Examining Uncertainty in Illness in Parents and Children With Chronic Kidney Disease and Systemic Lupus Erythematosus: A Mediational Model of Internalizing Symptoms and Health-Related Quality of Life

Abstract

To examine if parent illness uncertainty is indirectly associated with child depression, anxiety, and HRQOL in the CKD/SLE population. Parent–child dyads (N = 31) from outpatient rheumatology and nephrology clinics included children (ages 9–18) diagnosed with CKD (Stage 1, 2, or nephrotic syndrome) or SLE. Parents completed demographic and uncertainty measures and children completed uncertainty, depression, anxiety, and HRQOL measures. This cross-sectional study examined mediational models using the percentile bootstrapping method. Parent uncertainty had an indirect effect on child depression, anxiety, and HRQOL through the mediator, child uncertainty. In other words, parents’ illness uncertainty regarding their child’s condition correlates to the child’s illness uncertainty, which then is associated with the child’s mental health and wellbeing. Reverse mediations illustrated that parent uncertainty did not mediate child uncertainty and outcome variables. Results extend previous research by examining parent and child illness uncertainty in understudied conditions (CKD/SLE) and the relationship to outcome variables commonly related to depression (e.g., anxiety and HRQOL). Findings allow health psychologists and medical personnel to understand the impact of uncertainty on the child’s wellbeing and HRQOL. Clinical implications, including using specialized interventions to address illness uncertainty, are discussed.

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References

  1. Al-Yateem, N., Docherty, C., Altawil, H., Al-Tamimi, M., & Ahmad, A. (2017). The quality of information received by parents of children with chronic ill health attending hospitals indicated by measures of illness uncertainty. Scandinavian Journal of Caring Sciences,31, 839–849. https://doi.org/10.1111/scs.12405.

    Article  PubMed  PubMed Central  Google Scholar 

  2. American College of Rheumatology. (2012). Systemic lupus erythematosus in children and teens. Retrieved from https://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Systemic_Lupus_Erythematosus_in_Children_and_Teens/.

  3. American Kidney Fund. (2015). Nephrotic syndrome in children. Rockville, MD. Retrieved from http://www.kidneyfund.org/kidney-problems/nephrotic-syndrome/nephrotic-syndrome-in-children/.

  4. Bailey, D. E. Jr., Landerman, L., Barroso, J., Bixby, P., Mishel, M., Muir, A., …, Clipp, E. (2009). Uncertanity, sypmptoms, and quality of life in persons with chronic hepatitis C. Psychosomatics, 50(2), 138–146.

    PubMed  PubMed Central  Article  Google Scholar 

  5. Bakr, A., Amr, M., Sarhan, A., Hammad, A., Ragab, M., El-Refaey, A., & El-Mougy, A. (2007). Psychiatric disorders in children with chronic renal failure. Pediatric Nephrology,22, 128–131.

    PubMed  Article  PubMed Central  Google Scholar 

  6. Barberis, N., Costa, S., Gitto, L., Larcan, R., Buemi, M., & Santoro. D. (2016). Role of emotional intelligence as a mediating factor between uncertainty and anxiety hospital in chronic renal patients. Illness, Crisis, & Loss, 0, 1–16.

  7. Brunner, H. I., Bishnoi, A., Barron, A. C, Houk, L. J., Ware, A., Farhey, Y., …, Passo, M. H. (2006). Disease outcomes and ovarian function of childhood-onset systemic lupus erythematosus. Lupus, 15(4). 198–206.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  8. Calderon-Margalit, R., Golan, E., Twig, G., Leiba, A., Tzur, D., Afek, A., …, Vivante, A. (2018). History of childhood kidney disease and risk of adult end-stage renal disease. New England Journal of Medicine, 378(5), 428–438.

    PubMed  Article  PubMed Central  Google Scholar 

  9. Center for Disease Control and Prevention. (2016). Health-related quality of life (HRQOL). Retrieved from https://www.cdc.gov/hrqol/.

