Posttraumatic stress, family functioning, and social support in survivors of childhood leukemia and their mothers and fathers

Problems, Stressors and Needs of Children and Adolescents with Cancer

BACKGROUND

Cancer diseases in children and adolescents are considered to be one of the most serious health problems in the world. It is estimated that about 151,435 cases are diagnosed in children annually. Children with cancer experience many comorbid symptoms related to diagnosis and treatment that can profoundly affect their lives. They experience physical and emotional suffering, which affects their well-being and physical fitness, influencing the prognosis and deteriorating their physical, mental and social functioning. Given the limited data, an attempt was made to assess the problems of the biopsychosocial sphere of need and stressors among children and adolescents treated for cancer. Accurate symptom assessment is essential to ensure high-quality care and effective treatment.

PATIENTS AND METHODS

The qualitative study was conducted in pediatric oncology of hospitals in Poland. Children diagnosed with cancer were invited to participate in the study to assess their problems, stressors and needs.

RESULTS

The study included 520 people, where female sex constituted 48% and male 52%. The mean age of the children is 13.2 SD = 2.5. Negative experiences related to the disease are experienced by 82% of children. Among the surveyed children, the most experienced were anxiety (61%). The conducted research shows that as many as 69% of all respondents experienced states that indicate severe depression. The most common somatic problems reported by children were pain (58%). The most dominant areas of life that had a negative impact was body image (85%).

CONCLUSIONS

Children and adolescents diagnosed with neoplastic disease experience many problems and stressors in every sphere of life, which undoubtedly affects a high level of unmet needs. The main category of needs concerning the challenges faced by children with cancer was psychological and care problems. In the youth group, the needs were mainly related to education and social support.

The Psychoneuroimmunology of Stress Regulation in Pediatric Cancer Patients

Stress is a ubiquitous experience that can be adaptive or maladaptive. Physiological stress regulation, or allostasis, can be disrupted at any point along the regulatory pathway resulting in adverse effects for the individual. Children with cancer exhibit significant changes to these pathways in line with stress dysregulation and long-term effects similar to those observed in other early-life stress populations, which are thought to be, in part, a result of cytotoxic cancer treatments. Children with cancer may have disruption to several steps in the stress-regulatory pathway including cognitive-affective function, neurological disruption to stress regulatory brain regions, altered adrenal and endocrine function, and disrupted tissue integrity, as well as lower engagement in positive coping behaviours such as physical activity and pro-social habits. To date, there has been minimal study of stress reactivity patterns in childhood illness populations. Nor has the role of stress regulation in long-term health and function been elucidated. We conclude that consideration of stress regulation in childhood cancer may be crucial in understanding and treating the disease.

Active Music Engagement and Cortisol as an Acute Stress Biomarker in Young Hematopoietic Stem Cell Transplant Patients and Caregivers: Results of a Single Case Design Pilot Study

This paper reports the results of a single case design pilot study of a music therapy intervention [the Active Music Engagement (AME)] for young children (age 3.51 to 4.53 years) undergoing hematopoietic stem cell transplantation (HCST) and their caregivers. The primary aims of the study were to determine feasibility/acceptability of the AME intervention protocol and data collection in the context of HCST. Secondary aims were to examine caregivers' perceptions of the benefit of AME and whether there were changes in child and caregiver cortisol levels relative to the AME intervention. Results indicated that the AME could be implemented in this context and that data could be collected, though the collection of salivary cortisol may constitute an additional burden for families. Nevertheless, data that were collected suggest that families derive benefit from the AME, which underscores the need for devising innovative methods to understand the neurophysiological impacts of the AME.

Online Validation of a Battery of Questionnaires for the Assessment of Family Functioning and Related Factors

BACKGROUND

Family functioning relies on different factors that are related to the individual characteristics of each member, the social context in which the family nucleus is integrated, and the internal and interpersonal family factors. The Short Version of the Family Assessment Measure-III, Dyadic Adjustment Scale, Inventory of Parent and Peer Attachment, Twenty-item Toronto Alexithymia Scale, Hospital Anxiety and Depression Scale, and Multidimensional Scale of Perceived Social Support are among the most commonly employed self-report measures for the assessment of family functioning and related factors. Traditionally, these scales have been administered using paper-and-pencil versions. However, with increased access to the Internet, online administration of questionnaires has become more common. The present study aimed to validate an online version of each of the above-mentioned questionnaires in a heterogeneous sample of Italian healthy individuals.

METHODS

One-hundred participants were recruited for each questionnaire. A crossover design was used in each validation. The minimum important difference (MID) was applied to evaluate the differences in the variances of the paper-and-pencil and online format scores. A MID >0.5 is a reasonable first approximation of a threshold of important change. Taking into account the cross over design, mean difference between pencil-and-paper and online versions, and Intraclass Correlation Coefficient were also estimated by mixed models.

RESULTS

The MID was <0.5 for all the instruments used. Therefore, no significant difference was observed between the score variances of the paper-and-pencil and online formats of all the questionnaires. Moreover, for each questionnaire the difference between the means of online and paper-and-pencil administrations scores (mean O-P) was calculated. We reported 95% confidence intervals that did not include the 0; therefore, mean (O-P) was not statistically significant.

CONCLUSIONS

The current findings indicate that the online versions of all the questionnaires we administered can be considered reliable tools for the assessment of family functioning and related factors.

