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Psychiatric Disorder in Children with Physical Disabilities

NAOMI BRESLAU, PH.D.


Psychiatric disorder in 304 children with four congenital conditions was compared with
that of 360 normal children and across conditions, three that involve the brain and one that
does not. Children with physical disability were at increased risk for psychiatric disturbance.
Those with conditions involving the brain had greater psychopathology than children with
cystic fibrosis. Severity of physical disability had little effect on psychopathology. The risk
of psychiatric disturbance in children with conditions involving the brain varied directly
with level of mental retardation. In addition, brain involvement conferred a risk of social
isolation independent of mental retardation. The unique feature of severe psychopathology
secondary to physical disorder was marked social isolation accompanied by a low level of
aggressive behavior outside the home.
Journal of the American Academy of Child Psychiatry, 24, 1:87-94, 1985.

In a 1981 review, Pless and Zvagulis (1981) observed character of a disorder, be it diabetes, cerebral palsy,
that current studies challenged views regarding the etc., is believed to be secondary. As to the nature of
psychological concomitants of chronic physical illness the child's maladjustment, little attention has been
in children. Whereas earlier studies showed consist- given to delineating the specific behavioral domains
ently that chronic illness predisposes children to psy- that might in theory be expected to be affected. In
chopathology (Knowles, 1971; Lawler et aI., 1966; short, adaptation paradigms, explicit or implicit, have
McCullum and Gibson, 1970; Pless and Pinkerton, typically deemphasized the diagnostic classification of
1975; Tropauer et aI., 1970), more recent reports failed psychological sequelae just as they have deemphasized
to find marked differences between children in several the diagnostic specificity of the physical disorder
chronic disease categories and comparable controls which is presumed to be their cause.
(Drotar et al., 1981; Gayton et al., 1977; Klein and An alternative approach to the study of psychopa-
Simmons, 1979; Tavormina et aI., 1976). The inescap- thology in children with physical disorder, one which
able conclusion, as the authors stated, is that "the overcomes some problems in the adaptation model,
picture is not nearly as clear as it was once thought to was illustrated by Rutter and his colleagues in the Isle
be" (Pless and Zvagulis (1981), p. 191). Thus, the of Wight Study (Rutter et aI., 1970a, 1970b). They
belief that chronic illness in children is associated distinguished between two major classes of chronic
with psychopathology has been replaced by uncer- physical disorder: that which involves the brain and
tainty. Clearly, explanatory schemes that have served that which does not. This distinction and the finding
this field of research must be reexamined. that the rate of psychiatric disturbance in children
A dominant theme in the current literature on child- with physical disorder which involves the brain was
hood chronic illness is adaptation to disability. (An markedly higher than that of children with other
important illustrative work is Pless and Pinkerton physical disorders were major contributions. The
(1975).) In contrast to investigations that focus on marked excess in psychiatric disorder in children with
specific chronic conditions, the adaptation perspective brain damage was interpreted as evidence of a direct
emphasizes factors common to all chronic illnesses- somatic effect on behavior, whereas the excess in
chronicity, the handicapping potential of the disease, psychiatric disturbance in children with other physical
and the child's sense of being different. The specific handicaps (a finding of marginal significance in that
study) was interpreted as evidence of an indirect in-
Received Dec. 3, 1983; accepted Feb. 27, 1984. fluence on behavior, a psychological response to phys-
Dr. Breslau is Associate Professor of Sociology, Department of ical illness and its debilitating effects.
Psychiatry, Case Western Reserve University School of Medicine,
Cleveland, OH 44106, where requests for reprints should be ad- Important issues remain unanswered, however. Al-
dressed. though the risk of psychological disturbance among
Field work was supported by grants from the Cleveland Foundation children with chronic physical disorder is highest
and the C. S. Mott Foundation. Analysis (and a follow-up study now
underway) has been supported by NIH grant HD16821 and a NIMH when the brain is involved, it is unclear whether or
Research Scientist Development Award MH-00380. not the more severe physical disability that often
The helpful comments of David Reiss, M. D., and Helen Orvaschel, accompanies brain involvement could account for the
Ph.D., are gratefully acknowledged.
0002-7138/85/2401-0087 $02.00/0 1985 by the American Acad- greater psychological risk (Rutter, 1981). Further, al-
emy of Child Psychiatry. though intellectual impairment is viewed as an impor-
87
88 NAOMI BRESLAU