  10. Centers for Disease Control and Prevention. (2017). National chronic kidney disease fact sheet, 2017. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention.

  11. Cleanthous, S., Newman, S. P., Shipley, M., Isenberg, D. A., & Cano, S. J. (2013). What constitutes uncertainty in systemic lupus erythematosus and rheumatoid arthritis? Psychology & Health,28, 171–188.

    CAS  Article  Google Scholar 

  12. Decker, C. L., Haase, J. E., & Bell, C. J. (2007). Uncertainty in adolescents and young adults with cancer. Oncology Nursing Forum,34, 681–688.

    PubMed  Article  PubMed Central  Google Scholar 

  13. Dotis, J., Pavlaki, A., Printza, N., Stabouli, S., Antoniou, S., Gkogka, C., & Papachristou, F. (2016). Quality of life in children with chronic kidney disease. Pediatric Nephrology,31, 2309–2316.

    PubMed  Article  PubMed Central  Google Scholar 

  14. Fedele, D. A., Mullins, L. L., Eddington, A. R., Ryan, J. L., Junghans, A. N., & Hullman, S. E. (2009). Health-related quality of life in college students with and without childhood-onset asthma. Journal of Asthma,46, 835–840.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  15. Fonseca, R., Bernardes, M., Terroso, G., de Sousa, M., & Figueiredo-Braga, M. (2014). Silent burdens in disease: Fatigue and depression in SLE. Autoimmune Diseases,2014, 1–9.

    CAS  Article  Google Scholar 

  16. Fortier, M. A., Batista, M. L., Wahi, A., Kain, A., Strom, S., & Sender, L. S. (2013). Illness uncertainty and quality of life in children with cancer. Journal of Pediatric Hematology/oncology,35, 366–370. https://doi.org/10.1097/mph.0b013e318290cfdb.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Fritz, M. S., & MacKinnon, D. S. (2007). Required sample size to detect the mediated effect. Psychology Science,18, 233–239.

    Article  Google Scholar 

  18. Gerson, A. C., Wentz, A., Abraham, A. G., Mendley, S. R., Hooper, S. R., Butler, R. W., …, Furth, S. L. (2010). Health-related quality of life children with mild to moderate chronic kidney disease. Pediatrics, 125(2), e349.

    PubMed  PubMed Central  Article  Google Scholar 

  19. Gipson, D. S., Selewski D. T., Massengill, S. F., Wickman, L., Messer, K. L., Herreshoff, E., …, DeWalt, D. A. (2013). Gaining the PROMIS perspective from children with nephrotic syndrome: A Midwest pediatric nephrology consortium study. Health and Quality of Life Outcomes, 30(11), 2–9.

  20. Ha Dinh, T. T., Bonner, A., Clark, R., Ramsbotham, J., & Hines, S. (2016). The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: A systematic review. JBI Database of Systematic Reviews and Implementation Reports,14, 210–247.

    PubMed  Article  PubMed Central  Google Scholar 

  21. Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomed Information,42, 377–381.

    Article  Google Scholar 

  22. Hayes, A. (2012). PROCESS: A versatile computational tool for observed variable mediation, moderation, and conditional process modeling [Statistical program]. Retrieved from http://www.afhayes.com/public/process2012.pdf.

  23. Hayes, A. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York, NY: Guilford Press.

    Google Scholar 

  24. Heath, J., MacKinlay, D., Watson, A.R., Hames, A., Wirz, L., Scott, S., …, McHugh, K. (2010). Self-reported quality of life in children and young people with chronic kidney disease. Pediatric Nephrology, 26(5). 767–773. https://doi.org/10.1007/s00467-011-1784.

  25. Hinton, D., & Kirk, S. (2017). Living with uncertainty and hope: A qualitative study exploring parents’ experiences of living with childhood multiple sclerosis. Chronic Illness,13, 88–99.

