Social support, social conflict, and adjustment among adolescents with cancer

Virtual Group Activities as a New Platform for Socialization in Children With Pediatric Cancer: A Case Series From the COVID-19 Pandemic

Socialization with peers is essential for development yet reduced when children and adolescents are undergoing cancer treatment. Providing opportunity for social experiences is a key role for providers working in the pediatric oncology setting. Traditional in-person socialization activities were significantly impacted by coronavirus disease-2019 restrictions, and psychosocial providers were forced to adapt their practice. This case series illustrates four unique scenarios that highlight virtual social interactions as both feasible and beneficial. While virtual socialization groups were intended to be temporary, the experiences described suggest that ongoing video-based options for some socialization activities are likely prudent for some pediatric populations.

Randomized Trial of a Supportive Psychotherapy for Parents of Adolescents and Young Adults With Hematologic Malignancies

BACKGROUND

Cancer regularly disrupts health and developmental trajectories in adolescents and young adults (AYAs). Parents have been shown to have a substantial impact on the health and cancer survivorship activities of AYA patients in the form of symptom management. However, no randomized controlled trial has evaluated a coping support intervention (CSI) program for parents of AYAs with cancer aged 18 to 40 years.

PATIENTS AND METHODS

From November 30, 2012, to August 29, 2016, parents of AYAs with hematologic malignancies were randomized in a phase III controlled trial (1:1 ratio, stratified sampling) to either the research-based CSI AYA-Parents group (CSI group; n=82) or the standard care (SC) group (n=70). CSI consisted of 5 sessions to achieve the enhancement of parental adaptive coping as the primary outcome (per the adaptive coping scale of the 28-item Brief COPE, a validated multidimensional self-assessment-questionnaire recommended for clinical cancer research). Measures of adaptive coping, depression, and mental health were collected at pre-CSI (measurement date T1), at the end of the intervention sessions (measurement date T2), and at follow-up (3 months). We calculated mean change scores in outcomes and estimated intervention effect sizes (Cohen's d) for changes from T1 to T2/T3, with 0.2 indicating a small effect, 0.5 a medium effect, and 0.8 a large effect. All statistical tests were 2-sided.

RESULTS

In the intention-to-treat analysis, the CSI group significantly improved their adaptive coping compared with the SC group (95% CI, 0.30-2.54; P=.013; d=0.405), whereas adaptive coping in the SC group deteriorated. The CSI group also experienced a significant decrease in depressive symptoms and improved mental health with clinical significance (95% CI, -1.98 to -0.30; P=.008; d=0.433, and 95% CI, -0.19 to 3.97; P=.074; d=0.292, respectively). Sensitivity analyses confirmed the robustness of the main intention-to-treat analysis.

CONCLUSIONS

CSI improved effectively adaptive coping and depression in parents of AYAs with hematologic malignancies. It may represent a novel family-based approach in AYA oncology care.

Patterns of Spillover Between Marital Adjustment and Parent-Child Conflict During Pediatric Cancer Treatment

Objective

When a child is diagnosed with cancer, problems may arise in family relationships and negatively affect child adjustment. The current study examined patterns of spillover between marital and parent-child relationships to identify targets for intervention aimed at ameliorating family conflict.

Method

Families (N = 117) were recruited from two US children's hospitals within 2-week postdiagnosis to participate in a short-term prospective longitudinal study. Children with cancer were 2-10 years old (M = 5.42 years, SD = 2.59). Primary caregivers provided reports of marital and parent-child conflict at 1-, 6-, and 12-month postdiagnosis.

Results

Results indicated that a unidirectional model of spillover from the marital to the parent-child relationship best explained the data. In terms of specific temporal patterns, lower marital adjustment soon after diagnosis was associated with an increase in parent-child conflict 6 months later, though this pattern was not repeated in the latter 6 months of treatment.

Conclusion

Targeting problems in marital relationships soon after diagnosis may prevent conflict from developing in the parent-child relationship.

Featured Article: Caregiver Perceptions of Stress and Sibling Conflict During Pediatric Cancer Treatment

Objective

The current study examined the effect of stress on sibling conflict during the first year of pediatric cancer treatment.

Method

Families (N = 103) included a child with cancer (aged 2-17 years, Mage = 6.46, SD = 3.52) and at least one sibling aged <5 years of the child with cancer (Mage = 8.34, SD = 5.61). Primary caregivers completed monthly questionnaires throughout the first year of treatment assessing five sources of stress (i.e., general life, cancer-related, financial, perceived treatment intensity, and life threat) and level of sibling conflict. Using multilevel modeling, we explored the effects of these stressors on conflict both at the within- and between-family levels to examine if changes in stress resulted in concurrent changes in conflict within an individual family, and whether greater average stress affected the trajectory of conflict between families, respectively.

