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PEDIATRICs PSYCHOLOGY/
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Psychology l o n of child patients
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Pediatric psychology is a field of scientific research and clinical practice to address the
psychological aspects of illness, injury, and the promotion of health behaviors in children,
adolescents, and their families in a pediatric health setting. Psychological issues are addressed
in a developmental framework and emphasize the dynamic relationships which exist between
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children, their families, and the health system as a whole.
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Therapists improve the lives and daily function of children who suffer from a K
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wide range of
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injuries, developmental or congenital conditions. They work with the child i and their family to
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assist each child to reach their maximum potential to function independently through their
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environment easily and effectively. The therapist improves physical function and quality of life of
Dr or other more costly invasive
a child. Therapy can reduce disability and the need for surgery
interventions resulting in a decreased burden on t o use of health care services. Therapists
future

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treat a wide variety of acute and chronic conditions like Autism, Cerebral palsy, impaired balance,
Muscular dystrophy, Developmental delay,
o n juvenile idiopathic arthritis, hypotonia and many more
orthopedic, cardio- pulmonary andlneurological conditions in different settings, from acute care
hospitals to home, schools andbein the community to promote active participation.
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Special Psychological Vulnerabilities of Young Children
Young children are especially vulnerable to psychological problems (Ingram & Price, 2001).

• They do not have a complex and realistic a view of themselves and their world as they will have
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later; they have less self - understanding; and they have not yet developed a stable sense of
identity or a clear understanding of what is expected of them a p
and what resources they might have to deal with problems. K
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• Immediately perceived threats are tempered less by considerations of the past or future and thus
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tend to be seen as disproportionately important. As a result, children often have more difficulty
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than adults in coping with stressful events (Mash & Barkley, 2006). For example, children are at
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risk for posttraumatic stress disorder after a disaster, especially if the family atmosphere is
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troubled—a circumstance that adds additional stress to the problems resulting from the natural
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disaster (Menaghan, 2010).
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• Children’s limited perspectives lead them to use unrealistic concepts to explain events. For
young children, suicide or violence against another person may be undertaken without any real
understanding of the finality of death.

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• Children also are more dependent on other people than are adults. Although in someoways this
dependency serves as a buffer against other dangers because the adults around him a por her might
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“protect” a child against stressors in the environment, it also makes the child highly
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experiences of rejection, disappointment, and failure if these adults, because of their own
problems, ignore the child (Lengua, 2006). S i
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• Children’s lack of experience in dealing with adversityDcan make manageable problems seem
insurmountable (Scott et al., 2010). to
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Reactions of Child Patients to Therapy

➢ Most children report feeling “White Coat Syndrome” when coming into contact with health
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professionals. White Coat Syndrome is a phenomenon in which people exhibit a blood pressure
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level above the normal range, due to anxiety experienced during a clinic visit.
✓ The therapist could avoid wearing the white coat p o
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➢ Children report feeling afraid or anxious as they anticipate and engage in healthcare settings.
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Health care can lead to heightened anxiety, and trigger trauma responses in children (Brown,
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2002). The most difficult period of hospitalization is when children unexpectedly and
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unwillingly have to encounter fearful and painful procedures and treatments for the first time.
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✓ The therapist can encourage the parent/caregiver to prepare a social story to prepare the child
for the therapy visit.
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➢ It has been observed that hospitalized children are often in a state of waiting and increased
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vigilance which results in dragging of time.
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✓ The therapist could schedule appointments to avoid any waiting time or make sure the child is
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distracted by occupying him in activities while in the waiting room. Provide distractions5such
Dr. Simi Kapoor
➢ Being confined to bed or being socially restricted can seem like an unending state of
imprisonment to children, regardless of the length of stay.

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➢ They are particularly vulnerable to stresses involved in adapting to their condition of illness
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and hospitalisation (Sartain, Clarke & Heyman, 2000). Heightened anxiety and stress can effect
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a child’s physical growth, personality, or emotional development (Brown, 2002).
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➢ Children are bewildered in an unknown medical environment, as i
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m are taking over
caregivers
S The following actions of the
control of their bodies, they feel a loss of autonomy and control.
health professional heighten the sense of bewilderment r.
▪ Requiring the patient take off their clothes and get upDon the exam table
to the visit – talking about the child as if he is
▪ speaking to the parent only, about the child, during
not there
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▪ choosing the pace and flow of the exam
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▪ holding children down for therapy
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▪ Scolded/ prohibiting the patient to explore the room, instruments being used, or to ask
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▪ dismisses the child’s fear -verbally or physically-without validating the emotions,
✓ instead empathize with their emotional response

