Stress response symptoms in adolescents during the first year after a parent’s cancer diagnosis

The association between parental chronic physical illness and adolescent functional somatic symptoms

BACKGROUND

Previous studies have found that adolescents with a chronically ill parent may experience more internalizing problems. It is less clear if this association is sex-related, and whether it is specific for functional somatic symptoms (FSSs) or concerns other internalizing or externalizing problems.

METHODS

In a prospective cohort of adolescents, oversampled on emotional and behavioral problems (n = 841; mean age 14.9 years), we examined the association between parental chronic illness and adolescent's FSSs, and internalizing and externalizing problems. Adolescent's internalizing and externalizing symptoms were measured using the Youth Self Report; parental chronic physical illness was reported during an interview. Associations were tested using linear regression analyses taking into account socio-demographic confounders. We also explored gender-interaction effects.

RESULTS

Having a chronically ill parent (n = 120; 14.3 %) was associated with more FSS in girls (B = 1.05, 95%CI = [0.23, 1.88], p = .013), but not in boys (sex-interaction: p = .013). In girls, an association was also found between parental chronic illness and more internalizing problems (B = 2.68, 95%CI = [0.41, 4.95], p = .021), but this association disappeared when FSSs were excluded from the Internalizing problem scores.

LIMITATIONS

The current study has a cross-sectional design and relied on self-reported parental chronic physical illness what may have induced misclassification.

CONCLUSION

Findings suggest that having a chronically ill parent is associated with more FSSs in adolescent girls and that this association is specific for FSSs instead of general internalizing problems. Girls with a chronically ill parent may profit from interventions to prevent the development of FSSs.

A Conceptual Model Depicting How Children Are Affected by Parental Cancer: A Constructivist Grounded Theory Approach

Cancer patients' children are vulnerable to psychosocial and behavioural issues. The mechanisms underlying how children are affected by their parent's diagnosis are unknown, warranting further research. This study investigated how children are affected by their parent's cancer diagnosis and provides a theoretical model conceptualising this experience. Informed by methods of grounded theory, embedded within a social constructivist framework, 38 informants (15 health professionals (HPs); 11 parents; 12 children (5 to 17 years)) were interviewed using a semi-structured format. Three themes were identified: (i) children were worried and distressed because they felt alone, (ii) parents were unable to tend to children's needs because they were overwhelmed by practical factors, and (iii) HPs were not detecting children due to barriers that affected their visibility in clinical settings. The proposed Alexander's Children's Cancer Communication (ACCC) Model and clinical recommendations made can be used to guide the clinical practice and development of future intervention research.

The Psychosocial Effect of Parental Cancer: Qualitative Interviews with Patients' Dependent Children

BACKGROUND

Children living with parental cancer are at an increased risk for various psychosocial, emotional, and behavioural problems. However, research regarding how children are affected by their parent's diagnosis is still developing and patients' children are typically invisible in clinical practice. This study aimed to investigate how children are affected by their parent's cancer diagnosis, from children's perspectives.

METHODS

Informed by methods of grounded theory and embedded within a social constructivist framework, twelve children (ranging from 5 to 17 years) living with a parent with cancer were interviewed using a semi-structured format assisted by a novel approach derived from play- and art-based developmental literature.

RESULTS

Findings indicate that patients' children are constantly worried and distressed, and there are barriers that can be overcome to mitigate this. Four overarching themes were identified: (I) Feeling worried and distressed; (II) Comprehending their parent's cancer diagnosis; (III) Being disconnected from their supports; and (IV) Needing someone to talk to.

CONCLUSIONS

Children experience considerable levels of ongoing worry and distress when a parent is diagnosed with cancer and have difficulties comprehending and articulating this. They also feel a level of disconnection from their usual support systems (e.g., parents) and are limited regarding who they can seek out and talk to. Mitigating children's ongoing worries and distress by promoting the availability and accessibility of parents and other supports to children, and reducing communication barriers between children and adults, should be a primary focus of psycho-oncology research and practice.