Results

At the between-family level, higher average levels of cancer-related stress, general life stress, and financial stress were associated with higher sibling conflict at the end of the first year of treatment. Perceived treatment intensity and life threat were not associated with conflict. No stressors were associated with conflict at the within-family level.

Conclusions

During pediatric cancer treatment, some stressors may spill over into family relationships and contribute to increases in sibling conflict.

How and Why School Is Important to Teenagers with Cancer: Outcomes from a Photo-Elicitation Study

BACKGROUND

Being diagnosed with cancer during the teenage years can be significant given that young people are at a key developmental, educational, and future-planning stage. Little is known about young people's attitude toward and engagement with school postdiagnosis, nor how this changes over time. We adopted a novel qualitative approach to examine accounts over time of young people recently diagnosed with cancer.

METHODS

Twelve teenagers (13-16 years), recently diagnosed with cancer, participated in photo-elicitation interviews at three time points (∼2, 6, and 9 months postdiagnosis), generating 30 interviews in total. Photo-elicitation interviews center around images that participants bring to represent key experiences and issues that matter to them. Transcripts were analyzed using interpretative phenomenological analysis.

RESULTS

Seven themes were generated, representing experiences over time. Themes convey how significant school was to the young people postdiagnosis, principally because it mattered to them to maintain a normative educational pathway. Young people felt tension between wanting to be the same as their peers but feeling distinctly changed. Keeping ownership and control of their cancer story within school was challenging. Survivorship brought, for some, a legacy of missed schooling.

CONCLUSION

Support for young people and reintegration plans for school need to be tailored to the young person's emerging way of understanding their cancer and recovery, and their orientation to coping. Young people need help to understand that schoolwork exemptions/extensions do not implicate academic deficiency, and how they could accept a "same but different" position as they continue to develop personally and educationally with their peers.

Bullying victimization and depressive symptoms in adolescence: The moderating role of parent-child conflicts among boys and girls

INTRODUCTION

The association between bullying victimization and depressive symptoms has been studied extensively over the years. Among the variables studied as having an impact on this association were different characteristics of the parent-child relationship. The current study was the first to specifically examine parent-child conflicts as a moderator in the association between victimization and depressive symptoms among adolescents. In addition, it was the first to examine the roles of the child and parent's gender in this moderation.

METHODS

505 7th-9th graders from two schools in two different cities across Israel (mean age = 12.736, SD = 0.8154) participated in this study. 223 (44.2%) of the participants were male. The participants filled out a battery of self-report questionnaires assessing the different study's variables.

RESULTS

Significant gender differences were found: among girls, the association between bullying victimization and depressive symptoms was stronger when the level of parent-child conflicts was high, while among boys, it was stronger when the level of conflicts was low.

CONCLUSIONS

Our results indicate that the psychological outcomes for victims depend on their relationship with their parents. Bullying intervention programs should include the victims' parents. Furthermore, intervention programs should be designed to fit the different needs of girls and boys.

Trajectories of marital, parent-child, and sibling conflict during pediatric cancer treatment

OBJECTIVE

The stress of having a child with cancer can impact the quality of relationships within the family. The current study describes the longitudinal trajectory of marital, parent-child, and sibling conflict beginning around the time of diagnosis through the first year of treatment. We examined the average level of marital, parent-child, and sibling conflict at each monthly time point in the first year of treatment; the proportion of families that fall into the distressed range of marital, parent-child, and sibling conflict at each time point; the typical trajectory of conflict during the first year of treatment and whether there are differences in trajectories across families.

METHOD

A total of 160 families of children newly diagnosed with cancer (Mage = 5.6 years; range = 2-18 years) participated in a short-term prospective longitudinal study. Primary caregivers provided monthly reports of marital, parent-child, and sibling conflict.

RESULTS

Using multilevel modeling (MLM), most families showed stability in quality of family relationships, although considerable between-family variability was observed. For married couples, 25-36% of couples were in the distressed range at one time point over the first year of treatment. For married couples, more distress occurred at earlier months, particularly month 3. For parent-child and sibling dyads, the most difficult time periods were during later months.

