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Chronic illness significantly increases the risk of psychiatric disorder in children and young people. Bennet et al1 report a systematic review of psychological interventions for mental health problems in children with chronic physical illness. They found only 10 studies meeting their criteria, only two of which were randomised controlled trials. This is despite the fact that large-scale epidemiological studies have consistently shown that chronic illness is common in childhood and that children with chronic illness are more likely to have psychiatric disorders.2 ,3 Chronic illness appears to be a generic risk factor rather than being associated with particular psychiatric diagnoses, although certain types of chronic illness, notably those involving the central nervous system, are associated with higher levels of psychiatric disorder.
The personal burden on children and their families, and the economic burden on health, education, social care and youth justice services in dealing with these long-term conditions are immense. A significant part of this burden relates to the higher rates of mental health disorder in children with chronic illness described above. Moreover, the sequelae of mental health disorders can exacerbate long-term physical health conditions, which in turn can exacerbate the mental health disorder setting up vicious cycles of worsening morbidity. Mechanisms are likely to be varied and cumulative. Chronic illness related neurological pathology might impact directly on behaviour. The stress and worry associated with being ill may directly influence the illness, for example, via cortisol mediated stress responses and their impact on glucose metabolism in diabetes, or have an indirect influence via failure to adhere to treatment regimes. Stress in the wider family may lead to parental discord and/or psychiatric disorder—both known to be strongly associated with childhood psychiatric disorder.
Much of the research exploring the association between chronic physical illness and psychiatric disorder has looked at specific physical diagnoses—commonly, asthma, diabetes or cancer. Pless and Nolan4 have long argued for a non-categorical approach to understanding such links, suggesting that the similarities of experience for children with chronic illness outweigh the differences due to particular diagnoses. While acknowledging that diseases affecting the neurological or sensory systems may lead to greater levels of problems, they identify a range of risk factors for psychosocial dysfunction that cross diagnostic boundaries, including severity, visibility, predictability, age of onset and duration, and pattern of medical care. Put simply, a child and family coping with severe asthma may have more in common with a family coping with a very unwell child with diabetes than with a child with mild asthma. A practical implication is that psychiatric liaison/health psychology services need to be provided for all children with chronic illness and that organisation around particular diagnostic groups may not be necessary or indeed desirable given that it can lead to services for some children but not others.
In recognition of the centrality of behaviour change in managing chronic illness (the need to adhere to medication, diets, restriction on activity, regular monitoring, etc), there is a growing literature on the use of psychological interventions to manage physical symptoms with evidence for the effectiveness of such interventions in improving, for example, HbA1 and lung function, and reducing pain and distress. Against this background, it might be seen as surprising that Bennet et al1 found so few studies evaluating interventions targeted at the known psychological sequelae of chronic illness.
But provision of services to address mental health problems in the community at large, and especially in those with paediatric illness (chronic or otherwise), has always been very variable in the UK, a situation recognised by the House of Commons Health Committee.5 Historically, there have always been significant differences by centre, and within centre by diagnosis. Although there are some outstanding services around the country, many paediatric units have no access at all to child health psychology/liaison psychiatry services. Where they exist, child psychiatry and child psychology services for children with chronic illness are often commissioned separately leading to a lack of integrated care.
Policy makers have recognised the potential value of better integrated physical and mental health services for children and young people. The Department of Health's 2011 strategy No Health Without Mental Health recognised that physical illness increases the risk of mental health problems, and mental health problems increase the risk of physical illness. The physical and mental health interface was identified as an opportunity for system efficiencies and savings combined with improvements made across the patient pathway.6 The Children and Young People's Health Outcomes Forum7 recommended that children and young people with a long-term condition or disability are also able to access holistic, child-friendly mental health and public health services.
However, the need for savings in the National Health Service generally has led to child and adolescent mental health services having to focus limited resources on serious mental disorders such as psychosis, severe depression and self-harm, and eating disorder. This has led to a further, recent deterioration in the availability of liaison psychiatry/health psychology provision to address the mental health and psychological well-being of children and young people with chronic illness.
All this is against a backdrop of an increasingly solid evidence base that mental disorders in children and adolescents can be successfully treated. Not only can they be successfully treated but we have evidence that intervening earlier reduces the risk of comorbid disorders developing and that effective early intervention prevents subsequent episodes of disorder in later development and on into adult life.8 There is no logical reason why the treatments known to be effective already for children's emotional and behavioural problems should not also be effective in the presence of chronic illness. The adaptations that Bennet et al1 found in the papers they reviewed were not changes to the fundamental principles of the treatment. They related to the need to accommodate to the burden of the chronic illness, for example, by offering flexible appointment times and locations.
It is extraordinary that at a time when clinical evidence and health policy agree that better, more integrated care for children with chronic illness can deliver improved long-term health outcomes and service delivery cost savings, the reverse is actually happening in children's services up and down the country.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
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