Depressive symptoms and adaptive style in children with cancer

Adaptive style and differences in parent and child report of health-related quality of life in children with cancer

The objective of this study was to examine the self-reported health-related quality of life (HRQL) of children with cancer, and the consistency between child and parent reports of child HRQL, as a function of the child's adaptive style. Participants included 199 children with cancer, 108 healthy children, and their parents. Children completed self-report measures of HRQL and adaptive style. Measures of adaptive style were used to categorize children as high anxious, low anxious, defensive high anxious or repressor. Parents completed measures reporting their children's HRQL. Adaptive style was a significant predictor of child-reported HRQL, particularly on the psychosocial scales, with children identified as repressors reporting the best HRQL. Adaptive style was also predictive of discrepancies between parent and child report of child HRQL. Repressor and low anxious children reported better HRQL than did their parents, while high anxious children reported poorer HRQL, regardless of health status. Adaptive style is a significant determinant of self-reported HRQL in children, particularly in psychosocial domains, while health status (i.e. cancer patient vs healthy control) is predictive only of physical health domains. Researchers and clinicians should be aware of the impact of child adaptive style when assessing HRQL outcomes using self- or parent report.

Coping and adjustment in children with cancer: a meta-analytic study

The current meta-analysis assessed the efficacy of coping strategies on psychological and physical adjustment in children with cancer (n = 1230). Coping strategies were operationalized in accordance with two coping taxonomies; the first is based on the general orientation of the child's coping attempts (approach or avoidance), and the second is based upon coping efforts to regulate the stressor and/or feelings of distress attributed to it (problem-focused and emotion-focused). Approach, avoidance, and emotion-focused coping were unrelated to overall adjustment. A small-to-medium but negative association was found between problem-focused coping and adjustment, indicating more use of the strategies that compose this dimension are associated with poorer adjustment. However, homogeneity analyses also indicated significant variation for all of these effect sizes. Follow-up moderator analyses found coping-adjustment relations were both dependent upon time since diagnosis and the particular stressor the child was dealing with during treatment.

Repressing distress in childhood: a defense against health-related stress

This paper is a review of empirical investigations of the repressive adaptive style in youth. Studies were selected on the basis of their adherence to Weinberger et al.'s (J Abnorm Psychol 88: 369-380, 1979) paradigm, consisting of the interaction between a measure of distress and a measure of defensiveness to categorize repressors. The presence of a repressive style of adaptation was identified in adolescence, especially among pediatric populations. Adolescent repressors were found to exhibit characteristics similar to those identified among adult samples (i.e., self-deception, biased self-reports, and inhibition of signals of distress). Only one study focused on young repressors' autonomic reactivity, which is another main characteristic of a repressive adaptive style in adulthood. Methodological inconsistencies between child studies are highlighted and weaknesses in the psychometric properties of defensiveness measures in childhood are discussed. Future investigations should examine the impact of a repressive adaptive style on health outcomes and behaviors to see if adult health data associated with a repressive style of adaptation are replicable in childhood.

Understanding medication adherence in pediatric acute lymphoblastic leukemia: a review

Significant numbers of children and adolescents with acute lymphoblastic leukemia (ALL) do not adequately adhere to their treatment regimen. Failure to take the appropriate amount of prescribed medication may result in disease relapse. Although a number of research studies have sought to identify the factors associated with medication nonadherence in this group, no systematic study has sought to evaluate the efficacy of intervention packages in improving adherence. The aim of the current paper is to provide an overview of the research investigating treatment adherence in ALL patients and to identify the relevant risk factors associated with reduced adherence with medication. The paper will further discuss the role of psychologic therapy in improving treatment adherence in children and adolescents with ALL, with a particular focus on identifying the need for controlled outcome studies.