CONCLUSION

Implications for development of interventions that target at-risk family relationships are discussed. Identifying processes that predict between-family variability in trajectories of family relationships is an important next step, particularly for the marital relationship. (PsycINFO Database Record

A qualitative study of adolescent and young adult cancer survivors' perceptions of family and peer support

This qualitative study examined adolescent and young adult survivors' perceptions of support from family and peers. A total of 26 survivors, aged 16-24 years, who had been diagnosed with cancer between the ages of 14 and 18, participated in semi-structured interviews. Three themes emerged for support: practical support, emotional support, and new sense of closeness. For lack of support, two themes emerged: absence during treatment and lack of understanding about appearance changes. These findings emphasize the perceived importance of family and peer support throughout adolescent and young adults' cancer trajectories and indicate a need for interventions to help adolescent and young adult develop and maintain support networks throughout treatment and survivorship.

Understanding the school experiences of children and adolescents with serious chronic illness: a systematic meta-review

BACKGROUND

Serious chronic illness can have a detrimental effect on school attendance, participation and engagement, leaving affected students at risk of failing to meet their developmental potential. An improved understanding of factors that help to explain or mitigate this risk can help educators and health professionals deliver the most effective support. This meta-review critiqued the available evidence examining the link between six chronic illnesses (asthma, cancer, chronic kidney diseases, heart diseases, cystic fibrosis and gastrointestinal diseases) and children's and adolescents' school experiences and outcomes, as well as investigating the medical, school, psychosocial and sociodemographic factors that are linked to poorer or better school outcomes.

METHODS

We searched CINAHL, Cochrane Database, EMBASE, ERIC, MEDLINE, ProQuest Theses and Dissertations, and PsycINFO (2000-2015). Systematic and narrative reviews, and meta-analyses, of original studies examining students' subjective school experiences and objective school outcomes were eligible. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria to critically appraise all systematic reviews. The Grading of Recommendations Assessment, Development, and Evaluation system guided our recommendations for practice and research.

RESULTS

Eighteen reviews of 172 studies including more than 40 000 students were eligible. Therefore, we chose to conduct a meta-review to provide an overview of the literature on the relationship between chronic illness and school experiences and outcomes. We also explored the associated medical, school, psychosocial and sociodemographic factors affecting the relationship between illness and school experiences and outcomes.

CONCLUSION

Students with chronic illness demonstrate mixed school experiences and outcomes that are often worse than students without chronic illness. Modifiable factors, such as students' engagement with school, may be novel yet appropriate targets of educational support to ensure that these students reach their full schooling potential.

Support and conflict in relationships and psychological health in adolescents and young adults with cancer

Perceived support and conflict between adolescents and young adults with cancer and their primary caregivers, other family, close friends, and medical staff were examined in relation to adolescents and young adults' psychological health. Adolescents and young adults ( n = 115, 51% male, ages 12-24 years, M (standard deviation)  = 16.07 (2.29)) in outpatient cancer treatment perceived more support and conflict within familial relationships than other relationships. Among familial relationships, perceived support and conflict were associated with psychological health; within other relationships, only support was associated with psychological health. Interactions among family were most strongly correlated with psychological distress; interactions with friends were stronger correlates of posttraumatic stress symptoms, positive affect, and posttraumatic growth.

The Importance of Being There: Perspectives of Social Support by Adolescents with Cancer

Adolescents with cancer are confronted with many challenges. The extent to which they are able to deal with such challenges appears to be partly contingent on a positive strong social support system. In this article, the author describes findings specific to the sources of social support that 15 adolescents with cancer found to be most important in getting them through the cancer experience. Data were collected as part of a longitudinal qualitative interpretive study and involved individual interviews, focus group interviews, and participant observation as the main sources of data. The relationships that adolescents maintained with their nuclear families, health care team members, and special friends were the 3 main supportive relationships in the adolescents'lives. The act of others “being there” was seen by the adolescents as the key element of a supportive relationship and involved 6 main behaviors. Although the 3 key supportive relationships were essential in helping adolescents get through cancer, these relationships were at times a source of stress for adolescents.

Providing Children and Adolescents Opportunities for Social Interaction as a Standard of Care in Pediatric Oncology

Experiences with peers constitute an important aspect of socialization, and children and adolescents with cancer may experience reduced social interaction due to treatment. A literature review was conducted to investigate the evidence to support a standard of care evaluating these experiences. Sixty-four articles were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Moderate quality of evidence suggest that social interaction can be beneficial to increase knowledge, decrease isolation, and improve adjustment and constitute an important, unmet need. The evidence supports a strong recommendation for youth with cancer to be provided opportunities for social interaction following a careful assessment of their unique characteristics and preferences.

