Repressive adaptation in children with cancer

The constructs of repressive adaptive style and avoidant coping (blunting) were assessed as possible explanatory factors for previously reported findings of lower self-reported depression in children with cancer. Pediatric oncology patients 7-16 years old (n = 107) and healthy control participants (n = 442) completed measures of depressive symptoms, trait anxiety, defensiveness, and approach and avoidant coping. Oncology patients scored significantly lower on measures of depression and trait anxiety, and higher on defensiveness. Applying the adaptive style paradigm, the oncology group showed a significant excess of repressors. Depressive symptoms differed as a function of adaptive style, with repressors demonstrating the lowest levels of self-reported depression. Children with cancer also reported greater use of blunting, but this difference was small and appeared unrelated to depression scores. Within the cancer group, repressive adaptation was unrelated to time elapsed since diagnosis. These findings are discussed with reference to the ongoing controversy regarding cancer-personality style associations.

Psychological functioning of adolescent and young adult survivors of pediatric malignancy

OBJECTIVE

To assess the psychological functioning of adolescent and young adult survivors of pediatric malignancy, and identify risk factors for maladjustment.

DESIGN

Patients age > or = 14.5 years (N = 161) receiving surveillance follow-up at a major pediatric cancer center completed the SCL-90-R, a self-report measure of psychological symptomatology. Comparisons were made with the normative standardization sample, and the relationship of selected demographic and medical variables with psychological distress was explored using logistic regression analyses.

RESULTS

Survivors mean scores on all SCL-90-R subscales were lower than those of the standardization sample, and the distribution of scores on the Anxiety, Psychoticism, Global severity Index, and Positive Symptom Total scales were significantly below normative values. No SCL-90-R subscale displayed an excessive frequency of clinically elevated scores. For patients who displayed clinical elevations on the SCL-90-R, three factors were identified which were associated with increased risk of maladjustment; older patient age at follow-up, more frequent disease relapse, and more severe functional impairment.

CONCLUSIONS

This cohort of childhood cancer survivors is characterized by very low levels of psychological distress and significantly better psychological health than would be expected according to normative data. These findings contrast with those of another study from the same institution in which a fourfold increase in social and behavioral problems was found amongst younger survivors, in the age range 7-15. The use of self-report vs. parent-report, and the potential influence of repressive adaptation on the self-reports of pediatric cancer survivors, are raised as possible explanations for these findings.

Repressive adaptation in children with cancer

The constructs of repressive adaptive style and avoidant coping (blunting) were assessed as possible explanatory factors for previously reported findings of lower self-reported depression in children with cancer. Pediatric oncology patients 7-16 years old (n = 107) and healthy control participants (n = 442) completed measures of depressive symptoms, trait anxiety, defensiveness, and approach and avoidant coping. Oncology patients scored significantly lower on measures of depression and trait anxiety, and higher on defensiveness. Applying the adaptive style paradigm, the oncology group showed a significant excess of repressors. Depressive symptoms differed as a function of adaptive style, with repressors demonstrating the lowest levels of self-reported depression. Children with cancer also reported greater use of blunting, but this difference was small and appeared unrelated to depression scores. Within the cancer group, repressive adaptation was unrelated to time elapsed since diagnosis. These findings are discussed with reference to the ongoing controversy regarding cancer-personality style associations.

Health-related behaviors of survivors of childhood cancer

The health-related beliefs and behaviors of long-term survivors of childhood cancer are important because of vulnerability to adverse late effects from their primary malignancy and its therapy. A health behavior survey was completed by 110 parents of long-term survivors ranging in age from 11-17 years, and by 40 adult long-term survivors of childhood cancer ranging in age from 18-29 years. The survey included questions on the former patient's frequency of alcohol and tobacco use, as well as diet, exercise, sleep, dental, and seatbelt habits. The reported prevalence of tobacco and alcohol use was less than 10% among those less than 18 years old. Among the adults, tobacco (17.5%) and alcohol (72.5%) use was greater, but problem drinking was infrequently reported. In order to assess their perceived vulnerability, we asked the parents and the young adult patients to rate the strength of their belief that it is more important for the patient to keep healthy compared to most other children or young adults. Contrary to our expectation, demographic factors such as the patient's gender, socioeconomic level, or time elapsed since completion of therapy exerted minimal influence on their responses. Over 80% of parents and 60% of young adult survivors believed that it was more important for the former patient to remain healthy compared to most other people. However, this shared belief in increased vulnerability was inconsistently expressed in the patient's health behaviors. These results suggest that specific changes are needed in the health assessment and education of long-term survivors of childhood cancer.

