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Motivational disposition towards psychological characteristics of israeli children with inflammatory bowel diseases: A case-control study

Published:August 28, 2021DOI:https://doi.org/10.1016/j.pedn.2021.08.020

      Highlights

      • Children with IBD are more prone to stress when exposed to negative environments.
      • Psychological stress is also related to the internal characteristics of patients.
      • This study reveals a set of specific psychological characteristics relevant to IBD.
      • These characteristics represent the stressful psychological dynamics of patients.
      • Health workers are encouraged to be aware of the patients' characteristics.

      Abstract

      Background

      Psychological stress is a general and non-specific factor associated with many health conditions, including Inflammatory Bowel Diseases (IBD). It is related not only to external stressors but also to internal characteristics which enhance patients' vulnerability to stress.

      Purpose

      To identify specific psychological characteristics of pediatric IBD related to stress.

      Design and methods

      A case-control-cohort study that compared the psychological characteristics of 49 patients and 56 comparisons. The psychological characteristics were defined by four belief types – beliefs about self, general beliefs, beliefs about norms, and goals – which refer to a set of specific themes.

      Results

      The belief types differentiated between the two groups, and the patients were characterized by six themes: like routines, strive to get others' love, caring about the body and the health, doing things only at their own pace, expressing negative emotion without regulations, and feeling over-identification with others. Patients' likelihood of being characterized by the themes is 2.18 to 2.90 times higher than the comparisons.

      Conclusion

      Children with IBD are characterized by a set of specific psychological characteristics. These characteristics were discussed mainly concerning generating chronic stress (e.g., over-identification with others) and interpersonal conflicts (e.g., doing things only at their own pace) among the patients.

      Implications for practice

      It is suggested to healthcare workers to be aware of the specific psychological characteristics of children with IBD, and sensitive to these characteristics during interactions with them. Besides, the characteristics may pave the way for developing a targeted psychological intervention that corresponds specifically to the patients' needs.