Psychopharmacology in pediatric critical care

Psychopharmacologic treatment in pediatric critical care requires a careful child or adolescent psychiatric evaluation, including a thorough review of the history of present illness or injury, any current or pre-existing psychiatric disorder, past history, and laboratory studies. Although there is limited evidence to guide psychopharmacologic practice in this setting, psychopharmacologic treatment is increasing in critical care, with known indications for treatment, benefits, and risks; initial dosing guidelines; and best practices. Treatment is guided by the knowledge bases in pediatric physiology, psycho-pharmacology, and treatment of critically ill adults. Pharmacologic considerations include pharmacokinetic and pharmcodynamic aspects of specific drugs and drug classes, in particular elimination half-life, developmental considerations, drug interactions, and adverse effects. Evaluation and management of pain is a key initial step, as pain may mimic psychiatric symptoms and its effective treatment can ameliorate them. Patient comfort and safety are primary objectives for children who are acutely ill and who will survive and for those who will not. Judicious use of psychopharmacolgic agents in pediatric critical care using the limited but growing evidence base and a clinical best practices collaborative approach can reduce anxiety,sadness, disorientation, and agitation; improve analgesia; and save lives of children who are suicidal or delirious. In addition to pain, other disorders or indications for psychopharmacologic treatment are affective disorders;PTSD; post-suicide attempt patients; disruptive behavior disorders (especially ADHD); and adjustment, developmental, and substance use disorders. Treating children who are critically ill with psychotropic drugs is an integral component of comprehensive pediatric critical care in relieving pain and delirium; reducing inattention or agitation or aggressive behavior;relieving acute stress, anxiety, or depression; and improving sleep and nutrition. In palliative care, psychopharmacology is integrated with psychologicapproaches to enhance children's comfort at the end of life. Defining how best to prevent the adverse consequences of suffering and stress in pediatric critical care is a goal for protocols and for new psychopharmacologic research [23,153].

Depression in paediatric cancer: an overview

Research into depression in paediatric cancer is in its early stages, but nevertheless has presented interesting challenges regarding the recognition and measurement of depression in a medically ill population. In this article we discuss the complex interaction between physical and psychological variables, and the diagnostic difficulties arising from this. We review the epidemiological findings regarding prevalence, evaluating the apparently low prevalence rate in the light of methodological weaknesses. Hypotheses put forward to explain the findings are discussed. We conclude by highlighting areas for future research.

Adaptive style and symptoms of posttraumatic stress in children with cancer and their parents

OBJECTIVE

To examine symptom levels of posttraumatic stress (PTS) in children with cancer and their parents as a function of patient and parent adaptive style.

METHOD

Participants included 162 pediatric cancer patients and their parents. Patients completed self-report measures of PTS and adaptive style. Parents reported on their own adaptive style and PTS, as well as levels of PTS in their child.

RESULTS

Adaptive style was a significant correlate of PTS. Children identified as low anxious (LA) or repressors (REP) obtained lower levels of PTS than did high anxious (HA) children, both by self-report and parent report. Parents identified as LA or REP self-reported lower levels of PTS than HA and also reported lower levels of PTS in their children.

CONCLUSIONS

Patient and parent adaptive style are significant determinants of PTS in the pediatric oncology setting. These findings, in combination with the generally low levels of PTS in the pediatric oncology population, raise questions about the utility of the posttraumatic stress model for understanding the experiences of children with cancer, although such a model may be more applicable to parental response.

Perceptions of distress among adolescents recently diagnosed with cancer

With the goal of studying perceived distress among adolescents recently diagnosed with cancer, 56 adolescents were interviewed by telephone 4 to 8 weeks after diagnosis. The interviews included a structured interview guide, the Hospital Anxiety and Depression Scale, and the subscales Mental Health and Vitality from SF-36. "Losing hair" and "missing leisure activities" were identified as the most prevalent aspects of distress, whereas "missing leisure activities" and "fatigue" were rated with the highest levels of distress. "Worry about not getting well," "mucositis," "nausea," "pain from procedures and treatments," and "worry about missing school" were rated as the overall worst aspects by most adolescents. Twelve percent reached the cutoff score for potential clinical anxiety and 21% for potential clinical depression. Ratings of Mental Health and Vitality were lower than norm values. Prevalence of pain from procedures/treatments was higher among those who scored in the clinical range of depression, and more adolescents who were treated at a local hospital scored in the clinical range of anxiety. The findings show that ratings of prevalence, levels, and aspects perceived as the worst are not necessarily in accordance, that adolescents scoring in the clinical range of psychological distress are in the minority, and that the adolescents experience reduced physical and mental well-being.

