The Child with Cancer and His Family

3. complete dependence on the family, complete obedience, a sense of guilt toward the parents;

4. relations within the family may not change at all, or may change adequately to the situation.

Over the course of the illness the types of relationships may be transformed. Fixation on the child's illness is often accompanied by parental disorientation in upbringing (a change in parenting style), when some parents strive to satisfy all of the child's needs, while others, on the contrary, believe that firmness and adherence to principle in upbringing can help the child recover [24]. Such a parenting style ultimately leads to a complete loss of control over the child's behavior.

Three main types of behavior of the parents of a sick child can be distinguished [24]:

The realistic type, in which adequate relations between family members, including siblings, are preserved. The parents are sociable, approachable, and serve as an example of self-confident, adaptive behavior. The parents' concern and anxiety are not pathological.

The pessimistic type, in which relatives practically reject the sick child. There is a loss of the parents' vital interests or an excessive fixation on the healthy child. All family members are in a state of chronic emotional fatigue and tension. Such behavior may be either a sign of masked depression or a striving to avoid responsibility.

The unjustifiably optimistic type, in which the seriousness of the illness is ignored and the severity and depth of the child's disease or condition are underestimated. Such an attitude leads to a situation in which, upon subsequent deterioration of the child's condition, the parents fall into severe psychological decompensation (prolonged depression,

suicide attempts). The parents' behavior does not help, but aggravates the condition of the sick child and of other family members.

These types of situations are not constant and, in different periods of the illness, may replace one another or even manifest in various combinations.

d) A child's conception of death is influenced by the child's age and his life experience, including the ethnic, religious, and cultural atmosphere in which the child is growing up [1, 6].

The development of a healthy child's conceptions of death passes through several definite stages [1, 24]:

1. Up to 4–5 years of age, children do not understand what death is. They consider everything to be alive. At this age children perceive things in an inseparable unity and do not attempt to distinguish between the living and the non-living.

2. At the age of 5–7 years, children begin to think and talk about death; a fear of death forms as an awareness of the fact of the finitude of existence. The well-known child psychologist A.I. Zakharov holds that already after the age of 5, with the development of abstract thinking and an increase in cognitive activity, an awareness of one's own «self» in time is formed, and the child makes a disturbing discovery: that he will die in the end, like all other people. Before this, the child believed in the permanence of the surrounding world, in the notion that he would live forever. The gradually arising thoughts of death and the fear of death that inevitably accompanies these thoughts are, in the opinion of A.I. Zakharov, inherent in most children of senior preschool age. Moreover, girls are afraid considerably more often than boys, since the self-preservation instinct that underlies the fear of death is more pronounced in them

. On the whole, a healthy, psychologically adequately developing child does not perceive death at this age as something that will affect him personally.

3. After 7-10 years, children begin to grasp the irreversibility of death more precisely. If a child grows up without serious problems and ordeals, the thought of death relates to the distant future.

4. In senior adolescence, the child's concept of death is formed as it is in an adult.

Seriously ill children are capable of discussing their

approaching or possible death. They understand far more than we suppose. Even younger children with severe illnesses, especially cancer, experience the seriousness of the illness and the possibility of death, and express fear about this [24]. In children's experience, the fear of death more often manifests itself in play and drawings [1, 11, 12, 24].

Personal reactions to illness

In some children in the hospital, behavior is characterized by regressive forms and aggressive reactions. Observations show that children of senior school age are more susceptible to the psychogenic influence of the ward environment.

The personal psychological reactions of children to serious illness fit the definition of characterological (T.P. Simpson, 1935) and pathocharacterological reactions described in Russian child psychiatry.

Characterological reactions are a transient, situationally conditioned change in the behavior of a child or adolescent, which manifests predominantly in a certain micro-environment, has a clear psychological orientation, does not lead to disturbances of social adaptation as a whole, and is not accompanied by disturbances of somatic functions.

