Educators are vital to the mental health of children and adolescents, so I am delighted to begin another year of “The Shrink in the Classroom.” I am grateful for the suggestions and constructive criticism that I have received in e-mails from as far away as India and Thailand. Please continue to send me your thoughts and let me know how this column can best help you deal with psychological issues in the classroom.
As the school year begins, teachers confront new students and concerns. Even students who are well known within a school may have changed dramatically during the summer, and these changes can pose new challenges.
One difficult issue that teachers may face is determining how best to respond to the student who, during vacation or abruptly during the school year, has developed a chronic or even life- threatening medical illness. These diagnoses are almost always unexpected. Overwhelmed and disheartened, the teachers, parents, and even the physicians caring for these children may be inclined to neglect the psychosocial issues that are central to every child's development. Development does not cease when a child becomes ill, however, and everyone who works with physically ill children should ensure that these children continue to grow and learn emotionally. Indeed, attention to the medically ill child's well-being can improve the course of the child's life, both physically and psychologically.
The Child and the Illness
Considering all chronic illnesses together is misleading. The psychosocial problems associated with individual diseases are a complex combination of the family's ability to cope, the medical problems associated with the particular disease, and, perhaps most important, the emotional and developmental make-up of the stricken child.
For example, Inflammatory Bowel Disease often begins in childhood. Children with this condition may have Chron's Disease or Ulcerative Colitis, both of which often involve arthritis and painful stomachaches and gastrointestinal upset. Many of the medications that these children take—such as prednisone, a steroid—have side effects that are physically disfiguring and create anxiety. Although young people with inflammatory bowel disease are often miserable because of their condition, the disease is rarely fatal, and most children with these problems do not actively confront their own mortality.
By contrast, such conditions as cancer often carry the emotional burden associated with a potentially fatal illness. Although up to two-thirds of childhood cancers are now curable, anti-cancer treatments—such as radiation and chemotherapy—are caustic and traumatic, and the word cancer has terrifying emotional resonance.
All serious threats to children's health are unsettling to those who are stricken and to those who know them. In a society where serious children's illnesses are relatively rare, we believe that children simply are not meant to fall dangerously ill, and we may be unprepared to understand the effects of these untoward events in a child's life.
Think Developmentally
Developmental guidelines can help us understand how children feel and think when they are sick. For example, preschool children often believe that they are somehow to blame for their illness. Their normally egocentric view of the world makes them feel that their current discomfort is the result of past transgressions. Although people of all ages are subject to such thinking during extreme stress, adults often fail to realize the extent to which toddlers are convinced that they alone are the cause of their disease. As children age, this view persists, although it usually fades to the background.
Very young school-aged children often believe that their entire body is injured, even if their symptoms affect only a small part of their capacity to function. Thus, the 6-year-old with bone cancer of the arm may lie rigid in her bed, terrified to move any part of her body. The fundamental trust that her body will behave, a relatively recent realization for a 1st grader, has been shattered, and she will need reassurance and coaching to believe that the rest of her body is unharmed.
As children grow older, rules and procedures become more important. Older elementary school students will become attached to the routines of their treatment, and they may find solace in the predictability of their trips to the hospital and the order in which procedures and medications occur.
By contrast, teenagers often feel rebellious toward their care. They may have participated wonderfully in their regimen as pre-adolescents, but the onset of puberty has brought with it a desire for independence, difficult to achieve at the other end of an IV. Adolescents benefit from frank discussions of what they can and cannot do. My work with adolescents who have undergone liver transplants includes a candid discussion of why even a little bit of alcohol is dangerous and potentially life threatening. Adolescents respond if they believe that they are being treated as much as possible like the adults they are hungry to become.
Never Assume
When dealing with children afflicted with any medical illness, a guiding principle should be to never assume. Knowing for certain how a child is feeling is impossible before getting to know him or her. Some children may be worried about the hair loss associated with cancer treatment, whereas others who take the effects of the medication in stride may be worried about their newly discovered mortality. To assume either scenario before learning how the child actually feels is to risk losing the child's trust that you can help him or her make sense of the predicament.
Psychiatric Illness and Medical Illness
The incidence of psychiatric conditions—depression, post-traumatic stress disorder, and a variety of anxiety disorders—increases in young people who suffer medically, and we should not ignore these issues simply because they seem normal in such trying situations.
The medical community is paying increasing attention to how children and adolescents develop symptoms of trauma (see “Coping with the Unthinkable,” Educational Leadership, November 2001), especially as a result of physical illness. As medicine has advanced, children now survive more harrowing illnesses and are subjected to more caustic treatments than even a decade ago. For these children, the tendency to develop post-traumatic stress disorder often relates to the extent to which the parents feel traumatized. Such findings accentuate the need to attend to the entire family to ensure the best outcome.
In the School
Teachers often ask how best to accom-modate students who suddenly become gravely ill. Should the rest of the class know? Should the teacher ask ques-tions? What allowances should the student have as he or she struggles with both schoolwork and medical care? In addressing these issues, one should think developmentally but never assume what will be best without first checking. The following vignette illustrates the complexities of each child's experience at school:J is a 14-year-old boy recently diagnosed with osteosarcoma, cancer of the bone. He is in treatment and is doing relatively well, although his regimen has caused him to lose 20 pounds and much of his hair. He is a good student and almost always cheerful, but classmates and teachers have felt unsure how to help him as he becomes increasingly gaunt and tired. An assignment in his biology course requires a 15-minute oral presentation. J decides to talk about the definition of cancer and the various means for treating it. He finds helpful the effort to intellectualize his condition. When his teacher asks him to talk more about his personal experience, however, J stumbles, and the class and teacher feel enormously uncomfortable as a result.
J's story points to a number of important issues. First, he may need time to rest throughout the day, and the teacher should allow rest periods to take place with little fanfare. Second, J should have the opportunity to discuss to what extent he would like his illness to be acknowledged at school. Some students gladly receive get-well cards and public displays of good will. Others prefer a more discreet approach. J was happy to present a general discussion of cancer, but he felt uncomfortable talking about his own experience. After all, he was still trying to make sense of his predicament, and wasn't sure he wanted to discuss it in a public forum. Checking in with J ahead of time would have protected him and his well-meaning teacher from an uncomfortable situation.
Teachers who are sensitive to these complexities can assist the seriously medically ill student's development in beneficial ways. School is a normal place, and normalcy is a luxury that quickly departs when a child falls dangerously ill. In this sense, school becomes a refuge, and educators should understand their crucial role in protecting this sanctuary.
