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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 35  |  Issue : 3  |  Page : 143-150

Psychiatric profile of physically ill pediatric patients


1 Department of Psychiatric, Beni Suef University, Egypt
2 Department of Psychiatric, Faculty of Medicine, Cairo University, Cairo, Egypt
3 Department of Pediatrics, Faculty of Medicine, Beni Suef University, Egypt
4 Department of Psychiatry, Faculty of Medicine, Bani Sweif, Beni Suef Governorate, Egypt

Date of Submission11-Aug-2014
Date of Acceptance10-Sep-2014
Date of Web Publication11-Nov-2014

Correspondence Address:
Hani H Dessoki
Department of Psychiatry, Prof. and Chairman, Beni Suef University
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1105.144336

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  Abstract 

Background
Mental health is an important component of overall health and mental disorders that can cause suffering, disability, and, rarely, even death. Pediatric-psychiatric liaison programs have evolved to enable the staff pediatricians to receive adequate training to assess emotional, behavioral, and family problems that may be an integral part of the patient's symptoms.
Objectives
The aim of the current study is to assess the prevalence of psychiatric symptoms among physically ill children ranging in age from 16 to 18 years attending the pediatric outpatient clinic in Beni Suef University Hospital and to compare the differences in psychiatric symptoms in relation to sex and the nature of physical illness among these patients.
Participants and methods
This survey study is a cross-sectional, observational, and comparative study. The study was carried out in the Pediatric outpatient clinic of Beni Suef University Hospital. A random sample of 300 Egyptian children with acute and chronic illness aged between 6 and 18 years, fulfilling the inclusion and exclusion criteria, participated in this study over an 8-month duration starting from May 2011 to December 2011. All participants of the study, both patients and informants, were subjected to a screening test using 'the Child Behavior Checklist for ages 6-18,' and intelligence quotient (IQ) was assessed for all sharing patients using the 'Stanford-Binet Intelligence Scale.'
Results
One hundred and seventy (56.7%) of the 300 selected patients were females and 130 (43.3%) were males; 260 of these patients attended regular schools. Out of the total number of patients, 155 (51.67%) presented with acute illness, whereas 145 (48.33%) had chronic illnesses. The mean IQ score was 79.8 ± 15.2 and only 22.3% of the sample (67 patients) had an 'average' IQ. Sex-based comparison of IQ results showed that female patients had significantly higher IQ scores (82.2 ± 13.6 with P = 0.035). However, Child Behavior Checklist 6-18 scores showed that 223 out of 300 patients had diagnosable Internalizing disorders with internalizing T-scores above 70; 118 (52.9%) of these were females compared with 105(47.1%) males, with a statistically significant difference (P = 0.026). Meanwhile, 203 patients had diagnosable externalizing disorders with externalizing T-scores above 70; 104 (51.2%) of these were females. IQ scores differed significantly, being higher in acute illnesses (82.3 ± 13.6 vs. 77.8 ± 15.9 and P = 0.025). Another significant difference between patients with acute illnesses and those with chronic illnesses was clear in the internalizing T-score and the externalizing T-score (higher in acute illnesses, P = 0.028 and 0.034, respectively).
Conclusion
The current status of psychiatric problems in pediatric physically ill patients calls for mandatory cooperation in pediatric consultation-liaison services in the Beni Suef Governorate.

Keywords: acute and chronic illness, liaison, pediatric psychiatry


How to cite this article:
Dessoki HH, Fakhry H, Khalil MA, Gomaa MA, Gohar SM, Meebid M, Elkhair TA. Psychiatric profile of physically ill pediatric patients. Egypt J Psychiatr 2014;35:143-50

How to cite this URL:
Dessoki HH, Fakhry H, Khalil MA, Gomaa MA, Gohar SM, Meebid M, Elkhair TA. Psychiatric profile of physically ill pediatric patients. Egypt J Psychiatr [serial online] 2014 [cited 2021 Dec 2];35:143-50. Available from: http://new.ejpsy.eg.net/text.asp?2014/35/3/143/144336


  Introduction Top


Liaison services have been described by many authors by different models of functioning, but the terminology 'Liaison child psychiatry' in most of the literature refers mainly to the partnership of child psychiatry and pediatric services that can also include other specialties related to children aiming at providing integrated medical and psychological care for children (Mattsson, 1976; Minuchin et al., 1978). Graham (1984) once pointed out that the principles of appropriate referral to child psychiatry consultation services are less necessary when there is regular contact between.

