustrate some simple and creative methods of intervention in coping with chronic illness in multidisciplinary teams or settings, in order to introduce new perspectives concerning the bio-psycho-social complexity of a case. Ideally, all professionals involved could use such approaches—in particular, where psychiatrists, psychologists and allied-mental health professionals are not readily available.

Today, there is a constantly increasing number of solid organ transplants performed in children, together with better survival and a very good quality of life. Nevertheless, life before and after a transplant is never easy, and not only the patients, but also everybody else involved, faces new challenges almost every day.

Children, adolescents or adults suffering from chronic physical health conditions are at a higher risk to develop secondary emotional problems, their risk for psychiatric disorders being at least two times higher than for healthy children. Nevertheless, the prevalence of psychiatric disorders such as anxiety or depression has not been extensively studied in young cardio-thoracic transplant recipients. There is clinical evidence that anxiety disorders could be more common in this group, particularly generalized anxiety disorders, and maybe other affective problems as well.

In addition to psychotherapies, psychosocial interventions have gained acceptance in the treatment of psychiatric as well as psychosomatic disorders over recent decades.

Goals for psychosocial interventions
In the treatment of children or adolescents with severe chronic conditions such as heart or lung disease, and those undergoing a transplant, there are numerous goals for psychosocial interventions, such as an overall stress reduction, minimization of symptoms, strengthening of coping skills, supporting adherence to treatment, and improving quality of life.

With psychiatric problems, family interventions often derive from a systemic approach, individually adapted to the needs of the patients and families involved. In each case, family members need different levels of support, from coping strategies to better communication and understanding within the family and psycho-education.

Methods and interventions
To help health care staff, from nurse practitioners to medical doctors, and parents and others caring for a chronically ill youngster, it is worthy to adapt an appreciative attitude towards the patient, his individual course of illness, the severity of symptoms, and so on. A typical opening question of a conversation could be directed towards coping strategies: "How did you manage so far?", and could be followed by an inquiry about strengths and competences: "Which skills did you use in order to overcome all those challenges?" All replies to these questions should be made as concrete as possible, scrutinized if necessary, and generally listened to carefully, because they often bear a new perspective or solution within already that has not become obvious to the patient so far.

Brief, solution-focused therapy approaches can make a difference in a patient's daily life, by showing him how much he has achieved so far within his severe condition, or how many resources he was able to mobilize within himself or within his family or support system.

De Shazer proposed to work with a 'problem exception' instead of focusing on the problem itself. By looking at those times when the complaint does not occur, clients or patients are invited to concentrate on a possible solution. "Which are the times or areas of life where the problem, e.g. pain, is not an issue? What is different then?"

A patient may describe the exceptions as just randomly occurring, but no matter how often they happen, talking about these events can support the idea that life is slowly getting better, pain is sometimes less already, and quality of life constantly improving.

In children, where the reported exceptions seem to happen just like that, a combination with the prediction task usually makes another strong impact on the course of the disorder. It will emphasize the higher frequency of the exception, as much as helping all participants to realize what already works. "Today, I would like you to predict whether the next day will be a good day (i.e. with less breathing problems), and I would like you to observe what made it a good day?"

Working with narrative therapeutic approaches can also be helpful for the whole family system by offering ideas on family beliefs, strengths or resources. Within these models, children and adolescents can be advisers on their own lives, by integrating individual thoughts and meanings (Selekman).

Supportive methods such as counselling, psychotherapy or other elements of non-medical care are closely related, and form the ground for a positive therapeutic relationship, which again is a solid predictor of patient outcome. To thoroughly understand the impact of psychotherapy and psychosocial interventions on somatic conditions, as much as the most effective methods, further research is needed.


Disclosure Statement: The authors have no conflicts of interest to disclose.


References:

De Shazer S: Putting Difference to Work. Norton and company. New York & London (1991)

Hymovich DP and Hagopian GA: Chronic Illness in Children and Adults. A Psychosocial Approach. Philadelphia (1992)

Selekman MD: Solution-focused therapy with children. Harnessing Family Strengths for Systemic Change. The Guilford Press. New York (1997)

Swanston H, Williams K and Nunn K: The psychological adjustment of children with chronic conditions. Vol. 5 in Kosky R, O'Hanlon A, Martin G and Davis C (Series Eds.). Clinical approches to early intervention in child and adolescent mental health. Adelaide, Australian Early Intervention Network for Mental Health in Young People (2000)

Wong, M.G. and Heriot, S.A. Parents of children with cystic fibrosis: How they hope, cope and despair. Child: Care, Health and Development 2008; 34: 344-354