Family cohesion and expressiveness promote resilience to the stress of pediatric bone marrow transplant: a preliminary report

The effect of perceived family environment as a determinant of adjustment in children undergoing bone marrow transplant (BMT) was assessed in a prospective, longitudinal study. Measures of patients' social competence, behavior problems, and self-esteem, along with perceived family conflict, cohesion, and expressiveness, were obtained before hospital admission for BMT and again in the period 6 to 12 months post-BMT. Significant declines were observed in post-BMT social competence and overall self-concept. Before BMT, perceptions of family conflict showed a moderate inverse correlation with patient adjustment, whereas family cohesion and expressiveness were unrelated or were weakly related with adjustment measures. In contrast, all pre-BMT family environment variables were highly predictive of adjustment post-BMT. Using a cross-lagged correlational approach, it was determined that perceived family cohesion and expressiveness act as protective factors, promoting resilience to the stresses of BMT, whereas family conflict acts directly as a risk factor that adversely affects adjustment regardless of stress level.

Psychological effects of bone marrow transplantation on children and adolescents: preliminary report of a longitudinal study

The number of pediatric bone marrow transplantation (BMT) survivors is growing rapidly, yet little is known about the long-term neuropsychologic and psychosocial sequelae of this procedure. Using a prospective, longitudinal design, 64 pediatric patients undergoing BMT were evaluated with standardized measures of global intelligence, academic achievement and selected tests of neuropsychologic function. In addition, adjustment was assessed with parent and patient report measures of social competence, behavior problems and self-esteem. Patients were evaluated prior to admission for BMT, and again in the period 6-12 months after BMT. Longitudinal findings are reported on an initial cohort of 25 survivors. Cognitive and neuropsychologic function remained stable during the study period. The few significant changes from baseline which were observed were in the direction of improvement, and may be attributed to practice effects. In contrast, declines were observed in patient social competence, self-esteem and general emotional well-being. BMT conditioning regimens appear not to be associated with significant neuropsychologic impairment in the first year after transplant. However, a longer period of follow-up is necessary before neuropsychologic late-effects can be ruled out. The first year after BMT is characterized by significant psychosocial difficulties for survivors. Adjustment issues may provide a more salient focus of study during this time frame.

Avoidant coping in children with cancer

Compared coping styles in children with cancer (n = 66) and a normative control group of healthy children (n = 414), using a newly designed instrument, the Children's Behavioral Style Scale (CBSS). We hypothesized that children in the oncology group would make greater use of an avoidant coping style (blunting) than controls. Results confirmed the primary hypothesis; children with cancer endorsed greater use of blunting or avoidant coping than did healthy children. A new conceptual model of coping style was introduced utilizing CBSS scores to identify children as Monitors, Blunters, Active, or Passive copers. Using this model, a similar proportion of Active and Passive copers were found in both groups, while the shift towards Blunting in the oncology group was accentuated. Within the oncology group, a positive relationship between Blunting scores and time elapsed since diagnosis was observed, suggesting that the increased Blunting in children with cancer is a reactive phenomenon, at least partly a response to the contingencies of cancer and its' treatment. These findings may provide an alternative interpretation to previous reports of increased defensiveness and repression in children with cancer.

The impact of a grief workshop for pediatric oncology nurses on their grief and perceived stress

Coping with the death of a pediatric patient with whom the nurses has developed a close relationship is reported by nurses as the most stressful experience of being a pediatric nurse. Such losses are inevitable for a pediatric nurse regardless of subspecialty and can contribute to a nurse leaving the specialty or the discipline. To prevent those consequences, nurses' grief needs to be acknowledged, and their grieving needs to be facilitated. The purpose of this study was to determine the impact of a grief workshop on grief symptoms and perceived stress in two groups of pediatric oncology nurses who differed in years of experience in the specialty. Study findings indicated that the workshop affected the two groups differently, with the more experienced nurses reporting significantly higher stress levels after the workshop than did the less experienced nurses. Study findings are interpreted and recommendations for future work are offered.

Measurement of behavioral, affective, and somatic responses to pediatric bone marrow transplantation: development of the BASES scale

A new measure to assess behavioral, affective and somatic outcomes in the acute phase of bone marrow transplant is described. The Behavioral Affective and Somatic Experiences Scale (BASES) is a 38 item nurse-report instrument, with five subscales labeled Somatic distress, Compliance, Mood/Behavior, Interactions, and Activity. A series of pilot studies were conducted to refine the content of the BASES scale and to establish its psychometric properties in terms of internal consistency, inter-rater reliability, and validity. Internal consistency (Chronbach's alpha) for the subscales ranged from .742 to .902. Inter-rater reliability was good, with a median correlation between paired nurse observations of .866. A parent report version of the BASES scale has also been developed, and the finding of significant parent-nurse correlations provides preliminary evidence of the validity of the measure. Potential uses of the BASES scale in the pediatric BMT setting are discussed.