Mental health is an important component of overall health and mental disorders that can cause suffering, disability, and, rarely, even death (Pratt et al., 2007). Chronic medical illness is often associated with emotional problems that may be the major source of concern compared with the original physical problem (Gareson and Baer, 1990; Lane et al., 2002).

Worldwide, there are only a few standardized studies of juveniles in which extensive assessments of psychiatric status have been performed (Rani et al., 2006). Thus, data on psychiatric morbidity are needed to develop more effective plans to screen the youth population and to detect high-risk children and adolescents with psychiatric morbidity who need interventions in the community (Karen et al., 2005).

In Egypt, the total number of children ranging in age from 6 to 18 years in the 2011 Population Census was 26 418 350, which constitutes about 32.8% of the total Egyptian population (80 411 370) (Central Agency for Public Mobilization and Statistics, 2011). This raises the magnitude of the problem; as such, a percentage is considered a large one that cannot be ignored. Study of the prevalence of psychiatric disorders in this population group is essential for raising the new generations in an appropriate way assuring building up healthy society. To our knowledge, study of psychiatric disorders in this age group of children has received limited attention in the Beni Suef governorate. Our study was a trial to investigate the presence of such disorders in physically ill children visiting the outpatient pediatric clinic in Beni Suef University Hospital.

The aim of the current study is to assess the prevalence of psychiatric symptoms among physically ill children ranging in age from 6 to 18 years attending the pediatric outpatient clinic in Beni Suef University Hospital and to compare the differences in psychiatric symptoms in relation to sex differences (male or female) and the nature of physical illness (acute or chronic) among these patients.


  Participants and methods Top


Study design

This survey study is a cross-sectional, observational, and comparative study. The study was carried out in the Pediatric outpatient clinic of Beni Suef University Hospital. The Department of Pediatrics, Beni Suef University Hospital, is located in the northeast of Beni Suef city, which is located in the suburbs of the Beni Suef governorate, and serves both the urban and the rural catchment area of the population.

Partiicpants

Selection of sample

A random sample of 300 patients fulfilling the inclusion and exclusion criteria participated in this study. The first five cases were selected from among patients attending the pediatric outpatient clinic on Sundays and Wednesdays on a weekly basis over an 8-month duration starting from May 2011 to December 2011. We chose the first, second, third, fourth, and fifth names of each clinic.

Choice of cases

Patients were selected from among Egyptian children aged between 6 and 18 years with acute and chronic illness irrespective of their sex. Healthy children with no diagnosed physical illness were excluded from the study. All participants were screened to determine eligibility for participation in the study. Screening was performed using an interview form, which examined demographic data and information on complete medical history. On the basis of the responses, individual participants were approved for participation in this study. Acute Illnesses are diseases with a sudden onset and, usually, a short course. They may be mild or severe, but transient, usually do not interfere with daily life, mostly isolated to one body area, and respond to treatment e.g. common cold, gastroenteritis, etc. Chronic illnesses, however, often affect everyday life throughout childhood, involve multiple systems, require more care and resources, and have an uncertain outcome. Illness types were coded according to chronicity factor (chronic vs. acute) on the basis of consensus agreement of the consultation-liaison (C-L) team (Carter et al., 2003). Illnesses were coded as acute if they had recent/sudden onset (e.g. acute infection) or chronic if they involved recurrent/persistent symptoms or a lifelong condition (e.g. asthma, diabetes).

Ethical consideration

Ethical approval for the study was granted by the Ethics Research Committee of Beni Suef University Hospital, Pediatric Department, where patients were selected. An oral informed consent was obtained from all patients or their care givers, after they were informed in detail about the study and the procedures involved. Patients and their care givers were ensured about the confidentiality of information, that participation in the study was completely voluntary, and that they have the freedom to withdraw from the assessment at any time.

