The Swedish Journal of Scientific Research (sjsr)

ISSN: 2001-9211 Volume 1 Issue 3 August 2014

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PSYCHOLOGICAL PROBLEMS ASSOCIATED WITH
THALASSEMIA IN DIYALA PROVINCE, IRAQ
* Dr. Kareem Assi Obaid
* Pediatrics department, Medical College, Diyala University, Iraq.


















1. BACKGROUND
Thalassemia is a blood disorder passed down thro!h "amilies #inherited$ in whi%h the bod& ma'es an abnormal
"orm o" hemo!lobin. This disorder reslts in e(%essi)e destr%tion o" red blood %ells* and there is no e""e%ti)e treat+
ment. ,atients re-ire li"elon! blood trans"sion* sall& started within 6 to 1.months o" birth o" patient* whi%h on
other hand has its own %ompli%ations. /t is a %hroni% disease that mani"ests earl& in li"e that it leads to ps&%holo!i+
%al and so%ial problems "or parents .0e "o%sed on parents to assess the impa%t o" their %hild1s disease.
Abstract
ac!gro"nd# Beta+thalassemia major is a %hroni% disorder o" blood* ha)in! an e(tensi)e impa%t on the
a""e%ted %hild. /t in)ol)es li"elon! therapeti% re!ime* with repeated blood trans"sions. 0ith im+
pro)ed li"e e(pe%tan%&* de to impro)ed medi%al mana!ement ps&%hoso%ial aspe%ts o" thalassemia are
!ainin! importan%e.
Ob$ectives# Thalassemia is a %hroni% disease that mani"ests earl& in li"e that it leads to ps&%holo!i%al
and so%ial problems "or parents .0e "o%sed on parents to assess the impa%t o" their %hild1s disease
and to assess the beha)ioral problems in mlti+trans"sed thalassemi% %hildren and ps&%hoso%ial "a%+
tors a""e%tin! them.
Material and met%ods# This is a %ross se%tional std& %ond%ted in the Thalassemia Centre o" Al+batool
tea%hin! hospital* Di&ala* /ra-. The std& was %arried ot "rom A!st .213 to April .214* parents who
"l"illed the in%lsion %riteria were in%lded in the std&. The %riteria were5 a$ established dia!nosis o"
thalassemia o" their %hild and the %hild was re!istered with the Thalassemia Centre "or re!lar blood
trans"sion* b$ parents who pro)ided %onsent "or the std&
&es"lts# The CBC6 total s%ores were hi!h in 3.7 patients* indi%atin! the presen%e o" beha)ioral prob+
lems. 8i!her CBC6 s%ores were "ond in %hildren o" older a!e !rop* those with poor s%hool per"or+
man%e* whose mothers9 ed%ation was more than ei!hth standard* had histor& o" death o" thalassemi%
relati)e in "amil&* !reater dration o" dia!nosed illness* poor pre+trans"sion hemo!lobin le)el* and
who had lon!er periods o" s%hool absenteeism.
Concl"sions# Beha)ioral problems are %ommon in mlti+trans"sed thalassemi% %hildren. :arl& dia!no+
sis and inter)ention o" beha)ioral problems in these %hildren wold ma'e them %ope with thalassemia
better.
K'()O&D*# '+A,IO&A- P&O-'M*. C+I-D '+A,IO&. C+'CK -I*.. MU-.I/.&A0*1U*'D .+A-A*/
*'MIA. 1&'2U'0. +O*PI.A-I3A.IO0. -O04/.'&MCO*.-( CA&'.
The Swedish Journal of Scientific Research (sjsr)
ISSN: 2001-9211 Volume 1 Issue 3 August 2014