▪ fails to give the child power of who can be present in the room for the examination r
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✓ Healthcare providers must be cognizant of their power to potentially causeK the medical care
process to become a traumatic event for patients, regardless of theirm ior developmental
age
stage. S i
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r psychological trauma in pediatric
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✓ It is important for healthcare providers to learn to mitigate
care. Left untreated, childhood trauma caused byohealthcare-induced anxiety can cause
t Trauma predisposes children to various forms
significant mental health issues in a child’s life.
of psychopathology including anxiety,g s depression, and behavior problems.
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➢ Children fear mutilation, and suffer from guilt, pain, rage, and similar manifestations specific
to their developmental level (Lerwick, 2011, 2013). Child’s fear, subjective sense of life threat,
pain, acute physiological arousal (e.g., elevated heart rate), severe anxiety or traumatic stress
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during care, and the availability of interpersonal social support are common features in pediatric
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patients (Kahana et al., 2006).
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✓ The therapist might need to address this issue by K a
Providing counseling services. m i
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➢ When children are scared, tired or in pain, they are particularly dependent on the safe and
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stable environment of their home and on the support and love of their family members in order
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to be able to cope and feel strength and capable, since their limited coping skills and emotional
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resources are not ‘designed’ to handle the tremendous amount of physical and emotional stress
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on them during hospitalization. They report feeling lonely and scared, as they are taken
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away from the safe and empathetic environment of their home and being separated from
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parents (Simeonsson, Buckley & Monson, Dr.1993).
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➢ Children, due to their limited maturity and life experience, cannot adequately infer the true
causes of their hospitalization, and might instead interpret their hospitalization as a
punishment for something they have done wrong, aggravating their experience of fear,
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loneliness and frustration. This is a crisis that if not mastered properly may result in blocks or
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distortion in their process of development and might be exceedingly damaging to their sense of
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identity and self-esteem (Goslin, 1978).
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➢ It is often very difficult for children to feel confident and reassured that the treatment they
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receive is actually for the purpose of helping them and making them feel better in the long run.
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One of the most distressing event for children is undergoing a surgical procedure, which they
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often perceive as assaultive and mutilative, even if it is but a minor and routine procedure.
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Worry about the loss of bodily functions and fear of disfigurement are particularly prevalent for
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children. The experience of feeling different and the anticipation of a distorted body image may
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further aggregate the anxiety of hospitalised youth while recovering in the hospital, and can
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even pose a threat to their identity formation and sense of self.
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➢ The heightened levels of preoperative anxiety increase the possibility of negative
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psychological consequences throughout their recovery, such as continuing anxiety, separation
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anxiety, problems with sleep, nightmares, eatDr.
irritability
Simi Kapoor
and aggressiveness. 9
➢ Chronically ill children often suffer from additional anxiety and long-term adjustment
problems, as they often fall behind of their normal routines and activities which help them in
developing behavioral and emotional competencies further in life. For example, they often
express sadness and anxiety over missing out on school, and having limited chance of
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socializing with their friends and peers, or being involved in their family life and interactions
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with their parents and siblings.
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➢ The hospitalized children’s level of physical activities is inherently limited, and thus their
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means for making sense of the world around them are threatened. Hospitalized children
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tend to engage in less play activity, and when they do engage, their play is characterized by
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repetitive, solitary themes. D
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➢ Due to their developmental level and limited
s cognitive and emotional development, children
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use behavior instead of words, to communicate the emotions they feel. Common behavioral
o helplessness include
demonstrations of fear, anxiety,land
▪ aggression be
▪ Withdrawal
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▪ lack of cooperation Dr. Simi Kapoor 10
▪ regression
▪ intense separation anxiety exhibited by clinging to an attachment figure or object
▪ refusal to allow diaper changes without being held down
▪ severe sleeping issues r
▪ surrender in helplessness o o
▪ hide from the frightening experience a p
▪ be unable to communicate their needs clearly K
▪ unwanted and intrusive thoughts m i
▪ bad dreams S i
▪ Hypervigilance
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▪ exaggerated startle response D
▪ to
avoidance of reminders of the medical event (Kassam-Adams et al., 2016)

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healthcare. This distress impedes l
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Psychological and behavioral distress is present regardless of the incidence of invasive or painful
o execution of healthcare protocols, thus requiring more
provider
time in the treatment process.be
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Psychological dimensions Psychological Reactions
Emotional Distress Anger Angry mood, irritability, frustration
negative social cognitions- interpersonal sensitivity, envy, disagreeableness
Anxiety Fear, panic, anxious misery, worry, dread,
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Hyperarousal- tension, nervousness, restlessness, hypervigilance, exaggerated
startle response
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intense separation anxiety K a
somatic symptoms related to arousal - racing heart, dizziness, agitation

Depressive Symptoms Negative mood- sadness, guilt

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views of self - self- criticism, worthlessness
social cognition - loneliness, interpersonal alienation