Support after the completion of cancer treatment: perspectives of Australian adolescents and their families

Young people recovering from cancer may lack adequate support post-treatment, yet little is known about the types of support and information young Australians and their families need. This study investigated adolescent/young adult cancer survivors' and their families' perceptions of care and support needs after completing cancer treatment. Seventy semi-structured interviews were conducted with 19 survivors (mean age 16.1 years), 21 mothers, 15 fathers and 15 siblings. Interviews were recorded, transcribed and analysed using the conceptual framework of Miles and Huberman. Post-treatment, participants regarded medical staff positively but were reluctant to ask for their help fearing it may deflect resources away from patients still receiving treatment. Appraisals of social workers' and psychologists' support post-treatment were mixed. Formal emotional support was rarely accessed and participants reported that any additional funds should be directed to greater psychological support in this period. Participants also reported the need for additional financial support post-treatment. Clinicians need to be aware that while young people and their families may not demand support post-treatment, they may 'suffer in silence' or burden family members and friends with the responsibility of providing emotional support, though they may be experiencing distress also.

Physical symptoms, perceived social support, and affect in adolescents with cancer

Treatment for cancer among adolescents is often more intense and lasts longer than treatment for older or younger patients. It typically causes pain, fatigue, and nausea and affects social and emotional well-being. This study examined the relationships among demographics, physical symptoms, perceived social support from friends and family, and affect (positive and negative) in 102 adolescents (age 13-19) with cancer using correlational analyses. Additionally, perceived social support was explored as a mediator and moderator of the relationship between physical symptoms and affect using regression. Females reported significantly lower friend support and higher negative affect compared to males. Minority participants were more likely to endorse physical symptoms and less negative affect compared to White respondents. Higher report of physical symptoms was significantly related to greater negative affect, whereas higher perceived social support from friends was related to higher positive affect. Adolescents consistently reported high levels of social support from family and friends. Additionally, adolescents tended to report average levels of positive affect and low levels of negative affect compared to healthy populations. No significant mediation or moderation effects were found. This research highlights that females and minorities, and those with greater physical symptoms, may be more vulnerable to poor adjustment to cancer during adolescence. However, overall this study lends support to the notion that adolescents with cancer are an especially resilient population, as these patients endorsed generally high levels of social support and positive affect, with low levels of negative affect.

The impact of a cancer diagnosis on the education engagement of teenagers - patient and staff perspective

PURPOSE

Engagement with education during treatment is an important and complex issue for practitioners and an important psychosocial need of teenagers with cancer. There is limited research currently available specifically concerning the education of teenagers with cancer. This paper reports the outcomes from a patient and a practitioner questionnaire study which explore prominent issues and experiences in educational engagement for this population.

METHOD

Eighty-eight teenage cancer patients completed a questionnaire about their education experiences since diagnosis. Forty oncology practitioners completed an online questionnaire on experiences of education engagement of teenage patients. Questionnaires were developed from a systematic research review conducted by the authors and included; peer relationships, school attendance, reintegration and long term effects of cancer on attainment.

RESULTS

Among teenagers there was a significant relationship between successful maintenance of peer groups, successful reintegration into school and positive ratings of the education support. Teenagers who reported school as their primary source of support had significantly more successfully maintained peer groups. Practitioners rated peer support as the most important factor in education satisfaction for patients and stressed the need for collaborative planning between hospital, school and home.

CONCLUSIONS

Collaborative education planning should be initiated on diagnosis and aim to include non-academic variables, such as peer groups, which can influence successful maintenance of education. Further research is needed to understand the relationship between education engagement and teenagers' cancer experiences as a whole, as well as gaining a more in depth understanding of how teenagers experience their education after a diagnosis of cancer.

Psychosocial adjustment of siblings of children with cancer: a systematic review

OBJECTIVES

To promote a broader understanding of the psychosocial impact of childhood cancer on siblings, a systematic review was undertaken. Directions for future research are proposed and clinical strategies are suggested for addressing the needs of these children.

METHODS

Searches of Medline, PsycINFO and CINAHL revealed 65 relevant qualitative, quantitative, or mixed methods' papers published between 1997 and 2008. These papers were rated for scientific merit and findings were extracted for summary.