Quality of life after pediatric intestinal transplantation: the perception of pediatric recipients and their parents

The objective was to examine the perception of physical and psychosocial functioning of pediatric intestinal transplant recipients who are beyond the perioperative period and compare these with normal and chronically ill children. Child and parent forms of the Child Health Questionnaire were administered to all 29 pediatric intestinal transplant recipients between the ages of 5 and 18 years who had had a small bowel transplantation 1 year previous and had a functional allograft. Comparison was made with published norms and scores for pediatric patients on hemodialysis. Intestinal transplant recipients (on average 5 years after intestinal transplantation and at a mean age 11 years) reported similar scores in all domains compared with normal children. Parents of intestinal transplant recipients noted decreased function in several domains related to their child's general health, physical functioning, and the impact of the illness on parental time, emotions and family activities. Intestinal transplant recipients beyond the perioperative period perceive their physical and psychosocial functioning as similar to normal school children. Parental proxy assessments differ from the recipients, with the parent's perception of decreased general health and physical functioning for intestinal transplant recipients compared with norms.

Social, emotional, and behavioral functioning of children with hemophilia

This study examines the social, emotional, and behavioral functioning of children with hemophilia. Data were collected in the homes and schools of 40 boys with hemophilia and 40 comparison boys of the same race and age. Data on social, emotional, and behavioral functioning were collected from teachers, classmates, parents, and the participants. Children with hemophilia scored comparably with comparison peers in all areas of social functioning but reported more difficulties with emotional well-being, including more depressive symptomatology and lower self-perceptions. Parent report also indicated more difficulties with emotional well-being. Parents did not report significant differences in externalizing behavior problems. In conclusion, children with hemophilia were not found to be at increased risk of social or behavioral difficulties. However, both children with hemophilia and their parents identified more difficulties with emotional well-being. Nevertheless, approximately all mean scores for both groups remained within the normal range.

Psychosocial adjustment among pediatric cancer patients and their parents

Children with cancer face both physical and psychosocial challenges. However, there is not enough empirical evidence in Taiwan regarding how they and their families cope with their illness. The purpose of the present study was to explore the psychosocial impact of cancer on target children and their families as well as the degree of depression experienced by these children. Twenty-four pediatric cancer patients, aged 8 through 17 years, completed the Chinese version of Children Depression Inventory (CDI). Both these patients and 18 parents completed questionnaires about their psychosocial adjustment since the diagnosis of cancer. The results showed: (i) patients did not perceive significant changes in their psychosocial adjustment, whereas parents indicated significantly lower mood of patients and a slight decrease in the number of friends; (ii) both parents and siblings showed positive adjustment; and (iii) there was neither significant difference on the CDI scores between the pediatric cancer patients and a normative group, nor significant relationships between patients' CDI scores and demographic characteristics of both patients and their parents, parenting attitudes, as well as variables related to the illness. Lastly, the results are discussed in terms of issues of methodology and instruments. Possible direction for further investigations is suggested.

Survivors of childhood brain tumors: behavioral, emotional, and social adjustment

This paper reviews the literature on the psychological adjustment and quality of life in children who survive brain tumors. A total of 31 studies were reviewed. Findings are discussed in terms of the rates of general psychological adjustment, internalizing behavior problems, externalizing behavior problems, social competence, correlates or predictors of adjustment, and quality of life among survivors. Although these survivors appear to be at risk for compromised social competence and long-term quality of life, reports in the literature on rates of psychological adjustment in this population vary widely. Limitations in the current literature are discussed including inadequate assessment techniques, lack of appropriate comparison groups, and small sample sizes. Directions for future research are offered.

Repressive adaptive style in children with chronic illness

OBJECTIVE

The primary objectives of this study were 1) To assess whether previously reported findings of high levels of repressive adaptation in children with cancer are unique to the cancer population or are generally characteristic of children with serious chronic illness and 2) to assess the utility of including a new measure of anger expression in the adaptive style measurement paradigm.

METHODS

Measures of defensiveness, trait anxiety, and anger expression were obtained from three groups of children: those with cancer (N = 130), those with chronic illnesses (diabetes, cystic fibrosis, and juvenile rheumatoid disorders; N = 121), and healthy control participants (N = 368). Based on their self-reports, participants were categorized according to the adaptive style paradigm as either high anxious, low anxious, defensive high anxious, or repressor. The prevalence of these categories was compared across groups.