Pathocharacterological reactions are psychogenic personal reactions that manifest in various deviations of the behavior of a child or adolescent, lead to disturbances of social-psychological

adaptation and, as a rule, are accompanied by neurotic disorders, in particular somatovegetative ones.

Pathocharacterological reactions may arise either out of characterological ones, or be pathological from the very beginning (in children and adolescents with psychopathic character traits, cerebral residual-organic insufficiency, or during a disharmoniously proceeding transitional age period (the age-related, normative crisis) [10]. Like other forms of psychogenic reactions, pathocharacterological reactions are reversible, although under unfavorable conditions they may pass into more persistent forms of personality disorders.

In severe illnesses, the following forms of personal reactions may manifest most vividly: reactions of opposition, reactions of refusal, compensation, and hypercompensation. In adolescence, in addition to these forms, the reaction of emancipation can be added.

Reactions of protest (opposition)

At its core lies a complex of emotionally charged experiences that are very significant for the child: resentment, injured pride, dissatisfaction with the attitude of loved ones, and so on. These reactions always have a certain orientation and selectivity.

Reactions of active and passive protest are distinguished [7, 24].

Characterological reactions of active protest during illness manifest in the form of disobedience, rudeness, and defiant and aggressive behavior in response to the demands and recommendations of physicians and the observance of the clinic's regimen. Such forms of reaction are observed only in a psychologically traumatic situation, have a clear orientation against parents and medical staff, and against specific individuals who, in the child's opinion, are the source of unpleasant experiences. These reactions are relatively short-lived and are not prone to fixation. They are often observed in children with traits of emotional excitability [24].

Pathocharacterological reactions of active protest

differ in the considerably greater intensity of their manifestations, the presence of aggressive behavior, at times with a tinge of cruelty, a pronounced vegetative component (reddening of the face, sweating, tachycardia), a greater duration of the period of the child's altered affective state, and a tendency toward repetition and fixation of the disturbed behavior, which acquires a habitual character. These reactions may be observed against adults in general, and manifest not only in psychologically traumatic situations but also in ordinary ones (clinical observation No. 1).

D., 12 years old.

Diagnosis: Diffuse large B-cell lymphoma, stage II. Treated over the course of 8 months.

A boy from a single-parent family, with an older brother of 15. His upbringing is handled mainly by his grandmother. His mother is constantly away earning money in another city. The child was educated at a boarding school. In the oncology ward he was accompanied by his mother, who was forced to be absent frequently (she worked in low-skilled jobs). Upon admission the boy did not violate the regimen and did not stand out in any particular way. During the course of treatment, such characterological traits as deceitfulness and a tendency toward demonstrative, blackmailing behavior came to light. Once (several months after the start of treatment), following a violent quarrel with

his mother (she took away his laptop, behaving rudely in the presence of others) he tried to leave the ward «wherever his eyes would lead him, in order to croak», undressed, and was stopped by staff at the exit of the ward, wearing underpants, boots, and a winter hat. Before this he had torn off his IV lines and tried to remove his central venous catheter. Shouting and violent obscene abuse directed at his mother alternated with uncontrollable weeping. The child refused to return to the room and to continue treatment, declaring that he would run away anyway. For several hours he was very aggressively and angrily disposed toward his mother, and sat in the corridor for several hours, sobbing. Subsequently, such behavior (despite the psychocorrectional work with the adolescent and mother) recurred twice more in a less intense form. The triggering factor was again a conflict with his mother, who was making quite reasonable demands of the child.

Reactions of passive protest usually include refusal to cooperate with adults – physicians and parents. Children and adolescents refuse to fulfill the demands made by adults,

display dissatisfaction, resentment, and masked hostility toward loved ones, and emotional contact with the parents is lost. Children become capricious and unsociable, which was previously uncharacteristic of them. Refusal of food and selective refusal of speech – elective mutism – are possible

[3, 7].