      Keywords

      Introduction

      Aristotle, the well-known philosopher from the 4th century B.C., stated that the body and the soul are irrevocably connected; they reciprocally interact and influence each other (
      • Stanford Encyclopedia of Philosophy
      Aristotle's psychology.
      ). This philosophical statement is empirically supported in the case of Inflammatory Bowel Diseases (IBD) that includes Crohn's Disease (CD) and Ulcerative Colitis (UC). The etiology of IBD is associated with a complex interaction between genes and environmental factors (
      • Aujnarain A.
      • Mack D.R.
      • Benchimol E.I.
      The role of the environment in the development of pediatric inflammatory bowel disease.
      ;
      • Diefenbach K.A.
      Pediatric inflammatory bowel disease.
      ;
      • Scaldaferri F.
      • Fiocchi C.
      Inflammatory bowel disease: progress and current concepts of etiopathogenesis.
      ). An international study based on 75,000 patients identified 163 distinct genetic loci that play a significant role in determining the risk of CD and UC. Nevertheless, the authors of the study estimated that the genetic factors are accountable for less than one-third of the heritability of IBD (
      • Jostins L.
      • Ripke S.
      • Weersma R.K.
      • Duerr R.H.
      • McGovern D.P.
      • Hui K.Y.
      • Cho J.H.
      Host-microbe interactions have shaped the genetic architecture of inflammatory bowel disease.
      ). Thus, epidemiologists suggest that environmental factors could explain a significant fraction of that gap. These factors include having a small family, living in clean-urban homes, access to separate bathrooms, no bedroom sharing with siblings (
      • Ye Y.
      • Pang Z.
      • Chen W.
      • Ju S.
      • Zhou C.
      The epidemiology and risk factors of inflammatory bowel disease.
      ), and a high sugar diet (
      • Jakobsen C.
      • Paerregaard A.
      • Munkholm P.
      • Wewer V.
      Environmental factors and risk of developing paediatric inflammatory bowel disease - A population based study 2007–2009.
      ).
      In addition, data supported by several studies of both patients and animal models confirmed the role of stress and depression in the initiation and reactivation of IBD (
      • Ananthakrishnan A.N.
      Environmental risk factors for inflammatory bowel disease.
      ;
      • Rampton D.
      Does stress influence inflammatory bowel disease? The clinical data.
      ).
      • Jakobsen C.
      • Paerregaard A.
      • Munkholm P.
      • Wewer V.
      Environmental factors and risk of developing paediatric inflammatory bowel disease - A population based study 2007–2009.
      identified higher rates of parental divorce that occurred among families of children with IBD in the period before the diagnosis than those in the comparison families. A study conducted with adult patients reported that the occurrence of severe life events was more frequent during the 6 months preceding the diagnosis of CD than that reported by others with UC and healthy subjects (
      • Lerebours E.
      • Gower-Rousseau C.
      • Merle V.
      • Brazierm F.
      • Debeungny S.
      • Marti R.
      • Benichou J.
      Stressful life events as a risk factor for inflammatory bowel disease onset: A population-based case-control study.
      ). Moreover, the number of preceding experiences of stressful life events, and the perceived stress were associated with an increased risk of UC relapse (
      • Bitton A.
      • Sewitch M.J.
      • Peppercom M.A.
      • Edwardes M.D.D.B.
      • Shah S.
      • Ransil B.
      • Locke S.E.
      Psychosocial determinants of relapse in ulcerative colitis: A longitudinal study.
      ). A similar association was confirmed by follow-up studies that examined the effect of psychological factors on CD exacerbation. Patients with higher baseline depression scores and those who reported more symptoms during the follow-up study were at an increased risk of the disease relapse (
      • Mardini H.E.
      • Kip K.E.
      • Wilson J.W.
      Crohn’s disease: A two-year prospective study of the association between psychological distress and disease activity.
      ;
      • Mittermaier C.
      • Dejaco C.
      • Waldhoer T.
      • Oefferlbauer-Ernst A.
      • Miehsler W.
      • Beier M.
      • Tillinger W.
      • Gangl A.
      • Moser G.
      Impact of depressive mood on relapse in patients with inflammatory bowel disease: A prospective 18-month follow-up study.
      ).
      As in humans, several experiments on animals confirmed the contribution of psychological factors regarding intestinal inflammation (
      • Ananthakrishnan A.N.
      Environmental risk factors for inflammatory bowel disease.
      ;
      • Reber S.O.
      Stress and animal models of inflammatory bowel disease – An update on the role of the hypothalamo-pituitary-adrenal axis.
      ). A mice model showed that induced depression (by olfactory bulbectomy or chronic intracerebroventricular injection of reserpine) contributed to the reactivation of dormant chronic UC (
      • Ghia J.E.
      • Blennerhassett P.
      • Deng Y.
      • Verdu E.F.
      • Khan W.I.
      • Collins S.M.
      Reactivation of inflammatory bowel disease in a mouse model of depression.
      ). Manipulations of stress during the four days preceding the induction of UC (by intracolonic instillation of 2, 4, 6-trinitrobenzene sulfonic acid) led to an increased mucosal inflammatory response among rats (
      • Gué M.
      • Bonbonne C.
      • Fioramonti J.
      • Moré J.
      • Del Rio-Lachèze C.
      • Coméra C.
      • Buéno L.
      Stress-induced enhancement of colitis in rats: CRF and arginine vasopressin are not involved.
      ). Furthermore, a period of restraint stress lowered the threshold dose of dinitrobenzene-sulfonic acid required to reactivate UC in mice recovered from induced UC (
      • Qiu B.S.
      • Vallance B.A.
      • Blennerhassett P.A.
      • Collins S.M.
      The role of CD4+ lymphocytes in the susceptibility of mice to stress-induced reactivation of experimental colitis.
      ).
      Therefore, those studies suggest an association between psychological stress and IBD. However, stress is a general factor, related not only to the external events themselves but also to the internal characteristics of the person who experiences these kinds of events (
      • Vollrath M.
      Personality and stress.
      ). To the best of our knowledge, there are no studies that examined the specific psychological characteristics of children with IBD related to stress, and that described their internal dynamics. The present study was set to identify these kinds of characteristics and to give an account of the internal dynamics of children with IBD.