How is my child doing - parental understanding of their children when a parent has cancer

To explore the difficulties parents face when understanding their children's reactions to parental cancer and parents' reactions to their children's perceived needs.

Qualitative interviews with cancer patients and their partners.

Eleven patients and seven partners took part. Their children were aged 1-15 years. Eight patients were mothers and cancer was diagnosed median 28 (7-104) months ago.

Inductive analysis with systematic text condensation.

Parents were groping in the dark when understanding their children's reactions. They observed signs of distress in their children, but often avoided communication about emotional reactions. We suggest parental difficulties in containing own and children's emotions as an important cause for this situation.

Parents lacked relevant support offers for the family as a unit. Identification of children's difficulties cannot be based on parental evaluation alone. We suggest family support as part of standard care for patients with minor children.

Recognition of Insufficient Competence-Nurses' Experiences in Direct Involvement With Adolescent Children of Cancer Patients

BACKGROUND

A parent's cancer may have disruptive impact on his/her adolescent children. Currently, nurses have been regarded as central actors in direct involvement with patients' minor children. Development of an extended nursing role has become a pertinent issue.

OBJECTIVE

Adolescents' needs tend to be overlooked by nurses because of inexperience with this population. The aim of this study was to explore nurses' experiences of direct involvement with these adolescents, to get a deeper understanding about this phenomenon.

METHODS

Using a constructivist grounded theory approach, 12 interviews were conducted among Norwegian nurses within the cancer care context. The category insufficient competence was explored through analyzing participants' experiences of direct involvements with adolescents.

RESULTS

The recognition of insufficient competence became visible as nurses experienced being involved with a population about whom they held inadequate and limited knowledge. Adolescents were perceived as unpredictable and rejecting nurses' approaches. Consequently, nurses feared involvement and experienced failing on their assignments. After completing more or less failed attempts to establish good relationships with adolescents, the nurses request for more knowledge and experience in order to support this group.

CONCLUSIONS

Nurses are recognizing insufficient competence in direct involvement with adolescents, which calls for extended competence. Because nurses are not the only responsible actors performing in this field, building competence requires a broadened attention at both an individual and organizational level, across several healthcare disciplines, as well as through user participation.

IMPLICATIONS FOR PRACTICE

Competence building should be considered in light of organizational frameworks, collective learning possibilities across disciplines, and opportunities for involving adolescents/young adults as user participants.

A systematic review of the current interventions available to support children living with parental cancer

OBJECTIVE

Children living with parental cancer are vulnerable to distress and developmental disruption. This review aims to identify current interventions to support cancer patients' children and summarise how effective these are based on children's reports.

METHODS

Between 25 May 2015 and 6 August 2018, a broad search strategy was used to identify relevant references. Seven databases were searched, and grey literature was also vetted. This review was informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Cochrane guidelines.

RESULTS

Eight studies evaluating six interventions were retained. Research designs and interventions were heterogenous, and study quality was low. A limited number of significant results were reported by studies. These evidenced improvement for PTSD symptoms, emotional regulation, and depression. However, overall current interventions do not appear effective among patients' children.

CONCLUSION

Despite encouraging preliminary findings, interventions do not yet adequately support cancer patients' children. There is a need for more tailored and targeted interventions. A theoretical model conceptualising the impact of parental cancer may assist this.

PRACTICE IMPLICATIONS

Findings will assist future intervention research by promoting standardised levels of care among cancer patients' children, that is empirically supported, effective, and meets principles of non-maleficence.

Somatic symptoms in children who have a parent with cancer: A systematic review

BACKGROUND

This systematic review explored the occurrence and types of somatic symptoms in children (0-20 years) who have experienced parental cancer.

METHODS

We complemented a systematic literature search from PubMed and PsycInfo with a reference search. We identified 1,694 articles, which were independently screened by two authors; they further evaluated potentially relevant papers for quality and extracted the data. We found nine relevant studies (10 publications) on altogether 672 children with a parent who had cancer; four studies included a control group.