RESULTS

Children in the cancer and chronic illness groups both reported significantly higher levels of defensiveness and lower levels of anxiety than did the healthy control participants. Application of the adaptive style paradigm produced a significantly higher percentage of children identified as repressors in the both cancer and chronic illness groups relative to healthy children. Children classified as repressors also reported significantly less expression of anger than did nonrepressors.

CONCLUSIONS

An increased prevalence of repressive adaptation is not unique to children with cancer, but may be generally characteristic of children with serious chronic illness. Use of anger in place of anxiety as the repressed affect produced a similar distribution of adaptive styles in the study populations.

Psychosocial development in adolescents with Turner syndrome

Turner syndrome is a genetic condition in which part or all of the second X chromosome is missing. Our goal in this study was to examine the psychosocial adjustment of a sample of adolescent girls with Turner syndrome. Subjects included 122 girls with a diagnosis of Turner syndrome (TS) and a control group of 108 girls with no genetic disorder or chronic illness. Subjects were 13 to 18 years of age. A battery of questionnaires assessing social, academic, school, and behavioral functioning was administered. TS girls were seen as having significantly more problems in terms of social relationships and school progress and were more likely to meet criteria for attention-deficit hyperactivity disorder than control girls. The TS girls were also rated by a parent as less socially competent (e.g., fewer friends, less time with friends) than the control group. Social difficulties appear to be an area of vulnerability for TS girls. Counseling individuals with Turner syndrome and their families about the need to carefully develop and nurture social skills and relationships may prove useful in advancing the social adaptation of these young women.

Children with cancer with different survival perspectives: defensiveness, control strategies, and psychological adjustment

The main objective of the present study was to investigate whether children with cancer with different survival perspectives differ in their psychological adjustment, defensiveness and their use of cognitive control strategies. Furthermore, the study investigated which variables predict emotional adjustment of these children with cancer most adequately. A total of n=84 children (n=43 children in remission and n=41 children not in remission) participated in the study. They answered questionnaires about control strategies, defensiveness, anxiety and depression. No differences were found in any of the questionnaires between children in remission and relapse. Emotional adjustment of the children was predicted by defensiveness and by positive expectations about the course of the illness. The findings demonstrate the importance of having positive expectations for the emotional adjustment of children with cancer. The strength of the study is the inclusion of a substantial group of children with cancer who have a reduced survival perspective.

Trauma and personality correlates in long-term pediatric cancer survivors

To explore the relationship between PTSD and trauma-spectrum symptoms, including personality and functional correlates, in long term pediatric cancer survivors (N = 40), we assessed these constructs with a structured interview for PTSD, a clinical interview, and self-report questionnaires. Thirty-five out of 40 participants (88%) currently met at least one trauma symptom at a functionally significant level. These survivors demonstrate high levels of restraint and low levels of distress, representative of a repressive adaptive style. After more than 5 years since treatment completion, the relatively high levels of current trauma-spectrum symptoms may reflect the long-term deleterious impact of childhood cancer.

Posttraumatic stress disorder in children and adolescents: a review and analysis

Only recently has the mental health community recognized the applicability of diagnostic criteria for posttraumatic stress disorder (PTSD) in children and adolescents, including a consideration of specific age-related features. This paper provides a current review of the literature on PTSD pertaining to children and adolescents. Following a discussion of issues on diagnostic criteria and assessment of this affective disorder in this population, there is an overview of the existing literature on prevalence, comorbidity, risk factors, parental and family factors, and issues of gender and age of onset. The remainder of the paper focuses on the range of traumatic stressors in children and adolescents that can result in PTSD, including natural or human disasters, war and violence, chronic or life-threatening medical conditions, community violence and the witnessing of traumatic events, and physical and/ or sexual abuse and other forms of interpersonal violence. Throughout the paper, there is an emphasis on the importance of considering developmental factors. Finally, implications of the existing literature for future areas of research are addressed.