      The theoretical framework of this study is based on the cognitive orientation model of health (COH) which deals mainly with the psychological aspects associated with states of health and diseases. According to the model, the occurrence of any physical disease is based on interactions between the following three factors: a) the pathogen which is the carrier or instigator of the disease, such as viruses or microbes; b) the background factors that modulate the vulnerability of the organism to succumb to the pathogen or resist its impact; and c) the physiological mechanism or procedure that leads to the development and the occurrence of a given disease (
      • Kreitler S.
      The cognitive orientation for health: A tool for assessing health–proneness.
      ,
      • Kreitler S.
      The cognitive guidance of behavior.
      ,
      • Kreitler S.
      The structure and dynamic of cognitive orientation: A motivational approach to cognition.
      ,
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ).
      The COH model focuses on the background factors and deals mainly with identifying specific psychological characteristics of a given disease. These characteristics constitute a part of other background organismic factors and contribute to the context within which the pathogen operates and brings about a disease (
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ). The psychological characteristics for a given disease are defined by the COH model in terms of the following four belief types that refer to a set of relevant cognitive contents of the disease of interest: (a) beliefs about self, which express information about oneself, such as one's habits, actions, or feelings (e.g., “I like routines”), (b) general beliefs, which express information concerning reality and others (e.g., “Usually, people like routines”), (c) beliefs about rules and norms, which express ethical and social rules and standards (e.g., “One should always keep routines”), and (d) beliefs about goals, which express a person's wants, desires or dislikes (e.g., “I do want to like routines and fixed schedules”). If at least three belief types are supported by a person diagnosed with the disease, they form a vector called ‘psychological motivational disposition’ representing the motivation of being characterized by psychological characteristics relevant to patients with that disease (
      • Kreitler S.
      The cognitive orientation for health: A tool for assessing health–proneness.
      ,
      • Kreitler S.
      The cognitive guidance of behavior.
      ). The cognitive contents of the beliefs are called themes. The themes are specific to a particular disease, not conscious, and constitute the underlying meanings that the patient provides or attributes to the diagnosis. Thus, the themes are indirectly related to the disease and unconnected to the explicit meanings of the disorder itself. They represent the psychological dynamics that characterize patients with a disease in question, their tendencies, and conflicts (
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ).
      Specific psychological characteristics defined by the COH model were empirically identified concerning different health conditions and related areas. The four belief types refer to a relevant set of themes contributed to determining specific psychological characteristics associated with undergoing examinations of early detection of breast cancer (
      • Kreitler S.
      • Chaitchik S.
      • Kreitler H.
      The psychological profile of women attending breast-screening tests.
      ), ischemic heart disease (
      • Drechsler I.
      • Bruner D.
      • Kreitler S.
      Cognitive antecedents of coronary heart disease.
      ), gynecological infections (
      • Kreitler S.
      • Kreitler H.
      • Schwartz R.
      Cognitive orientation and genital infections in young women.
      ), and type 2 diabetes (
      • Kreitler S.
      • Weissler K.
      • Nurymberg K.
      The cognitive orientation of patients with type 2 diabetes in Israel.
      ). In addition, the model enabled the identification of relevant psychological characteristics in several conditions related to the digestive system, such as obesity (
      • Kreitler S.
      • Chemerinski A.
      The cognitive orientation of obesity.
      ), anorexia (
      • Kreitler S.
      • Bachar E.
      • Canetti L.
      • Berry E.
      • Bonne O.
      The cognitive orientation theory of anorexia nervosa.
      ), colon cancer (
      • Figer A.
      • Kreitler M.
      • Kreitler S.
      • Inbar M.
      Personality dispositions of colon cancer patients.
      ), and colorectal cancer (
      • Kreitler S.
      • Kreitler M.
      • Len A.
      • Alkalay Y.
      • Barak F.
      Psychological risk factors for colorectal cancer?.
      ;
      • Kreitler S.
      • Kreitler M.
      • Barak F.
      Psychosocial risk factors of cancer diseases: How specific are they?.
      ).
      Few studies have applied the CO model with children in regard to general behaviors that are not related to health conditions, e.g., curiosity and exploration (
      • Kreitler H.
      • Kreitler S.
      Motivational and cognitive determinants of exploration.
      ). This study is the first attempt to implement the theoretical and the methodological aspects of the COH model in the pediatric population. The rationale behind applying this model refers to the following advantages: first, it enables identifying specific psychological characteristics corresponding to a given disease and deepens our understanding regarding the psychological dynamics that enhance the patients' vulnerability to stress. Second, in contrast with other studies which dealt with stable personality components, such as the patients' temperament (
      • La-Barabera D.
      • Bonanno B.
      • Rumeo M.V.
      • Alabastro V.
      • Frenda M.
      • Massihnia E.
      • Nastri L.
      Alexithymia and personality traits of patients with inflammatory bowel disease.
      ), and some personality traits, such as type D personality, which is characterized by a tendency to experience negative emotions across various times and situations and inhibit emotions expression in social interactions (
      • Sajadinejad M.S.
      • Molavi H.
      • Asgari K.
      • Kalantari M.
      • Adibi P.
      Personality dimensions and type D personality in female patients with ulcerative colitis.
      ), the COH model allows identifying psychological characteristics that could be modified by standard guidelines of well-defined intervention (
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ). Third, while previous studies were based on different theories and approaches, the COH model enables identifying complete sets of psychological characteristics of different states of health in terms of the same theoretical and methodological framework. This last advantage is essential especially when there is a future interest in comparing and formulating solid conclusions concerning different studies or diseases.

