الفهرس 
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Abstract
Introduction:
Thalassemia is a chronic illness that is an inherited disorder of autosomal recessive gene disorder caused by impaired synthesis of one or more globin chains. The impairment alters production of hemoglobin (Hb).Thalassemia causes varying degrees of anemia, which can range from significant to life threatening (Weatherall, 1997).
Patients with thalassemia are exposed to many severe stresses which play important role in causation of anxiety including frequent blood samplings for laboratory tests, multiple transfusions and frequent subcutaneous injections of iron chelator drugs (Saravi et al, 2007).Depressive and anxiety symptoms are more prevalent among adolescents with thalassemia. In addition, in the same group, there were higher degrees of free floating anxiety, phobic anxiety, obsessive symptoms, somatic symptoms, depressive symptoms, and hysteria (Hamed et al, 2011).
Recent studies have suggested that painful interventions like frequent hospitalization, cannulation, use of chelating agents and splenectomy significantly associated with anxiety and depressive disorders (Yahia, et al., 2013).
Thalassemic patients were more vulnerable to anxiety and depression, indicating that screening and management for such psychiatric disorders should be considered in treating all such patients (Yahia et al, 2013).
Aim of the study:
The study aimed:
1.To assess the presence of psychiatric problems in children with thalassemia
2.To investigate the traumatic effect of the different procedures they are exposed.
The review included:
1.Chapter 1:
Posttraumatic stress disorder in children;introduction,patho-physiology, psycho-pathology, epidemiology, risk factors, diagnosis, differential diagnosis, comorbidity, assessment and treatment.
2.Chapter 2:Depression in children;introduction, epidemiology, etiology, psycho-pathology, risk factors, diagnosis, consequences, differential diagnosis, course & prognosis, screening and treatment.
3.Chapter 3:Thalassemia; introduction, epidemiology, α-thalassemia, β-thalassemia, clinical presentation, diagnosis, major complication, treatment options, survival, psychological disturbance in thalassemic children and psychological support.
The practical part
Subjects:
The study was conducted at Beni Suef University hospital this is a cross sectional comparative study consisting of two groups:
group 1:
Thirty patients with thalassemia recruited from pediatric outpatient clinic in Beni Suef university hospital and this group subdivided into group 1a (thalassemia major) and group 1b (thalassemia intermedia) through the period from October 2014 till April 2015 after taking approval from their parents after full explanation..
group 2:
Thirty control children recruited from pediatric outpatient clinic in Beni Suef university hospital not suffering from any chronic medical disease through the period from October 2014 till April 2015 after taking approval from their parents after full explanation.
Patients in both groups were matched in age and sex.
Inclusion Criteria
1.Both sexes
2.Age: 8- 12 years
3.IQ more than 70 assessed by Raven’s Progressive Matrices (RPM).
Exclusion Criteria
1.Patients with other chronic medical diseases
2.Patients with severe head trauma
3.Patients diagnosed with another psychiatric disorder
4.Patients who refuse to participate in the study.
METHODLOGY
Both groups were subjected to the following assessment procedures:
1.Psychiatric assessment sheet
2.Assessment of medical condition: diagnosis, age of onset, history of blood transfusion (rate and number); history of hospitalization (number and duration); history of splenectomy
3.Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997)(Alyahri. & Goodman,2006)
4.Children’s Depression Inventory (CDI) (Kovacs, 1992)(Ghareeb, 1995)
5.Raven’s Progressive Matrices(RPM) colored(Raven, 1981)(Ali, 2013)
6.The Children’s Revised Impact of Event Scale (CRIES) (Horowitz; et al.,1979).
7.Social standard scale(Fahmy& El-Sherbini, 1983).
Results of this study
1.On viewing the socio-demographic data of the sample. It can be noted that there was no statistically significant differences between the two groups concerning all of the socio-demographic data including age, sex&education.
2.There were 23 patients (76.7%) were thalassemia major and 7 patients (23.3%) were thalassemia intermedia.
3.As regard illness duration; it ranged from three years to 11 years and half with the mean of 8.0±2.2.
4.Regarding examination data in patients; 15 patients (50%) had mongloid features, 13 patients (43.3%) had Hepatosplenomegaly, growth retardation; 20 patients (66.7%) were growth retarded and 9 patients (30%) did splenectomy.
5.Regarding hospitalization rather than receiving blood transfusion; 8 patients (26.75) didn’t hospitalized, 14 patients (46.7%) hospitalized once, five patients (16.7%) hospitalized twice, two patients (6.7%) hospitalized three times and one patient (3.3%) hospitalized four times.
6.As regard abdominal pain reported/ month; it ranged from 0-20 with the mean of 5.9±6.7.
7.As regard frequency of Cannulation; 27 patients (90%) did Cannulation once/ month while three patients (10%) did Cannulation twice/ month.
8.Regarding frequency of blood transfusion/ year;15patients(50%)received blood monthly, 5 patients (16.7%) received blood every two months, two patients (6.7%) received blood every 3weeks, one patient (3.3%) received blood every two weeks, four patients (13.4%) received blood every three months, one patient (3.3%) received blood once/ year, two patients (6.7%) didn’t receive blood.
9.As regard iron chelating treatment; 28 patients (93.3%) received oral form of iron chelating treatment while two patients (6.7%) received both oral and I.V. routes of iron chelating treatment, while 10 patients (33.3%) had history of Deferoxamine intake.