tant mechanism in predisposing children with brain Method


involvement to psychiatric disorder, the particular The sample included children with cystic fibrosis,
ways in which it affects behavior are yet unclear. cerebral palsy, myelodysplasia, and multiple physical
Previous research provides few clues to guide the handicaps from four pediatric specialty clinics in two
formulation of hypotheses about the specific nature of teaching hospitals in Cleveland, Ohio, whose case
these direct or indirect psychological consequences. loads were representative of area children in these
The presence of brain involvement in many chroni- diagnostic categories. (See Breslau et al. (1981) for a
cally disabled children might suggest a higher risk of fuller description of this sample.) Families of patients
those behaioral syndromes which have been linked 3-18 years of age were asked to participate in the
with organic brain damage, chiefly, inattention, im- study. From 460 eligible families, 369 (80%) complete
pulsivity, and hyperactivity. However, a recent review interviews were obtained. In families with patients 6
of empirical findings concluded that, with few excep- years of age and older, data were obtained on the
tions, no specific behavior pattern attributable to psychological functioning of the child. Of the 304
brain damage had been identified (Rutter, 1981). It patients in this age range, there were 65 with cystic
might also be expected that the crippling effects of fibrosis, 98 with cerebral palsy, 63 with myelodyspla-
chronic physical illness would influence adversely the sia, and 78 with multiple physical handicaps, a mis-
child's mood and general outlook. It is generally as- cellaneous group of complex congenital disorders, usu-
sumed in the adult psychiatric literature that second- ally including neurological damage.
ary depression, i.e., depression preceded or accom- For a comparison group (controls) , a multiple-stage
panied by another psychiatric disorder, can occur also probability sampling scheme was employed to provide
in association with medical illness (Weissman et al., a representative sample of all Cleveland area families
1977). Furthermore, empirical evidence on depression with one or more children 3-18 years old. I From 530
secondary to chronic medical illness in adult patients eligible families, 456 (86%) complete interviews were
has been reported recently by Akiskal (1983). He obtained. In each control family, a randomly selected
described chronic secondary dysphoria in patients child between the ages of 3 and 18 years, the age range
with medical illness and chronic infirmity of childhood of the disabled children, was defined as the index
onset as "demoralization consequent to realistic and child. Psychological functioning was measured on 359
permanent adversity." An increased risk of depression index children who were 6-18 years old. Data were
in children hospitalized for medical conditions was gathered in 1978-1979 from mothers in home inter-
reported recently by Kashani et al. (1981). Note that, views using a structured questionnaire.
whereas behavioral syndromes associated with brain Children with disabilities and controls were nearly
damage (primarily, the hyperkinetic syndrome) are evenly distributed by sex and age. The two samples
viewed as caused directly by an organic lesion, depres- were also similar with respect to sibship size, age of
sive sequelae of childhood disability are presumed to youngest child, and maternal age and marital status.
be reactive. As such, they might accompany all chronic Controls had higher incomes and higher levels of
conditions, those with or without brain involvement. maternal education. There were also differences on
There is, then, empirical support for the brain in- these two factors across the four diagnostic groups:
volvement-psychiatric risk hypothesis. There is less children with cystic fibrosis were from families with
support for the hypothesis of psychiatric disturbance higher incomes and higher levels of maternal educa-
secondary to any chronic physical disease in child- tion. To adjust for these disparities, family income
hood . On the specificity of psychological sequelae, with and maternal education were controlled statistically
the exception of the possibility of secondary dysphoria in the analysis."
suggested by more recent studies (Akiskal, 1983; Ka- Psychological functioning was measured by the Psy-
shani et al., 1981), previous research is not instructive. chiatric Screening Inventory, developed and used by
This study examines empirically several of these
issues. Psychiatric disturbance in children with four I Familie s in which a child had a severe physical disorder or