      Purpose

      The purpose of the present study is to identify a set of specific psychological characteristics related to stress among children with IBD. It is based on the framework of the COH model which defines psychological characteristics in terms of four belief types that refer to a set of disease-relevant themes (
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ). The belief types constitute the motivational disposition toward being characterized by a set of psychological characteristics relevant for IBD, and the themes (the belief types contents) represent the psychological characteristics of the patients. Therefore, this study examines the psychological characteristics which enhance the patients' vulnerability to stress (
      • Vollrath M.
      Personality and stress.
      ) and describes their cognitive conflicts (
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ).

      Hypotheses

      Two hypotheses were examined in the current study. The first dealt with the basic motivation toward psychological characteristics relevant to IBD and tested the differences between the patients and the comparison group concerning the four belief types. It is expected that the diagnosed children would have higher scores than the healthy comparison subjects in at least three belief types – beliefs about self, general beliefs, beliefs about norms, and goals. The second hypothesis dealt with identifying the psychological dynamics that characterizes children with IBD. It is expected that the diagnosed children would have higher scores than the comparison subjects in a set of themes that characterize them and differentiate between the patients and others in the comparison group (the list of the themes is presented in Table 2).
      Both hypotheses are based on the assumption that the psychological characteristics are relevant for IBD itself but not for its state. Namely, they are not dependent on the disease duration, the patients' age at the onset, and not on the severity of the disease. This assumption indicates that the psychological characteristics are autonomous, notably because they are supposed to differentiate between the patients and the comparison group, but not to be affected by the duration and the severity of the disease (
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ). Therefore, this will provide an indicator for that these characteristics are relevant to the disease itself but not a result of coping with it. A control analysis will be conducted to examine this assumption regarding the autonomy of the psychological characteristics in relation to relevant medical parameters of pediatric IBD.

      Materials and methods

      Subjects

      The number of participants needed for this study was determined by statistical power analyses using G*Power 3.1 software (
      • Faul F.
      • Erdfelder E.
      • Buchner A.
      • Lang A.G.
      Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses.
      ). For a two-sided t-test with α = 0.05, power = 0.95, and a large effect size of d = 0.8 (
      • Cohen J.
      Statistical power analysis for the behavioral sciences.
      ), the power analysis indicated that the estimated sample size would be 84 participants. Concerning MANOVA analysis, the suggested sample size for F-test with α = 0.05, power = 0.95, a large effect size of f2 = 0.35 (
      • Cohen J.
      Statistical power analysis for the behavioral sciences.
      ), two groups, and four independent variables, was 60 participants. And finally, two-tailed logistic regression with α = 0.05, power = 0.95, and odds ratio = 1.7 (determined according to
      • Jakobsen C.
      • Paerregaard A.
      • Munkholm P.
      • Wewer V.
      Environmental factors and risk of developing paediatric inflammatory bowel disease - A population based study 2007–2009.
      study) required a total sample size of 103 participants. Therefore, the power analyses suggested an overall sample size of between 60 and 103 participants. According to these findings, 105 participants were recruited in the current study.
      49 participants were diagnosed with IBD, 28 patients with CD, and 21 with UC, 30 males and 19 females, whose mean age was 14.84 years (S.D = 2.50). Table 1 shows the medical characteristics of the patients. 56 participants were recruited to the comparison group with 23 males and 33 females, whose mean age was 14.41 years (S.D = 2.97). All participants in the comparison group had no chronic medical conditions. The two groups match in age (t (103) = 0.79, p = .43) and gender (χ2 (1, 105) = 4.25, p = .051).
      Table 1The medical characteristics of patients with IBD (N = 49).
      Medical variables
      IBD type
       Chron's disease n (%)28 (57.14)
       Ulcerative colitis n (%)21 (42.86)
       IBD duration (years) M ± SD, Range2.75 ± 3.61, 0–17
       Age at diagnosis (years) M ± SD, Range12.71 ± 3.80, 1–18
      PGA
      PGA = Physician's Global Assessment. It is a validated instrument through which physicians clinically evaluate disease activity on a 4-point scale (0 = inactive, 1 = mild, 2 = moderate and 3 = severe disease).
       Inactive n (%)18 (36.73)
       Mild n (%)13 (26.53)
       Moderate n (%)14 (28.57)
       Severe n (%)4 (8.16)
      Note. This table describes the medical characteristics of the patients. The participants in the comparison group have no medical issues or chronic diseases.
      IBD = Inflammatory Bowel Diseases.
      a PGA = Physician's Global Assessment. It is a validated instrument through which physicians clinically evaluate disease activity on a 4-point scale (0 = inactive, 1 = mild, 2 = moderate and 3 = severe disease).