Procedures and tools

All participants of the study, patients or their informants, were subjected to a screening test:

(1) The Child Behavior Checklist (CBCL) for ages 6-18 years (Achenbach and Rescorla, 2001): it is used to assess a child's problem behaviors and competencies by individuals who know the child well (parents or primary caregivers). The CBCL is a widely used method both in the school and the clinical setting. It is a component in the Achenbach System of Empirically Based Assessment developed by Thomas M. Achenbach to collect standardized data on the baiss of national norms; it is a syndrome-based scale with two parts: one assessing the child's social competence and the other assessing his/her emotional and behavior problems. Parents or primary caregivers rate the child in 20 areas of competence and 120 area of difficulty. The questions include physical concerns, problems, and strengths. The exam is considered the gold standard for behavioral assessments and is available in more than 20 languages. The CBCL/6-18 is a DSM-Oriented Scale that includes 118 items differentiating the individual's behavior into two broad-band dimensions (internalizing problems, externalizing problems) and a total problem score can then be assigned. It also includes the assessment of the following eight syndrome dimensions:

(a) Aggressive behavior: includes items that assess physically or verbally aggressive behaviors,

(b) Anxious/depressed: contains items assessing symptoms of separation anxiety, generalized anxiety, phobias, and depression,

(c) Attention problems: includes items that assess for symptoms of AD/HD,

(d) Rule-breaking behavior: consists of items assessing disobedience at home and school, defiance, and angry moods,

(e) Social problems: assesses difficulties with social interactions with peers,

(f) Somatic complaints: ύncludes items that assess for physical ailments such as headaches, nausea, aches and pains, and gastrointestinal symptoms,

(g) Thought problems: assesses the observance of strange or odd behaviors that are not age appropriate, and

(h) Withdrawn/depressed: assesses for symptoms of social withdrawal.

The standard score for the eight syndrome dimensions is reflected as a T-score, with a mean of 50 and a SD of 10. T-scores (40-59) indicate the 'average range' (65-69) for 'borderline clinical range', that is high enough to be of concern for further investigation, whereas T-scores (≥70) are considered significant for 'clinical range', that is so high as to be clearly deviant. During the assessment, parents or guardians are asked to reflect on the child's behavior during the previous 6 months and respond to each of the 118 items using a three-point scale: 0 is equal to not true, 1 is equal to somewhat or sometimes true, and 2 is equal to very true or often true.

(2) Stanford-Binet Intelligence scale: the scale consists of 15 subtests that are age-corrected, scaled scores, enabling interpretation of profile elevations and profile depressions. It is a widely used psychometric test to assess intelligence. Analysis of the standardization data is age specific (Ahmed and Melika, 1972).

Statistical analysis

The means, SDs, and ranges were calculated to provide an informal descriptive analysis for each CBCL/6-18 and Stanford-Binet Intelligence scale. The appropriateness of each statistical technique for the data was determined by reviewing whether assumptions specific to each statistical procedure used were fulfilled; these assumptions included the use of interval or ratio data, normality of the data, equal variances of dispersion, and linearity (Tabachnic et al., 2007).


  Results Top


The age range of the 300 selected patients in the current study was 6-18 years, mean ± SD (9.4 ± 3.1), and 130 patients (43.3%) were males and 170 (56.7%) were females. 260 of these patients attended regular schools, 19 were educated in specific schools for the mentally handicapped, and 21 were uneducated. Of the total number of patients, 155 (51.67%) presented with acute illness and 145 (48.33%) had chronic illnesses [Table 1]. As measured by the Stanford-Binet Intelligence scale, the intelligence quotient (IQ) scores of the entire study sample ranged from 23 to 96 (mean ± SD 79.8 ± 15.2) and only 67 (22.3%) samples had an 'average' IQ [Figure 1]. The scale scores of CBCL 6-18 for the entire study sample in [Table 2] showed that the mean ± SD of the internalizing T-score was 68.5 ± 11.6 compared with 66.6 ± 10.3 for the externalizing T- score.