Elective mutism occurs more often in children of preschool and junior school age. The child does not use speech and even actively refuses verbal communication with the persons who caused the psychologically traumatic situation (in the hospital, more often the mother or the doctor), or, not infrequently, with everyone around him (above all, with adults in a certain situation). These children may continue to communicate in the hospital with those people who do not participate in the treatment process. Upon returning home from the hospital, verbal communication resumes. The character of protest reactions is determined by the personality traits of the child and adolescent and by the age period. In stubborn, affectively excitable children, reactions of active protest arise more often, whereas in timid, self-doubting, infantile children, reactions of passive protest predominate.

The tendency toward protest reactions is especially great in the pubertal age, which is explained by the striving for independence at this age [24] (clinical observation No. 2; this illustration demonstrates not only elective mutism but also an anxiety-depressive syndrome).

I., 5 years old.

Diagnosis: Acute leukemia from B-mature lymphocytes, immunological variant B-IV, stage IV per S. Murphy.

Ill for 3 months. He stays in the ward accompanied by his mother. The child is from a two-parent family. By character he is timid, shy, sensitive, vulnerable, and introverted; he spends all his time in bed, lying down, which is connected with his generally poor state of health against the background of the chemotherapy being administered. Withdrawn, depressed, anxious, pronouncedly asthenic. Quiet. He does not enter into verbal communication, i.e., he does not respond to speech addressed to him, turns his back to the doctor or simply closes his eyes, but from nonverbal signs it is noticeable that he is trying to listen to the doctor's conversation with his mother. When his somatic condition worsens, the boy sharply

limits communication even with her, entering into contact strictly out of necessity, and then expressing himself monosyllabically. During periods of relatively satisfactory well-being he becomes more communicative and lively with his mother and even plays games with her for a short time. The boy does not enter into verbal contact with physicians or medical staff. According to his mother, he blames himself for his condition, for the fact, for example, that he cannot eat properly because he feels nauseous. He is very afraid of medical-diagnostic procedures. During such procedures he cries, clings tightly to his mother, and does not let her leave him.

Reaction of refusal

This reaction belongs to the pathocharacterological reactions, which are triggered by strong, deep negative emotions (despair, fears). The children are passive, express no desires, and do everything either after being asked or under compulsion. A restriction of contacts is observed.

Reaction of compensation

It manifests most vividly outside the hospital: during periods of stabilization and remission of the illness. Children and adolescents strive to make up for their weaknesses, failures, and physical defects, compensating for them with successes in another area. For example, a weak child with absolute restrictions on physical education and sports astonishes others with excellent academic performance and encyclopedic knowledge in various fields (clinical observation No. 3).

V., 15 years old.

Diagnosis: Ewing's sarcoma.

He received primary treatment in 2013. After 4 years a relapse of the disease was discovered. During remission and at present, despite the resumption of treatment, Vlad successfully studies in secondary school, constantly participates in international chess tournaments among persons with disabilities, and takes leading places.

Reactions of hypercompensation

Children persistently and stubbornly achieve success precisely in the area in which they are weak. For example, a weak child with limited physical abilities is successful in sports.

Reaction of emancipation

The reaction of emancipation belongs to the adolescent reactions [9, 10]. It is characterized by an increased striving of adolescents for independence and autonomy from parents and other adults. In sick adolescents it manifests in a striving to ignore all medical recommendations regarding treatment and lifestyle, to not spare oneself, and to disregard the rules of cautious and measured behavior (for example, defiant refusal to take medications, going for a walk in bad weather in unsuitable clothing, leaving the hospital at one's own discretion, refusing to account to parents or the attending physician) [24].

14.2. Mental disorders in children/adolescents with cancer

Factors predisposing to the occurrence of mental disorders are:

• hereditary predisposition;
• various harmful factors preceding the illness: toxicosis of pregnancy in the mother, asphyxia during childbirth, prematurity, head injuries, severe infections in the first year of life, etc.;
• premorbid character traits, relationships within the family, and the type of upbringing (these influence the forms of mental disorders);
• the somatogenic factor (consequences of damage to internal organs, hemorrhages, intoxications, hypoxia, and, with a prolonged illness, exhaustion of the body's compensatory capacities and a decline in immunity);
• the psychogenic factor (awareness and experiencing of the illness, separation from the family, accumulation of negative experience of illness, hospitalization, intensive treatment, etc.)