      Tools

      The psychological questionnaire

      The standard guidelines of the COH model for developing a tool intended to evaluate specific psychological characteristics of a disease of interest (
      • Kreitler S.
      The cognitive orientation for health: A tool for assessing health–proneness.
      ) were applied in this study to develop the cognitive orientation questionnaire of pediatric IBD (CO-IBD). The questionnaire's themes were identified in a pre-test stage that was based on a standard procedure of interviews defined by the COH model, and consists of four interviewing phases (
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ). The first phase deals with the interpersonal meaning that the patients provide to the disease. The answers of this phase are divided into keywords according to their contents, and in the second phase, the patients are asked to explain the meaning of each keyword from the previous phase. The patients' responses in the second phase are divided into keywords, and then again, in the third phase, the patients are requested to explain the personal meanings of each keyword of the responses of the previous phase. The same process is applied regarding to the fourth phase, and the responses in this phase are considered as an underlying personal meaning of the disease. They are classified for similarity in contents, and those classified in the same category are accepted as themes.
      Therefore, the outcome of this procedure is a set of themes that does not refer directly to the disease of interest but represents the underlying meanings of that disease (
      • Kreitler S.
      The cognitive orientation for health: A tool for assessing health–proneness.
      ,
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ). This procedure enabled identifying 23 relevant themes for IBD (Table 2 shows the complete list of themes). The identified themes need to be empirically confirmed or rejected as characteristics of children with IBD. This is done by examining the extent to which the four belief types refer to the identified themes, characterize participants who are diagnosed with IBD, and differentiate them from a comparison group. The themes which will not differentiate between the groups will be excluded from the questionnaire.
      Table 2The themes labels in the CO-IBD questionnaire.
      Num.Theme labels
      T1Dislikes clear rules and plans.
      T2Likes being an independent person.
      T3Likes being free without any tasks.
      T4Likes being active all the time – doing and achieving things.
      T5Planning everything in order to feel control over what happens.
      T6Likes routines and prefers doing the same every day – food, clothes, etc.
      T7Not caring about being successful at everything.
      T8Likes being quiet and avoids getting others' attention.
      T9Avoids hampering or disturbing others.
      T10Strives to get others' love and praise.
      T11Caring about the body and the health.
      T12Keeping promises to family and friends; sees oneself as a responsible person.
      T13Likes being excited and having a lot of adventures and fun.
      T14Dislikes planning things in advance.
      T15Expressing positive feeling; that makes others feel the same.
      T16Not pleasing parents and dislikes obeying their requests.
      T17Giving up and making tasks easier.
      T18Likes doing things at their own pace, not according to what they should do.
      T19Dislikes behaving like everyone.
      T20Expressing negative emotions, such as anger and fear; without caring how it affects others.
      T21Promising things without being stressed.
      T22Over-identification with others' feelings.
      Note. CO-IBD = Cognitive Orientation of Inflammatory Bowel Diseases. Num. = Number. T = Theme.
      For this purpose, the themes are phrased in terms of the four belief types in a CO-IBD questionnaire. Each theme is presented as a short story of two children followed by four questions related to the four belief types. The first question requested the participants to respond in line with what is true about one's self; the second requested them to answer in line with what is true in general, how things usually occur; the third in line with what should or ought to be; and the fourth in line with what one wanted to be. The following item is taken from the CO-IBD questionnaire to illustrate the participants' tasks. It refers to the theme of ‘expressing negative emotions, such as anger and fear; without caring how it affects others’ (T20 in Table 2).
      “Annie thinks that if she expresses feelings like anger, fear, or jealousy, that will hurt her family and friends. Thus, she tries to avoid expressing feelings like those, while Evie expresses negative feelings freely, without caring how they can affect others.
      Questions asked include:
      • A
        Who are you like? Who do you resemble, Annie who avoids expressing negative feelings? ___, or Evie who does not mind how her negative feelings could affect others? ___.
      • B
        In your opinion, how do most children react, like Annie? ___, or like Evie? ___.
      • C
        How should people react: should they like expressing negative feelings freely? ___, or shouldn't they express those kinds of feelings? ___.
      • D
        How do you want to be: Do you wish to be like Evie, who likes expressing negative feelings without caring about their effect on others ___, or would you rather be like Annie ___?”
      In each question, the subjects were requested to respond by selecting one of the two response alternatives. The reliability of the CO questionnaire in regard to different medical conditions was satisfactory, e.g., the value of alpha Cronbach was 0.72 for CO-type 2 diabetes (
      • Kreitler S.
      • Weissler K.
      • Nurymberg K.
      The cognitive orientation of patients with type 2 diabetes in Israel.
      ), 0.97 for CO-Anorexia (
      • Kreitler S.
      • Bachar E.
      • Canetti L.
      • Berry E.
      • Bonne O.
      The cognitive orientation theory of anorexia nervosa.
      ), 0.93 and CO-Asthma (
      • Roth Y.
      • Kreitler S.
      Psychological correlates of bronchial asthma in young adults: The cognitive orientation approach.
      ).