    PubMed  Article  PubMed Central  Google Scholar 

  26. Hullman, S. E., Eddington, A. R., Molzon, E. S., & Mullins, L. L. (2013). Illness appraisals and health-related quality of life in adolescents and young adults with allergies and asthma. International Journal of Adolescent Medicine and Health,25, 31–38.

    Article  Google Scholar 

  27. Irwin, D. E., Stucky, B., Langer, M. M., Thissen, D., DeWitt, E. M., Lai, L., …, DeWalt, D. A. (2010). An item response analysis of the pediatric PROMIS anxiety and depression symptoms scales. Quality of LIfe Research. 19, 595–607.

    PubMed  PubMed Central  Article  Google Scholar 

  28. Ji, L., Jing, W., Yanyan, H., Min, W., Juan, X., & Hongmei, S. (2012). Appearance concern and depression in adolescent girls with systemic lupus erythematosus. Clinical Rheumatology,31, 1671–1675.

    PubMed  Article  PubMed Central  Google Scholar 

  29. Jones, J. T., Cunningham, N., Kashikar-Zuck, S., & Bruner, H. L. (2015). Pain, fatigue, and psychological impact on health-related quality of life in childhood-onset lupus. Artritis Care & Research,68, 73–80.

    Article  Google Scholar 

  30. Kelly, M. M. (2016). Exploring the evidence: Children and adolescents with chronic kidney disease: A population at risk for more than just kidney disease. Nephrology Nursing Journal,43, 67–70.

    PubMed  PubMed Central  Google Scholar 

  31. Kilis-Pstrusiriska, K., Medyriska, A., Chmielewska, I. B., Grenda, R., Kluska-Jozwiak, A., Leszczynska, B., Niedomagata, J., …, Zwoliriska, D. (2013). Perception of health-related quality of life in children with chronic kidney disease by the patients and their caregivers: Multicentre national study results. Quality of Life Research, 22, 2989–2897.

  32. Knight, A., Vickery, M., Fiks, A. G., & Bargs, F. K. (2016). The illness experience of youth with lupus/mixed connective tissue disease: A mixed methods analysis of patient and parent perspectives. Pediatric Lupus,25, 1028–1039.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  33. Knight, A., Weiss, P., Morales, K., Gerdes, M., Gutstein, A., Vickery, M., & Keren, R. (2014). Depression and anxiety and their association with healthcare utilization in pediatric lupus and mixed connective tissue disease patients: A cross-sectional study. Pediatric Rheumatology,12, 42.

    PubMed  Article  PubMed Central  Google Scholar 

  34. Kogon, A. J., Matheson, M. B., Flynn, J. T., Gerson, A. C., Warady, B. A., Furth, S. L., & Hooper, S. R. (2015). Depressive symptoms in children with chronic kidney disease. Journal of Pediatrics,168, 164–170. https://doi.org/10.1016/j.jpeds.2015.09.040.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Krull, J. L., Cheong, J., Frtiz, M. S., & Mackinnon, D. P. (2015). Moderation and mediation in interindividual longitudinal analysis. In D. Cicchetti (Ed.), Developmental psychopathology, theory, and method (3rd ed., pp. 922–1144). Hoboken, NJ: Wiley.

    Google Scholar 

  36. Lai, J.-S., Beaumont, J. L., Jensen, S., Kaiser, K., Van Brunt, D. L., Kao, A. H., & Shih-Yin Chen, S. (2017). An evaluation of health-related quality of life in patients with systemic lupus erythematosus using PROMIS and Neuro-QoL. Clinical Rheumatology,36, 555–562.

    PubMed  Article  PubMed Central  Google Scholar 

  37. Lopes, M., Ferraro, A., & Koch, V. H. (2014). Health-related quality of life of children and adolescents with CKD stages 4-5 and their caregivers. Pediatric Nephrology,29, 1239–1247.

    PubMed  Article  PubMed Central  Google Scholar 

  38. MacKinnon, D. P., Lockwood, C. M., & Williams, J. (2004). Confidence limits for the indirect effect: Distribution of the product and resampling methods. Multivariate Behavioral Research,39, 99–128.