Cortisol as an Acute Stress Biomarker in Young Hematopoietic Cell Transplant Patients/Caregivers: Active Music Engagement Protocol

Objective: Primary aims of the proposed protocol are to determine the feasibility/acceptability of the active music engagement intervention protocol during hematopoietic stem cell transplantation (HSCT) and clinical feasibility/acceptability of the biological sample collection schedule.

Design: The authors propose a single-case, alternating treatment design to compare levels of child and caregiver cortisol in blood and saliva collected on alternating days, when the dyad receives and does not receive AME sessions. Included are the scientific rationale for this design and detailed intervention and sample collection schedules based on transplant type.

Setting/Location: Pediatric inpatient HSCT unit.

Subjects: Eligible participants are dyads of children 3–8 years old, hospitalized for HSCT, and their caregiver. Children with malignant and nonmalignant conditions will be eligible, regardless of transplant type.

Intervention: AME intervention is delivered by a board-certified music therapist who tailors music-based play experiences to encourage active engagement in, and independent use of, music play to manage the inter-related emotional distress experienced by children and their caregivers during HSCT. Dyads will receive two 45-min AME sessions each week during hospitalization.

Outcome Measures: Eight collections of blood (child) and saliva (child/caregiver) will be performed for cortisol measurement. The authors will also collect self-report and caregiver proxy measures for dyad emotional distress, quality of life, and family function. At study conclusion, qualitative caregiver interviews will be conducted.

Results: Planned analyses will be descriptive and evaluate the feasibility of participant recruitment, cortisol collection, planned evaluations, and AME delivery. Analysis of qualitative interviews will be used to gain an understanding about the ease/burden of biological sample collection and any perceived benefit of AME.

Conclusions: Behavioral intervention studies examining biological mechanisms of action in pediatric transplant populations are rare. Findings will provide important information about the feasibility/acceptability of collecting cortisol samples during a high-intensity treatment and advance understanding about the use of active music interventions to mitigate child/caregiver distress during the transplant period.

Understanding differences in the long-term psychosocial adjustment of pediatric cancer patients and their parents: an individual differences resources model

The experience of childhood cancer is a major life stressor for children and their parents. There is substantial variability among pediatric cancer patients and their parents in their ability to cope with the cancer. Although other models typically focus on the psychological resources families use to broadly cope with a diagnosis of pediatric cancer, we present a model that focuses specifically how parents and children cope with the stress of invasive and often painful treatment episodes. Our resources model is further distinct with its focus on individual differences in personal (e.g., personality traits) and social (e.g., social support) resources and the role these differences may play in psychosocial adjustment of families confronting pediatric cancer. We use findings from the broader pediatric cancer research literature and our own 15-year program of research on individual differences in psychological resources and parents and children's responses to treatment episodes to provide empirical support for our model. Support was found for the six premises of the model: (a) parent resources influence their longer-term psychosocial adjustment, (b) parent resources influence children's responses to treatment episodes, (c) parent resources indirectly influence their longer-term psychosocial adjustment through their responses to treatment episodes, (d) children's personal resources influence how parent responses to treatment episodes, (e) children's resources influence their longer-term psychosocial adjustment, and (f) children's resources indirectly influence their longer-term psychosocial adjustment through their responses to treatment episodes. Understanding how the availability of resources influences parents and children confronting cancer provides a foundation for future research on individual differences in resources and offers other avenues through which clinicians can assess and treat families at risk for poor psychosocial adjustment during treatment and in their life beyond cancer treatments.

Pediatric cancer, posttraumatic stress and fear-related neural circuitry

This review examines the neurobiological effects of pediatric cancer-related posttraumatic stress symptoms (PTSS). We first consider studies on prevalence and predictors of childhood cancer-related PTSS and compare these studies to those in typically developing (i.e., noncancer) populations. Then, we briefly introduce the brain regions implicated in PTSS and review neuroimaging studies examining the neural correlates of PTSS in noncancer populations. Next, we present a framework and recommendations for future research. In particular, concurrent evaluation of PTSS and neuroimaging, as well as sociodemographic, medical, family factors, and other life events, are needed to uncover mechanisms leading to cancer-related PTSS. We review findings from neuroimaging studies on childhood cancer and one recent study on cancer-related PTSS as a starting point in this line of research.

Development and validation of self- and caregiver-report of a distress screening tool for pediatric cancer survivors

PURPOSE

To develop and validate the Distress Screening Tool (DST) for child and adolescent cancer survivors.

METHODS

In part 1, items of the DST were generated through literature search and group interviews. Initially, the DST was tested on pediatric cancer survivors and their caregivers. In part 2, the modified version of the DST was retested with a different set of participants. Lastly, the psychometric properties and cutoff scores of the DST were evaluated on a separate set of survivors and caregivers.

RESULTS

In part 1, six items of the DST self- and caregiver-report versions were generated. The initial 6 DST items of both versions showed acceptable internal consistency, but low inter-item correlation. Following the item modification, both versions of the DST showed improved inter-item correlation. In part 2, the modified DST had acceptable internal consistency and convergent validity, with acceptable psychometric properties. Cutoff scores were also generated.

CONCLUSIONS

The DST could be a useful tool for pediatric cancer survivors.