Trauma spectrum adaptation: somatic symptoms in long-term pediatric cancer survivors

The authors assessed somatic symptoms and the degree of association among somatic symptoms, global adjustment, trauma symptoms, and personality characteristics in long-term pediatric cancer survivors. Forty cancer survivors completed self-report questionnaires and clinical interviews. Participants' level of somatic symptoms fell between nonclinic and psychiatric populations. Somatic symptom scores correlated with general adjustment in the negative direction and with posttraumatic stress disorder (PTSD) scores in the positive direction. The majority of participants met at least partial current PTSD criteria. Because these survivors demonstrate a repressive adaptive style but endorse somatic symptoms, the latter may represent a method for detecting trauma-related distress in this population.

Health-related quality of life in childhood cancer: discrepancy in parent-child reports

The purpose of our study was to describe reports of parents and of children with cancer on items taken from 4 domains of health-related quality of life (HRQL), bodily pain/distress, general health perceptions, physical functioning and limitations in role/social functioning as a result of physical health, and to examine whether differences in parent-child reports varied as a function of the child's health condition (cancer vs. healthy). Twenty-seven child-parent dyads with cancer and 27 child-parent dyads who were healthy (child ages 8 to 18 inclusive) completed measures of child HRQL [Child Health Questionnaire-Parent Form (CHQ-PF50) and Child Health Questionnaire (CHQ-CF87)] and demographic information at a scheduled out-patient general pediatric or pediatric oncology clinic appointment. Sixteen items included on both the CHQ-CF87 and CHQ-PF50 were examined to compare parent and child reports of child HRQL. As hypothesized, greater discrepancies were evident in the reports of parents of children with cancer than parents of children who are healthy [F(16,31) = 3.98, p < 0.0001]. Statistically significant discrepancies emerged in parent and child responses on 50% of the items in the sample of children with cancer, with parents reporting that their children experience more limitations in their lives than did the children themselves. In the healthy group, statistically significant discrepancies emerged on only 1 of the 16 items (6.3%).

Somatization, anxiety and depression as measures of health-related quality of life of children/adolescents with cancer

This descriptive study of health-related quality of life of children with cancer compared children/adolescents', parents' and teachers' ratings for somatization, depression and anxiety to determine if there were significant correlations among respondent scores. In addition, the percentage of agreement among respondents and significant differences based on age, gender, use of cranial radiation and treatment status were measured. Forty-three children/adolescents with cancer, currently receiving therapy for at least 1 year or who had completed therapy for no more than 3 years (excluding children who had received bone marrow transplants or who had brain tumors), were recruited, with a parent and teacher, from 3 university medical centers. The Behavioral Assessment System for Children questionnaires for children/adolescents, parents and teachers were used. Parents reported a higher level of depression for the children/adolescents with cancer than did the teachers or the children/adolescents themselves. Parents reported a higher level of anxiety for the children/adolescents than did the teachers. High positive correlations were found among scores from parents and teachers and among scores from parents and children/adolescents for the anxiety and depression but not somatization subscales. Children/adolescents and teachers had high, positively correlated scores only for the depression subscale. High, positive correlations were found between somatization, anxiety and depression within each group of respondents. A significant percentage of agreement between all respondents on ratings for at-risk status was obtained only for the depression subscale. Age was the only variable found to have an influence on scores and only for the anxiety subscale.

Review of research studies that evaluated the impact of treatment for childhood cancers on neurocognition and behavioral and social competence: nursing implications

ISSUES AND PURPOSE

Given the increasing incidence of childhood cancer, increasing survivor rates, and documented incidence of sequelae, nurses need evidence on which to base interventions for families at risk. The authors review and critique research studies that evaluated the impact of treatment for childhood cancers. Implications for nursing practice are discussed.

CONCLUSIONS

Research to evaluate the effects of treatment on neurocognition and behavioral and social competency of children with cancer has produced conflicting results. Most studies found deleterious effects on all three areas associated with childhood cancer treatment. Some studies, however, found no differences between childhood cancer survivors and children on therapy compared to normative data or healthy controls.

PRACTICE IMPLICATIONS

Knowledge of the short- and long-term impact of treatment for childhood cancer on neurocognition and behavioral and social competence allows nurses to design interventions that mitigate neurocognitive effects, decrease behavioral problems, and improve social competence.