Cavernous haemangiomas (angiomas) of the brain: clinically significant lesions

A review of 2000 consecutive magnetic resonance imaging (MRI) brain studies identified 18 (0.9%) patients with lesions that satisfied MRI criteria for cavernous haemangiomas. The clinical, computed tomography (CT) and MRI findings in 23 patients with probable cavernous haemangiomas were compared. Thirty-three lesions were identified with multiple lesions in five (22%) patients. In 19 (82%) patients the neurological presentation corresponded to a cavernous haemangioma. The presenting symptoms were: seizures in 11 patients (48%); progressive neurological symptoms and signs in four (17%); and acute symptoms and signs due to haemorrhage in four (17%). T2 weighted images suggested the diagnosis in all cases, with 24 (73%) lesions showing the typical appearance of an area of mixed signal intensity with a rim of low signal intensity. In the absence of acute haemorrhage, CT demonstrated well circumscribed, round or oval hyperdense lesions without significant mass effect and with normal surrounding brain tissue in the majority of cases. Although not diagnostic, these CT features are strongly suggestive of cavernous haemangiomas.

Oral ketamine premedication to alleviate the distress of invasive procedures in pediatric oncology patients

This study prospectively evaluated the efficacy of oral ketamine in alleviating procedure-related distress in pediatric oncology patients. Ketamine (10 mg/kg) was administered orally to 35 children and adolescents, ranging in age from 14 months to 17 years (mean = 6.5 years). Procedure-related distress was evaluated by using parent/clinician ratings and the Observational Scale of Behavioral Distress (OSBD-R). Eighty-seven percent of children were sedated within 45 minutes. Clinician and parent ratings were similar, with 77% rating procedural distress as low (0 to 3). The OSBD-R scores were low throughout all phases of the study. Although this study was neither randomized nor placebo-controlled, statistical comparison of the OSBD-R scores of the patients who received oral ketamine with those of historical controls (from a study previously performed at the same institution but using intravenous midazolam) showed significantly less distress (P < .001) during the procedure in children who received oral ketamine. Additionally, OSBD-R scores of the patients who received oral ketamine were significantly lower (P < .001) during all phases than those of the saline placebo group in the other study. No cardiorespiratory side effects related to ketamine were noted. The majority of patients showed recovery from sedation within 2 hours following the procedure. In conclusion, oral ketamine effectively alleviated procedure-related distress in pediatric oncology patients.

Parental management of fear in chronically ill and healthy children

This study was undertaken to determine the impact of children's health status on parental management of fear and avoidance, as well as the relationship between parenting strategies and children's fear and anxiety levels. Thirty-one children with a chronic life-threatening illness, 30 children with chronic non-life-threatening conditions, and 28 healthy children, and their mothers, were studied. Children's health status, by diagnosis, was not a significant determinant of maternal fear-management strategies. For chronically ill children, clinical health status, in terms of illness course, prognosis, physical impairment, and time since diagnosis were related to maternal parenting strategies and to children's levels of medically related fears. For the sample as a whole, maternal fear-management strategies were related to child sex, socioeconomic status, and mothers' trait anxiety. These results are discussed in terms the interactive effects of child characteristics, health status, fear/anxiety, and parenting strategies.

Adherence issues in pediatric bone marrow transplantation

The procedure of bone marrow transplantation entails a prolonged, aversive regimen in which adherence problems often develop, particularly with administration of oral antibiotic medications. A retrospective chart review revealed that 52% of pediatric patients evidenced significant adherence problems during the procedure. The highest rates of noncompliance were found in preschool and school-age children, with a surprisingly lower frequency in adolescents. Case summaries are presented to illustrate significant clinical issues and intervention strategies. These are discussed in terms of both their practical and theoretical significance regarding the determinants of adherence behavior.

Determinants of parenting stress in home apnea monitoring

Studied mothers of 30 infants who suffered an apneic episode and were subsequently placed on home apnea monitors, using measures of parenting stress, family resources and support, family coping activities, health locus of control, and maternal coping style involving preferences for information under threat. Comparison groups included mothers of 30 infants with mild congenital heart lesions and 30 mothers of normal healthy infants. Home monitoring was associated with increased levels of parenting stress; monitored infants were perceived as more demanding, and their mothers reported less attachment to the child. However, the magnitude of the differences between mothers of monitored and unmonitored infants was relatively small, and parenting stress outcome was more closely related to preexisting levels of family resources than to the child's health status. No significant relationship was found between stress outcome and family coping or maternal coping style.