Childhood Cancer and Brain Tumor Late Effects: Relationships with Family Burden and Survivor Psychological Outcomes

This study examines illness-specific family burden as a mediator of the association between late effects of childhood cancer and survivors' emotional and behavioral outcomes. Childhood cancer survivors (n = 65; ages 10-17) two or more years off-treatment completed measures assessing internalizing and PTSD symptoms. Parents reported on illness-specific family burden, late effects severity, and survivor internalizing/externalizing problems. Providers documented the number of late effects. Illness-specific family burden was correlated with provider-reported late effects (r = .29, p < .05) and parent report of severe late effects (r = .56, p < .01). Results supported an indirect effect of illness-specific family burden on number of late effects and parent-reported survivor internalizing problems, p < .05. Indirect effects were not found in models predicting PTSD and externalizing problems. Illness-specific family burden is an important intervention target for reducing internalizing problems in childhood cancer survivors with late effects.

Trajectories of child and caregiver psychological adjustment in families of children with cancer

OBJECTIVE

To describe the trajectory of patient and caregiver mental health from diagnosis through the first year of treatment for pediatric cancer and assess whether rates of clinically relevant symptoms were elevated compared with norms. We examined mean levels of internalizing and externalizing symptoms and posttraumatic stress symptoms (PTSS) in children with cancer, and depression, anxiety, and PTSS in caregivers during the first year of treatment; the proportion of patients and caregivers that scored in the clinical range at each time point; and the typical trajectory of symptoms in patients and caregivers and whether trajectories differed between individuals.

METHOD

Families (N = 159) of children newly diagnosed with cancer (Mage = 5.6 years; range = 2-18 years) participated in a short-term prospective study. Primary caregivers provided monthly reports of their own and their children's psychological adjustment.

RESULTS

On average, children were well-adjusted. However, compared with norms, there was a higher than expected proportion of children with clinically relevant internalizing symptoms around the time of diagnosis. On average children's symptoms declined over time, though variability was observed. Caregivers were less well-adjusted on average, with a high proportion reporting clinically relevant symptoms over time for depression and anxiety. Caregiver symptoms also declined over time, though considerable variability was observed.

CONCLUSION

Although most children remain well-adjusted during the first year of treatment, many caregivers experience clinically relevant symptoms of psychological distress. Implications for development of interventions targeting at-risk patients and caregivers are discussed. Identifying processes that predict between-family variability in trajectories of psychopathology is an important next step. (PsycINFO Database Record

Longitudinal analysis of quality-of-life outcomes in children during treatment for acute lymphoblastic leukemia: A report from the Children's Oncology Group AALL0932 trial

BACKGROUND

Children with average-risk acute lymphoblastic leukemia (AR-ALL) face many challenges that can adversely affect their quality of life (QOL). However, to the authors' knowledge, patterns and predictors of QOL impairment during therapy have not been well characterized to date.

METHODS

Patients with AR-ALL who were enrolled on the Children's Oncology Group AALL0932 trial were offered participation in this prospective cohort study if they were aged ≥4 years at the time of diagnosis and had an English-speaking parent. At approximately 2 months, 8 months, 17 months, 26 months, and 38 months (boys only) after diagnosis, parents completed the Pediatric Quality of Life Inventory Generic Core Scales Version 4.0 (PedsQL4.0) and McMaster Family Assessment Device instruments for QOL (physical, emotional, and social functioning) and family functioning, respectively. The proportions of individuals scoring in the impaired range (2 standard deviations below the population mean) were calculated at each time point. Longitudinal impairment patterns and predictors were examined.

RESULTS

A total of 594 participants with AR-ALL were diagnosed at a mean age of 6.0 years (standard deviation, 1.6 years). At 2 months, a substantial proportion of participants had impaired scores for physical (36.5%; 95% confidence interval [95% CI], 32.3%-40.8%) and emotional (26.2%; 95% CI, 22.5%-30.2%) functioning compared with population norms of 2.3%. These elevations persisted at 26 months. Emotional impairment at 2 months (odds ratio, 3.4; 95% CI, 1.5-7.7) was found to significantly predict emotional impairment at 26 months. In repeated measures analysis with multivariate modeling, unhealthy family functioning (odds ratio, 1.5; 95% CI, 1.1-2.1) significantly predicted emotional impairment controlling for age and sex. QOL outcomes were similar between sexes at the end of therapy (26 months for girls and 38 months for boys).

CONCLUSIONS

Many children with AR-ALL experience physical and emotional functioning impairment that begins early in treatment and persists. Early screening may identify high-risk patients who might benefit from family-based interventions. Cancer 2018;124:571-9. © 2017 American Cancer Society.

Predictors of Posttraumatic Stress and Posttraumatic Growth in Childhood Cancer Survivors

This longitudinal study aims to analyze predictors of posttraumatic stress symptoms (PTSS) and posttraumatic growth (PTG) among gender, age, objective factors of the disease and its treatment, family environment factors and negative emotionality. The sample consisted of 97 childhood cancer survivors (50 girls and 47 boys) aged 11-25 years who were in remission 1.7 to seven years at T1 and four to 12.5 years at T2. Survivors completed a set of questionnaires including the Benefit Finding Scale for Children and the University of California at Los Angeles Posttraumatic Stress Disorder Index. Regression and correlation analyses were performed. The relation between PTSS and PTG was not proven. A higher level of PTSS (T2) was associated with higher levels of negative emotionality (T1). A higher level of PTG (T2) was connected to a higher level of warmth in parenting (T1), female gender and older age at assessment. Medical variables such as the severity of late effects and the time from treatment completion did not play a significant role in the prediction of PTSS and PTG. PTG and PTSS are more influenced by factors of parenting and emotional well-being of childhood cancer survivors than by objective medical data.