By the severity of mental disturbances, a psychotic

level of disturbances and a non-psychotic level are usually distinguished.

Asthenic syndrome is a state of neuropsychic weakness, that is, of increased irritability and fatigability with a decline in productivity at work, an unstable mood, combined with vegetative symptoms and sleep disturbance.

The asthenic symptom complex is the least specific form of reaction; it may accompany the illness throughout its entire course or manifest only during periods of worsening of the somatic condition, during intensive chemotherapy, with concomitant infections, or during periods of recovery after infections.

Asthenia may be physical or mental. In somatic illnesses in children, mixed asthenia (physical and mental) is more often observed.

The symptoms of asthenic syndrome are:

Pronounced fatigue after minor exertion, increasing toward evening.

Attention disturbance (distractibility).

Irritable weakness (pronounced emotional lability with sharp mood swings, combined with heightened sensitivity (mental hyperesthesia) to all external stimuli). Children are irritable, capricious, prone to anger, tearful, dissatisfied with those around them, and prone to conflict. A change of emotions is noted over a minor pretext. Reactions are of an emotionally exaggerated nature. The pain threshold is lowered.

Headaches. More often, headaches of a diffuse, indefinite localization with an inconstant character are noted. They may be accompanied by vegetative or vestibular disturbances: dizziness, reddening of the eyes and face. Children note a connection between the pain and mental exertion, unpleasant events, and fatigue.

Sleep disturbances. Sleep is superficial and intermittent, with frequent awakenings in the first half of the night; after awakening they fall asleep with difficulty. In the morning such children feel «worn out».

During the period of manifestation of the illness, the manifestations of

physical asthenia are more pronounced; it is primarily characterized by a genuine decline of strength.

Anxiety syndrome in sick children. Anxiety is an emotional state or reaction,

characterized by inner agitation, restlessness, constriction, and tension localized in the chest. It is accompanied by a premonition and fearful expectation of impending misfortune, by pessimistic apprehensions directed toward the future.

Anxiety manifests as tension and wariness. Seriously ill children in a state of anxiety are impatient, often garrulous, fidgety, suspicious, and agitated; they cannot tolerate waiting and do not let their mother leave them. It is necessary to distinguish anxiety that is adequate in intensity and duration to the real situation that caused it from morbid, pathological anxiety that is conditioned by the disease process or is disproportionate in severity, intensity, and duration to the cause that provoked it. In most children and adolescents with anxiety syndrome of the psychotic level, anxious-suspicious traits were noted in the premorbid state [7, 24].

Fear reactions in sick children. Fear is an emotional state or reaction whose content

consists of apprehensions about one's own well-being or life.

Fear in the situation of illness and treatment performs a protective function. Usually such a fear reaction is normal and natural; it is short-lived and quickly reversible, and does not affect the child's behavior or his relations with those around him. But there may also be a pathological form of fear, which is no longer of a protective but of a destructive character and manifests in

the form of uncontrollable behavior and an exaggerated terror inadequate to the situation, and negatively affects relations with those around. In the situation of illness, situational and personal fears, described in the literature by psychiatrists and psychologists, may be observed.

Situational fear arises during hospitalization (separation from the home environment) and when painful diagnostic and therapeutic manipulations and procedures are performed. In these situations children may feel pronounced fear, even to the point of terror and panic.

Personal fear represents a characteristic of one's character. Children with anxious-suspicious personality traits are predisposed to such fears.