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decreased positive affect and engagement- loss of interest, meaning, and
purpose D
Stress
to
feeling overwhelmed
perceived lack of control of capacity to manage one’s life
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cognitive-perceptual disruption
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o nfeel a loss of autonomy and control

e l Sense of loneliness and frustration

specific evaluations of
illness and treatment
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suffer from guilt
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Dr. Simi sense of identity and self-esteem 12
 Fear of missing out on activities
comparisons of one’s predicament with siblings and other children not going
through the treatment

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Behavioral reactions Aggression
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Withdrawal
lack of cooperation K a
Regression
surrender in helplessness m i
hide from the frightening experienceS i
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cling to an attachment figure or object
be unable to communicate their needs clearly
phobias D
sleep
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Sleeping issues, nightmares
eating Eatingsissues
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incontinence
Relationships lon Peers - quality of relationships with friends detitiorates, their friendship may
be terminate as their due to their absence their friends choose other companions
They may feel that they will lag behind their peers
n t Family- feel a sense of burden on their parents

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Three sets of factors predict risk in developing psychological pathologies (long term
consequences) as a result of health care (Pine and Cohen, 2002):

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(1) children who exhibit high degrees of psychological pathologies before the treatment traumatic
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exposure;
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(2) level of exposure and frequency of exposure to therapy
(3) social factors, lack of support – parental/caregiver K a
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Additional risk factors include S i
• children with limited intellectual ability
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• female D
• younger age
• instability in family life
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• intense exposure to frightening events this creates a predisposition to pathologies
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Children with these risk factors may recover at a slower pace and may need psychological
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intervention. Children are psychologically unprepared for anxiety and the resulting emotional
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strain from a health crisis. Dr. Simi Kapoor 14
Coping in children (Peterson, 1989) includes three facets:
(1) active vs avoidant
(2) internal vs external
(3) emotionally-focused vs problem-focused
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1) Avoidant coping is used more during the acute phase of healthcare or hospitalization and
active coping is used more often in the recovery phase (LaMontagne, 1984). By focusing
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children’s attention on a specific aspect of medical care, they feel better equipped to recover
faster than children who are avoidant in their experience. S i
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2) An internal locus of control refers to the belief that events or outcomes come as a result of
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one’s own choices and actions. Choosing an internal locus of control correlates positively with
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active coping approaches, such as seeking information about the illness or procedure and
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alertness to stressful stimuli. In young children aged 0-2, the internal locus of control is
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associated with attachment of the primary caregiver and the child will rely upon them for age-
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appropriate information and for physical safety. An external locus of control has been shown
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to be interrelated with avoidant coping strategies, such as avoiding information about the
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event, denying worries, and distancing one’s self from stressful stimuli. This response is
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displayed in children with an avoidant attachment
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pattern with their primary caregiver. 15
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Managing Strategies
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A. Current strategies for reducing anxiety and stress in children include

✓ distraction,
✓ creating an inviting physical environment, r
✓ child and parental preparation o o
✓ positive staff interactions. a p
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mtrauma, and trauma
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responses in children, CARE (choices, agenda, resilience and emotions)
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B. In an effort to reduce healthcare-induced distress leading to anxiety,
process can be used
which is based on four principles: (Lerwick, 2016) r .
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(1) Choices: Provide power in a powerless environment - providing an empowering environment
significantly decreases a patient’s risk for healthcare-induced trauma and other undesirable
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psychological effects of treatment. Providing ssmall choices about seemingly insignificant matters
n provider’s care. Communicating openly and offering
foster empowerment to a patient in aohealth
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choices to the patient will go fareto create an environment of safety and empowerment. If there are
several family memberst
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present, ask patients whom they would like in the room. Wait for
permission to beginethen examination. The physician can set up an environment of trust and safety
that will serve ast
Dr. Simi Kapoor 17
a foundation to medical care for the rest of the patient’s life.
(2) Agenda: Letting the patient and family know what to expect and what is expected of them -
speaking directly to the child patient on what is being assessed, and how it may help will let the
patient know exactly what to expect. Introduce programs of acquainting the children with the
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hospitals, its routines, anticipated surgery that the children may need to undergo, and involving
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their parents in the process.
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(3) Resilience: Start with strengths and reframe negatives; K a
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(4) Emotions: Recognize and normalize common fears and responses - pediatric patients require
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an extra level of care in their healthcare process. They require added patience, flexibility, and
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containment for their ever-changing emotions. Their primary need is to know they are safe and to
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be given age-appropriate and developmentally-appropriate information in order to combat
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heightened anxiety levels and trauma responses, which can hinder the delivery of quality
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healthcare and create harmful long-term psychological effects.
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C. They need to be recognized as ‘little people’ who are yearning to be treated not just as ‘bodies’
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but as humans with emotions, pain, illness, and concerns, by providing age-appropriate
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communication, support and empathy and devise means of interventions for those children who
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display marked signs of distress. Dr. Simi Kapoor 18
D. If a child does not possess a strong attachment to their primary caregiver, such as a parent,
medical personnel may need to step in and offer the child additional assistance in identifying
their internal locus of control. Choices foster personal power to children and can encourage a
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strong internal locus of control. Those that deliver healthcare should have awareness and training
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in how to treat children appropriately based on style of coping in hopes of decreasing levels of
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perceived trauma and healthcare-induced anxiety.
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E. PROMIS Pediatric/Parent Proxy Profile - A collection of 8-item short forms assessing anxiety,
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depressive symptoms, fatigue, pain interference, physical function-mobility, and peer
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relationships as well as a single pain intensity item to be used by the psychologist if the therapist
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has further concerns and feels that the patient needs psychological intervention.