Prevalence and predictors of posttraumatic stress symptoms in parents of children with ongoing treatment for cancer in South China: a multi-centered cross-sectional study

PURPOSE

Parents of children with ongoing cancer treatment are exposed to risks of developing posttraumatic stress symptoms (PTSS), but little is known about the prevalence and predictors of PTSS among Chinese parents of children with cancer. This study aimed to examine the predictors of PTSS, and explored the correlation of depression, resilience, and family functions with severe PTSS.

METHODS

This cross-sectional survey was conducted from May 2014 to September 2015 among the parents of cancer children treated in four general hospitals in South China. PTSS in the parents were measured using post-traumatic stress checklist-civilian version (PCL-C). Multiple regression analyses were performed to evaluate the predictive values of depression, resilience, family functioning, and the demographic variables for severe PTSS.

RESULTS

A total of 279 parents (192 mothers and 87 fathers) participated in the survey. Severe PTSS, as defined by a PCL-C score ≥50, were reported in 32.97% (n = 92) of the total participants, 26.44% (23/87) in the fathers and 35.94% (69/192) in the mothers. The level of PTSS was positively correlated with depression (r = 0.782, P < 0.01) and a poor general family function (r = 0.325, P < 0.01) and negatively correlated with resilience (r = -0.236, P < 0.01). Multivariate analyses indicated that depression, general family function, gender, and education level were significant predictive factors of severe PTSS in the overall parents, accounting for 64.2% of the variance in the prediction of PTSS (R ² = 0.642, F = 122.602, P = 0.000). For the mothers, depression and family function accounted for 66.5% of the variance in the prediction of PTSS (R ² = 0.665, F = 187.451, P = 0.000); for the fathers, depression and educational level accounted for 58.8% of the variance in the prediction of PTSS (R ² = 0.588, F = 59.829, P = 0.000).

CONCLUSION

Parents, especially the mothers, of children with ongoing treatment for cancer are at risk of developing PTSS. Supportive psychological interventions to attenuate the negative emotions of the parents and improve their family functions are important means to promote their natural protective mechanisms to cope with the stressful events.

Psychosocial Outcomes of Sharing a Diagnosis of Cancer with a Pediatric Patient

PURPOSE

This innovative pilot study was designed to provide research-based evidence on the variables to consider informing a child of his/her cancer diagnosis, so as to minimize the negative psychosocial effects of the cancer experience on survivors. The hypotheses of the study were that "good information" about cancer, will allow the child a better understanding way to cope with treatment and improve sociopsychological outcomes at adulthood.

METHODS

Ninety-one adult childhood cancer (CC) survivors got the questionnaires while waiting to their routine checkup at a grate CC medical center in center Israel.

RESULTS

To our surprise and not according to the hypothesis, there was a difference between children diagnosed up to 12 years of age and those diagnosed during adolescence. (Participants were divided into two groups according to their age at diagnosis: from birth to 12 years old and from age 12-18). In the group diagnosed at a younger age, those who had received "good information" were found to have better quality of life, lower mental pain, and higher mental pain tolerance than did those in the same group (diagnosed at a younger age) who received "not good information." By contrast, in the group diagnosed during adolescence, those who had received "not good information" scored higher on these measures than did their counterparts who had received "good information."

CONCLUSION

Given that information conveyed to children diagnosed with cancer can have a significant impact on survivors' quality of life, further research is needed to determine the precise information to be divulged to children at the time of diagnosis. In the meantime, extreme caution, sensitivity, and careful judgment are required.

CLINICAL RELEVANCE

Findings of the current study and of future studies can be used to formulate clear guidelines for assessing a child's readiness and the information to be divulged, so as to improve the quality of life of CC survivors.

Profiles of Resilience and Growth in Youth With Cancer and Healthy Comparisons

OBJECTIVE

Inconsistent links between posttraumatic stress symptoms (PTS) and posttraumatic growth (PTG) in youth following a stressful life event have been observed in previous literature. Latent profile analysis (LPA) provides a novel approach to examine the heterogeneity of relations between these constructs.

METHOD

Participants were 435 youth (cancer group=253; healthy comparisons = 182) and one parent. Children completed measures of PTS, PTG, and a life-events checklist. Parents reported on their own PTS and PTG. LPA was conducted to identify distinct adjustment classes.

RESULTS

LPA revealed three profiles. The majority of youth (83%) fell into two resilient groups differing by levels of PTG. Several factors predicted youth's profile membership.

CONCLUSIONS

PTS and PTG appear to be relatively independent constructs, and their relation is dependent on contextual factors. The majority of youth appear to be resilient, and even those who experience significant distress were able to find benefit.

Satisfaction with support versus size of network: differential effects of social support on psychological distress in parents of pediatric cancer patients

OBJECTIVE

This study examined the direct and buffering effects of social support on longer-term global psychological distress among parents coping with pediatric cancer. In both sets of analyses, we examined whether these effects depended on the dimension of social support provided (i.e., satisfaction with support versus size of support network).

METHOD

Participants were 102 parents of pediatric cancer patients. At study entry, parents reported their trait anxiety, depression, and two dimensions of their social support network (satisfaction with support and size of support network). Parents subsequently reported their psychological distress in 3- and 9-month follow-up assessments.

RESULTS

Parents' satisfaction with support had a direct effect on longer-term psychological distress; satisfaction was negatively associated with distress at both follow-ups. In contrast, size of support network buffered (moderated) the impact of trait anxiety and depression on later distress. Parents with smaller support networks and higher levels of trait anxiety and depression at baseline had higher levels of psychological distress at both follow-ups; for parents with larger support networks, there was no relationship.