      Scoring

      Each question in the questionnaire is assigned a dichotomy coding of 1 or 2, with code 2 given when the participant chose the theme of interest and 1 when the opposite theme was chosen. Based on the coding, the themes and the four belief types define a prediction matrix, with the belief types as headings of the columns and the themes in the rows. Accordingly, the CO-IBD questionnaire provides two types of scores:
      • 1.
        The means for each belief type across all themes. The values of the means are between 1 and 2 (continuous numbers, a higher score indicates more support of the belief type). The four means (one for each belief type) collectively represent the basic motivational disposition for being characterized by specific psychological characteristics relevant to IBD.
      • 2.
        The sum for each theme across the four belief types. The values of the themes' scores are between 4 and 8 (8 indicates higher support for the theme of interest). These kinds of scores represent the cognitive contents of the psychological characteristics.

      The medical parameters

      At the time of the psychological measuring, the following medical parameters were recorded by the attending physician:
      • 1.
        The disease duration (in years).
      • 2.
        The age of the participants (in years) at the time of the diagnosis.
      • 3.
        Physician's Global Assessment (PGA): this is a validated instrument through which physicians clinically evaluate the disease activity on a 4-point scale: 0 = inactive, 1 = mild, 2 = moderate, and 3 = severe disease activity.

      Procedure

      The patients answered the CO-IBD questionnaire while visiting a hospital for treatments or follow-ups. The healthy comparison subjects responded to the questionnaire from school. The questionnaire was administered in a paper-pencil format. Before the participants responded, a researcher introduced the study purpose and the participants' tasks to the children, providing a pertinent explanation to their parents, and asked all subjects to sign a written consent form that contained detailed relevant information regarding the study. Relevant medical characteristics of the patients were recorded by the attending physicians. The study was conducted in line with Helsinki guidelines and approved by both the hospital and the ministry of education institutional ethical committees (approval numbers: 3895 and 9586, respectively).

      Results

      A preliminary analysis was conducted to find out the interrelationships among the four belief types which will be treated as independent variables in the first hypothesis. Table 1 in the supplementary materials presents the correlation matrix of the four belief types. The range of the shared variances of those variables is between 4.41 and 12.25%. Additional preliminary analysis was conducted to determine whether the psychological characteristics (consisted of the four belief types and the themes) are autonomous (
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ), i.e., related to the disease itself but not to its medical characteristics: the disease duration, the patient's age at the time of the diagnosis, and their PGA scores. The results are summarized in Table 2 in the supplementary materials. Since this study focused on autonomous psychological characteristics (associated with the disease itself, but not with its characteristics), the psychological characteristics that are not dependent on the medical parameters of IBD were included in the analyses of the hypotheses, but those which are dependent on the state of the disease (T5 and T9) were excluded from these analyses (see the notes of Table 2 in the supplementary materials).
      The first hypothesis focused on examining the differences between children with IBD and the comparison group regarding the four belief types. A multiple analysis of variance (MANOVA) yielded a significant model that differentiated between the two groups (F (4, 100) = 10.23, p < .001, Wilks' Λ = 0.71, ƞ2 = 0.29). The model is based on four comparisons illustrated in Fig. 1. The mean scores of IBD patients were higher than those of the comparison subjects in all belief types. A correction for multiple comparisons was conducted by implementing Holm's sequential Bonferroni procedure (
      • Holm S.
      A simple sequentially rejective multiple test procedure.
      ). The p-values of all belief types met these criteria.
      Fig. 1
      Fig. 1The results of MANOVA analysis that compared the four belief types of the IBD patients (N = 49) and the comparison subjects (N = 56).
      Note. IBD = Inflammatory Bowel Diseases.
      Y-axis represents the mean scores of each belief type. The means of each group are presented within the bars. The error bars represent the standard deviations.
      The p-values were adjusted in line with the criteria of Holm's sequential Bonferroni procedure. The four comparisons were statistically significant in accordance with this procedure. The degree of freedom in each F-test = 1. The effect size was calculated in terms of partial eta squared (
      • Richardson J.T.E.
      Eta squared and partial eta squared as measures of effect size in educational research.
      ). It is 0.13, 0.18, 0.08, and 0.14 for beliefs about self, general beliefs, beliefs about norms, and goals, respectively.
      The second hypothesis focused on identifying a set of relevant themes that characterize children with IBD and differentiate them from others in the comparison group. This hypothesis was tested in two stages, with the first based on t-tests, comparing means to identify the themes that differentiate between the two groups and to exclude those that do not differentiate between them. Table 3 summarized the results of the compared means between the two groups: 11 themes were excluded due to non-satisfied level of significance; three themes tended to differentiate between the patients and the comparison children in significance levels of 0.05 to 0.09; six themes differentiated between the groups in significance level of less than 0.05, and four out of the six themes met the criteria of the Holm's sequential Bonferroni procedure (
      • Holm S.
      A simple sequentially rejective multiple test procedure.
      ).
      Table 3Comparing the means and SDs of IBD patients and the comparison group regarding the psychological themes.
      IBD patients (N = 49)Comparison group (N = 56)pEffect size
      The effect size was calculated in terms of partial eta squared. The values of 0.00, 0.05, 0.13 indicate small, medium, and large effects, respectively (Richardson, 2011).
      Num.MSDMSDt(df)
      T15.691.195.291.261.67(102)0.090.03
      T26.060.835.910.731.00(102)0.320.01
      T35.780.805.490.921.68(102)0.090.03
      T47.261.017.070.930.96(101)0.330.01
      T65.730.975.291.102.17(102)0.030.04
      T75.161.014.870.981.49(102)0.140.02
      T86.451.396.071.251.46(102)0.140.02
      T10
      T10, T11, T18, and T22 were significant to a satisfactory level of the criteria of Holm's sequential Bonferroni procedure.
      6.450.715.980.863.00(103)0.0030.08
      T11
      T10, T11, T18, and T22 were significant to a satisfactory level of the criteria of Holm's sequential Bonferroni procedure.
      5.800.645.270.923.43(98.34)0.0010.10
      T127.240.787.040.761.39(103)0.160.02
      T137.060.246.940.421.74(96)0.080.03
      T145.551.065.481.140.32(101)0.750.00
      T157.161.016.911.121.21(101)0.220.01
      T165.451.265.131.221.34(103)0.180.02
      T175.180.884.950.931.34(102)0.180.02
      T18
      T10, T11, T18, and T22 were significant to a satisfactory level of the criteria of Holm's sequential Bonferroni procedure.
      6.410.895.811.402.54(101)0.010.06
      T197.101.166.781.421.24(97)0.220.02
      T206.590.616.260.892.22(93.98)0.020.05
      T215.840.775.731.030.62(99.35)0.530.00
      T22
      T10, T11, T18, and T22 were significant to a satisfactory level of the criteria of Holm's sequential Bonferroni procedure.
      7.270.536.761.043.03(97)0.0030.09
      Note. Num = themes numbers. The themes labels are presented in Table 2. IBD = Inflammatory Bowel Diseases. T5 and T9 were excluded from this analysis since they are associated with the state of the disease.
      a The effect size was calculated in terms of partial eta squared. The values of 0.00, 0.05, 0.13 indicate small, medium, and large effects, respectively (
      • Richardson J.T.E.
      Eta squared and partial eta squared as measures of effect size in educational research.
      ).
      b T10, T11, T18, and T22 were significant to a satisfactory level of the criteria of Holm's sequential Bonferroni procedure.
      The second stage of the analysis dealt with predicting the participant's group, based on the themes that differentiated between the two groups in the t-tests at a p-value less than 0.05. Table 4 shows that three of those themes significantly contributed to the model of logistic regression. The likelihood of the patients to be characterized by the themes T10, T11, and T22 is 2.18 to 2.90 times higher than the comparisons. In addition, the model enabled predicting whether the participant belongs to the patients or the comparison group at 75.8% accuracy, 25.8% better than a random prediction of 50%. The difference between the two percentages (75.8% versus 50%) is significant (χ2 (1, 99) = 14.05, p < .001).
      Table 4The logistic regression analysis of identifying the IBD patients and the comparison participants based on the six themes that yielded significant differences between the two groups in the t-test
      See Table 3.
      .
      Theme num.B
      Since the B's values in this kind of regression are in log-odds units, it is suggested to interpret them based on the values of the Exponent B's.
      SEExponent B
      The Exponent B's values express how many times each theme increases the likelihood of being in the IBD group.
      95% CI for exponent B