RESULTS

The studies typically focused on children's psychosocial reactions on parental cancer rather than somatic complaints, so symptom prevalence cannot be reliably summarized. Several studies were small, and the types of somatic symptoms were only specified in five studies. Somatic symptoms were reported as a measure of emotional reactions in the remaining four studies. Three studies provided longitudinal data. The main types of specific symptoms reported were eating problems, pain, sleeping troubles, and bed-wetting. Children of cancer patients tended to show an increase of unspecified somatic symptoms and pain, but evidence was inconsistent. There was a tendency that somatic complaints were associated with increased emotional distress in the children. The material did not allow for separate analysis by age group or bereavement status.

CONCLUSIONS

Children in families with parental cancer may present with somatic complaints, but the prevalence and significance is not possible to estimate due to very sparse research in this area. Health professionals or counselling providers should not overlook this possible sign of distress. Qualitative studies report significant health anxiety in these children; this may represent a specific topic for counselling in this population. Targeted studies are needed to evaluate the prevalence and significance of somatic symptoms, and especially vulnerable groups need to be identified.

'It is that bad but it isn't that bad': Exploring children's experiences of their mother's non-terminal cancer with a focus on attachment, resilience and trauma

Recent years have shown a welcome trend in the number of people surviving cancer. The impact of cancer survival has focused primarily on the patient perspective, and limited research has explored the effect of parental cancer on children. No research to date can be found which explores children's experiences of parental cancer from a narrative perspective yet the way in which people tell their story is associated with emotional wellbeing. Measures of attachment, resilience and trauma were completed by 10 children (six girls, four boys aged 10-18 years) all of whom have a mother with non-terminal cancer. Each child also completed a narrative interview where they spontaneously described their experiences. Interviews were analysed drawing on narrative and thematic approaches to ensure the structural and performative as well as content of the stories could be understood. Experiences were interpreted within the context of attachment, resilience and trauma. Clinically high levels of trauma were found within this group even for securely attached and resilient children. The narrative analysis corroborated this finding. Implications for services supporting families are discussed.

Study protocol: a randomized control trial of African American families fighting parental cancer together

Background

African American adults experience a disproportionate burden and increased mortality for most solid tumor cancers and their adolescent children are negatively impacted by the illness experience. The purpose of this randomized clinical trial is to evaluate the efficacy of a culturally sensitive family-based intervention program developed for African American families coping with solid tumor parental cancer using an intention-to-treat approach. Primary outcome is adolescent depressive symptoms at end of treatment.

Methods

A sample of 172 African American families will be enrolled from two diverse oncology centers (Helen Graham Cancer Center in Newark, DE, and Kimmel Cancer Center in Philadelphia, PA). Eligible families will be randomized either to a 5-session intervention Families Fighting Cancer Together (FFCT) or a 5-session parent-only psycho-educational (PED) program. Assessments will occur at weeks 0 (baseline), 8 (end-of-treatment), 24, and 52.

Discussion

Treatments to help African American adolescents cope with the impact of parental cancer are scarce and urgently needed. If successful, this proposed research will change the nature of intervention support options available to African Americans, who are overrepresented and underserved by existing services or programs.

Trial registration

This project is registered with ClinicalTrials.gov (Protocol #: NCT03567330).

How does parental cancer affect adolescent and young adult offspring? A systematic review

OBJECTIVES

To i) identify and synthesise evidence published since 2007 regarding the impact of parental cancer on adolescent and young adult offspring, ii) identify methodological and evidence gaps addressed during this period and iii) highlight those requiring further attention.

DESIGN

A systematic review and thematic synthesis of peer reviewed literature regarding the impact of parental cancer upon AYA offspring.

DATA SOURCES

Online searches of CINAHL, Embase, Medline, PsychInfo and Scopus databases were conducted. Reference lists of included articles were screened and additional searches by prominent authors were performed.