First and foremost, fear manifests in nonverbal behavior: a frightened or bewildered facial expression, a wandering gaze, a trembling or poorly modulated voice, crying, sobbing, fidgeting, flight. Fear is accompanied by subjective sensations: a «heavy» head, «cottony» legs», being all «wet», the heart pounding wildly. These descriptions more often concern acute situational fear. Fear often does not manifest outwardly; it can be judged by indirect signs: avoidance of visits to the treatment room and other rooms associated with unpleasant or painful situations. Children become suspicious, and listen to or eavesdrop on the conversations of adults, especially of the doctor and the mother. The facial expressions of such children are tense and worried; they rarely smile and become wary and quarrelsome. Nightmares may also be a manifestation of fears.

Factors influencing the development of fears:

Childhood age. Fears are natural for children and important for development and the acquisition of life experience. The manifestation of fear and its intensity depend on individual characteristics and the social conditions in which the formation of the child's personality takes place. It has been established that girls experience more fears than boys.

Family composition. In single-parent families, children are, as a rule, already unsure of themselves and feel helpless and unprotected. In the situation of illness, an overprotective mother repeatedly aggravates the child's lack of independence and self-confidence, and as a result the already existing fears are intensified and the appearance of new ones is stimulated.

The parents' age. The anxiety of mothers who married late and were long without children is reflected in their children, which, moreover, is also characteristic of young women who became mothers prematurely

[6, 24].

The parents' personality traits. Fears are, first and foremost, associated with the anxious-suspicious personality traits of the parents, who often not only reinforce but also intensify the child's anxiety, forming a certain type of reaction to the surrounding world. Most fears are nevertheless transmitted unconsciously.

Depressive syndromes

In children and adolescents, depression rarely corresponds to the classic form of affective pathology, which is characterized by: a melancholic mood, ideational (thought) and motor (movement) retardation, the vitality of the affect (the experience of a deep, precordial melancholy – a painful lack of feeling that is localized «somewhere in the chest» and brings the patients «unbearable» suffering), thoughts of one's own worthlessness, a sense of guilt, suicidal thoughts, diurnal fluctuations of mood (a subjective improvement of well-being in the second half of the day), inversion of sleep (disturbance of the sleep-wake cycle), and the patient's lack of awareness of his illness. In addition, the structure includes various somatovegetative symptoms: dryness of the skin, dilation of the pupils (mydriasis), decreased appetite, loss of body weight, and slowing of intestinal peristalsis [3, 7, 23].

The variants of depression observed in children in the oncology ward of the Institute are the depressive-dysphoric, anxious-depressive, apathetic-adynamic, and melancholic variants.

Depressive-dysphoric variant

This variant of depression manifests as a gloomy-melancholic, irritable-malicious mood. Such children are sullen, uncommunicative, at times grumbling, and dissatisfied both with themselves and with the surrounding world. The mood background may fluctuate under the influence of external stimuli. Thoughts of an unjustly inflicted offense often spin in their heads (clinical observation No. 4).

E., 16 years old.

Diagnosis: Osteogenic sarcoma, stage IV. Treated over the course of a year.

From early childhood she was raised by her grandmother. She moved to live with her mother only in adolescence. Before hospitalization she lived with her mother, a 7-year-old half-sister, and her stepfather. Relations with the stepfather are formal. There is no close, trusting relationship with the mother. She also maintains relations with her biological father only formally. By character she is secretive, restrained in her emotions, and sullen. During the course of treatment her withdrawnness and depression increased. She was constantly in a gloomy-irritable mood. She was rude to her mother and dissatisfied with everything. She refused to make contact with the psychotherapist and child psychologist. The situation was periodically aggravated by a worsening of her somatic condition against the background of polychemotherapy. Her emotional state improved after the arrival of her grandmother, who replaced her mother, and after a course of anti-anxiety medications.

Anxious-depressive variant

This variant manifests as a feeling of inner and outer (motor) restlessness, tension, and anxiety. The children are restless and strive for a constant change of place. In some children, on the contrary, a mild motor retardation is noted. The children are anxious, fearful, and wary. They may be troubled by obsessive fears for their health and by a sense of guilt without specific content. They often blame themselves for the onset of the illness. A panic fear of the illness is possible. In most children, sleep disturbance is noted.