CONCLUSION

Social support can attenuate psychological distress in parents coping with pediatric cancer; however, the nature of the effect depends on the dimension of support. Whereas interventions that focus on increasing satisfaction with social support may benefit all parents, at-risk parents will likely benefit from interventions that ensure they have an adequate number of support resources.

Childhood Cancer in Context: Sociodemographic Factors, Stress, and Psychological Distress Among Mothers and Children

OBJECTIVE

To examine associations between sociodemographic factors (single parenthood, family income, education level, race), stress, and psychological distress among pediatric cancer patients and their mothers.

METHODS

Participants completed measures assessing sociodemographic variables, depressive symptoms, posttraumatic stress symptoms, general stress, and cancer-related stress within the first year of the child's (ages 5-17 years) cancer diagnosis or relapse. Mothers (N = 318) provided self-reports and parent report of their children; children aged 10-17 years (N = 151) completed self-reports.

RESULTS

Each sociodemographic variable demonstrated unique associations with mothers' and children's stress and distress in bivariate analyses. A cumulative sociodemographic risk measure was positively correlated with all stress and distress variables. In regression analyses predicting mothers' and children's distress, independent and cumulative sociodemographic measures were no longer significant when accounting for levels of stress.

CONCLUSIONS

Findings highlight the need to consider the ecological context of pediatric cancer, particularly the impact of sociodemographic disadvantage on stress and distress in this population.

Health-related hindrance of personal goals of adolescents with cancer: The role of the interaction of race/ethnicity and income

This study examined the interaction of race/ethnicity and income to health-related hindrance (HRH) of personal goals of adolescents with cancer. Adolescents (N = 94) receiving treatment for cancer completed a measure of HRH, (including identification of personal goals, rating the impact of health on goal pursuit, and ratings of goal appraisals). The interaction of race/ethnicity and income on HRH was examined. Goal content and appraisal were compared by race/ethnic groups. The interaction between race/ethnicity and income was significant in predicting HRH, with HRH increasing for minority adolescents as income increases and HRH decreasing for white adolescents as income increases. Higher income minority adolescents reported the most goals. Low income minorities reported the least difficult goals. Goal content did not differ between groups. Sociodemographic factors contribute to HRH in adolescents with cancer. Structural and psychosocial support during treatment to maintain goal pursuit may improve psychosocial outcomes.

Posttraumatic stress and psychological growth in children with cancer: has the traumatic impact of cancer been overestimated?

PURPOSE

To examine posttraumatic stress disorder and posttraumatic stress symptoms (PTSD/PTSS) in children with cancer using methods that minimize focusing effects and allow for direct comparison to peers without a history of cancer.

PATIENTS AND METHODS

Children with cancer (n = 255) stratified by time since diagnosis, and demographically matched peers (n = 101) were assessed for PTSD using structured diagnostic interviews by both child and parent reports, and survey measures of PTSS and psychological benefit/growth by child report.

RESULTS

Cancer was identified as a traumatic event by 52.6% of children with cancer, declining to 23.8% in those ≥ 5 years from diagnosis. By diagnostic interview, 0.4% of children with cancer met criteria for current PTSD, and 2.8% met lifetime criteria by self-report. By parent report, 1.6% of children with cancer met current criteria and 5.9% met lifetime criteria for PTSD. These rates did not differ from controls (all Ps >.1). PTSS levels were descriptively lower in children with cancer but did not differ from controls when all were referring to their most traumatic event (P = .067). However, when referring specifically to cancer-related events, PTSS in the cancer group were significantly lower than in controls (P = .002). In contrast, perceived growth was significantly higher in the cancer group when referring to cancer (P < .001).

CONCLUSION

These findings suggest no evidence of increased PTSD or PTSS in youths with cancer. Although childhood cancer remains a significant and challenging event, these findings highlight the capacity of children to adjust, and even thrive, in the face of such challenge.

Temperament, personality, and quality of life in pediatric cancer patients

OBJECTIVE

The developmental psychology literature shows that children with higher levels of effortful control (EC) and ego-resilience (ER) display greater social competence and better emotional adjustment. This study examined whether these dispositional attributes contribute to positive quality of life (QOL) in pediatric cancer patients.

METHOD

Participants were 103 pediatric cancer patients (and their parents) who were part of a larger parent study. At study entry, parents reported their own anxiety and depression and their children's EC and ER. At 3-month follow-up, parents reported children's QOL.

RESULTS

ER was positively correlated with children's QOL. EC showed a positive indirect effect on QOL through ER. Inclusion of potential correlates of pediatric QOL (e.g., parent neuroticism) did not change these relationships.

CONCLUSIONS

Temperament and personality play significant roles in pediatric cancer patients' QOL. Assessing dispositional attributes early in treatment may help identify children at risk for poor QOL during and after treatment.

Posttraumatic Stress Symptoms in Parents of Pediatric Cancer Patients: A Mediational Analysis

OBJECTIVE

Prior research finds that anxiety and depression among parents of pediatric cancer patients are associated with posttraumatic stress symptoms in response to children's cancer. This study examined whether this relationship is mediated by parents' negative affective reactions in response to their children's cancer-related treatment procedures.

METHODS

Participants were parents of 101 patients within six months of diagnosis who had completed at least two treatment-related procedures. Parents completed measures of trait anxiety and depression at baseline and posttraumatic stress symptoms at 3-month follow-up assessment. On the day of each treatment procedure, parents completed measures of state anxiety immediately before and negative mood and distress immediately after the procedure.