REVIEW METHODS

Study selection, data extraction and quality analysis was undertaken by three independent researchers. Extracted study data was iteratively reviewed and discussed to achieve consensus regarding thematic synthesis of included studies.

RESULTS

Database and hand-searching yielded 1730 articles, 54 of which were included in the final synthesis. Included studies are discussed with respect to the following themes: i) study design and quality; ii) measurement and sampling; iii) positive and negative aspects of parental cancer; iv) needs; v) communication and information; vi) coping strategies; vii) interventions; and viii) family functioning and other predictors. Twenty-nine studies reported negative impacts related to parental cancer, while eight identified positive outcomes related to post-traumatic growth. Five returned null or mixed findings. Unmet needs were frequently explored and a new validated measure developed. Communication and information were particularly important for offspring, though these needs were often unmet and parents wanted guidance regarding discussions with their children. Offspring may adopt a variety of coping strategies, some of which appear maladaptive, and may cycle between different approaches. Few evaluations of interventions were identified, and further work in this area is needed. Further evidence has emerged that poorer family functioning and other family and illness-related factors predict worse psychosocial outcomes for offspring, however evidence for other predictors such as age and gender remain mixed.

CONCLUSIONS

Additional evidence for the negative psychosocial impact of parental cancer on adolescent and young adult offspring, their needs, and factors predicting psychosocial outcomes has emerged in the last decade. However, substantial gaps and methodological issues remain and evidence for the development, efficacy or implementation of interventions for this population is very limited. There is also a clear need for greater focus on bereaved and young adult offspring and those from non-western cultural groups, who remain under-represented in research conducted to date.

Posttraumatic Stress Disorder Symptoms and Family Functioning in Adult Children Facing Parental Cancer: A Comparison Study

This study analyzed posttraumatic stress disorder (PTSD) symptoms and family functioning in a sample of adult children caregivers of cancer patients and in a group of adult children of nonchronically ill parents. Participants completed measures of family functioning and PTSD symptoms. The parental cancer group was subdivided into PTSD subgroups, and significant differences, on family functioning, were found. In the parental cancer group, the predictors of PTSD symptoms were being a woman and having an enmeshed or chaotic family functioning. Chaotic functioning mediated the relationship between family communication/satisfaction and PTSD symptoms, in the parental cancer group. Finally, there was a higher prevalence of PTSD symptoms in the parental cancer group, and participants with a probable PTSD diagnosis showed higher levels of family imbalance. This study shows that adult children facing parental cancer, who have a poorer family balance, may benefit from interventions that target family functioning.

Psychometric properties of the Parenting Concerns Questionnaire in cancer survivors with minor and young adult children

OBJECTIVE

Although cancer patients with minor children have become more of a focus of psycho-oncological research, little is known about specific parenting concerns. Instruments to assess the concerns and worries of parents with cancer are rare. The Parenting Concerns Questionnaire (PCQ) addresses this issue. We analyzed parenting concerns in cancer survivors and evaluated the German version of the PCQ.

METHODS

A total of 1416 cancer survivors with minor and young adult children (≤21 years) were recruited in a register-based study. Descriptive analyses as well as reliability and validity analyses were conducted. We performed a confirmatory factorial analysis of the factor structure proposed by the authors of the original version on the PCQ.

RESULTS

Seventy-three percent of the cancer survivors were women, average age was 47.5 years (SD 5.9). Mean time since diagnosis was 44 months (SD 23.4). Between 18 and 31% of survivors reported that they were concerned about their children. The PCQ proved to be a reliable and valid instrument showing medium correlations with standardized measures in expected directions and discriminating between survivors with and without use of psychosocial support services. The factor structure was supported by the confirmatory factorial analysis.