Behavioral Problems of Asthmatic Children

Behavioral problems of 116 children with asthma were studied at the Linn Medical Center in Haifa, Israel, where they were under treatment. Parents were administered a medical questionnaire and the Achenbach Child Behavior Checklist. The study examines the relationship between asthmatic children of various levels of severity of the illness and behavioral problems. A comparison was made among the Achenbach scale, level of compliance with treatment procedures, and level of severity of the illness. Another comparison was made between age groups and level of behavioral problems. Significant differences were found between all three illness severity groups and two variables—somatic complaints and social problems. Differences were also found between age groups for the withdrawn variable.

Repressive-defensive style and physiological reactivity among children and adolescents with asthma

OBJECTIVE

This study evaluates the concordance of two self-report methods of operationalizing repressive-defensive style in children with asthma. It was hypothesized that, compared with low-anxious children, repressive-defensive children would exhibit increased physiological reactivity during a stressful laboratory task, despite comparable self-reports of state anxiety.

METHODS

Ninety-one children and adolescents (mean age = 11.5 years) with asthma participated in the study. Repressive-defensiveness was operationalized as self-reported low distress coupled with high defensiveness or restraint. Self-report data reflecting trait anxiety, defensiveness, and personality style were used to classify children as repressive-defensive by two independent methods. Physiological reactivity was operationalized as standardized changes in peripheral temperature, heart rate, and/or skin conductance from baseline to a stressful task. For the stressful task, children spoke into a tape recorder about a stressful or embarrassing event.

RESULTS

Each method classified 20% of children as repressive-defensive. However, of the children classified as repressive-defensive by either method (n = 26), only 38% (n = 10) were classified as repressive-defensive by both methods. In addition, regardless of the classification method, repressive-defensive children did not consistently differ from low-anxious children with respect to physiological reactivity under stress, one of the hallmarks of repressive-defensiveness in adults.

CONCLUSION

These results cast doubt on our ability to measure repressive-defensiveness reliably using self-report measures. Future research should determine whether children and adolescents can be reliably classified as repressive-defensive, whether this classification is related to physiological reactivity as in adults, and whether repressive-defensiveness plays a role in emotionally triggered asthma symptoms.

Psychotherapeutic practice in paediatric oncology: four examples

Psychotherapy, often used with children treated for a solid tumour, is seldom described. We present four examples of such therapies: a mother who refused enucleation for her 7-month-old boy; a boy's jealousy towards his sister who was being treated for a brain tumour; a teenager troubled by his scar; a 7-year-old boy embarrassed by the unconscious memory of his treatment when he was 5 months old. All names have been changed, for reasons of privacy. Psychotherapies aim to help children and parents to cope with the violent experience of having cancer, to recover their freedom of thought and decision-making concerning their life, their place in the family, their body image, their self-esteem, their identity. These descriptions of brief psychotherapy could help paediatricians to gain a more thorough understanding of the child's experience, to improve collaboration with psychotherapists and to confront clinical skills of psychotherapists.

Denial in cancer patients

Denial is a basic mechanism for coping with stressful themes, common in healthy and sick individuals. This article deals with the role and functions of denial in cancer, reviewing empirical studies about the effects of denial on cancer prevention, screening, undergoing tests for early detection, delay in seeking medical attention and getting treatment, complying with medical instructions, and coping with the disease in different stages. Special sections are devoted to the possible role of denial as a risk factor for cancer, the effects of denial on disease course and survival, and the relation of denial to immunocompetence. Major conclusions are that denial may have a positive effect when applied in the first phase of coping, after diagnosis, because it reduces anxiety. This holds also for the terminal stage. The negative effects of denial are that it may interfere with getting treatment (e.g., delay in going to the doctor, not showing up for follow-ups, noncompliance), may disrupt the process of assimilating the stressful event, may affect adversely interpersonal relations, and constitutes a cumulative stressor depressing even immunocompetence. The use of denial varies with the severity of the situation, the patient's personality, and his or her familial and cultural background. A large body of research examined the hypothesis that a tendency toward denial could be one of the risk factors for cancer. Despite evidence supporting the occurrence of denial as a correlate of cancer, a lot of research is necessary to clarify the role of denial in general and of anger specifically as a factor affecting the occurrence of cancer and the course of disease and survival.