Comparison of demographic data of different sexes in the study sample indicated no statistically significant difference in the mean age (P = 0.381). However, there was a highly significant difference between males and females in education (P = 0.005), with more males [91 (70%)] in the primary stage of education than females [88 (51.8%)] and more females [49 (28.8%)] in mentally handicapped schools compared with males [8 (6.2%)]. There was also a significant difference in birth order, where males were more as first child; while females were more in the remaining orders (P = 0.034). There was no statistically significant sex-related difference in acute physical illnesses besides acute respiratory tract infection (more in females, P = 0.044). However, chronic physical illnesses showed a highly statistically significant difference between males and females in neurological diseases (more in females, P = 0.006), and a significant difference in blood diseases (more in males, P = 0.035), heart diseases (more in females, P = 0.024), and rheumatoid arthritis (more in males, P = 0.043). A sex-based comparison of IQ results in [Table 3] showed that female patients had significantly higher IQ scores (P = 0.035) on comparing their mean score of the Stanford-Binet intelligence scale (82.2 ± 13.6) with that of male patients (77.8 ± 16.9). Comparison of CBCL 6-18 scores between both sexes in the same [Table 3] showed significantly higher mean scores of females in the internalizing T-score (P = 0.038) and the externalizing T-score (P = 0.024). Meanwhile, the mean scores on the individual syndrome dimensions showed a significant difference, with males showing higher anxious/depressed scores (P = 0.045), withdrawn/depressed scores (P = 0.031), attention problems (P = 0.044), and aggressive behavior scores (P = 0.045). However, for CBCL 6-18 scores, 223 of 300 patients had diagnosable internalizing disorders with internalizing T-scores above 70; 118 (52.9%) of these were females compared with 105 (47.1%) males, with a statistically significant difference (P = 0.026). Meanwhile, 203 patients had diagnosable externalizing disorders with externalizing T-scores above 70; 104 (51.2%) were females compared with 99 (48.8%) males, with a statistically highly significant difference (P = 0.006).
Table 1 Percentages of pediatric diagnoses among the study sample patients

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Table 2 Scale scores of the child behavior checklist 6– 18 for the entire study sample

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Table 3 Sex differences in psychometric assessment results

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Table 4 Comparison between patients with acute and chronic illnesses in psychometric assessment

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Figure 1: Stanford Binet IQ scores of the whole study sample

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There were no significant differences in demographic data between patients with acute illness and chronic illness in age, sex, education, and birth order. However, [Table 4] shows a significant difference between the mean IQ scores of patients with acute illnesses (82.3 ± 13.6) and those with chronic illnesses (77.8 ± 15.9), being more in acute illnesses (P = 0.025). Another significant difference between patients with acute illnesses and those with chronic illnesses was in the internalizing T-score and the externalizing T-score (more in acute illnesses, P = 0.028 and 0.034, respectively). Syndrome dimensions showed variable results, with significantly higher means for patients with acute illness in anxious/depressed scores (P = 0.045), withdrawn/depressed scores (P = 0.031), attention problems (P = 0.044), and aggressive behavior scores (P = 0.045). Patients with diagnosable internalizing disorders with CBCL 6-18 had internalizing T-scores above 70, statistically significantly higher among patients with urinary tract infection and acute fever of unknown origin as acute illnesses compared with those who had scores less than 70 in the same category of (P = 0.028 and 0.020, respectively) and neurological diseases (P = 0.001) and rheumatoid arthritis (P = 0.001) as chronic illnesses. Moreover, among acute illnesses, externalizing T-scores of CBCL 6-18 were significantly higher in patients with acute gastroenteritis (P = 0.019) and acute respiratory tract infection (P = 0.020), and in patients with chronic illnesses such as neurological diseases and rheumatoid arthritis, with high statistical significance (P = 0.001 and 0.006, respectively).{Table 4}


  Discussion Top


Child psychiatry witnessed a major evolution late in the last century as a result of the work carried out by Michael Rutter in the first comprehensive population survey of 9-11-year-old children in London and the Isle of Wight (1970). That study addressed many important questions for child psychiatry such as rates of psychiatric disorders, the role of intellectual development, and physical impairment, with a specific focus on potential social influences on children's adjustment (Rutter, 1990). Our study was a trial that aimed to investigate similar factors in the Beni Suef Governorate in Egypt with a wider age range and restricted to physically ill children visiting the outpatient pediatric clinic in 'Beni Suef University Hospital'. Our trial was also carried out because of the limited research on child behavior during physical pediatric illnesses in relation to C-L services (Levy et al., 2008).

Out of the total number of patients, 155 (51.67%) presented with acute illness and 145 (48.33%) had chronic illnesses. [Table 1] shows that among acute illnesses, the highest frequencies were for acute respiratory tract infection, 87 (29%), and acute gastroenteritis, 35 (11.67%), which are the most common causes of acute pediatric illnesses and are considered the leading causes of death among children in developing countries, estimated to be 1.4-2.5 million deaths/year (Gregorio et al., 2007) and 1.9 million (Williams et al., 2002), respectively.