    PubMed  PubMed Central  Article  Google Scholar 

  39. Maikranz, J. M., Steele, R. G., Dreyer, M. L., Stratman, A. C., & Bovaird, J. A. (2006). The relationship of hope and illness-related uncertainty to emotional adjustment and adherence among pediatric renal and liver transplant recipients. Journal of Pediatric Psychology,32, 571–581.

    PubMed  Article  PubMed Central  Google Scholar 

  40. Marciano, R. C., Bouissou Soares, C. M., Diniz, J. S. S., Lima, E. M., Silva, J. M. P., Canhestro, M. R., …, Oliveira, E. A. (2011). Behavioral disorders and low quality of life in children and adolescents with chronic kidney disease. Pediatric Nephrology, 26(2), 281–290.

    PubMed  Article  PubMed Central  Google Scholar 

  41. Marsolo, K., Shuman, K., Nix, J., Morrison, C., Mullins, L. L., & Pai, A. L. H. (2017). Reducing parental uncertainty around childhood cancer: Implementation decisions and design trade-offs in developing an electronic health record-linked mobile app. JMIR Publications,6, e122. https://doi.org/10.2196/resprot.7523.

    Article  Google Scholar 

  42. Mattsson, M., Möller, B., Stamm, T., Gard, G., & Boström, C. (2012). Uncertainty and opportunities in patients with established systemic lupus erythematosus: a qualitative study. Musculoskeletal Care,10, 1–12. https://doi.org/10.1002/msc.220.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  43. Mazzoni, D., Cicognani, E., & Prati, G. (2016). Health-related quality of life in systemic lupus erythamatosus: A longitudinal study on the impact of problematic support and self efficacy. Lupus,26, 125–131.

    PubMed  Article  PubMed Central  Google Scholar 

  44. McKenna, A. M., Keating, L. E., Vigneux, A., Stevens, S., Williams, A., & Geary, D. F. (2006). Quality of life in children with chronic kidney disease-patient and caregiver assessments. Nephrology, Dialysis, Transplantation,21, 1899–1905.

    PubMed  Article  PubMed Central  Google Scholar 

  45. Meacock, R., Dale, N., & Harrison, M. J. (2013). The humanistic and economic burden of systemic lupus erythematosus: A systematic review. PharmacoEconomics,31, 49–61.

    PubMed  Article  PubMed Central  Google Scholar 

  46. Mishel, M. H. (1983). Parents’ perception of uncertainty concerning their hospitalized child. Nursing Research,32, 324–330.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  47. Mishel, M. H. (1988). Uncertainty in illness. Journal of Nursing Scholarship,20, 225–232.

    CAS  Article  Google Scholar 

  48. Mishel, M. H. (1990). Reconceptualization of the uncertainty in illness theory. State of the Science,22, 256–262.

    CAS  Google Scholar 

  49. Moorthy, L. N., Robbins, L., Harrison, M. J., Peterson, M. G. E., Cox, N., Onel, K. B. M., & Lehman, T. J. A. (2004). Quality of life in paediatric lupus. Lupus,13, 234–240.

    PubMed  Article  PubMed Central  Google Scholar 

  50. Mullins, L. L., Molzon, E., Suorsa, K. L., Tackett, A. P., Pai, A. L. H., & Chaney, J. A. (2015). Models of resilience: Developing psychosocial interventions for parents of children with chronic health conditions. Family Relations: Interdisciplinary Journal of Applied Family Studies,64, 176–189.

    Article  Google Scholar 

  51. National Kidney Foundation (2017a). About Chronic Kidney Disease. Retrieved from https://www.kidney.org/kidneydisease/aboutckd.

  52. National Kidney Foundation. (2017b). Nephrotic Syndrome. Retrieved from https://www.kidney.org/atoz/content/nephrotic.