congenital conditions is compared with that of physi- known mental retardation were not eligible, The random selection
of controls avoids the problems that plague st udies using matched
cally unimpaired children and across conditions, three cont rols, in which known an.d unknown confoundings rema in ~n
that involve the brain and one that does not. The role matched. Further. our sampling scheme produced a representative
of mental retardation and severity of handicap in sample of t he general population , (i.e., a normative sample) rather
than an idiocvncratic sample of indeterminate generalizability, as
connecting brain involvement with psychiatric disor- might he the "case when cont rols are matched. When a random
der is then examined. Finally, the pattern of disorder sample is used, "matching" is accompl ished stat ist ically in the
of psychiatrically impaired disabled children is com- anal ysis.
2 Differen ces in racial compositio n acro ss diagnostic groups were
pared with that of psychiatrically impaired children not controlled for in the an alysis, since race was not significantly
who are free of physical disability. associated with any of the psychological variables.
PSYCHIATRIC DISORDER IN DISABLED CHILDREN 89
Langner and colleagues in an epidemiologic study of Fighting, Delinquency, and Isolation. (See item de-
New York City children (Greene et aI., 1973; Langner scr iption in Table 1.) The sum of the 35 items provides
et aI., 1974, 1976). The construction of the inventory a composite measure of psychiatric disorder and a
was based on a factor analysis of a large pool of items cutoff point of six distinguishes between severe psy-
describing specific behaviors. It was designed for use chiatric impairment and moderate or no impairment.
in community samples as a general screening instru- (See Langner et al, (1976) for the method used to
ment and although it is not a diagnostic tool, it covers determine the cutoff point.)
a wide range of behaviors with predictive value for Mental retardation: Although uniform IQ measures
psychiatric disorder. The inventory consists of the were not available, information on test results con-
mothers' answers to 35 items and comprises 7 sub- tained in clinic records were used to classify the dis-
scales, each with 5 items, measuring 7 areas of child abled children into three levels of mental retardation:
behavior: Self-Destructive Tendencies, Mentation severe, moderate, and none. None of the cystic fibrosis
Problems, Conflict with Parents, Regressive-Anxiety, patients fell in either of the subnormal groups,

TABLE 1
An In ventory for Screening Child Psychiatric Impairment"
Pathognomonic
Subscale Item Descr iption Respon se Code = 1
(All Others = 0 )
Self-destructive tendencies 1. Talks of kill ing self now Yes
2. Talked of kill in g self in past Yes
3. Hurt often/many accidents Often
4. Cries a great deal Often
5. Sad, depressed mood Often
Mentation problems 1. Loses train of thought Yes
2. Thinks slowly Yes
3. Throat clearing Yes
4. Trouble remembering things Yes
5. Average grades failing Failing
Conflict with parents 1. Bad home behavior Poor
2. Refuses when directed by other Often + alway s
3. Often in an angry mood Often
4. Often blows up ea sily with other Often
5. When loses temper throws and Yes
breaks things
Regressive anxiety 1. Battles over food Often
2. Ofter fidgety Often
3. Wakes in a panic often Often
4. Falls down often Often
5. Picky/choosy with food Often
Fighting 1. Thinks teachers and others against him Yes
2. Often lies to protect self Often
3. Gets along with other children Poorly
at school poorl y
4. Unhappy at schoo l Unhappy
5. Teases other children Yes
Delinquency 1. Lies so much , can' t bel ieve X Yes
2. Often does rash things Yes
3. Comes home at promised time rarely Rarely + never
or never
4. Ha s been in trouble with police Yes
5. Run s away from home 4-5 times 4-5+
Isolation 1. Often withdraws from others Often
2. Rarel y or never in happy mood Rarel y + never
3. Spends too much time alone Yes
4. Has no close friends None
5. Doesn't keep friend for year or more No
Sourc e: T. S. Langner, .J. D. Ger sten, E. D. McCarthy, et a!' : A screening inventory for assessing psych iatric impairment in children 6
t o 18. J ournal of Consulting and Clinical Psychology, 44:286, 1976.
90 NAOMI BRESLAU

