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INTRODUCTION

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Each day children and adolescents face a wide range of medical illnesses including allergies, asthma, epilepsy, cancer, diabetes, and obesity, all of which appear to be increasing in prevalence.1 According to the 2005 to 2006 National Survey of Children with Special Health Care Needs Chartbook, the two most common are allergies (53%) and asthma (38.8%).2 The increasing prevalence of these has been partly attributed to medical advances that have reduced mortality rates, so that children with chronic medical conditions now live longer.3,4 The increased prevalence of childhood illnesses is also related to increased exposure to toxic stress, sedentary lifestyle, and an unhealthy diet leading to increased childhood obesity and subsequently other comorbid medical disorders.3

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Ten to twenty million children in the United States have a medical condition, and about 10% of them are impacted by it in their daily lives.5 Illnesses affect the emotional and social wellbeing of children and their parents, and increase the stress-level of the family system as well.6 For example, illness characteristics (such as pain or fatigue) and required treatments (such as steroid medication) can interfere with school participation, which in turn can lead to academic difficulties and social isolation as well as increased caregiving and financial demands on their parents. Children with chronic illness are also more prone to bullying by peers,7 which can then further exacerbate their physical symptoms and lead to greater psychological distress.8 While the majority of children with medical illness are resilient,5 when compared to their healthy counterparts, they have an increased risk for the development of psychiatric problems.6,9,10 It is estimated that 20% of children with chronic health conditions will have psychiatric problems.5

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Children with medical illness can present with both internalizing and externalizing psychiatric problems. Internalizing problems are manifested in symptoms of depression, anxiety and somatic complaints whereas externalizing problems are reflected in hyperactivity, aggression, or “acting-out” (Table 20-1). That said, internalizing problems tend to occur more frequently in medically ill children.11,12 For example, a meta-analysis assessing behavioral outcomes of children with medical illness concluded that internalizing symptoms were more prominent than externalizing symptoms.13 It is hypothesized that certain characteristics associated with physical illness, such as the sense of losing control, restrictions of positive activities, isolation from peers, and pain, are the driving force for the development of internalizing symptoms.

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TABLE 20-1Internalizing and Externalizing Symptoms in Children
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This chapter focuses specifically on diagnostic considerations and challenges in psychiatric assessment and differential diagnosis of depression in children with medical illness. Asthma, obesity, epilepsy, cancer, and diabetes mellitus are specifically ...

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