  53. Page, M. C., Fedele, D. A., Pai, A. L. H., Anderson, J., Wolfe-Christensen, C., Ryan, J. L., & Mullins, L. L. (2012). The relationship of maternal and child Illness uncertainty to child depressive symptomotology: A mediational model. Journal of Pediatric Psychology,37, 97–105.

    PubMed  Article  PubMed Central  Google Scholar 

  54. Pai, A. L. H., Mullins, L. L., Drotar, D., Burant, C., Wagner, J., & Chaney, J. M. (2007). Exploratory and confirmatory factor analysis of the child uncertainty in illness scale among children with chronic illness. Journal of Pediatric Psychology,32, 288–296.

    PubMed  Article  PubMed Central  Google Scholar 

  55. Parker, A. P., Davis, W. J., Latini, D. M., Baum, G., Wang, X., Ward, J. F., …, Kim, J. (2015). Relationship between illness uncertainty, anxiety, fear of progression, and quality of life in men with favourable-risk prostate cancer undergoing active surveillance. Urological Oncology, 117. 469–477.

    PubMed  PubMed Central  Article  Google Scholar 

  56. Paz, Z., & Watcher, S. (2017). Systemic lupus erythematosus (Juvenile). The American College of Rheumatology. Retrieved from http://www.rheumatology.org/Practice/Clinical/Patients/Disease_And_Conditions/Systemic_Lupus_Erythematosus_in_Children_and_Teens.

  57. PROMIS. (2014). PROMIS pediatric profile instruments. Retrieved from https://www.assessmentcenter.net/Manuals.aspx.

  58. Pugh-Clarke, K., Naish, P. F., & Mercer, T. M. (2006). Quality of life in chronic kidney disease. Journal of Renal Care,32, 167–171.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  59. Reuman, L., Jacoby, R. J., Fabricant, L. E., Herring, B., & Abramowitz, J. S. (2015). Uncertainty as an anxiety cue at high and low levels of threat. Journal of Behavior Therapy and Experimental Psychiatry,47, 111–119.

    PubMed  Article  PubMed Central  Google Scholar 

  60. Richardson, A., Raine-Fenning, N., Deb, S., Campbell, B., & Vedhara, K. (2016). Anxiety associated with diagnostic uncertainties in early pregnancy. Ultrasound Obstetrics and Gynecology,50, 247–254. https://doi.org/10.1002/uog.17214.

    Article  Google Scholar 

  61. Ruperto, N., Buratti, S., Duarte-Salazar, C., Pistorio, A., Reiff, A., Bernstein, B., & Ravelli, A. (2004). Health related quality of life in juvenile-onset systemic lupus erythematosus and its relationship to disease activity and damage. Arthritis and Rheumatism,51, 458–464.

    PubMed  Article  PubMed Central  Google Scholar 

  62. Sharkey, C., Bakula, D. M., Baraldi, A. N., Perez, M. N., Suorsa, K. I., Chaney, J. M., & Mullins, L. L. (2017). Grit, illness-related distress, and psychosocial outcomes in college students with a chronic medical condition: A path analysis. Journal of Pediatric Psychology,23, 552–560.

    Google Scholar 

  63. Steele, R. G., Aylward, B. S., Jensen, C. D., & Wu, Y. P. (2009). Parent and youth-reported illness uncertainty: Associations with distress and psychosocial functioning among recipients of liver and kidney transplantations. Children’s Health Care,38, 185–199.

    Article  Google Scholar 

  64. Stewart, J. L., Mishel, M. H., Lynn, M. R., & Terhorst, L. (2010). Test of a conceptual model of uncertainty in children and adolescents with cancer. Research in Nursing & Health,33, 179–191. https://doi.org/10.1002/nur.20374.

    Article  Google Scholar 

  65. Szulczewski, L., Mullins, L. L., Bidwell, S. L., Eddington, A. R., & Pai, A. (2017). Meta-analysis: Caregiver and youth uncertainty in pediatric chronic illness. Journal of Pediatric Psychology,42, 395–421.