RESULTS

Trait anxiety was positively associated with state anxiety immediately before procedures and negative mood after procedures. Depression was positively associated with state anxiety immediately before procedures and negative mood and distress after procedures. Both trait anxiety and depression were positively associated with posttraumatic stress symptoms at 3-months follow-up. Parent state anxiety, negative mood, and distress partially mediated the effects of trait anxiety and/or depression on posttraumatic stress symptoms. Controlling for child age and social desirability did not affect these relationships.

CONCLUSIONS

Parents' trait anxiety and depression may influence cancer-related posttraumatic stress partially through their effect on parents' negative affective reactions at the time of their child's treatment procedures. These findings provide a more nuanced understanding of how parents' affect in response to procedures contributes to parent posttraumatic stress and suggest that interventions targeting treatment-related affective reactions of parents with high trait anxiety and/or depression may reduce the risk for longer-term distress and posttraumatic stress symptoms.

Perceptions of communication, family adaptability and cohesion: a comparison of adolescents newly diagnosed with cancer and their parents

PURPOSE

To describe and compare adolescent and parent perspectives on communication, family adaptability and cohesion, as well as relationships among these variables, during the first month of an adolescent's cancer diagnosis.

METHODS

Seventy adolescent-parent dyads were enrolled as part of a larger multi-site study. The adolescents ranged in age from 11 to 19, and 61% were males. Parents were predominately mothers (83%). Dyads were predominately non-Hispanic Caucasian (63%). Measures included the Parent-Adolescent Communication Scale and the Family Adaptability and Cohesion Evaluation Scale (FACES II). Paired t-tests, Pearson correlations, intra-class correlation coefficients and multiple linear regression analyses were completed.

RESULTS

Adolescent scores on communication, family adaptability and cohesion were significantly lower than parent scores. The inter-dyadic agreement between adolescents and parents was low. Communication, family adaptability and cohesion were examined separately for adolescents and for parents, and significant relationships were found. Both adolescent- and parent-perceived communication was significantly associated with family adaptability and cohesion outcomes.

CONCLUSIONS

Differences were found in adolescent and parent perceptions of communication, family adaptability and cohesion. When both adolescents and parents had better perceived communication, this was associated with better perceived family adaptability and cohesion. Results suggest that the development of interventions to enhance adolescent-parent communication could help foster better family adaptability and cohesion, which may ultimately impact their psychological adjustment. In addition, understanding the degree to which adolescents and parents disagree on their perceptions, including the results that parents generally have more favorable perceptions, may be a useful starting point when developing interventions.

Concordance of parent proxy report and child self-report of posttraumatic stress in children with cancer and healthy children: influence of parental posttraumatic stress

OBJECTIVE

This study examined the relationships between parental posttraumatic stress symptoms (PTSS), child PTSS, and parent-child concordance for child PTSS.

METHOD

Participants were children with cancer (n = 199), and healthy children (n = 108) and their parents. Children self-reported on PTSS and parents completed measures of child and parent PTSS.

RESULTS

In the cancer group, child and parent reports of child PTSS were significantly correlated with no mean differences between reporters. In contrast, correlations were non-significant in the control group, and parents reported significantly lower levels of child PTSS than children. Increased parental PTSS was associated with better concordance in the cancer group but not in the control group. In fact, in the cancer group, parent-child concordance was strongest at the highest level of parental PTSS.

CONCLUSIONS

Parents of children with cancer were found to be accurate reporters of their children's distress, even with high levels of reported personal distress. In contrast, parents of healthy children appear primarily influenced by personal distress when reporting child PTSS. Although multiple informant assessments are always desirable, it appears that utilization of a single informant may be reasonable in the cancer setting when access to informants is limited.

Cumulative family risk predicts sibling adjustment to childhood cancer

BACKGROUND

Prolonged, intensive treatment regimens often disrupt families of children with cancer. Siblings are at increased risk for distress, but factors underlying this risk have received limited empirical attention. In this study, the authors examined associations between the family context and sibling distress.

METHODS

Siblings of children with cancer (ages 8-18 years; N = 209) and parents (186 mothers and 70 fathers) completed measures of sibling distress, family functioning, parenting, and parent post-traumatic stress. Associations between sibling distress and each family risk factor were evaluated. Then, family risks were considered simultaneously by calculating cumulative family risk index scores.

RESULTS

After controlling for sociodemographic covariates, greater sibling distress was associated with more sibling-reported problems with family functioning and parental psychological control, lower sibling-reported maternal acceptance, and lower paternal self-reported acceptance. When risk factors were considered together, the results supported a quadratic model in which associations between family risk and sibling distress were stronger at higher levels of risk.

CONCLUSIONS

The current findings support a contextual model of sibling adjustment to childhood cancer in which elevated distress is predicted by family risk factors, both alone and in combination.