Of the 300 patients, 145 (48.33%) had chronic illnesses, with the highest frequencies for neurological diseases, 42 (14%), followed by bronchial asthma, 28 (9.33%), and heart diseases 27 (9%). Disorders of the nervous system are important causes of mortality and morbidity worldwide (El-Tallawy et al., 2013). Bronchial asthma had the second highest frequency among chronic illnesses in our sample and this was in agreement with Shakurnia et al., 2010, who reported the high prevalence of asthma in a random sample of schoolchildren in Ahvaz city, southwest Islamic Republic of Iran. Nowadays, with better medical care, early detection, and proper management, the majority of infants with critical diseases can be expected to survive the first year of life. Children with complicated congenital defects are able to live longer lives (Lindberg et al., 2002); even those born with heart defects survive to adulthood (Perloff, 1991) with lifelong follow-up and occasional hospitalization. There will be a group in which a cure is not possible, but effective palliative measures are available to improve both morbidity and mortality in such a group, that is, children with chronic illnesses (Halger, 2001).

The age range of the 300 selected patients in the current study was 6-18 years (mean ± SD 9.4 ± 3.1) and 130 (43.3%) were males and 170 (56.7%) were females. Two hundred and sixty of these patients attended regular schools and 19 were educated in specific schools for mentally handicapped. As measured by the Stanford-Binet Intelligence Scale, the IQ scores of the entire study sample ranged from 23 to 96 (mean ± SD 79.8 ± 15.2), and only 67 (22.3%) of the sample had an 'average' IQ [Figure 1]. This may be related to the high frequency of neurological diseases among the chronic diseases of the sample, which are usually accompanied by variable degrees of mental retardation. Also, children with chronic diseases are more likely have intellectual impairment as [Table 4] showed a significant difference between the mean IQ scores of patients with acute illnesses (82.3 ± 13.6) and those with chronic illnesses (77.8 ± 15.9), being lower in children with chronic illnesses (P = 0.025). This is in excellent agreement with the result of Wary and Sensky (1999), who reported that feeding difficulties in children with heart diseases could lead to failure to thrive and consequent developmental and intellectual function impairment.

The scale scores of CBCL 6-18 for the entire study sample in [Table 2] showed that the mean ± SD of the internalizing T-score was 68.5 ± 11.6 compared with 66.6 ± 10.3 for the externalizing T-score. This result was in agreement with Lebovidge et al. (2003), who found that children with chronic diseases have an increased risk of overall, internalizing, and to a lesser extent externalizing behavior problems.

The current study found a significant difference between male and female patients in CBCL 6-18 scores, with significantly higher mean scores for females in the development of such behavioral problems and with a higher number of female patients scoring above 70 in both internalizing disorders and externalizing disorders. This result can be attributed to the fact that girls show greater vulnerability to interpersonal concerns, reactivity to stressful life events, and reliance on support from parents and peers for coping and social competence compared with boys (Leadbeater et al., 1995; Gore et al., 2003). However, patients in our sample had high scores on both internalizing and externalizing scales. Parental overprotection can explain the development of externalizing symptoms in physically ill children, reflecting excessive control that interferes with the child's ability to develop a sense of autonomy or competence (Gilbert and Silvera, 1996; Ryan and Deci, 2000). Development of internalizing symptoms following externalizing symptoms has been reported previously by Fischer et al. (1984) and Pihlakoski et al. (2006), and peer rejection was suggested by Keiley et al. (2003) to be the mediating factor in the development of depression from externalizing symptoms as children struggle with the effects of their disruptive or aggressive behavior. This can explain the significantly high scores of male patients in the individual Syndrome dimensions of anxious/depressed scores (P = 0.045) and withdrawn/depressed scores (P = 0.031) if we consider such problems to occur following the attention problems (P = 0.044) and aggressive behavior problems (P = 0.045).