whereas 40% of the children in the other three diag- cant. In each of these behavioral domains, children
nostic groups were classified as either severely or with cystic fibrosis scored significantly lower, indicat-
moderately retarded. ing less psychopathology, than children in each of the
Severity of disability was assessed by a 6-item "ac- remaining three diagnostic groups, according to
tivities of daily living" (ADL) scale, which measures Scheffe comparisons. Moreover, their scores on these
the extent to which the child gets help in eating, scales were not significantly different from those of
dressing, washing, toileting, going up or down stairs, controls, as additional analyses confirmed (data not
and going outdoors. Responses to each item range shown). Adjusted differences on the total Inventory
from 1 (never) to 4 (most of the time) and scale scores, did not reach statistical significance, although the
from 6 (low) to 24 (high disability). Internal consist- trend was in accord with the Mentation Problems and
ency reliability was 0.88. Isolation results. The proportion of children classified
as severely impaired psychiatrically by diagnosis also
Results followed the same pattern. Eleven percent of cystic
Comparison of Disabled Children and Controls fibrosis patients fell in this category, whereas 30% of
those with cerebral palsy, 27% with myelodysplasia,
A comparison of disabled children and controls on and 39% with multiple physical handicaps were so
the 7 subscales of the Psychiatric Screening Inventory classified (chi square = 10.9, df = 3, P < 0.02). In this
and the total score is presented in Table 2. Adjusted comparison, as in the Mentation Problems and Isola-
means and F ratios are from a series of analyses of tion comparisons, differences across cerebral palsy,
covariance in which income and mother's education myelodysplasia, and multiple physical handicaps were
were controlled. Disabled children scored significantly not statistically significant. On Conflict with Parents
higher than controls on four subscales: Mentation and Regressive-Anxiety, two areas on which disabled
Problems, Conflict with Parents, Regressive-Anxiety, children as a group also scored significantly higher
and Isolation. Their mean score on the total inventory
was also significantly higher. The proportion of dis-
TABLE 2
abled children with severe psychiatric impairment,
Adjusted Means of Psychiatric Scores from Analyses ofCovariance
that is, scoring 6 or above on the total inventory, was of Disabled Children and Controls, with Income and Maternal
more than twice as large as that of the controls, 27% Education as Cooariates (N = 633)
and 11%, respectively (chi square = 29.5, df = 1, P < Disabled Controls
0.0001). (:W4) (:~;,9)
F
Self-dest ruct ive tendencies 0.17 0.1,'; 0.27
Type of Physical Condition Mentation problems DO 0.;'8 81.11'
Conflict with parents 0.46 0.26 1~.78'
The association between type of physical condition
Regressive-anxiety 0.65 0.4:3 16.14'
and psychiatric disorder was examined by a series of Fighting 0.4,r1 0.4:1 0.14
analyses of covariance, with family income and ma- Delinquency 0.19 0.19
ternal education as covariates (Table 3). In two areas, Isolation 0.57 0.22 41.08'
Mentation Problems and Isolation, differences across Total score :3.80 2.26 41.3~'

the four diagnostic groups were statistically signifi- 'p < 0.000;'.