Children's positive dispositional attributes, parents' empathic responses, and children's responses to painful pediatric oncology treatment procedures

Pain/distress during pediatric cancer treatments has substantial psychosocial consequences for children and families. The authors examined relationships between children's positive dispositional attributes, parents' empathic responses, and children's pain/distress responses to treatment procedures. Participants were 41 pediatric cancer patients and parents. Several weeks before treatment, parents rated children's resilience and positive dimensions of temperament. Parents' pretreatment empathic affective responses to their children were assessed. Children's pain/distress during treatments was rated by multiple independent raters. Children's resilience was significantly and positively associated with parents' empathic affective responses and negatively associated with children's pain/distress. Children's adaptability and attention focusing also showed positive relationships (p < 0.10) with parents' empathic responses. Parents' empathic responses mediated effects of children's resilience on children's pain/distress. Children's positive dispositional attributes influence their pain/distress during cancer treatments; however, these effects may be mediated by parents' empathic responses. These relationships provide critical understanding of the influence of parent-child relationships on coping with treatment.

The role of family phenomena in posttraumatic stress in youth

TOPIC

Youth face trauma that can cause posttraumatic stress (PTS).

PURPOSE

(1) To identify the family phenomena used in youth PTS research; and(2) to critically examine the research findings regarding the relationship between family phenomena and youth PTS.

SOURCES

Systematic literature review in PsycInfo, PILOTS, CINAHL, and MEDLINE. Twenty-six empirical articles met inclusion criteria.

CONCLUSION

Measurement of family phenomena included family functioning,support, environment, expressiveness, relationships, cohesion, communication, satisfaction, life events related to family, parental style of influence, and parental bonding. Few studies gave clear conceptualization of family or family phenomena. Empirical findings from the 26 studies indicate inconsistent empirical relationships between family phenomena and youth PTS, although a majority of the prospective studies support a relationship between family phenomena and youth PTS. Future directions for leadership by psychiatric nurses in this area of research and practice are recommended.

Life satisfaction in adult survivors of cancer during adolescence: what contributes to the latter satisfaction with life?

PURPOSE

To compare the general and health-related life satisfaction (LS) in long-term survivors of adolescent cancer with a community sample and to identify medical and psychosocial factors associated with LS.

METHODS

LS of 820 survivors (age M = 30.4 ± 6.0 years; time since diagnosis M = 13.7 ± 6.0 years) was assessed with the Questions on Life Satisfaction (FLZ(M)) and compared to an age- and sex-matched community sample. The effects of medical, psychological, and socio-demographical factors on the survivors' general and health-related LS were investigated by means of multiple regression analyses.

RESULTS

Survivors were significantly less satisfied than the comparison group in terms of both their general (P < .001, d = -.35) and health-related (P < .001, d = -.47) life. Somatic late effects, symptoms of depression and anxiety, and less posttraumatic growth were associated with impaired general and health-related LS. Moreover, being married contributed significantly to higher general LS.

CONCLUSION

Adult survivors of cancer with onset during adolescence are experiencing less LS than the general population. Long-term routine follow-up visits are recommended to identify persisting effects of cancer survival on LS and to provide support for those with special needs. Physicians need to pay special attention to potential risk factors such as psychological distress, somatic late effects, persistent psychological distress, and a lack of posttraumatic growth, which are negatively correlated with LS.

Primary caregivers of children affected by disorders of sex development: mental health and caregiver characteristics in the context of genital ambiguity and genitoplasty

Purpose. To determine the relationship between having a child with a DSD including ambiguous external genitalia, as well as the decision of whether or not to have early genitoplasty for that child, on the mental health and parenting characteristics of caregivers. Materials and Methods. Caregivers were recruited from centers that specialize in DSD medicine and completed the Beck Depression Inventory 2nd Edition (BDI-2), Beck Anxiety Index (BAI), Parent Protection Scale (PPS), Child Vulnerability Scale (CVS) and Parenting Stress Index/Short Form (PSI/SF). Results and Conclusions. Sixty-eight caregivers provided informed consent and completed the study. Among female caregivers whose children never received genitoplasty, greater parenting stress was reported (F(1, 40) = 5.08, p = .03). For male caregivers, those whose children received genitoplasty within the first year of life reported more overprotective parenting and parenting stress than those whose children received genitoplasty later than 12 months of age (F(1, 13) = 6.16, p = 0.28); F(1, 15) = 6.70, p = .021), respectively).

Conducting a randomized clinical trial of an psychological intervention for parents/caregivers of children with cancer shortly after diagnosis

OBJECTIVE

To report acceptability, feasibility, and outcome data from a randomized clinical trial (RCT) of a brief intervention for caregivers of children newly diagnosed with cancer.

METHOD

Eighty-one families were randomly assigned following collection of baseline data to Intervention or Treatment as Usual (TAU). Recruitment and retention rates and progression through the protocol were tracked. Measures of state anxiety and posttraumatic stress symptoms served as outcomes.

RESULTS

Difficulties enrolling participants included a high percentage of newly diagnosed families failing to meet inclusion criteria (40%) and an unexpectedly low participation rate (23%). However, movement through the protocol was generally completed in a timely manner and those completing the intervention provided positive feedback. Outcome data showed no significant differences between the arms of the RCT.

CONCLUSIONS

There are many challenges inherent in conducting a RCT shortly after cancer diagnosis. Consideration of alternative research designs and optimal timing for interventions are essential next steps.

Parents' Empathic Responses and Pain and Distress in Pediatric Patients

We investigated the relationship between parents' empathic responses prior to their children undergoing cancer treatment procedures and children's pain/distress during the procedures. We hypothesized: (1) parents' empathic distress would be positively associated with children's pain/distress, (2) parents' empathic concern would be negatively associated with children's pain/distress; and (3) parents' enduring dispositions and social support would be associated with their empathic responses. Parents completed: (1) measures of dispositions and perceived social support several weeks before their children underwent the procedures, and (2) state measures of empathic distress and empathic concern just before the procedures. Empathic distress was positively associated with children's pain; empathic concern was negatively associated with children's pain/distress. Predictions about dispositions and social support were also substantially confirmed.

