Noeker Meinolf, Schmitz Muriel, Schmiedeke Eberhard, Zwink Nadine, Reutter Heiko, Schmidt Dominik, Jenetzky Ekkehart
Department of Pediatrics, Pediatric Psychology, University of Bonn, Adenauerallee 119, 53113, Bonn, Germany.
Pediatr Surg Int. 2011 Oct;27(10):1079-83. doi: 10.1007/s00383-011-2953-x.
BACKGROUND/PURPOSE: Following a recent classification of the VATER Association provided by the CURE-Net consortium (submitted), we investigate medical predictors of psychological stress and anxieties in this particular condition.
We developed a new set of questionnaires measuring psychological adjustment and quality of life outcome in conditions associated with anorectal and/or urogenital malformation (one self- report form to be completed by patients 7-17 years of age, two parent report forms with one relating to patients with an age range of 0-6 years, resp. 7-17 years of age). The questionnaire "Malformation-related Stress and Anxieties" comprises 26 items belonging to five subscales (I. Functional and cosmetic impairment, II. Intimacy and relationship, III. Social inclusion, IV. Psychological functioning, V. Family functioning). Every item can be responded to with respect to both actual, present problems already experienced as well as to future anxieties anticipating future development and adjustment (a perspective which especially applies in younger patients). Internal consistencies of the scales are good, resp. very good (Cronbach's α = .85 concerning present sources of anxiety scale, resp., .94 concerning future anxieties scale). The items are supplied with a Likert-type 5-point scale. We administered the questionnaire in N = 17 children and adolescents suffering from VATER via parental (proxy) report.
As most medical risk factors affected nearly the entire sample, statistical analysis excluded investigation of differential impact on psychological stress experience and anxieties in subjects exposed versus not exposed. Special attention, therefore, was paid to those medical parameters with the best statistical power to differentiate between individuals of high versus low psychological outcome. Medical predictors differentiating between individuals with high versus low adjustment comprise post-operative infections of the urinary tract (t[15] = -3.78, p = .09), wound infections (t[15] = -3.04, p < .01), stoma complications (t[15] = -2.11, p = .08) (e.g., prolapsed (t[13] = -2.37, p = .05), other treatment complications (t[15] = -2.59, p < .05) and presence of a megacolon (t[13] = -2.44, p = .06).
From the perspective of stress psychology, the findings may indicate that particular medical characteristics of a malformation may operate via two different pathways: (a) pathway of severity of a particular medical risk factor: the presence of a megacolon, for example, may restrict quality of life and successful adjustment via multiple and long term functional impairments associated and (b) pathway of subjective predictability and controllability of treatment course. In accordance with theoretical models from stress psychology, the psychological impact of complicating factors such as wound-healing infections is not operating via severity of impairment, but via implicit messages they convey, indicating a low predictability and controllability of course of disease and treatment. As a result, they may increase intensity of worry and anxieties upon further difficulties still to come during future development. As a conclusion, psychological counseling may not only address concrete functional impairments and stressors, but also basic feelings of insecurity, controllability and self-efficacy.
背景/目的：继CURE-Net联盟（已提交）最近对VATER协会进行分类之后，我们对这一特殊情况下心理压力和焦虑的医学预测因素进行了调查。
我们编制了一套新的问卷，用于测量与肛门直肠和/或泌尿生殖系统畸形相关情况的心理调适和生活质量结果（一份由7至17岁患者填写的自我报告表，两份家长报告表，一份针对0至6岁患者，另一份针对7至17岁患者）。“与畸形相关的压力和焦虑”问卷包括26个项目，分为五个子量表（一、功能和外观损害；二、亲密关系和人际关系；三、社会融入；四、心理功能；五、家庭功能）。每个项目既可以针对已经经历的实际当前问题进行回答，也可以针对预期未来发展和调适的未来焦虑进行回答（这种观点尤其适用于较年轻的患者）。量表的内部一致性良好，分别为非常好（关于当前焦虑源量表的克朗巴哈α系数为0.85，关于未来焦虑量表的克朗巴哈α系数为0.94）。这些项目采用李克特式5点量表。我们通过家长（代理）报告对17名患有VATER的儿童和青少年进行了问卷调查。
由于大多数医学风险因素几乎影响了整个样本，统计分析排除了对暴露组与未暴露组心理压力体验和焦虑的差异影响进行调查。因此，特别关注那些在区分心理结果高与低的个体方面具有最佳统计效力的医学参数。区分调适高与低的个体的医学预测因素包括尿路感染（t[15]=-3.78，p=0.09）、伤口感染（t[15]=-3.04，p<0.01）、造口并发症（t[15]=-2.11，p=0.08）（如脱垂（t[13]=-2.37，p=0.05）、其他治疗并发症（t[15]=-2.59，p<0.05）以及巨结肠的存在（t[13]=-2.44，p=0.06）。
从压力心理学的角度来看，研究结果可能表明畸形的特定医学特征可能通过两种不同的途径起作用：（a）特定医学风险因素的严重程度途径：例如，巨结肠的存在可能通过与之相关的多种长期功能损害限制生活质量和成功调适；（b）治疗过程的主观可预测性和可控性途径。根据压力心理学的理论模型，诸如伤口愈合感染等复杂因素的心理影响不是通过损害的严重程度起作用，而是通过它们传达的隐含信息起作用，表明疾病和治疗过程的可预测性和可控性较低。因此，它们可能会增加对未来发展中仍将出现的进一步困难的担忧和焦虑强度。总之，心理咨询不仅可以解决具体的功能损害和压力源，还可以解决基本的不安全感、可控性和自我效能感。