    PubMed  PubMed Central  Article  Google Scholar 

  66. Talkovsky, A. M., & Norton, P. J. (2016). Intolerance of uncertainty and transdiagnostic group cognitive behavioral therapy for anxiety. Journal of Anxiety Disorders,41, 108–114.

    PubMed  Article  PubMed Central  Google Scholar 

  67. The Renal Association. (2018). Identifying patients with CKD stages G1 & G2. Retrieved from https://renal.org/information-resources/the-uk-eckd-guide/stages-1-2-ckd/.

  68. Tong, A., Lowe, A., Sainsbury, P., & Craig, J. C. (2006). Experiences of parents who have children with chronic kidney disease: A systematic review of qualitative studies. Pediatrics,121, 349–360.

    Article  Google Scholar 

  69. Tucker, L. B., Uribe, A. G., Fernandez, M., Vila, L. M., McGwin, G., Apte, M., & Alarcón, G. S. (2008). Adolescent onset of lupus results in more aggressive disease and worse outcomes: Results of a nested matched case-control study within LUMINA, a multiethnic US cohort (LUMINA LVII). Lupus,17, 314–322.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  70. Tunnicliffe, D., Singh-Grewal, D., Chaitow, J., Mackie, F., Manolios, N., Lin, M., …, Tong, A. (2016). Lupus means sacrifices: Perspectives of adolescents and young adults with Systemic Lupus Erythematosus. Arthritis Care and Research, 68(6), 828–837. https://doi.org/10.1002/acr.22749.

    Article  Google Scholar 

  71. Varni, J. W., Magnus, B., Stucky, B. D., Liu, Y., Quin, H., Thissen, D., …, DeWalt, D. A. (2014). Psychometric properties of the PROMIS® pediatric scales: Precision, stability, and comparison of different scoring and administration options. Quality of Life Research, 23, 1233–1243. https://doi.org/10.1007/s11136-013-0544-0.

    PubMed  PubMed Central  Article  Google Scholar 

  72. Varni, J. W., Seid, M., & Kurtin, P. S. (2001). Reliability and validity of the pediatric quality of life inventory version 4.0 generic core scales in healthy and patient populations. Medical Care,39, 800–812.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  73. White, M. M., Chaney, J. M., Mullins, L. L., Wagner, J. L., Hommel, K. A., Andrews, N. R., & Jarvis, J. N. (2005). Children’s perceived illness uncertainty as a moderator in the parent-child distress relation in juvenile rheumatic diseases. Rehabilitation Psychology,50(3), 224–231.

    Article  Google Scholar 

  74. Wonghongkul, T., Dechaprom, N., Phumivichuvate, L., & Losawatkul, S. (2006). Uncertainty appraisal coping and quality of life in breast cancer survivors. Cancer Nursing,29(3), 250–257.

    PubMed  Article  PubMed Central  Google Scholar 

  75. Wright, J., Afari, N., & Zautra, A. (2009). The illness uncertainty concept: A review. Current Pain and Headache Reports,13, 133–138.

    Article  Google Scholar 

  76. Zelko, F., Beebe, D., Baker, A., Nelson, S. M., Ali, A., Cedeno, A., …, Brunner, H. I. (2012). Academic outcomes in childhood-onset systemic lupus erythematosus. Arthritis Care & Research, 64, 1167–1174.

    Article  Google Scholar 

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Jennifer L. Petrongolo, Nataliya Zelikovsky, Rachel M. Keegan, Susan L. Furth, and Andrea Knight declare that they have no conflict of interest.

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Petrongolo, J.L., Zelikovsky, N., Keegan, R.M. et al. Examining Uncertainty in Illness in Parents and Children With Chronic Kidney Disease and Systemic Lupus Erythematosus: A Mediational Model of Internalizing Symptoms and Health-Related Quality of Life. J Clin Psychol Med Settings 27, 31–40 (2020). https://doi.org/10.1007/s10880-019-09617-3

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Keywords

  • Chronic illness
  • Depression
  • Anxiety
  • Health-related quality of life
  • Uncertainty in illness