Miatton et al. (2007) found that general adjustment problems of internalizing and externalizing behavior problems were significantly more in children with chronic diseases than in children with acute illnesses. They attributed this to frequent hospitalization and not being able to fully participate in sports and social activities, which consequently reduced social participation and acceptance by peers. Oates et al. (1994), Goldberg et al. (1997), and Visconti et al. (1999) found higher scores for internalizing behavior on the childhood checklist for children with chronic diseases as well. Children with chronic disease were often physically less able to interact with their environment because of the limiting nature of their condition, which might hinder the development of other skills such as exploratory behavior and thus increase the feeling of basic anxiety and impulsivity as well as a feeling of inferiority (Kramer et al., 1989). However, our study found a significant difference between patients with acute illnesses and those with chronic illnesses in the internalizing T-score and the externalizing T-score (higher in acute illnesses, P = 0.028 and 0.034, respectively). Our findings confirm the results of Levy et al. (2008), who reported that children with more acute or life-threatening illnesses had more in-hospital behavior problems than patients with chronic illness. We agree with them that the relationship between child behavior and illness characteristics is dependent on the chronicity and the severity of the physical illness. Those with more recent diagnoses are less likely to be familiar with the hospital environment and are more likely to be exposed to unfamiliar, acutely intensive treatments. Furthermore, those with life-threatening illnesses may be more prone to concerns about the potentially severe nature of their illnesses during physical consultation. Although children with chronic illnesses (compared with acute illnesses) had lower ratings of in-hospital behavior problems, they had higher ratings of behavior problems out of the hospital (compared with children before acute illness onset). Some previous research has shown greater internalizing behavior out of the hospital in samples of children with chronic illness conditions. One likely explanation for this finding is that children with acute illnesses were ill for only a very brief period of time before consultation, and their pre consultation behavior therefore reflected the absence of the illness. Hence, the comparison of acute versus chronic illness for out-of-hospital behavior was more accurately a comparison of chronic illnesses with no illness (Thompson and Gustafson, 1996).

Clinically, the findings of our study may have significant implications because they suggest factors that could potentially reduce behavior problems (particularly internalizing) in the hospital outpatient setting. For example, increased familiarity (through the use of exposure, play, and education) with hospital staff and procedures may help children with acute illnesses to adapt in the same way as children with greater exposure to the hospital environment. In addition, addressing appraisals of threat from illness or treatment (e.g. through the use of coping skills training and cognitive-behavioral therapy) may improve adjustment in the hospital. The results of the present study highlight the need for increased attention to outpatient behavior and outpatient C-L settings to better understand factors predicting child adjustment during physical illness, with the ultimate goal of identifying risk factors, protective factors, and targets for intervention.

Other findings in our study indicated higher internalizing disorders among patients with specific acute illnesses such as urinary tract infection and acute fever of unknown origin and among patients with neurological diseases and rheumatoid arthritis as chronic illnesses. Externalizing disorders were significantly higher in patients with acute gastroenteritis and acute respiratory tract infection as acute illnesses and in patients with neurological diseases and rheumatoid arthritis as chronic illnesses. These data should be researched further and confirmed by investigating internalizing and externalizing problems among patients with different categories of physical diagnoses.

Finally, the current status of psychiatric problems in pediatric physically ill patients in Beni Suef University Hospital requires mandatory cooperation in pediatric C-L services in the Beni Suef Governorate. With the limited available resources compared with 144 pediatric C-L programs in the USA (Shaw et al., 2006), one should keep in mind that Graham (1984) once pointed out that the principles of appropriate referral to child psychiatry consultation services are less necessary when there is regular contact between specialists. With the best healthcare facilities, a survey of the 144 pediatric C-L programs in the USA received reports of common problems of financial and staffing constraints (61%) and a decrease in funding (30%) (Shaw et al., 2006). Therefore, we agree with Graham's recommendation on the policy of cooperation between different departments in the University Hospital to introduce integrated C-L services to children and adolescents as our team work presented in this study (Graham, 1984) [38].

Clinical implications

Our study is an attempt to provide further details on the psychological profile of physically ill pediatric patients. Data collected from the study trial provide recommendations for the inclusion of a psychiatric assessment in all pediatric examination guidelines to direct health resources toward early detection and better recognition and treatment of psychiatric disorders among physically ill children and adolescents.

Limitations

(1) Despite the high number of patients included in the study (300), this number cannot be considered representative of all physically ill children, and thus our results cannot be generalized. Further research in this area with a larger sample size is recommended with categorical psychiatric diagnosis of cases.

(2) We could not exclude the Somatic Complaints subscale in the CBCL 6-18, although its inclusion could have led to possible confusion between somatic complaints and physical illness. However, no significant findings were obtained for this syndrome dimension.


  Acknowledgements Top


 
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