Apathetic-adynamic variant of depression

Apathetic-adynamic depression is characterized by a decrease in the patient's drives, and in the psychomotor sphere it manifests as retardation (adynamia), and in the affective sphere – as apathy. Apathy as a radical of depressive mood is characterized by a feeling of indifference and detachment. Patients with apathetic depression are distinguished by an insufficiency of volitional drives. A smoothing-out of the diurnal fluctuations of well-being is noted. In addition, the structure of the depressive syndrome includes the symptom of vital asthenia – «energetic exhaustion» – a sensation of general weakness reaching the degree of impotence; there is a sharp exhaustibility of the basic mental and physiological processes.

Such children spend all their time in bed; it is difficult to make them get up or leave the room. Nothing interests them; they do not want to do anything. During the day they are inactive. Their facial expression is meager and inexpressive. The affect is monotonous. They enter into contact formally, speak quietly, and their voice is little modulated. Lethargy is noted, along with an absence of the liveliness and inquisitiveness inherent in children. They complain of distractibility and a constant feeling of fatigue and weariness. Their movements are slowed. Such children seem passively

D., 7 years old.

Diagnosis: Burkitt's lymphoma, stage III.

Ill for about 5 months. From a two-parent family. He is in the ward accompanied by his mother. Upon admission and during the first month of treatment he appeared apathetic and indifferent to everything. He spent all his time in bed. His facial expression was inexpressive. His speech was quiet and monotonous. He answered questions monosyllabically. He showed no interest in his condition (illness). In conversation he reported that he wanted nothing, was interested in nothing, and constantly felt weakness and fatigue. He tired quickly. In terms of movement he seemed constrained and slowed. His appetite was decreased. His emotional state was aggravated by the severity of his somatic condition, owing to the course of the underlying disease and the treatment.

The melancholic depression variant

It is characterized by a combination of melancholic (mournful) affect with ideational and motor retardation. All aspects of life are perceived in melancholy, gloomy tones. Nothing brings these patients joy or pleasure. The children look sad, often cry, are silent, and withdrawn. They do not enter into contact themselves, and their head is bowed down. Mental retardation is noted; they spend all their time in bed and are interested in nothing. They associate their grief and suffering with the illness (clinical observation No. 6).

M., 12 years old.

Diagnosis: Diffuse large B-cell lymphoma, stage III A.

She received treatment for about 2.5 months. She is in the ward accompanied by her mother, with whom warm relations have developed. From a two-parent family. By character she is impressionable and sensitive. She has difficulty tolerating separation from her biological older sister, with whom she has a very close, trusting relationship and who is a support and example for the patient. After she learned of the illness, she drew attention to herself by holding herself aloof, not striving to communicate with other children, and often crying alone. She looked depressed, with an unhappy facial expression. Silent and withdrawn. She said that she was worried about how she would tolerate the main program of treatment. She experienced frustration (she was disheartened by the fact of the discovery of this illness, by the length of the forthcoming treatment, by possible complications caused by the treatment, by the forced isolation, and by the abrupt change in her way of life). She is retarded in terms of movement. On the whole, owing to the peculiarities of her personality, she is strongly susceptible to the influence of external, current (negative) circumstances associated with the illness.

Psychoorganic syndrome

This syndrome is characterized by a disorder of the intellectual-mnestic sphere (decline of memory, impairment of concentration of attention, difficulty in the intellectual processing of information, a low level of task performance), emotional disturbances (lability, coarsening of emotions, euphoria, apathy), and disturbances of activity (hyper- or hypoactivity) [23] (clinical observation No. 7).

I., 4 years old.

Diagnosis: Atypical teratoid-rhabdoid tumor of the brain. Complications of the disease: symptomatic epilepsy.