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0orldwide* thalassemia poses a serios pbli% health problem de to the hi!h pre)alen%e. /t e(tends "rom the
<editerranean basin and parts o" A"ri%a* thro!hot the <iddle :ast* the /ndian =b+%ontinent* =oth+:ast Asia*
<elanesia and into the ,a%i"i% /slands* with reported rates ran!in! "rom .7 to .>7 ?1@. :a%h &ear* >2*222 to
122*222 %hildren die o" thalassemia major in low and middle in%ome %ontries* while abot ;7 o" the world9s pop+
lation is a %arrier o" a hemo!lobin disorder ?1@. The more se)ere "orms are beta+thalassemia major* whi%h war+
rants re!lar blood trans"sion at an earl& a!e* and thalassemia intermedia whi%h presents later and re-ires less
"re-ent trans"sions. The aim o" re!lar blood trans"sions is to eliminate the primar& %ompli%ations o" se)ere
thalassemia b& amelioratin! anemia and sppressin! er&thropoiesis. ,atients are sall& trans"sed at an earl&
a!e. The %hroni%it& and %ompli%ations o" thalassemia a""e%t the -alit& o" li"e o" )i%tims and parents and %ase
ph&si%al* ps&%holo!i%al* and e%onomi% problems ?.@. As there is no de"initi)e %re "or this disease* the majorit& e(+
%lsi)el& depend on blood trans"sions as a treatment option that %reates a brden not onl& on health s&stem bt
also on the a""e%ted "amilies* who are )lnerable to* so%ial* and ps&%holo!i%al problems ?3*4@. Aarios Balit& o"
6i"e #BO6$ stdies %ond%ted worldwide on thalassemia indi%ated poor indi%ators "or the s""erers ?>@.
/t is e(pe%ted that these %hildren are at hi!h ris' o" de)elopin! beha)ioral and ps&%hoso%ial problems li'e
opposition* passi)eness* an(iet&* phobias and depression* whi%h a""e%t their sel"+%on"iden%e and !i)e rise to
emotions and tho!hts whi%h ne!ati)el& a""e%t their -alit& o" li"e and %omplian%e to therap&.?6@ <an& o" the
thalassemi% %hildren e(perien%e "ear related to intra)enos line insertion and sb%taneos in"sion pmps.
Children with thalassemia in the pre+s%hool and laten%& a!e !rops are sall& an(ios and e(%essi)el& dependent
on their parents.?;@ The& displa& ps&%hosomati% s&mptoms and are "re-entl& absent "rom s%hool. Thalassemi%
%hildren ha)e more o" ne!ati)e sel"+%on%ept when %ompared to their normal %onterparts.?C@. Re!lar blood
trans"sions impro)e the o)erall sr)i)al o" mlti+trans"sed %hildren bt despite the pro!ress made in pre)entin!
trans"sion+transmitted in"e%tions TT/s$ o)er the last "ew &ears* TT/s %ontine to be a problem in man& parts o" the
world #D$. Blood trans"sion is the main ris' "a%tor "or transmittin! )iral hepatitis* parti%larl& in patients with
hematolo!i%al diseases #12$.The TT/ problem is dire%tl& proportional to the pre)alen%e o" in"e%tion in the blood
donor %ommnit& #11$. ,atients with thalassemia %ommonl& re%ei)e trans"sions and ths* are e(posed to
trans"sion+asso%iated in"e%tions .Amon! these in"e%tions* hepatitis B and hepatitis C are the most %ommon #1.$.
8epatitis B is an important in"e%tion in patients with thalassemia and pre)ention b& )a%%ination is ne%essar&
.Trans"sional hemosiderosis is a "re-ent %ompli%ation in patients with trans"sion dependent %hroni% diseases
s%h as thalassemia and se)ere t&pe o" si%'le %ell diseases. As there are no ph&siolo!i%al me%hanisms to e(%rete
the iron %ontained in trans"sed red %ells #1 nit o" blood %ontains appro(imatel& .22 m! o" iron$ the e(%ess o" iron
is stored in )arios or!ans. Cardiom&opath& is the most se)ere %ompli%ation %o)erin! more than ;27 o" the %ases
o" death o" thalassemi% patients. Altho!h the %rrent re"eren%e standard iron %helator de"ero(amine #DEO$ has
been sed %lini%all& "or o)er "or de%ades* its e""e%ti)eness is limited b& a demandin! therapeti% re!imen that
leads to poor %omplian%e. Despite poor %omplian%e* be%ase o" the in%on)enien%e o" sb%taneos in"sion* DEO
impro)ed %onsiderabl& the sr)i)al and -alit& o" li"e o" patients with thalassemia. De"eriprone sin%e 1DDC and
De"erasiro( sin%e .22> were li%ensed "or %lini%al se. The oral %helators ha)e a better %omplian%e be%ase o" oral
se* a %omparable e""i%a%& to DEO in iron e(%retion and probabl& a better penetration to m&o%ardial %ells.
Considerable in%rease in iron e(%retion was do%mented with %ombination therap& o" DEO and De"eriprone. The
proper se o" the three %helators will impro)e the pre)ention and treatment o" iron o)erload* it will red%e
%ompli%ations* and impro)e sr)i)al and -alit& o" li"e o" trans"sed patients. ?13*14 .?
.. <AT:R/A6= AND <:T8OD=
This is a %ross se%tional =td& %ond%ted in the Thalassemia Centre o" Al+batool tea%hin! hospital* Di&ala* /ra-. The
std& was %arried ot "rom A!st .213 to April .214. All ,arents who bro!ht their %hildren "or blood trans"sion
The Swedish Journal of Scientific Research (sjsr)
ISSN: 2001-9211 Volume 1 Issue 3 August 2014