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Implication for the Therapist

➢ Putting yourselves into children’s shoes: the therapist must practice patience and try to speak
to them at their level, both physically and mentally.
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In physical aspects, squatting can help children ward off their fear about visiting the doctor’s
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easier to gain their cooperation. K a
office. In addition, getting to the eyes of the patient will comfort him/her, which will make it

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➢ Greeting them with a smile and empathy: it has a major impact on the child. It’s important to
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greet the child with a smile when they are entering the room or meeting them for the first time.
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This is a way to show them the setting is friendly and safe for them.
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Children would tend to pick up the non-verbal communication more easily than verbal, so smiling

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is the best way to develop a connection initially. Empathizing with the child is also necessary
since visiting a doctor’s office is a common fear among the children.
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➢ Let Them Warm Up to You : Many pediatric patients get nervous when they first come in for
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their appointment. You want them to feel comfortable, so give them the chance to warm up to
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you and the environment around them. Dr. Simi Kapoor 20
Make conversation with these patients about topics other than their condition. This helps you get
to know them and establish a relationship. Ask them questions that don't relate to the visit. This
could be about school, sports or other activities, or their weekend plans. You can also ask about
something that interests them, such as their favorite movie or book.
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These types of questions will help get them talking about something that they’re more
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comfortable with. It gives you the chance to relate to them on a personal level. This will help the
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patient trust you and feel less nervous about the appointment. It will also show parents that you
genuinely care about their child’s well-being. S i
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➢ Walk Them Through the Appointment: Pediatric patients might be nervous because they don’t
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know what to expect. A good way to reduce their nervousness is by walking them through the
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process so they know what’s going to happen next. Even preparing them for simple things can
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help. For example, before using the equipment, warn them that it may feel cold. You can also
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try distracting the patient by talking to them during the unpleasant parts of the appointment.
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➢ Using age-appropriate vocabulary: Engaging the pediatric patients would depend on the age,
maturity, as well as developmental levels. Therapists should avoid medical jargons and talk to
them in words that they will understand.
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With teenagers and young adults, the therapist must talk with the same respect she would use
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when handling an adult patient.
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Other patients who are developmentally delayed will struggle to communicate at the average level
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of their age group. This is why it’s important to not only communicate based on age but also at the
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developmental level of the patient. They need to be addressed according to their mental age and
not their chronological age. S i
Make eye contact when talking to the patient. You want the
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rpatient to know that your attention is
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on them, not their parents. Keeping parents in the conversation is important. But you want
t focus and that the care is for them.
pediatric patients to know that they are your primary
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➢ Provide a child-friendly atmosphere: Making the therapy space child-friendly is important to
e Before greeting a child patient, the place should be
deal with the fear factor inbchildren.
prepared with bright tcolors and comforting stuffed animals, toys, books, etc. These things will
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tethink it’s a fun place and they will not get scared about being in the doctor’s
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➢ Ask the Parent Questions/ addressing their anxieties: Some children are at different
developmental stages, it’s important to talk to the parent to determine where the child is at so
you know how best to communicate. Their parents will know better than anyone how they
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communicate, so the parents can give you tips on this. They can start the conversation with
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their children who are shy or difficult to talk to. Parents would also know of allergies,
vaccination records, and the family’s medical background that the child might not know.
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➢ Be Tolerant With Parents: Parents want to protect their children and keep them healthy.
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Sometimes, they’re as nervous as their kids and are more difficult to deal with than the patient.
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They might make assumptions, get frustrated, or unsettled. This could then upset the patient.
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First time parents are especially prone to be anxious about their children’s wellbeing.

Try talking to the parents separately if n g s

necessary, so that the conversation doesn’t affect the
l o even if the parent is anxious or angry.
patient. Stay calm and keep your patience
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