Low-end specificity of childhood measures of emotional distress: consistent effects for anxiety and depressive symptoms in a nonclinical population

Previous research regarding the low-end specificity of self-report measures of affective distress in children suggests that defensiveness acts differentially to lower scores on self-report measures of depressive symptoms, but not on self-report measures of anxiety. This investigation examined this issue in a nonclinical sample of 442 children, ages 7 to 16. Participants completed measures of depressive symptoms (Children's Depression Inventory), anxiety symptoms (State-Trait Anxiety Inventory for Children) and defensiveness (Children's Social Desirability Scale). In contrast to previous research, the results in this study indicated similar effects of defensiveness on measures of depressive symptoms and anxiety. Low-end depression participants obtained significantly higher defensiveness scores, as did low-end anxious participants. In an attempt to circumvent the effects of defensiveness, we measured anhedonia (Pleasure Scale for Children, or PSC) as a proxy of depressive symptoms. We also found the PSC to be subject to the effects of defensiveness at approximately the same magnitude as the measures of anxiety and depressive symptoms.

Approaches to the measurement of depressive symptomatology in children with cancer: attempting to circumvent the effects of defensiveness

This study explored an alternative self-report approach to the measurement of depressive symptoms in children that was hypothesized to be less prone to the distorting influences of defensiveness. Children with cancer (n = 107) and healthy controls (n = 442) completed measures of adaptive style (defensiveness, anxiety), a standard depression inventory, and an anhedonia measure used as a proxy estimate of depressive symptoms. As predicted, children with cancer reported significantly fewer depressive symptoms than did healthy controls on the depression inventory, whereas no differences were found on the measure of anhedonia. However, self-report of anhedonia was found also to be subject to the influence of defensiveness, and neither the depression inventory nor the anhedonia measure was significantly related to parent and physician ratings of depression. An approach that combined self-report measures of depression and anhedonia did not significantly improve the identification of children rated as depressed by parents or physicians. Measurement of anhedonia may provide an interesting avenue for further research, but there is still no adequately validated self-report instrument for the measurement of depressive symptoms in children with cancer.

Illness narratives: discursive constructions of self in pediatric oncology

Narratives from adolescents in treatment for cancer were examined for the variety of ways in which self is constructed in discourse. Narratives were elicited by the second author (Bearison) from 75 children ranging in age from 3 to 19 years and at various stages of treatment for cancer. The present study examined a subset of these data. According to discourse theory, narratives are a means of constructing and understanding the self, particularly during unsettling life events that perturb the self-system. Adolescents who have cancer strive to make sense of the threatening and uncertain consequences of treatment, and their narratives reflect this struggle and their attempt to resolve it. The present study identified three narrative domains of self (biomedical, social, and personal) and considered variations among them according to the following features: (1) degree of otherness (i.e., to what extent and in what manner are other people, family, peers, and medical staff brought into the discourse), (2) expression of self as agent versus object, and (3) a series of linguistic markers denoting the narrative voice: understatement, exaggeration, reassurance, passive voice, and the use of personal and impersonal pronouns. In addition, expressions of denial and control were identified as central issues of self in narrative. Findings indicated that there were patterns of co-occurrence of discourse features that constituted different narrative styles by which participants gave voice to their struggle to redefine the self.

A review of the literature on resilience in the adolescent with cancer: Part II

Adolescents with cancer experience multiple stressors that may stem from both the illness and from normal developmental tasks. Some adolescents remain or become resilient even when faced with multiple challenges. An understanding of what contributes to resilience in the adolescent cancer experience is important in caring for adolescents with cancer and childhood cancer survivors. The purpose of this article is to provide a synthesis of the literature related to resilience in the adolescent cancer experience. Research recommendations based on theoretical and methodological limitations noted in the review are presented.

Depression in pediatric chronic illness. A diathesis-stress model

Depression in pediatric chronic illness has been receiving increasing attention in recent years. Studies to date have typically focused on characteristics of illness as the major determinants of the development of depression, but characteristics of the child have received less attention. This review suggests that a diathesis-stress model can be a fruitful heuristic that would incorporate illness characteristics and attributes of the child and environmental effects in an overall framework to guide future research and treatment.

