Pediatric Psychology:
Coping with Medical Stressors
Melissa Stern
PSY 4930
November 21, 2006
Medical Stressors
Injections
Blood draws (venipunctures)
Other painful/uncomfortable
procedures:
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Chemotherapy
Lumbar punctures
Hospitalization
Chronic Illness
How common are medical
stressors?
By the age of 5=10 preventative
injections
5 million medical procedures/yr
2 million children < 15 are
hospitalized/yr.
12.6 million children have a chronic
illness
What affects a child’s ability to
cope?
Developmental factors
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Age
Cognitive maturity
Emotional maturity
Coping style
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Sensitizers vs. repressors
Primary vs. secondary coping
Changes over time
Family variables
Illness/Treatment characteristics
Developmental Considerations
Infancy/Toddlerhood
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Separation from parents
Interfere with development of attachment,
interpersonal trust, self-regulation
Show most severe reactions:
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Inconsolable crying
Apprehension
Somatic complaints
Regression
May delay social development
Noncompliant and oppositional behavior
 Limit setting
Developmental Considerations
Middle Childhood

Most affected in academic or peer contexts
 Medical treatments may affect cognition
 Frequent school absences
 Bullying
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Cognitive considerations
 Rule-oriented thinking may promote adherence
(e.g., a belief that recovery results from strict
adherence)
Developmental Considerations
Adolescence
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Adolescent concerns may interfere with
appropriate coping
 Developing autonomy
 Peer and romantic relationship
 Self-consciousness about appearance
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Adherence decreases
Cognitive maturity can be protective
 Sophisticated coping strategies
Understanding of Illness
Preoperational Stage
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Thinking is based on naïve perception (e.g., seeing
is believing)
Believe that illness is caused by external events,
objects, or people
 Cold is caused by trees or happens when someone
stands near you
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May understand the idea of contagion, but do not
understand the process
Causes and consequences are confused
Understanding of Illness
Concrete Operations Period
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Understand contamination—something
harmful causes illness
Later, can understand internalization
(swallowing or breathing can affect the
inside of the body)
Invisible objects (e.g., germs) cause illness
Understand that an object causes illness
because of it’s qualities
Understanding of Illness
Formal Operations Period
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Understand that illness may be caused by
physiological or psychological states
Understand abstract concepts (e.g., poor
nutrition)
However, their understanding of illness is
often overestimated—concrete thinking still
predominates
Understanding of Pain
Infants & Toddlers
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In the past, newborns were thought not to
experience pain
In infants, pain responses are global, diffuse, and
prolonged
By 6-8 months, infants display anticipatory fear
and avoidance behavior
By age 2, response to pain is localized,
expressions of anger, or appeals for aid are more
common
Understanding of Pain
Preschool Period
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Pain is viewed as an unpleasant physical
entity caused by external events
Coping is mostly passive:
 Rely on medicine or parents for relief
Understanding of Pain
Middle Childhood
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Pain is a feeling
Can differentiate pain based on intensity, quality,
or duration
Physical and psychological causes are recognized,
but not integrated
Children may initiate coping responses:
 Exercising or talking with friends
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Level of understanding is related to type of pain
 Injections vs. Headaches
Understanding of Pain
Adolescence
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Cognitively sophisticated explanations of
pain and it’s causes (e.g., using
metaphors)
Understand that both physiological causes
and psychological causes can occur
simultaneously
Understand the adaptive purpose of pain
Coping Styles
Coping: “constantly changing cognitive and
behavioral efforts to manage specific external
and/or internal demands that are appraised
as taxing or exceeding the resources of a
person”
Research in this area has been divided into
coping during anticipation/ preparation phase
and the encounter itself
Coping Styles:
Anticipation Phase
Sensitizers: Cope with stressor by
gathering information and becoming
familiar with the upcoming encounter
Repressors: Turn away from the
stressor using denial or distraction
Coping Styles:
Anticipation Phase
Primary control: Coping style that
involves attempts to modify external
conditions
Secondary control: Style that attempts
to modify internal events (oneself)
Secondary is most effective with
uncontrollable stressors
Primary is best with controllable
stressors
Interventions to Promote
Coping
Primary goals
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Encourage positive relationships
Emotional support
Age appropriate information
Types of Interventions
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Education, Modeling, Coping Skills Training
Coping Interventions
Educational interventions
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Include using dolls to explain procedures, written
materials for parents, videotapes
Have been shown to be efficacious with a variety
of medical procedures
 Fewer distress behaviors
 Higher parental satisfaction
 Less parental anxiety
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Developmentally appropriate information is crucial
Coping Intervention
Modeling interventions
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Based on social learning theory
Involve an educational component and a
modeling component
 Model may be a peer (live or videotaped), doll,
or puppet
 Model is shown to engage in positive coping
skills
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Participant modeling vs. Symbolic modeling
Coping Interventions
Coping skills training
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May include both education and modeling,
but focuses on teaching coping techniques
Coping strategies taught include
 Relaxation, imagery, distraction
Other considerations
Children undergoing repeated medical
procedures do not respond as well to
interventions
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Post-traumatic reactions
Behavioral techniques may be used to
reduce anxiety
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Operant techniques, systematic
desensitization
Other considerations
Mixed results regarding parental
participation
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Parental presence is usually helpful, unless
the parent is anxious
Usually is most helpful during preparation
for medical procedures
Health Policy
Less than half of surveyed hospitals
used preparation-focused interventions
(e.g., education, modeling, or coping
skills)
Most use narrative preparation, tours,
play therapy, or printed material
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These have not been supported empirically
Family Variables & Coping
Family variables are important to consider
when children undergo medical stressors
Family and individual characteristics are more
important than disease characteristics
Family variables influence child coping
through:
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Parent coaching
Modeling
Home environment
Family Environment
Adaptability, Cohesion, Communication,
Conflict
Family flexibility may promote positive coping
Low cohesion may promote avoidant coping
High family competence (problem solving
together) was related to better coping
Parent Mental Health
Relationship between parent mental health
and child illness is bidirectional
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More parents of children with chronic illnesses
seek psychological services
Maternal anxiety, distress, etc. can negatively
impact the management of child’s illness
Factors that influence parents mental health
can also impact the child
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Social support
Dimensions of Chronic Illness
Duration
Age of Onset
Limitation of
Activities
Visibility
Expected Survival
Mobility
Physiological
Functioning
Cognition
Emotional/Social
Sensory Functioning
Communication
Course
Uncertainty
Stigma
Pain
Happy Thanksgiving!!