RESULTS

Siblings of children with cancer do not experience elevated mean rates of psychiatric disorders, but a significant subset experiences post-traumatic stress symptoms, negative emotional reactions (e.g. shock, fear, worry, sadness, helplessness, anger, and guilt), and poor quality of life in emotional, family, and social domains. In general, distress is greater closer to time of diagnosis. School difficulties are also evident within 2 years of diagnosis. Qualitative studies reveal family-level themes such as loss of attention and status as well as positive outcomes including increased sibling maturity and empathy.

CONCLUSIONS

Research regarding siblings of children with cancer continues to be methodologically limited. The conclusions of qualitative and quantitative studies differ considerably. We propose a research agenda to propel this field forward including greater attention to alterations in normative development (as opposed to psychiatric conditions), development of more appropriate quantitative measures, examination of potential moderators of adaptation, and use of prospective longitudinal designs. Siblings of children with cancer are a psychosocially at-risk group and should be provided with appropriate supportive services.

How can the multi-disciplinary team meet the psychological needs of adolescents with cancer? A review of the literature

A cancer diagnosis is likely to have a devastating effect when it occurs, but it is possibly especially problematic during adolescence. The many challenges faced by adolescents have led to a concern for their psychosocial well-being. There is evidence to support the notion that the provision of effective psychosocial care improves the outcomes of patients with cancer. The review of the literature has identified that amongst the psychological challenges; there is uncertainty and fear around the status and progression of the cancer. Issues such as body image and sexuality and fertility have been highlighted as a major cause of concern for adolescents. The literature suggests health professionals need to be trained in such areas to give the appropriate care and support. It has also been identified that hopefulness and a positive attitude by patients, families and the multi disciplinary team contribute to positive outcomes. Nurses play a key role in providing psychosocial care as they are primarily the ones who deliver the daily care and can be used as a mediator between the multi disciplinary team. Other disciplines such as Clinical Nurse Specialists, Activities Coordinators, Social workers and Psychotherapists all contribute to the overall direction and experience of care.

Interactions with parents and friends among chronically ill children: examining social networks

OBJECTIVE

Children with medical conditions often experience a combination of positive and negative social interactions with parents and friends. Adult research examining cross-domain buffering effects has documented that supportive social ties can make up for shortcomings in other social relationships. This study examined whether negative effects of strained relationships with loved ones can be buffered when children feel supported by individuals in different support networks (i.e., cross-domain buffering effects).

METHOD

Children with Type I diabetes (n = 56), chronic asthma (n = 54), and cystic fibrosis (n = 17) completed questionnaires during an outpatient hospital visit that assessed perceptions of support and strain from parents and friends, quality of life, self-concept, and emotional/behavioral difficulties. Parental strain was conceptualized as parental overprotection and parental rejection.

RESULTS

Hierarchical regression analyses showed that friend support buffered the adverse effects of parental strain on child quality of life, self-concept, and emotional/behavioral difficulties. Interestingly, parental support did not buffer the negative effects of experiencing strained relationships with friends; only main effects on outcome were found. These findings partially support our hypotheses of cross-domain buffering.

CONCLUSIONS

In this study, friendships were a protective factor for children who experienced strained relationships with parents. In contrast, although parent support had a direct impact on child outcome, it did not make up for feeling rejected by friends. Because close relationships are often strained during medical stressors, findings underscore the importance of promoting social connectedness in chronically ill children to maximize opportunities for experiencing positive social relationships.

Marshalling Social Support: A "Care-Getting" Model for Persons Living with Cancer

This paper offers a stress theory based conceptual framework for understanding proactive options for care-getting for patients living with cancer that is also relevant to patients living with other chronic or life threatening illnesses. Barriers and facilitators to active efforts for obtaining responsive care from both informal and formal sources are discussed. This "Care-Getting" model explores benefits of proactive care-getting for diminishing physical discomfort/suffering, burden of illness and disability, and psychological distress. We highlight unique issues in care-getting that patients face at different stages of the life course. Implications of prior research related to the model for practice and intervention are discussed.

Psychosocial functioning in parents of adult survivors of childhood cancer

BACKGROUND

Although significant progress has been made in identifying long-term sequelae for adult survivors of childhood cancer, comparatively little attention has been paid to the functioning of their parents. In a previous study, we observed that a majority of adult survivors are accompanied to clinic visits by at least 1 parent, suggesting ongoing concern for their children's health. In the current study, we explore psychologic stressors that characterize this population and might account for this finding.

