Cross-disciplinary approach to medicopsychological rehabilitation of children patients after transplantation of hematopoietic stem cells
Roman B. Miroshkin, Elena V. Fisun, Nataliya V. Sitnikova, Julia A.Viluzhanina
Clinical Rehabilitation Research Center “Russkoye pole”, D.Rogachev National Medical Resarch Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russian Federation
IntroductionThe main directions of rehabilitation for the children who had an oncologic disease are the best possible management aiming for recovery of physical health, restoration of physiological
and cognitive functioning, like as psychological well-being. Our aim was to describe dictinct problems occurring in rehabilitation of children who underwent hematopoietic stem cell transplantation (HSCT).
Patients and methodsA cohort of 229 children (1 to 18 years old) underwent rehabilitation treatment at the CRRC “Russian Field” after HSCT which was performed during the period of 01.01.15 to 25.08.17. Associated physical, physiological, neurocognitive and psychological disturbances were observed in these patients, as follows:
• primary disease;
• aggressive treatment;
• consequences of a psychological trauma caused by negative and sudden change of lifestyle; painful medical procedures and manipulations; awareness of a life-long risk; long-term strict limitations in activities; high anxiety of family members, separation of relatives;
• long-term social isolation;
• changed mode of child-parental relations (increased tendencies for excessive care, low-quality emotional communication between parents and children); problems with executing the age-matched tasks.
ResultsThe mentioned problems mutually influence each other. Hence, for example, poor well-being of the child, restrictions in mobility influences his psychological condition, and, vice versa, increased anxiety, depressive tendencies reduce motivation for treatment and rehabilitation, decreasing their efficiency.
Thus, efforts of different experts are necessary in rehabilitation process: involvement of physicians, psychologists, teachers, social workers. Each of them deals with certain aspects of tasks directed to restoration of the areas and functions injured in the course of illness and its treatment. However, some difficulties occur quite often when resolving rehabilitation tasks. One may efficiently cope with these problems only at the interdisciplinary cooperation level.
Interdisciplinary interaction of psychologists in the rehabilitation process evolves between doctors, experts for reconstitution medicine, nurses, teachers.
A demand of psychologists for cooperation is associated with solution of certain psychological problems:
1. The problems coupled with physiological functions. For their resolution, the psychologists at the Center use shortterm strategic therapy approaches, behavioral therapy; therapeutic
stories and informing are applied.
• nutritional disturbances: changes of taste preferences and perception, refusal of certain meals, “infantilism” of alimentary behavior (preference of homogenized foods, lack of unassisted feeding), emetic reaction during uptake of non-preferred meals, lack of appetite.
Along with psychologists, a dietarian should participate, in order to control body mass deficit of the patient, supply of special nutrients, consulting caloric requirements for the specific patient.
• sleep disorders;
• enuresis, encopresis.
To solve group of problems, consulting a neurologist is purposeful. Moreover, therapy of enuresis and an encopresis requires preliminary survey in order to exclude organic pathology.
2. Problems in training, development, motivation and will passivity. These problems are coupled with cognitive disturbances caused by chemotherapy and also to restricted solution of relevant age tasks in the course of the disease and treatment (observed in 35% of children). Understanding of self educational problems by the child as well as “hyper-sponsoring” parental strategy may cause a feeling of own restraints, disability, and, therefore, result into passivity for motivation and will. Therefore along with actions for formation of the motivational and strong-willed sphere and correction of the child parent relations restoration of cognitive functions and stimulation of cognitive activity is necessary. Correctional programs are for this purpose developed. At the same time cooperation with teachers and speech pathologists for the organization of regular trainings is represented very useful. Also patients with motor and cognitive disturbances are recommended to participate in the creative circles and master classes organized in CRRC’s “Russian Field”.
3. Problems with social communication, i.e., closeness, restrictions of social contacts, are observed in 75% of children (according to the diagnostics with Aсhenbaсh’s questionnaire). They result from a long social isolation and psychological trauma. Along with psychological methods (consultations, use of projective techniques, art therapy, attending psychological groups), an experience of immediate communication and social activity is effective. To this purpose, the psychologists are often appealing to teachers and tutors asking them to involve certain children into concerts, competitions, working at a multi-studio and etc. A demand from doctors, experts in reconstitution medicine, medical nurses for psychological assistance may be caused by the following issues:
• Emotional problems in pediatric patients (fears, anxiety, depressive trends) are diagnosed in 50% of children after HSCT;
• Behavioral problems (aggression, hysterics, disobedience, obsessions etc.);
• Difficulties in the child-parental relations.
Due to the specified emotional and behavioral problems, children refuse medical manipulations, procedures, or therapeutic physical training, or actively resist them. In such cases physicians address psychologists for definition of behavioral coping strategy with these patients. Upon situational inquiries, the psychological intervention consists of distinct references for the patient’s parents, e.g., how a child should be psychologically prepared for manipulation, as well as recommendations for medical staff on arranging dialogue and interactions with a child in question. For example, the nurses who are carrying out manipulations are advised not to persuade the child as “not to be afraid” (it often causes a counterreaction), and to tell him in advance about the matter of expected procedure since a correct information causes reduction of anxiety. During the procedure, it is the child offered a task which concentrates attention on something not associated with clinical procedure.
Doctors and nurses quite often pay attention to the features of child-parent interactions, and, in case of aggression, increased emotional intensity of their relations (from side of both parents and children) they inform the psychologists aiming for appropriate psychocorrective measures.