Hospital visits linked to post-traumatic stress syndrome
Richard Shaw helps kids at Packard Children’s cope with the stresses accompanying medical treatment.
BY KRISTA CONGER
Anyone who has ever tried to convince a reluctant toddler to get dressed knows how impossible the simple task can seem. Now imagine trying to persuade that same child to swallow bitter chemotherapy medicine or to endure yet another needle poke for an essential blood test. A first-of-its-kind national survey conducted by a Lucile Packard Children's Hospital researcher indicates that pediatricians and parents increasingly turn to the experts for help: pediatric psychiatrists trained to guide children and families through the emotionally fraught waters of medical diagnoses, procedures and side effects.
"There are inevitable side-effects of life-saving medical treatments, and the psychological issues are only beginning to catch up with the medical technology," said child psychiatrist Richard Shaw, MD. "Most people don't recognize how traumatic these treatments may be." Shaw is the medical director of the hospital's psychiatric consultation-liaison program and first author of the research, published in the January/February issue of the journal Psychosomatics.
Shaw and his co-authors found that more than 60 percent of similar programs experienced a significant increase in requests for services during the past five years. During the same time period, 30 percent of these programs reported a decrease in funding, and collection rates for this type of service average only one-third of the charges submitted.
The research is grounded in Shaw's real-world experience. Within a single day, he and his four colleagues in the consultation-liaison program may be called to the bedside of an organ transplant recipient reluctant to take anti-rejection drugs, a child refusing an important medical test or struggling with a frightening diagnosis such as cancer, or a patient who is refusing or unable to eat. They are also often called on to facilitate interactions between hospital staff and angry or frightened parents who may clash with the medical staff over their child's treatment.
"We draw from a range of intervention strategies—individual and family therapy, behavior modification, hypnosis and psychopharmacology, for example—to help patients with an enormous variety of clinical issues," said Shaw, who is also an associate professor of psychiatry and behaviorial sciences at Stanford.
One case stands out in his mind: that of a 14-year-old girl who developed post-traumatic stress disorder after an emergency intubation during admission. She panicked whenever a physician entered her room.
"Her oxygen level would drop as a result, but the oxygen mask made her feel as if she were suffocating," said Shaw. "After her discharge, she was afraid to go to sleep at night, thinking that she'd never wake up."
Her response was not all that unusual: The researchers found that most children referred to psychiatric consultation-liaison programs needed help adjusting to their illnesses and dealing with this type of medical post-traumatic stress. Suicide assessment is also a common request, the survey found.
Confused or anxious parents may also experience long-term psychological trauma as a result of their children's medical problems. The effect may be particularly acute for mothers of premature infants; recent studies suggest that about half of these women develop PTSD after their experiences.
"Most of these women have spent months anticipating a happy ending to their pregnancies," said Shaw. "They feel out of control when they unexpectedly have a premature infant who must be hospitalized indefinitely, and whom they can't hold or care for themselves." Shaw and his colleagues are currently conducting an intervention study using cognitive behavioral therapy to prevent emotional distress in parents with children in the neonatal intensive care unit.
"If it's not treated appropriately, they can have nightmares, flashbacks and anxiety," Shaw said. "It can also influence how they parent their child as they get older, making them hypervigilant to the most minor physical symptom, or causing them to overcompensate in areas of discipline and boundary setting."
Another important and relatively rare service the team provides is treatment for children with feeding disorders—particularly those who were dependent on gastrostomy tubes for months or years.
"Many of these children have missed the critical developmental windows during which you learn to eat," said Shaw. "They may get stuck on the G-tubes because their parents are reluctant to remove the tubes and run the risk of weight loss." The team has had a 100 percent success rate weaning patients from the tubes to oral feeding using a protocol of three weeks inpatient treatment followed by three weeks of outpatient treatment. They've also had success in using hypnosis to re-establish eating in kids with oral aversions due to traumatic medical experiences or choking.
Although such a service is not well reimbursed, Packard Children's Hospital is committed to providing it in the face of the growing need. "Managing a patient's mother is not a reimbursable procedure," said Shaw. "But the hospital really supports us. Together we're taking a proactive stance, trying to prevent psychological trauma when possible and developing protocols for early intervention."