TABLE a
Adjusted Means of Psychiatric Scores from Analyses ofCovariance of Disabled Children in Four Diagnostic Groups, with Income and
Maternal Education a.~ Covariates (N = 304)
Cystic Cerebral Multiple
Myelodysplasia
Fibrosis Palsy Handicaps F
(63)
(6,'j) (98) (78)
Self'-dest ruct ive tendencies 0.12 0.16 0.22 0.21 0.49
Mentat ion problems" 0.82 L''iO 1.41 l.S2 3.71'
Conflict with parents 0..';0 0.49 0.38 0.50 0.40
Regressive-anxiety 0.71 0.68 0.58 0.68 0.80
Fighting 0.57 0.52 0.38 0.36 1.~4
Delinquency 0.18 0.19 0.11 0.29 1.,'j6
Isolation" 0.18 0.70 0.60 0.81 6.~0"
Total score :1.O8 4.24 3.68 4.~6 2.20
, p < n.nz, " P < 0.000,';.
"Cystic fibrosis is significantly different (p < 0.0;') from cerebral palsy. myelodysplasia, or multiple handicaps, according to Scheffe
comparisons.
PSYCHIATRIC DISORDER IN DISABLED CHILDREN 91
than controls, the differences across diagnostic groups ity of disability on this relationship were estimated in
were slight and not statistically significant. a hierarchical regression analysis in which type of
Taken together, these results indicate that disabled condition (cystic fibrosis vs. other), mental retarda-
children, irrespective of type of condition, manifested tion and severity were the independent variables. Ad-
disturbance in the areas of Conflict with Parents and ditionally, five child and family variables (child's age
Regressive-Anxiety. Aside from this common psycho- and sex, family income, maternal education and race)
pathology, children with cerebral palsy, myelodyspla- were used as covariates, to control for their effects.
sia, and multiple physical handicaps, all conditions Table 5 shows the results for Mentation Problems and
which involve the brain, also exhibited marked dis- Isolation, the two subscales that measure behavioral
turbance in the areas of Mentation Problems and domains in which children with conditions involving
Isolation, areas in which children with cystic fibrosis, the brain showed increased disturbance. Three suc-
a condition not involving any brain abnormality, were cessive regressions were calculated for each dependent
not different from controls. variable. In the first, the dependent variable was re-
gressed on type of condition, but only after the effects
Mental Retardation of the set of covariates had been partialled out. In the
A series of analyses of covariance of psychiatric second, mental retardation was added to the equation
scores across three levels of mental retardation was and the coefficient of type of condition was recalcu-
performed on 221 children with cerebral palsy, mye- lated. In the third, severity of disability was added and
lodysplasia, and multiple physical handicaps for whom the coefficients of type of condition and mental retar-
the presence and level of mental retardation was as- dation were each recalculated with the effects of all
certainable. Table 4 shows that the total Inventory other variables held fixed.
and two subscales, namely, Mentation Problems and
Isolation, had statistically significant positive associ-
TABLE 5
ations with mental retardation. Fighting, a subscale
Hierarchical Regressions of Mentation Problems and Isolation
measuring aggressive behavior outside the home, was (Standardized Partial Regression Coefficients) (N = 304)
inversely related to mental retardation, the severely
retarded scoring below those with moderate or no
Mentation problems
retardation (p < 0.02). Differences on the remaining
Step 1. Condition (Xl) 0.18'
subscales were not significant. The rate of severe Step 2. +Mental retardation (X2) 0.09 0.29'
psychiatric impairment was also associated with men- Step 3. +ADL (X3) 0.07 0.26' 0.08
tal retardation; being 53% among the severely re- Isolation
tarded, 35% among the moderately retarded and 26% Step 1. Condition (x.l 0.25'
among those with no retardation (chi square = 8.9, df Step 2. +Mental retardation (X2) 0.19' 0.18'
Step 3. +ADL (X3) 0.16' 0.13' 0.11
= 2, p < 0.02).
Condition: cystic fibrosis = 0; others = 1; MR or mental retar-
Multivariate Analysis dation: none = 0, moderate or severe = 1. ADL or severity of
disability (see definition under "Method"). Regression coefficients
The brain involvement-psychiatric disorder associ- were estimated with a set of covariates entered before Step 1: child's
ation and the effects of mental retardation and sever- age and sex, family income, mother's education, race. p < 0.05.

TABLE 4
Adjusted Means of Psychiatric Scores from Analyses of Covariance of Children with Cerebral Palsy, Myelodysplasia, and Multiple Handicaps
in Three Leuels of Mental Retardation with Income and Maternal Education as Covariates (N = 221)"
Severe Moderate No
Mental Mental Mental
F
Retardation Retardation Retardation
(30) (63) (128)
Self-destructive tendencies 0.14 0.12 0.23 1.04
Mentation problems 2.50 1.86 1.14 13.97"
Conflict with parents 0.53 0.59 0.43 1.02
Regressive-anxiety 0.95 0.71 0.63 2.06
Fighting 0.14 0.35 0.53 4.20'
Delinquency 0.26 0.23 0.21 0.13
Isolation 1.19 0.81 0.62 4.53'
Total score 5.71 4.68 3.80 4.53'
" Information on status of mental retardation of 18 children with cerebral palsy is not available. p < 0.02, p < 0.0001.
92 NAOMI BRESLAU