Symptoms of posttraumatic stress in parents of children with cancer: are they elevated relative to parents of healthy children?

OBJECTIVE

To examine posttraumatic stress symptoms (PTSS) in parents of children with cancer as a function of time since diagnosis, treatment status, and relapse history, and as compared to parents of healthy children.

METHOD

Participants included parents of 199 children with cancer, comprising a cross-sectional sample of diagnoses and treatment phases, ranging from currently on therapy to long-term survivors, and 108 parents of healthy children obtained via acquaintance control methods. Parents completed a standardized self-report measure of PTSS.

RESULTS

Within the cancer group, parental report of PTSS differed as a function of treatment status and time since diagnosis. Parents of children on active treatment endorsed similar levels of PTSS as control parents, whereas parents of children off treatment reported significantly lower levels of PTSS than did controls. Similarly, parents of long-term survivors reported significantly lower levels of PTSS than did controls, while parents of recently diagnosed children did not differ from controls on PTSS. In contrast, parents of children who had suffered a relapse reported significantly higher levels of PTSS, and were much more likely to be identified as a posttraumatic stress disorder (PTSD) case.

CONCLUSIONS

As a group, parents of children with cancer did not demonstrate any evidence of increased PTSS relative to parents of healthy children. Time since diagnosis, child treatment status, and relapse history are significant determinants of parent PTSS. Only parents of children who experienced a relapse appear to be at increased risk of PTSD. The current results appear discrepant from the existing literature, and possible explanations for these discrepancies are examined.

The effects of response bias on self-reported quality of life among childhood cancer survivors

BACKGROUND

Several studies of long-term adjustment in childhood cancer survivors (CCS) report very positive outcomes, while other studies find significant adjustment problems. These inconsistencies have prompted some investigators to suggest survivors may be biased responders, prone to underreporting on self-report measures. This study tested the hypothesis that CCS are elevated on self-deception response bias (SDRB), and that SDRB is associated with higher ratings of quality-of-life (QOL).

METHODS

One hundred and seven adult (mean age = 31.85) survivors of childhood cancers completed a demographic questionnaire, Short Form-12 (SF-12), Functional Assessment of Cancer Therapy-General (FACT-G), and Self-Deception Enhancement scale (SDE), an SDRB measure.

RESULTS

Survivors' QOL scores were similar to normative groups, but they evidenced much higher levels of response bias. SDE scores were significantly correlated with the FACT-G, and SF-12 Mental Health (but not Physical Health) scores even after accounting for demographic and treatment-related variables.

CONCLUSIONS

CCS show a biased response style, indicating a systematic tendency to deny difficulties on QOL measures. This may complicate QOL studies by inflating survivors' reports of their socio-emotional functioning. Understanding how response bias develops may help us learn more about cancer survivors' adaptation to illness, and the effects of the illness experience on their perceptions of QOL.

PTSD and psychological distress in Icelandic parents of chronically ill children: does social support have an effect on parental distress?

The purpose of the study was to investigate psychological distress and the prevalence of PTSD among Icelandic parents of chronically ill children, and the potential effects of social support on distress, at two points in time. The Impact on Family scale (IFS), the Trauma Symptom Checklist (TSC), the Harvard Trauma Questionnaire (HTQ) and the Crisis Support Scale (CSS) were completed by 105 parents of children with various diseases (69 mothers and 36 fathers). Despite the heterogeneity of the sample in terms of disease type, PTSD was present in 13.2% of the parents and an additional 28.6% had subclinical PTSD. Time since diagnosis, length of hospitalizations and disease-related daily care predicted 40% of the HTQ total score.

Allostatic Load in Women With and Without PTSD Symptoms

Allostatic load (AL) is the cumulative physiological "cost" of prolonged stress. An AL composite measure successfully predicts morbidity and mortality among the elderly but has not been reported in "high stress" samples with posttraumatic stress disorder (PTSD). Accordingly, AL was measured in mothers (ages 29-55) of pediatric cancer survivors and control mothers of healthy children. A significant "dose-response" pattern (high to low AL) emerged: cancer mothers meeting all PTSD criteria, cancer mothers with no/low symptoms, and controls, respectively. Results indicate elevated AL can be detected in relatively young women with high stress histories, and particularly those with PTSD.

Brief report: the risk of posttraumatic stress disorder in mothers of children diagnosed with pediatric cancer and type I diabetes

OBJECTIVE

To evaluate the risk of and predictors of enduring and late-onset posttraumatic stress disorder (PTSD) among mothers of children diagnosed with type I diabetes and cancer.

METHOD

Mothers (N = 99) of children diagnosed with cancer or diabetes for at least 12 months completed a structured clinical interview for PTSD and self-report measures of PTSD, depression, anxiety, and stressful life events.

RESULTS

There was no significant difference in the rate of PTSD between the two groups. Overall, fewer mothers (7%) met criteria for PTSD on the structured clinical interview than those on a self-report measure of PTSD (17%). Mothers who reported more depressive symptoms, anxiety, and stressful life events tended to report significantly more PTSD symptoms.

CONCLUSIONS

The findings extend prior research regarding the prevalence rate and predictors of PTSD and PTSD symptoms in pediatric populations. It is recommended that clinicians exercise caution when interpreting prevalence rates for PTSD that are derived from self-report measures.