CONCLUSIONS

Assessing parenting concerns gives an additional insight into the situation of parents with cancer. In our sample of cancer survivors, we identified one out of three survivors being concerned regarding the impact of their illness on their children. The PCQ can be considered as a valid and reliable instrument with regard to identifying concerned parents with cancer. Copyright © 2015 John Wiley & Sons, Ltd.

Childhood injury after a parental cancer diagnosis

A parental cancer diagnosis is psychologically straining for the whole family. We investigated whether a parental cancer diagnosis is associated with a higher-than-expected risk of injury among children by using a Swedish nationwide register-based cohort study. Compared to children without parental cancer, children with parental cancer had a higher rate of hospital contact for injury during the first year after parental cancer diagnosis (hazard ratio [HR] = 1.27, 95% confidence interval [CI] = 1.22-1.33), especially when the parent had a comorbid psychiatric disorder after cancer diagnosis (HR = 1.41, 95% CI = 1.08-1.85). The rate increment declined during the second and third year after parental cancer diagnosis (HR = 1.10, 95% CI = 1.07-1.14) and became null afterwards (HR = 1.01, 95% CI = 0.99-1.03). Children with parental cancer also had a higher rate of repeated injuries than the other children (HR = 1.13, 95% CI = 1.12-1.15). Given the high rate of injury among children in the general population, our findings may have important public health implications.

DOI:http://dx.doi.org/10.7554/eLife.08500.001

A diagnosis of cancer can be devastating for both a person and his or her family. Over the past 40 years, the number of individuals in Sweden diagnosed with cancer has more than doubled leaving growing numbers of families coping with the aftermath. Many individuals diagnosed with cancer have young children. Parents with cancer and their spouses often struggle to cope with disease and the demands of parenting simultaneously. In fact, previous research has shown children with a parent who has cancer have a greater risk of behavioral problems or distress than children with two healthy parents.

Whether the stress of having a parent with cancer also affects the children’s physical wellbeing hasn’t been studied much. One concern in particular is whether these children may be at increased risk of injury. Injuries are the most common reason for a child to visit a hospital and in some cases lead to deaths. Children who are not well supervised or whose parents have poor mental health are at increased risk of injury. Coping with cancer and the mental anguish it causes may distract parents and possibly place their children at increased risk of injury.

Based on data from nationwide population and health registers in Sweden, Chen, Regodón Wallin et al. now provide evidence that a child with a parent who has cancer is at a greater risk of injury than a child with two parents who are free of cancer. The analysis also revealed that the risk is particularly great if the parent with cancer also develops mental illness after the cancer diagnosis. The risk of injury is greatest in the first year after the parent’s diagnosis. Fortunately, the elevated risk of injury decreases overtime and is almost non-existing after the third year. The analyses suggest that providing extra support for parents with cancer might help to reduce the risk of injury in their children.

DOI:http://dx.doi.org/10.7554/eLife.08500.002

Psychosocial Problems of Teenagers Who Have a Parent With Cancer: A Population-Based Case-Control Study (Young-HUNT Study)

Purpose

High prevalence of psychosocial problems has been observed in clinical studies of teenagers who have a parent with cancer. In contrast, we used a population-based design to study such problems in teenagers who have a parent with cancer (cases) compared with matched teenagers with cancer-free parents (controls). We hypothesized that higher prevalence of psychosocial problems would be observed in cases compared with controls and that sex differences would be observed between cases and controls.

Methods

We used data from a cross-sectional population-based survey of teenagers (Young-HUNT study). Among 8,986 teenage participants, 120 of their parents had invasive cancer before the Young-HUNT study according to the Norwegian Cancer Registry. These parents had 143 teenagers (cases) participating in the Young-HUNT study. Matched on sex, age, and municipality, 429 control teenagers with cancer-free parents were drawn from the Young-HUNT study. Six psychosocial problems were studied.

Results

No significant differences in psychosocial problems were observed between cases and controls in the total sample. Fewer case daughters reported eating problems compared with control daughters, and more case sons reported eating problems compared with control sons. More case daughters than case sons reported somatic stress symptoms and low self-esteem and displayed more caseness of anxiety/depression. These three sex differences were also observed among controls, indicating that they were general sex differences.