10.As regard family history of thalassemia; 22 patients (73.3%) had at least one member of the family had thalassemia
11.As regard family history of psychiatric disorders (p = 0.89); there was no statistically significant difference between the two groups.
12.As regards socioeconomic status(p = 0.55); there was no statistically significant difference between the two groups.
13.As regards history of abuse(p =0.04); there was statistically significant difference in the control group.
14.Children with thalassemia showed less participation in school activities than the control group (p= 0.02).
15.As regard trauma type; majority of children with thalassemia19 patients (63.3%) had multiple traumatizing agents, 9 patients (30.0%) of subjects had one traumatizing agent, while 2 patients (6.7%) of subjects had no traumatizing agent.(73.3%)patients were traumatized from blood transfusion, (60.0%)were traumatized from cannulation,(26.7%) were traumatized from splenectomy and (23.3%) were traumatized from hospitalization, while (16.7%) were traumatized from Deferoxamine intake.
Psychometric tests study
16.As regarding Strength & difficulty questionnaire (SDQ) in both groups; control group showed more peer relationship problem(p = 0.04).
17.As regards children depression inventory scale (CDI):there was statistically significant difference between the two groups regarding severity of depressive symptoms (p = 0.00).
18.As regarding children revised impact of event scale (CRIES); there was statistically significant difference between the two groups regarding CRIES scores (p = 0.00) and CRIES positive cases.
19.As regards CRIES score and CRIES subscales score (intrusion, avoidance & arousal), there was highly statistically significant difference between the two groups, this means that group 1 showed more post-traumatic stress symptoms compared to group 2 (p = 0.00),(p = 0.00),(p = 0.00),(p = 0.00).
Correlative studies:
20.There was no significant relationbetween CRIES scores and sex of group 1(p = 0.86).
21.There was no significant relationbetween CRIES scores and type of thalassemia in group 1 (p = 0.40).
22.CRIES scores there was a statistically significant positive correlation between CRIES scores and frequency of blood transfusion per year (p=0.01) and duration of illness/years (p= 0.01), this means that post traumatic symptoms increase with increased frequency of blood transfusion / year and longer duration of illness.There was a non-statistically significant correlation between CRIES score and other thalassemia medical history.
23.CRIES total score and thalassemia complication regarding CRIES scores there was statistically significant relationbetween CRIES score and splenectomy (p=0.02), this means that splenectomy increase post traumatic symptoms in patient group. There were no statistically significant relationregarding CRIES score and mongoloid features (p = 0.26), deferoxamine (p = 0.29), growth retardation (p = 0.19), HCV infection (p = 0.25) hepatosplenomegaly (p = 0. 07) and family history of thalassemia (p = 0.69).
24.There was no statistically significant relationbetween CRIES score and method of iron chelating treatment (p = 0.20).
25.There was no statistically significant relationbetween CRIES score & socioeconomic status (p = 0.19).
26.Regarding different trauma from medical procedures &CRIES total score & subscales scores showed that there was statistically significant correlation regarding blood transfusion as traumatizing agent and CRIES total score(p = 0.02) and arousal (p = 0.04) and intrusion (p = 0.02) subscales, this means that blood transfusion showed more post-traumatic stress symptoms mainly arousal & intrusion symptoms.
27.Regarding splenectomy as traumatizing agent; there was statistically significant correlation regarding CRIES total score (p = 0.04) and avoidance (p = 0.04) andarousal (p = 0.04) subscales, this means that splenectomy showed more post-traumatic stress symptoms mainly avoidance &arousalsymptoms.
28.Regarding deferoxamine as traumatizing agent; there was statistically significant correlation regarding CRIES total score (p = 0.03) andarousalsubscale (p = 0.04), this means that deferoxamine showed more post-traumatic stress symptoms mainlyarousalsymptoms.
29. There was statistically significant correlation between trauma type & CRIES total score (p = 0.04).
30.There was statistically significant correlation between CRIES score and CDI scores(p= 0.00).
31.Therewas no statistically significant correlation between CRIES score and strength & difficulty questionnaire SDQ (p= 0.41) or its subscales emotional subscale score (p= 0.15), conduct subscale score (p= 0.49), hyperactivity subscale score (p= 0.47), peer problem subscale score (p= 0.06) & prosocial subscale score (p= 0.78).
32.There was no significant relationbetween CDI scores and sex of group 1 (p = 0.84).
33. There was no significant relationbetween CDI scores and type of thalassemia in patient group (p = 0.19).
34.There was a statistically significant positive correlation between CDI scores and number of hospitalization (p=0.02), frequency of abdominal pain duration/ month (p= 0.03) and frequency of blood transfusion per year (p=0.02). There was a non-statistically significant correlation between CDI score and other thalassemia medical history.
35.Regarding CDI score in relation to thalassemia complication; There was statistically significant relationregarding mongoloid features (p = 0.03), this means that depressive symptoms increase with mongoloid features & family history of thalassemia. While there were no statistically significant differenceregarding growth retardation (p = 0.36), splenectomy (p = 0. 47), Deferoxamine (p= 0. 37), Hepatosplenomegaly (p = 0.52), HCV infection (p= 0.67)and family history of thalassemia (p = 0. 11).
36.There was no statistically significant relationbetween CDI scores and method of iron chelating treatments (p = 0.09).
Conclusion:
The present study concluded that posttraumatic stress disorder is more common in children with thalassemia. They reported blood transfusion, splenectomy and deferoxamine intake as traumatizing agents.