Ill for about 2 years. He constantly takes anticonvulsant (Depakine Chrono) therapy. Periodically, disinhibition and general restlessness increase. A constant, pronounced emotional lability is noted: mood swings from sobbing to laughter; from despondency and sullenness to irascibility. The span of attention is reduced. Distractible. On examination his gaze is from under his brows, distrustful, suspicious. He either does not answer questions, or answers monosyllabically and immediately withdraws. With children he behaves more amicably (periodically).

In the literature, mental disorders with disturbance of consciousness are described in seriously ill children: hallucinatory-delusional syndromes, delirious syndrome, oneiroid syndrome, syndrome of asthenic confusion, and amentive syndrome [24]. In the ward of chemotherapy and combined treatment of malignant tumors in children of the N.N. Petrov Research Institute of Oncology, we have not observed such states.

14.3. Psychological and psychopharmacological care for seriously ill children and their families

For the prevention of and assistance to the child and family in characterological and pathocharacterological reactions, it is necessary to conduct psychological (psychotherapeutic) work with the parents (correction of the parenting style); work with the child or adolescent himself (an awareness of the unacceptability of certain behavioral stereotypes); and to help work through the negative experiences associated with the illness and the stay in the hospital.

The treatment of mental disorders in children with cancer consists of psychotherapeutic influence on the patient and his environment, as well as, when necessary, the use of psychotropic drugs. The psychotherapy of children suffering from severe somatic illnesses is determined by age-related features. With

increasing age of the children and duration of the illness, they come to an awareness of the connection of their illness with the problems of life, death, and the future. With the awareness of this connection and with increasing experience of deprivation (the reduction or complete deprivation of the ability to satisfy basic needs – psychophysiological or social), the probability of crisis and

psychopathological reactions increases [24]. The aim of psychotherapeutic care for seriously ill children is the prevention and correction of crisis and psychopathological reactions.

The task of psychotherapy is adaptation to the current situation of the illness and the conditions of the hospital, improvement of parent-child relations, prevention of social isolation, formation of constructive strategies for coping with the crisis situation, strengthening of the patients' internal resources, reinforcement of psychological defenses in order to stabilize the emotional state, and psychological correction of the experiences associated with conceptions of illness, the meaning of life, death, and the future in sick children.

The specific tasks of psychotherapy include reducing emotional tension, anxiety, and bewilderment, diminishing the sense of guilt, optimizing the family's attitudes toward the future, and indirectly influencing the sick child through the parents.

Depending on the psychological and mental state of the child

and parents, we use, to a greater extent, the following types and methods of

psychotherapy:

Rational, explanatory psychotherapy (conducted in children from 7

years of age) [18].

Logotherapy (effective in work with adolescents) [22].

Cognitive-behavioral psychotherapy in work with parents and adolescents [20, 21].

Positive psychotherapy [13].

Existential psychotherapy (with parents and adolescents) [26].

Play therapy (especially effective in children of preschool and junior school age) [15].

Art therapy [16].

The Gestalt approach in work with a family with a somatically ill child [5, 8].

Psychological counseling of parents as an independent type of psychological care [17].

Family psychotherapy, including the analytic-family psychotherapy of N.V. Aleksandrova and E.G. Eidemiller [15].

Directed visualization in work with adolescents [4, 14].

Counseling of children and parents by means of serial drawings and stories by I.M. Nikolskaya [11].

Resource trances [2, 25].

Fairy-tale therapy [19].

Indirect hypnotic interventions (the Ericksonian approach) [2, 25]. The absence of an effect of psychotherapy in some patients, repeated

decompensations, and the presence of persistent, clear psychopathological symptoms indicate the need to use psychotropic drugs in children.

In our practice, in both children and adults, we use drugs with a pronounced anti-anxiety action – hydroxyzine, adaptol. Drugs with nootropic and anti-anxiety activity – phenibut, tenoten (children's and adult), mexidol. Antidepressants with an anxiolytic (anti-anxiety) and hypnotic effect – trazodone; with an anxiolytic and stimulating effect – fluoxetine.