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those parents who "l"illed the in%lsion %riteria were in%lded in the std&. The %riteria were5 a$ established dia!+
nosis o" thalassemia o" their %hild and the %hild was re!istered with the Thalassemia %entre "or re!lar blood trans+
"sion* b$ parents who pro)ided %onsent "or the std&.Data was %olle%ted on a -estionnaire %omprisin! .> -es+
tions that was sel"+ desi!ned to assess the ps&%holo!i%al and so%ial problems* #name* date o" dia!nosis* "amil& his+
tor& o" thalassemia* "amil& death* %onsan!init&* no#"re-en%&$ o" trans"sions* )olme o" trans"sions* %helation
t&pe* %hroni% illness* no.o" a""e%ted siblin!s* bone marrow aspiration* parents ed%ation* serm "erritin* li)er "n%+
tion test* 8BsAG and Anti 8CA* hepatospelnome!al&* bone %han!es* so%ial problems* "inan%ial problems* wei!ht*
hei!ht* OEC* s%hool per"orman%e* beha)ioral problems* dr! rea%tion$.
3. R:=U6T=
There was a preponderan%e o" males in parenteral treatment !rop and "emales in oral treatment !rop #Table 1$
and o)erall there were >6 males haematolo!i% amon! the 122 patients in the std&. Apart "rom > indi)idals with
b+thalassemia were not re%ei)e %helation therap&* all other patients had oral or parenteral %helation therap& . Dr+
in! the D months had ta'en 122 %ase as sample o" thalassemi% patients in Di&ala %it& to assess the ps&%hoso%ial
problems and the reslts in #table 4$ e(plain the so%ial problems and beha)ioral problems more %ommon in paren+
teral treatment while the s%hool absen%e hi!her in oral %helation treatment !rop . /n# table 1 $ the demo!raphi%
data o" the patients. Table . e(plain the %omorbidit& asso%iated with both treatment !rop.
Table 15 Demo!raphi% data o" the patients parti%ipatin! to the std&.

FFFFFFFFFFFF Oral C%elation
56 case
Parenteral C%elation
78 case
P val"e
4ender
Male
1emale

13 #2.4C7$
14 #2.>17$

42 #>C7$
.C #417$


Parents 'd"cation
0O0
Primary
*econdary
+ig% ed"cation

. #2.2;7$
1. #2.447$
; #2..>7$
6 #2...7$

12 #2.147$
.. #2.3.7$
31 #2.4>7$
> #2.2;7$


P%ysical activity
0ormal
lo9

13 #2.4C7$
1. #2..67$

36 #2.>.7$
3. #2.4;7$

Table .5 Co+morbidities asso%iated with the disease in both modes o" Chelation.
FFFFFFFFFFFF
Oral C%elation
.; %ase
Parenteral C%elation
6C %ase
P val"e
bone %han!es 1. #2.447$ 4; #2.6D7$
6i)er D #2.337$ 16 #2..37$
=pleen 13 #2.4C7$ >; #2.C37$
The Swedish Journal of Scientific Research (sjsr)
ISSN: 2001-9211 Volume 1 Issue 3 August 2014


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8epatitis#t&pe B*C$ . #2.2;7$ 6 #2.2C7$
Other %hroni% disease . #2.2;7$ 6 #2.2C7$
Bone aspiration 4 #2.147$ 12 #2.147$

Table 35 Disease %hara%teristi%s

FFFFFFFFFFFF Oral C%elation
56 case
Parenteral C%elation
78 case
P val"e
A!e o" onset*
At or be"ore 1
st
&ear
A"ter 1
st
&ear

.2 #2.;47$
; #2..>7$

>2#2.;37$
1C#2..67$

Ere-en%& o" trans"sion*
<onthl&
6ess than month
<ore than month

14 #2.>17$
11 #2.427$
. #2.2;7$

3D #2.>;7$
.D #2.4.7$
1 #2.217$

Table 4
Oral C%elation
56case
Parenteral C%elation
78 case
P val"e
=o%ial problems 6 #2...7$ .; #2.3D7$
=%hool absen%e 1D #2.;7$ .D #2.4.7$
Einan%ial problems 1. #2.447$ 32 #2.447$
Beha)ioral problems 1. #2..67$ 3. #2.4;7$
4. D/ =CU==/ON
=tdies o)er the past .> &ears ha)e shown that pre)alen%e o" beha)ioral disorders amon! thalassemi% %hildren
ran!ed "rom .3 to C27*?1>+16@ and these ps&%holo!i%al distrban%es ad)ersel& a""e%t %omplian%e to treatment in
thalassemia.?1;@ /n the present std&* it was "ond that 3.7 o" thalassemi% %hildren had %lini%all& abnormal CBC6
total s%ores. =td& b& &alen et al. in Tr'e& had also re)ealed that older a!e #G1. &ears$* hi!her ed%ation o"
mothers and poor s%hool per"orman%e were asso%iated with hi!her ris' o" beha)ioral problems.?1@ /n this std&*
3.7 had beha)ioral problems and 627 had poor s%hool per"orman%e whi%h is similar to the reslts o" a std& in
=oth Tr'e&?1C@ where 317 o" thalassemi% %hildren had an(iet& disorders and 627 had poor s%hool per"orman%e.
The %hildhood ps&%holo!i%al problems amon! thalassemi% %hildren were similar to that seen in other %hroni%
ph&si%al illnesses bt had been neither re%o!niHed nor treated @. 1D ?

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Address :or correspondence#
Author: Dr. Kareem Assi Obaid . Pediatrics department, Medical College, Diyala Univer-
sity, Iraq.
E-mail: karimalhamdany@yahoo.com