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New research underscores importance of 'holistic assessments' of families
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The mental and physical health of one family member can affect the rest of the family — a complicated issue highlighted in two recently published studies.
“I think it’s really important for primary care physicians to pay attention to this,” Marian Earls, MD, MTS, FAAP, chair of the American Academy of Pediatrics Mental Health Leadership Work group, told Infectious Diseases in Children.
Earls, who was not involved in the research, suggested that pediatricians should include healthy children in developmentally appropriate conversations about illness or stressors in the family.
“It wouldn’t be a hard thing to do,” she said.
Impact of parents’ mental health on children
Kathryn Dreyer, principal data analyst for The Health Foundation in London, and colleagues conducted a retrospective, cross-sectional study of electronic health records of patients registered at a multi-site general practice in South East London to observe trends in health care use by children and young people (CYP). They found that parental depression was associated with a higher use of health care services among CYP.
“Our research highlights how the wider household context, in terms of health care-seeking behavior and long-term conditions, can influence how children use health care services,” Dreyer told Infectious Diseases in Children. “Understanding the different factors that influence the way children and young people access health care services is important as it can be used to help design effective approaches that are informed by insight into the whole family context and could deliver better outcomes for both children and their parents.”
According to the study, records from 25,252 registered patients were collected between Sept. 22, 2015, and Sept. 21, 2016. The final cohort included 6,124 CYP living in 3,373 households.
At 16% (n = 980), depression and/or anxiety was the most common long-term condition for parents and was positively associated with all secondary care use by CYP. Although older CYP without a long-term condition were least likely to use health care services, there was a significant association between parental depression and general practice use among CYP aged 11 to 15 years — a stronger relationship than in the younger age groups (rate ratio [RR] = 1.28; 96% CI, 1.04-1.57).
The most surprising outcome of the study, according to Dreyer, was that “a child with a parent who has depression is 41% more likely to have ED attendance than a child whose parent does not have depression.”
Because the study focused on the general use of health care services and not the mental health status of CYP, the reason behind the association is unknown. Earls believes it could be a combination of several factors. A parent with mental illness may have “more concerns about their kid” and could be likely to “bring them in more frequently,” she said. It could also be that, as a reaction to their parent’s condition, CYP experience somatic symptoms, prompting increased health care use.
“It is important that all parents receive appropriate health care and that they are well supported, particularly with respect to mental health,” Dreyer said. “Emerging innovative models of care that integrate different health and social care services may present an opportunity to facilitate more family appointments, which provide a holistic assessment of family needs.”
Pediatricians should not treat parental mental health, but Earls said it is completely possible to assess families as interconnected units. According to Earls, it can be easy to forget to check in on the emotional health of patients, but pediatricians are in a unique position to pay attention to the emotional health of the children, as well as to be supportive of parents with mental illness.
“We are asking primary care, particularly in pediatrics, to ask families about stressors, about social determinants that may be impacting the family and about parental mental health as well as parental strengths and protective factors, so that physicians can anticipate and do things that are preventive or supportive,” Earls said.
Siblings’ health another factor to consider
In an analysis of qualitative research from 12 studies, Antoinette Deavin, BSc, MRes, DClinPsy, from the department of clinical psychology at Lancaster University in the United Kingdom, and colleagues explored the experiences of healthy children with siblings who have pediatric chronic illness (PCI).
Deavin told Infectious Diseases in Children that previous studies investigating the experiences of healthy children living with siblings who have PCI “relied on parental reports of well-being or distress,” effectively excluding the healthy siblings’ perspective.
A total of 1,788 records were identified during their initial literature search — a list that was eventually narrowed down to a dozen. A meta-synthesis of the studies generated two major themes — “changing relationships” and “managing changes” — that were further categorized into five subthemes. These subthemes included “changing family relationships,” “changing relationship to self,” “coping, acceptance, and adjustment,” “support from friends, peers and support groups,” and “negative reactions from others.”
“Previous findings of studies relating to children who have a sibling with a chronic illness showed varying levels of distress, some clinically significant and others similar to their peers,” Deavin said. “The literature had not been viewed as a whole and therefore lacked an overarching psychological understanding and subsequent clinical recommendations.”
The researchers observed that the changes in the family relationship due to PCI can dampen communication. In particular, one study discussed “reciprocal silence” between parents and the healthy child — perhaps because the child thought that the parents have “enough to worry about” and did not want to “burden” them with questions or problems.
The researchers also observed a trend of “suppression of healthy siblings’ needs” throughout the studies. They found that children living with a sibling with a PCI tend to take on a caring role within the family, increase prosocial behaviors and appear to be emotionally self-sufficient. Although parents and professionals may perceive the healthy child to be functioning and thriving, the child could still experience high levels of distress, according to the researchers.
“This identity often shaped how they interacted with others outside the family and, eventually, their future careers — eg, caring professions,” Deavin said. “However, in order to maintain this identity, it meant that the healthy sibling often felt they had to suppress their own emotional needs.”
Based on the findings of the review, the researchers suggested implementing family-centered clinical interventions to encourage open communication. Some recommendations included access to a health professional for the healthy sibling, age-appropriate discussions of the disease, leaflets, support groups, charity events, sibling days, online resources, sibling forums, buddy systems or websites.
“We should be very intentional about checking in with siblings, monitoring their social/emotional health and engaging them,” Earls commented. “Primary care clinicians talk to the parent and they talk with the child who is sick, but they don’t necessarily ask about possible impact on the apparently healthy the sibling. I thought that was really powerful.”
Deavin said that not all healthy children will experience distress stemming from the systemic changes associated with having a sibling with PCI.
“However, all children have needs and are developing and learning how to relate to others and view themselves,” she said. “In an ideal world it is the adults’ responsibility, be they parents, teachers or clinicians, to make sure both children’s needs are considered.” – by Marley Ghizzone
References:
Deavin A, et al. Pediatrics. 2018;doi:10.1542/peds.2017-4151.
Dreyer K, et al. BMJ Paediatr Open. 2018;doi:10.1136/bmjpo-2018-000266.
Disclosures : Deavin, Dreyer and Earls report no relevant financial disclosures.