Conclusion

In this population-based study, teenagers who had a parent with cancer did not have higher prevalence of psychosocial problems than controls. Sex differences observed in previous clinically based studies were confirmed but may simply reflect sex differences observed among teenagers in general.

When a parent has cancer: challenges to patients, their families and health providers

At least 14% of cancer patients live with minor children. Being a parent with cancer has far-reaching consequences for individual treatment decision-making and quality of life in patients and their families. Even though the majority of children and adolescents do not show clinically relevant symptoms of psychopathology, worries about the survival of the parent and the future development of the family are present, and experienced as distressing, in most children. Open communication by parents and clinicians has been found to be of major importance for children and adolescents in adjusting to parental cancer. Support for parents with cancer on relevant parenting issues, starting in the diagnostic phase, should be acknowledged as an important facet of cancer care to reduce the psychosocial burden for cancer patients and their families.

Coping skills and mental health status in adolescents when a parent has cancer: a multicenter and multi-perspective study

OBJECTIVE

Parental cancer increases the risk of psychosocial problems in adolescents. We investigated the frequency and efficacy of adolescents' coping strategies and relationships between those strategies and mental health status. Age and gender differences regarding coping and mental health were also investigated.

METHODS

In total, 214 adolescents from 167 families participated in a cross-sectional, multicenter study. All participants were recruited from standard oncological care. Among the participants, 52% utilized a child-centered intervention program. Adolescents' coping skills were measured using KIDCOPE. Mental health status was rated by adolescents and parents by the SDQ for symptomatology and the KIDSCREEN for well-being.

RESULTS

We found that 29% of the adolescents showed emotional and behavioral problems. We found gender differences in mental health status but not in coping. Adolescents used a broad spectrum of coping strategies. Active problem-solving, distraction, acceptance, wishful thinking and seeking social support were the most frequently used coping strategies. The utilization of certain coping skills was mediated by their perceived efficacy. Problem-focused or approach-oriented coping strategies generally are associated with better mental health, while avoidance-oriented coping are associated with worse mental health. Emotion-focused coping was associated with both lower and higher mental health.

CONCLUSION

The strategies used by adolescents to cope with parental cancer are associated with their mental health. Problem-solving and approach-oriented coping strategies should be facilitated by psychological interventions regardless of age and gender. Age and gender differences in adolescents' mental health should be further investigated because these differences are not explained by differences in coping strategies.

Parental cancer: factors associated with children's psychosocial adjustment--a systematic review

OBJECTIVE

Children of cancer patients have an increased risk of developing psychosocial problems. But not all children are alike vulnerable to this stressful event. Thus, knowledge of risk and protective factors is required to design specific diagnostic tools and interventions for this vulnerable population. This study aims to provide a review and methodological evaluation of current studies examining factors associated with children's psychosocial adjustment when a parent has cancer.

METHODS

Four databases were systematically searched for quantitative research articles examining associative factors of children's adjustment. Study characteristics were analyzed and methodological quality was assessed by two independent reviewers.

RESULTS

28 studies examining associative factors in 2896 families were identified. The included studies used a broad range of instruments assessing children's adjustment. Most patients were female breast cancer patients with middle to high socio-economic status. The majority of included studies used correlational approaches and cross-sectional designs. None of the studies examined toddlers or assessed children's quality of life. Across studies with low to high quality, we found no evidence of illness-related factors, except worse disease status that was related to lower adjustment. Evidence from moderate to high quality studies suggest that better family functioning indicates better adjustment, whereas parent's depressive mood indicates worse adjustment of the children. Child-related factors were inconsistent.

CONCLUSION

Health professionals should pay attention to cancer patients' dependent children. In order to identify this at-risk population, parent's depressive mood and poor family functioning should be considered. Future studies should also assess children's quality of life and child-related factors.