      LL-UL
      p
      T60.380.301.460.82–2.620.20
      T100.780.372.181.05–4.520.03
      T110.900.422.451.08–5.560.03
      T180.420.261.520.92–2.500.10
      T200.430.321.530.82–2.860.18
      T221.070.472.901.15–7.310.02
      Note. Theme num. = theme number. See their labels in Table 2.
      IBD = Inflammatory Bowel Diseases. CI = confidence interval; LL = lower limit; UL = upper limit.
      R2 = 0.40. Model χ2 = 35.05, df = 6, p < .001. % correct predication = 75.8, p < .001. n = 99.
      a See Table 3.
      b Since the B's values in this kind of regression are in log-odds units, it is suggested to interpret them based on the values of the Exponent B's.
      c The Exponent B's values express how many times each theme increases the likelihood of being in the IBD group.

      Discussion

      The purpose of the present study was to identify specific psychological characteristics of pediatric IBD. It is based on the COH model and examined two hypotheses that were confirmed. The first showed that the four belief types differentiated between the patients and the comparison group. This result is in line with the COH model and several previous studies that confirmed the necessity of at least three belief types in determining the motivational disposition of psychological characteristics for various health states (
      • Drechsler I.
      • Bruner D.
      • Kreitler S.
      Cognitive antecedents of coronary heart disease.
      ;
      • Figer A.
      • Kreitler M.
      • Kreitler S.
      • Inbar M.
      Personality dispositions of colon cancer patients.
      ;
      • Kreitler S.
      • Weissler K.
      • Nurymberg K.
      The cognitive orientation of patients with type 2 diabetes in Israel.
      ;
      • Kreitler S.
      • Kreitler M.
      • Barak F.
      Psychosocial risk factors of cancer diseases: How specific are they?.
      ). Thus, there is a motivational disposition for psychological characteristics relevant to children with IBD. The contents of the characteristics were examined in the second hypothesis where patients were characterized by the following six themes: like routines and prefer doing the same every day – food, and clothes, etc. (T6), strive to get others' love and praise (T10), caring about the body and the health (T11), like doing things at their own pace, not according to what they should do (T18), expressing negative emotion, such as anger and fear; without caring how it affects others (T20), knowing and feeling exactly what others feel, such as friends and family members (T22).
      An in-depth analysis of the earlier mentioned themes reflects specific psychological dynamics that indicates the presence of stress and conflicts among the patients. Some themes are related to stress simply because of their contents (
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ). Continual striving to reach others' love, pleasing them (T10), and over-identification with others' feelings (T22) could be harmful to the patients' well-being and accompanied by tension. This last tendency may make the patients more vulnerable to others' feelings since, in case of identification with relatives and close people, sensitive individuals could experience the same emotions that people who were confronted with a given situation felt (
      • Yzerbyt V.
      • Dumont M.
      • Wigboldus D.
      • Gordijn E.
      I feel for us: The impact of categorization and identification on emotions and action tendencies.
      ). In addition, neuroscience evidence proposed that there is a shared neurological representation in the brains of the individual who does an activity and the observer (
      • Decety J.
      • Chaminade T.
      When the self represents the other: A new cognitive neuroscience view on psychological identification.
      ). An example of the shared brain representation is the ‘mirror neurons’ which were revealed firstly in monkeys (
      • Gallese V.
      • Fadiga L.
      • Fogassi L.
      • Rizzolatti G.
      Action recognition in the premotor cortex.
      ;
      • Rizzolatti G.
      • Fadiga L.
      • Gallese V.
      • Fogassi L.
      Premotor cortex and the recognition of motor actions.
      ) and then in humans (
      • Fadiga L.
      • Fogassi L.
      • Pavesi G.
      • Rizzolatti G.
      Motor facilitation during action observation: A magnetic stimulation study.
      ). These kinds of neurons were activated not only when an individual performed an action, but also when the individual observed the action being performed by others (
      • Cochin S.
      Observation and execution of movement: Similarities demonstrated by quantified electroencephalography.
      ). Hence, it seems that the tendency of over-identification with others affects the real experiences of people and their neurological and emotional state. The negative consequence of this tendency may appear among IBD patients especially when it is accompanied by the tendency of pleasing others (T10). Then, one may cope with self-effacements (for example, by setting others' needs before the own ones) which was also identified, along with the tendency of pleasing others, by a previous study as characteristics of adult patients with colorectal cancer (
      • Kreitler S.
      • Kreitler M.
      • Len A.
      • Alkalay Y.
      • Barak F.
      Psychological risk factors for colorectal cancer?.
      ). This overlap between the psychological characteristics of pediatric IBD and colorectal cancer is expected since both diagnoses affect the same body system – the digestive one – and because IBD is a risk factor for colorectal cancer (
      • Lukas M.
      Inflammatory bowel disease as a risk factor for colorectal cancer.
      ).
      Additional foci of stress are related to the contradictions among the contents of the themes that characterize patients with a given disease (
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ). It is difficult to reach others' love and praise (T10) when one is used to expressing negative feelings without any consideration of the environment (T20). Furthermore, the last theme (T20) is associated with social conflicts, interpersonal problems (
      • Besharat M.A.
      • Shahidi V.
      Mediating role of cognitive emotion regulation strategies on the relationship between attachment styles and alexithymia.
      ;
      • Birditt K.S.
      • Fingerman K.L.
      Do we get better at picking our battles? Age group differences in descriptions of behavioral reactions to interpersonal tensions.
      ;
      • Garofalo C.
      • Velotti P.
      • Zavattini G.C.
      • Kosson D.S.
      Emotion dysregulation and interpersonal problems: The role of defensiveness.
      ), and severity of symptoms in psychiatric diagnoses, such as borderline personality disorder (
      • Herr N.R.
      • Rosenthal M.Z.
      • Geiger P.J.
      • Erikson K.
      Difficulties with emotion regulation mediate the relationship between borderline personality disorder symptom severity and interpersonal problems.
      ). Thus, it could constitute a source of social conflicts and increase the frequency in which one experiences tensioned relationships with others. A similar social effect could be triggered when one insists, in a long term, to perform duties at his own pace, not as required (T18). This tendency is suggested to promote social conflicts among IBD patients because the attitudes of uncaring about performing tasks and about the feelings of others are negatively associated with compliance and altruism (
      • Frick P.J.
      • Ray J.V.
      Evaluating callous-unemotional traits as a personality construct.
      ), but they are positively associated with expressions of irresponsibility and unstable interpersonal relationships (
      • Feilhauer J.
      • Cima M.
      • Arntz A.
      Assessing callous-unemotional traits across different groups of youths: Further cross-cultural validation of the inventory of callous-unemotional traits.
      ).
      In addition, it seems that doing things only at their own pace (T18) does not go hand in hand with striving to get others' love (T10). Thus, one may feel tension due to simultaneous activation of each contradictory pairs of the themes (
      • Festinger L.
      Theories of cognitive dissonance.
      ;
      • Harmon-Jones E.
      • Mills J.
      An introduction to cognitive dissonance theory and an overview of current perspectives on the theory.
      ), or may feel frustrated at not being able to express oneself fully due to activation of only one theme of the contradictory pair (
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ). Therefore, the discussed psychological dynamics is compatible with previous studies that suggested an association between psychological stress and IBD (
      • Ananthakrishnan A.N.
      Environmental risk factors for inflammatory bowel disease.
      ;
      • Bitton A.
      • Sewitch M.J.
      • Peppercom M.A.
      • Edwardes M.D.D.B.
      • Shah S.
      • Ransil B.
      • Locke S.E.
      Psychosocial determinants of relapse in ulcerative colitis: A longitudinal study.
      ;
      • Lerebours E.
      • Gower-Rousseau C.
      • Merle V.
      • Brazierm F.
      • Debeungny S.
      • Marti R.
      • Benichou J.
      Stressful life events as a risk factor for inflammatory bowel disease onset: A population-based case-control study.
      ;
      • Mardini H.E.
      • Kip K.E.
      • Wilson J.W.
      Crohn’s disease: A two-year prospective study of the association between psychological distress and disease activity.
      ;
      • Mittermaier C.
      • Dejaco C.
      • Waldhoer T.
      • Oefferlbauer-Ernst A.
      • Miehsler W.
      • Beier M.
      • Tillinger W.
      • Gangl A.
      • Moser G.
      Impact of depressive mood on relapse in patients with inflammatory bowel disease: A prospective 18-month follow-up study.
      ;
      • Rampton D.
      Does stress influence inflammatory bowel disease? The clinical data.
      ), and it seems that it served as a source of chronic stress and conflicts.
      Besides these insights, there are unexpected ones related to few themes that seem to be connected to the hygiene hypothesis regarding pediatric IBD. This hypothesis suggests that decreased microbial exposure in early life has an impact on the immune system and the activation of T helper type 2-related disease (
      • Aujnarain A.
      • Mack D.R.
      • Benchimol E.I.
      The role of the environment in the development of pediatric inflammatory bowel disease.
      ). Previous studies examined many environmental markers of hygiene, such as having a small family, living in clean-urban homes, access to separate bathrooms, and no bedroom sharing with siblings (
      • Ye Y.
      • Pang Z.
      • Chen W.
      • Ju S.
      • Zhou C.
      The epidemiology and risk factors of inflammatory bowel disease.
      ). However, there are no studies that examined the psychological themes which may be related to the hygiene hypothesis. The tendency of strict caring about one's body and health (T11), restricting oneself to limited lifestyle options and specific types of food (T6) may reflect a high hygienic lifestyle. Thus, these themes may be related to hygiene and may have an effect on being exposed to microbes and childhood infections.