PROCEDURE

Responses to measures of psychosocial functioning (ie, Brief Symptom Inventory, Impact on Family Scale, Impact of Events Scale, Parent Experience of Child Illness Scale) were compared between 27 parents of adult survivors (mean age=25.6 y) of pediatric cancer and 28 parents of current pediatric cancer patients (mean age=10.2 y) on, or within 1 year of, active treatment.

RESULTS

Compared with parents of pediatric cancer patients on treatment, parents of adult survivors demonstrated few significant differences in overall psychologic functioning, posttraumatic stress symptoms, and adjustment to the disease experience. Indeed, the 2 groups differed only in their report of objective and family burden (eg, financial cost, time off from work, less time with family members), and in their levels of anger associated with the illness experience.

CONCLUSIONS

Results suggest that parents who continue to accompany their adult child to clinic may remain psychologically vulnerable many years after the end of treatment, and that the impact of having a child with a life-threatening illness may not diminish even years into the child's survivorship.

Psychosocial issues in adolescents with cancer

Cancer in adolescents is uncommon and when it occurs raises a number of unique challenges for both the patient and their families. Adolescence is a period of time of significant physical and emotional changes and a diagnosis of cancer during this time has a major impact on their psychological and physical development. In this review we will look at the psychosocial issues facing adolescents who have cancer. We will address adolescent development, issues related to informed consent and assent, initial responses to the diagnosis of cancer, quality of life and the experience of the adolescent with cancer, psychological adjustment, support systems, body image issues, sexuality, education, hope, and treatment compliance.

Social support and adolescent cancer survivors: a review of the literature

With survival rates increasing dramatically in pediatric cancer, concern has increasingly focused on the psychosocial aspects of the cancer experience. Clearly, the experience of a cancer diagnosis and treatment of cancer places high demands on the coping of adolescents. Research has shown social support to be effective in decreasing stress and enhancing coping in adolescents facing such demands. A review and critical analysis of studies of social support in adolescent cancer survivors was conducted. The seventeen studies were mainly descriptive and exploratory in nature with social support examined for a number of outcome variables in eight of the studies. Findings from this review indicate that support from parents (especially the mother) and friends were extremely important and that the adolescents were satisfied with family support. Support from friends was described as less satisfactory. Methodological concerns of the reviewed studies include small samples and a lack of consistency in the instruments used to assess social support. Future studies of social support for adolescent cancer survivors should include larger samples to determine gender, age group, and ethnic differences and to allow the examination of social support theoretical models specific to the developmental and chronic illness situation of these adolescents.

Sarcomas in Adolescents and Young Adults

Adolescents and young adults, caught between the traditionally binary medical systems for children and adults, may be treated variably, depending on which side of the dichotomy they find themselves. As a result, their unique needs may go unmet because they occupy the fringes of the more typical child and adult patient populations. Soft tissue sarcomas in adolescents and young adults are a case in point, spanning the gap between the two fields but focusing on neither. Increasing age seems to be a poor prognosticator for soft tissue sarcomas, but is probably only a marker for other biological variables, patient characteristics, and treatment differences. This article discusses the issues unique to the management of soft tissue sarcomas in this population, pointing out what age-specific data are known and what areas are ripe for collaborative research between medical and pediatric oncologists.

Intersections of gender and age in health care: adapting autonomy and confidentiality for the adolescent girl

Autonomy and confidentiality are central topics in adolescent health care, both pertaining to findings that nonparent adults often benefit adolescent girls' psychological resilience. Traditionally, autonomy captures a patient's right to self-determine a course of treatment, whereas confidentiality is understood as privacy between doctor and patient. The author proposes a revision of these constructs to accommodate the psychology of adolescent girls in health care contexts through a case study of a 17-year-old girl's hospitalization. In particular, the importance of voice and trust in girls' psychology calls for understanding autonomy as self in relationship and confidentiality as mutual confidence. Suggestions for practice are guided by the premise that girls' health care can foster psychological risk or resilience, depending on the doctor-patient relationship.

Psychiatric aspects of pediatric cancer

Recent progress in the understanding of psychological and social factors related to cancer is important because cancer is the most common fatal disease of childhood and adolescence. Research interest in children and adolescents who have survived cancer also has increased over the past several years. Attention has focused on the long-term social outcomes of these children and adolescents. With increased survival, quality-of-life issues have assumed a more prominent role in the treatment protocols being developed for childhood cancer. The presence of long-lasting uncertainty about recurrence of the disease or second malignancy together with recognition of cognitive and physical side effects of treatment make childhood cancer a potentially chronic condition. Survivors experience actual or potential threats to future health; more than half have medical cognitive or psychological problems.