The regression coefficient of Mentation Problems turbed and 39 controls, also classified as severely
on condition, with the covariates held constant, was disturbed according to the same criterion (i.e., scoring
0.18. The effect of mental retardation in accounting 6 or above on the total inventory). The symptom
for the association between Mentation Problems and configuration of the two groups of disturbed children
type of condition can be estimated by the reduction were similar in important respects. In both groups,
in this regression to 0.09 (not significant), a reduction Mentation Problems were the most prominent, al-
of 50%. The effect of controlling additionally for se- though the physically disabled scored higher. Scores
verity of disability is indicated by a slight change in were nearly the same on Self-Destructive Tendencies,
the coefficient to 0.07. The unique effect of mental Conflict with Parents, and Regressive-Anxiety. On
retardation on Mentation Problems, when the remain- the other hand, there were also important disparities
ing variables are controlled, is 0.26 (p < 0.05), whereas between the two groups: Disturbed controls scored
the unique effect of type of condition is 0.07 (not markedly higher than disturbed disabled children on
significan t). the two aggressive subscales (Fighting and Delin-
The results of the Isolation regression were consid- quency), whereas on Isolation the order of the groups
erably different. Controlling for mental retardation was reversed.
reduced the regression coefficient of Isolation on con-
Summary and Discussion
dition from 0.25 to 0.19, a 24% reduction. The unique
effect of type of condition on Isolation was slightly The results of this study can be summarized as
higher than of mental retardation, 0.16 and 0.13, re- follows:
spectively (for both, p < 0.05). 1. Children with chronic physical conditions, as an
Severity of disability had little effect on either Men- aggregate, were at increased risk for severe psychiatric
tation Problems or Isolation; nor did severity account impairment (according to their scores on the total
materially for the association between either of these Inventory) and manifested more symptoms in four
psychiatric subscales and type of condition. behavioral domains. Physical conditions involving
In sum, the association between type of condition- brain abnormality were associated with more perva-
cystic fibrosis versus the other three diagnostic sive psychopathology: In addition to Conflict with
groups-and Mentation Problems was accounted for Parents and Regressive Anxiety, on which children
largely by mental retardation. In contrast, the effect with these conditions were equally as disturbed as
of type of condition on Isolation was to a considerable children with cystic fibrosis, they showed marked ex-
extent independent of mental retardation: Children cess in Mentation Problems and Isolation, areas in
with conditions involving the brain, even when they which children with cystic fibrosis were indistinguish-
were not mentally retarded, were more isolated than able from nondisabled counterparts. Furthermore, the
children with cystic fibrosis. risk of severe psychiatric impairment was markedly
higher in conditions involving brain abnormality; one
Forms of Psychopathology third of children with these conditions were severely
Table 6 presents a comparison between 83 disabled disturbed.
children classified as psychiatrically severely dis- 2. The risk of severe psychiatric impairment in
children with conditions involving the brain varied
TABLE 6 with level of mental retardation: Severely retarded
Comparisons of Severely Disturbed Children Amon/4 the Physicallv children were twice as likely as children with no
Disabled and Controls (N = 122) retardation to be classified as severely disturbed. In
Disabled Controls addition there was a direct association between mental
(N = 8~) (N = ~9) retardation and two behavioral domains, Mentation
X (S.D.) X (S.D.)
Problems and Isolation. Mental retardation accounted
almost entirely for the link between brain involvement
Self-destructive 0.46 (0.80) 0.64 (0.8~) 1.12
tendencies
and Mentation Problems. In contrast, brain involve-
Mentation prob- 2.76 (1.24) 2.05 (1.34) 2.86' ment was associated with Isolation quite apart from
lerns mental retardation. Thus, although children with con-
Conflict with 1.14 (0.98) 1.18 (1.17) 0.17 ditions involving the brain who were also mentally
parents retarded were more isolated than those who were not
Regressive-anx- 1.12 (0.82) 1.08 (0.74) 0.28
iety
retarded, the latter were still more isolated than chil-
Fighting 0.98 (0.96) 1.64 (0.90) -~.63"
dren with cystic fibrosis. Severity of physical disability
Delinquency 0..')2 (0.74) 0.97 ( 1.1:3) -2.66' bore little relationship to psychiatric disturbance,
Isolation 1.~2 (1.17) 0.74 (0.82) 2.80' when type of condition and mental retardation were
Total Score 8.~0 (2.59) 8.~1 (:l.4~)
controlled.
, p < 0.05, " p < 0.001. 3. Severe psychological disturbance secondary to
PSYCHIATRIC DISORDER IN DISABLED CHILDREN 93
physical disability had a similar symptom pattern to haviors captured in Langner's Inventory primarily as
that of severe disturbance in the general population Conflict with Parents, a cluster on which disabled
of children. In both types, Mentation Problems pre- children did in fact score markedly higher than chil-
dominated and the levels of symptoms of Self-De- dren free of disability.