      Implications for practice

      The identification of the psychological characteristics has critical implications concerning the clinical level. Firstly, being aware of children with IBD characteristics could serve nurses and healthcare workers while providing services to the children and is essential for clinicians-patients quality interaction. For example, the knowledge about the tendency of the patients to do things at their own pace (T18) will avoid misinterpretation concerning relevant situations, such as a delay in completing tasks related to treatment adherence and could be used to tailor a personal treatment plan that corresponds to the patients' pace. In addition, being aware of the tendency of over-identification with others could help healthcare workers to be able to identify health-related situations in which patients over-identify with others and to help them to deal optimally with these situations.
      Secondly, besides the awareness, nurses may benefit from this study's results to personalize the patients' treatment in line with their characteristics. They may evaluate, in a patient intake meeting in which a healthcare worker collects relevant demographic and clinical data, the extent to which each psychological characteristic is dominant in a patient and make a treatment plan that takes into consideration the specific characteristics of a patient. For example, when a patient likes routines (T6), it is suggested to keep a fixed setting for the treatment meetings, such as schedule meetings in advance on the same days and times. Fixed treatment sitting could also include using the same room in a day hospital clinic by the same nurse. Keeping the same nurse for a patient could also be essential for the nurse patients' relationships and treatment adherence.
      Thirdly, this study results could guide nurses and other healthcare workers, such as psychologists and social workers, when they collaborate intending to organize a parental support group focuses on the bio-psych-social needs of the children. Focusing on the patients' characteristics that reflect the internal dynamics of the children could assist parents to optimally deal with the patients' needs, such as doing things at their own pace (T18) and having a routine (T6).
      And fourthly, since the identified patients' characteristics could be manipulated based on the COH model guidelines, nurses and healthcare workers will be able to organize personal group therapy, or some kind of training for children focused on reducing stress and conflicts by changing some related to stress characteristics, such as expressing negative emotions, e.g., anger and fear without caring about how it affects others (T20) and over-identification with others' feelings (T22). The process of changing the themes is based on mobilizing the extent by which the patients support the relevant themes, each separately in terms of the four belief types. For example, when the theme of interest is ‘Like doing things at their own pace, not according to what should be done’ (refers to T18), the intervention will focus on recalling or thinking about real or hypothetical situations in which the patients performed their duties at the required pace (reflects beliefs about self), and about duties that people perform at the required pace (reflects general beliefs). In addition, the intervention will deal with duties that should be done at the required pace (reflects beliefs about norms), and those that patients wish to perform at the expected pace (reflects beliefs about goals). This procedure, which makes patients aware of a situation where the theme is not valid, is supposed to attain some reductions in the patients' support of that theme. However, according to the COH model, changing a single theme is insufficient to end with any effect on the patient's state of health. The success of the intervention depends on establishing a stable and well-grounded motivational disposition representing the four belief types regarding a sufficient number of relevant themes (
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ). Thus, the present study is a pioneer for suggesting a new generation of targeted interventions that focus on the specific characteristics and dynamics of children with IBD. According to the COH model, changing few themes is insufficient to end with any effect on the patients' stress levels. The success of the intervention depends on establishing a stable motivational disposition representing the four belief types regarding a sufficient number of relevant themes (
      • Kreitler S.
      Psycho-oncology for the clinician: The patient behind the disease.
      ). Thus, the present study may be considered as initiating a new generation of targeted interventions that focus on the specific psychological characteristics and dynamics of children with IBD.

      Limitations and future studies

      The findings in this study are subject to several limitations. The first is related to the sample that was recruited in a certain medical center. The diagnosed children in other medical centers had not the opportunity to be presented in the study and the sample may not represent all of the diagnosed population. The second limitation is that the present study compared the patients' group with a healthy comparison one without including other pediatric diagnoses that are necessary to verify that the identified psychological characteristics are unique only to children with IBD. The third limitation refers to the stability of the psychological characteristics over time. This study was designed to be a cohort study that estimated the psychological characteristics at one point in time with no long-term follow-up. The fourth limitation is that this study was based on the results of previous studies to interpret the identified psychological characteristics in terms of stress. The stressful contents of the psychological characteristics require empirical examination by proving a statistical correlation between the psychological characteristics and stress.
      These limitations may serve as a basis for future studies that will focus on re-examining the identified psychological characteristics in larger samples from several medical centers and examine the stability of the characteristics over time by designing longitudinal studies. In addition, more studies are needed to further examine the validity of the CO-IBD questionnaire by involving samples of other pediatric diagnoses to ensure that the identified characteristics are unique only to IBD. Finally, future studies are recommended to implement the COH model's clinical guidelines on children with IBD and examine the effect of this sort of intervention on the patients' stress levels.

      Main conclusions

      The main conclusions that emerge from this study suggest that children with IBD are characterized by specific psychological characteristics. Those characteristics represent the psychological motivation for specific dynamics of the patients. They underlie chronic stress and cognitive conflicts of the patients. Nurses and healthcare workers could benefit from the knowledge about children with IBD characteristics to promote an optimal treatment plan that meets patients' needs, such as keeping a fixed treatment setting (related to the theme of like routines). They also could use the results of this study to enrich the support therapies they provide to the patients and their families. For example, raise the parents' awareness concerning patients' characteristics and reducing the patients' stress by manipulating some characteristics, such as refining the theme of expressing negative emotions without caring about how it affects others.

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Appendix A. Supplementary data

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