Psychological impact of home apnea monitoring: temporal effects, family resources, and maternal coping style

Mothers of 30 infants who had experienced an emergency apnea episode and were placed on a home apnea monitor were studied longitudinally, using measures of mood disturbance (anxiety, depression, hostility, fatigue, vigor and confusion). Mothers were assessed at the time of hospitalization immediately following the apnea episode, after approximately one month of home monitoring, and after three months of home monitoring. Measures of family resources, health locus of control, and coping style, involving preference for information under situations of threat, were obtained as predictor variables. A high level of mood disturbance was seen initially, but this was transient, diminishing significantly after the first month of monitoring. Level of family resources was highly predictive of mood disturbance throughout the study period, while health locus of control beliefs were predictive of changes in mood disturbance over time. These findings suggest a means for identifying families at higher risk for maladaptive responses, and in need of more intensive psychosocial support.

Network analysis of an arterial tree

The arterial tree of a Sprague-Dawley rat was casted and carefully mapped with the aim of comparing its network characteristics with those suggested by the classical model of an arterial tree. It is shown that if the tree is to be measured accurately, the concept of 'whole vessels' on which the classical model is based must be abandoned since such vessels do not actually exist in the network, nor can they be accurately defined. The concept of 'vessel segments' is proposed instead and its use is demonstrated. A total of 1313 vessel segments in the arterial tree of the rat are mapped and divided into well defined 'levels'. The length and diameter of each segment are measured and the distribution and averages of these at different levels are presented as indicators of the branching characteristics of the tree.

Morphometric analysis of the distributing vessels of the kidney

Branching angles and branch diameters of the distributing vessels in the renal networks of rats were measured and the results are compared with data reported previously from the coronary network of the same species. Comparison is also made with what is known to be optimum on theoretical grounds to determine to what extent the branching characteristics of the renal network are governed by considerations of optimality, and to what extent they are affected by other considerations, relating particularly to the role that the network plays in the blood processing function of the kidney.

Psychological response to amniocentesis: II. Effects of coping style

Differences in coping style were assessed in a group of women undergoing amniocentesis and a control group not having the procedure. Subjects were divided into two groups according to coping style; "monitors" (information seekers) and "blunters" (information avoiders). In the amniocentesis group, coping style was associated with differences in mood state and change in mood state over time. "Monitors" experienced greater mood disturbance than "blunters" both before and during the procedure, but this effect disappeared after communication of amniocentesis results. Coping style was not associated with differences in maternal attitudes toward pregnancy or maternal-fetal attachment. In the control group, there were no differences between "monitors" and "blunters" on any of the mood state or pregnancy measures. Implications of these findings for providers of genetics services are discussed.

Psychological response to amniocentesis: I. Mood state and adaptation to pregnancy

The responses of a group of pregnant women undergoing amniocentesis and control women not having the procedure were studied using objective, self-report measures of mood state, attitudes toward pregnancy, and maternal-fetal attachment. Questionnaires were completed on three occasions: after genetic counseling (time-1), after amniocentesis (time-2), and 1 wk after communication of results (time-3) for amniocentesis subjects, and at comparable points in the pregnancy for control subjects. Amniocentesis and control subjects differed markedly in their pattern of change in anxiety scores over time, with amniocentesis subjects being more anxious than control subjects at time-2 and less anxious at time-3. Results were similar but less pronounced for depression scores, whereas there were smaller differences between groups on measures of anger and confusion. Unusual patterns of mood state changes were seen in the control group, which were related to a history of previous fetal loss. The groups did not differ in their attitudes toward pregnancy, but amniocentesis subjects showed a greater relative increase in attachment to the fetus than did control subjects. Overall, amniocentesis subjects were faring as well or better on every measure taken at time-3 and were showing improvement on all measures. In contrast, control subjects were demonstrating a trend toward increasing mood disturbance. These results suggest that any amniocentesis-related psychological disturbances are only transient and are outweighed by the receipt of normal results, which appear to enhance emotional adaptation to pregnancy.

The subsequent pregnancy after stillbirth: anticipatory parenthood in the face of uncertainty

Interviews were conducted with fifteen couples who had experienced a previous neonatal death and a subsequent successful pregnancy. Discussions focused on the stresses that were unique to the subsequent pregnancy, and parental adaptation to them. Results show that parents experienced markedly increased anxiety that was difficult for them to manage. Parental coping involved vigilant exploration of possible negative outcomes, and a withdrawal from outward signs of investment in the pregnancy. This did not appear to impair adaptation to parenthood, however, although anxiety regarding the child's health continued for several months after delivery. Implications of these findings for clinicians are discussed.