structive Tendencies, Conflict with Parents and Re- Future research should clearly include data gathered
gressive-Anxiety were nearly identical. The unique directly from children via recently developed interview
feature of psychopathology secondary to physical dis- methods (Herjanic and Reich, 1982; Puig-Antich et
order, according to these results, appeared to be al., 1980). In addition, considerations should be given
marked Isolation accompanied by a relatively low level to the age at which children with chronic conditions
of aggression outside the home. might develop secondary depression. If such sequelae
Psychological disturbance associated with chronic are manifested first in late adolescence or young adult-
physical illness not involving brain abnormality must hood, the failure to detect dysphoria in this study
be interpreted as reactive rather than organic in origin. might in part be the result of the children's age at
Thus the finding that children with cystic fibrosis assessment.
scored significantly higher than controls on Conflict The finding that children with conditions involving
with Parents and Regressive-Anxiety indicates a risk the brain were markedly worse off than children with
for psychopathological response to physical disease. cystic fibrosis, a condition not involving brain abnor-
Further, the finding that in respect to this risk chil- mality, replicates findings reported by Rutter et al.
dren with cystic fibrosis were not different from chil- (1970a) and by Seidel et al. (1975). In the former, as
dren with conditions involving the brain suggests that in the study reported here, the non-brain-involved
disturbance of this sort is a common response to a conditions were less likely to be accompanied by visi-
variety of physical disorders, including those in which ble handicaps, a difference that constituted a potential
associated brain abnormality might confer a risk of alternative explanation to the brain involvement-psy-
direct organic effect on behavior. What, then, is the chiatric disorder association. However, in the latter,
nature of this reactive disturbance? The subscale Con- children with and without brain abnormalities were
flict with Parents comprises symptoms indicating op- comparable in terms of visible handicaps, ruling out
positional disorder (DSM-III). Items in the Regres- visible crippling as cause.
sive-Anxiety subscale have been previously inter- In the present study, children with brain involve-
preted as tapping general neurotic disturbance in chil- ment scored markedly higher on the Mentation Prob-
dren (Langner et al., 1974). lems subscale. Mental retardation was the key factor,
There is no direct evidence in these data that chil- suggesting that Mentation Problems in these children
dren with "chronic physical conditions are more de- might measure an aspect of their mental retardation.
pressed than children generally, or that one physical And since mental retardation in these children had
condition more than any other predisposes children known organic causes, Mentation Problems too must
to secondary depression. On Self-Destructive Tend- have had direct organic origins. Mentation Prob-
encies, a subscale capturing dysphoric mood and sui- lems-difficulties concentrating, trouble remembering
cidal ideation or attempts, disabled children were not things, and slow thinking-might also be functional
different from controls; nor were the differences across in origin. They might constitute cognitive signs of
diagnostic groups statistically significant. While these depressive disease, or an aspect of impairment in
results do not lend support to the secondary depres- functioning associated with a variety of psychiatric
sion hypothesis, their interpretation must take into disorders. Note that psychologically disturbed controls
account the limitations of Langner's Psychiatric also scored high on Mentation Problems. Since these
Screening Inventory for assessing depression. Since children were free of chronic physical conditions,
the inventory is based on information gathered from brain abnormality or mental retardation, their Men-
mothers, rather than from the children themselves, tation Problems were most likely functional. Previous
depressive moods and thoughts were undoubtedly analysis of Langner's data indicated that Mentation
underestimated, since these symptoms might not be Problems accompanied various types of psychological
obvious to mothers (or other informants) (Lapouse disorders, those with suspected organic basis and those
and Monk, 1958; Robins, 1978). Nonetheless, reliance without (Eisenberg et al., 1976). Thus, although Men-
on informants, chiefly mothers and teachers, has been tation Problems in children with these conditions were
the most widely used approach in psychiatric epide- closely linked to mental retardation of known organic
miology of childhood. causes and strongly supporting an organic interpre-
It might be that depressive mood in children tends tation, the symptoms themselves are diagnostically
to be identified by parents as irritability or excessive nonspecific and could also reflect functional disturb-
anger (American Psychiatric Association, 1980), be- ance.
94 NAOMI BRESLAU

Children with conditions involving the brain also F. (1977) , Children with cyst ic fibrosis: ps ychological test findings
of patients, siblings and parents. Pediatrics, 59:888-894.
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