Social, emotional, and behavioral functioning of children with cancer

OBJECTIVE

It was hypothesized that children with cancer would have more social problems and difficulties with emotional well-being than case control, same race/gender, similarly aged classmates.

STUDY DESIGN

Using a case controlled design, children with any type of cancer requiring chemotherapy except brain tumors (n = 76), currently receiving chemotherapy, ages 8 to 15, were compared with case control classroom peers (n = 76). Peer relationships, emotional well-being, and behavior were evaluated based on peer, teacher, parent, and self-report, and were compared using analysis of variance and structural equation modeling.

RESULTS

Relative to case controls, children with cancer were perceived by teachers as being more sociable; by teachers and peers as being less aggressive; and by peers as having greater social acceptance. Measures of depression, anxiety, loneliness, and self-concept showed no significant differences, except children with cancer reported significantly lower satisfaction with current athletic competence. There were also no significant differences in mother or father perceptions of behavioral problems, emotional well-being, or social functioning. Scores on all standardized measures were in the normal range for both groups. Comparisons of the correlation matrices of children with cancer and to the correlation matrix of the comparison children using structural equation modeling suggested they were not significantly different.

CONCLUSIONS

Children with cancer currently receiving chemotherapy were remarkably similar to case controls on measures of emotional well-being and better on several dimensions of social functioning. These findings are not supportive of disability/stress models of childhood chronic illness and suggest considerable psychologic hardiness.

Psychiatric symptomatology in adolescents with cancer

Adolescents with cancer need to cope with their disease and treatment while accomplishing the tasks unique to this developmental period. In this pilot study, the prevalence of psychological morbidity among adolescents with cancer was examined. In addition, assessment methods and risk factors were explored. Forty-three recently diagnosed adolescents with cancer completed the Hospital Anxiety and Depression Scale (HADS), the Beck Depression Inventory (BDI), and the Rotterdam Symptom Checklist (RSCL) and underwent a full psychiatric assessment. In the psychiatric interviews, 9% of the sample was diagnosed with a depressive mood disorder. Results suggest that self-report rating scales can be useful assessment instruments if used as complementary tools. Psychosocial assessment of the adolescent with cancer is nevertheless difficult. This appears to be due to an atypical symptomatology pattern and a tendency toward the masking of distress. Case examination of depressed patients suggests that illness and treatment factors may not be primary risk factors for the development of psychological morbidity. External stressors such as poor family support and past sexual abuse, when compounded by illness and treatment factors, may be more relevant.

Consultation-liaison in child psychiatry: a review of the past 10 years. Part II: Research on treatment approaches and outcomes

OBJECTIVE

To critically review the research and reports on consultation-liaison psychiatry in the past 10 years.

METHOD

Articles contributing to the conceptualization of child psychiatric consultation in medical, epidemiological, and nonmedical domains were reviewed.

RESULTS

Information was organized into methodology and treatment outcome categories. Nonmedical consultation articles were briefly reviewed. Articles reporting therapeutic techniques in consultation-liaison work and outcome studies are described.

CONCLUSIONS

In spite of constraints imposed by managed care upon referral to specialists, the current epoch finds child psychiatrists both better equipped and more compelled to use their skills in innovative ways to help children in different domains.

Emotions, coping and the need for support in families of children with cancer: a model for psychosocial care

In the case of childhood cancer, the personal threats are severe for both the child, the parents and other family members. For the child, there is the threat to physical integrity, safety, security, and above all, to life. For the parents, there is the threat of losing the child. However, a number of studies have shown that psychopathological disturbances are rarely found in children with cancer or their parents. We may conclude from this that most children and parents use coping strategies that protect them from developing psychopathology. In organising support for families with a child with cancer, much can be learned from children's and parent's perceptions and reactions. When problems of adjustment arise, a thorough analysis of how children and parents perceive their situation, as well as an extensive analysis of their coping efforts, is necessary to direct effective supportive actions. A psychosocial support model is proposed which can be helpful in interpreting these emotions and coping strategies.

Consultation-liaison in child psychiatry: a review of the past 10 years. Part I: Clinical findings

OBJECTIVE

To critically review clinical reports on pediatric consultation-liaison psychiatry over the past 10 years.

METHOD

Articles contributing to the understanding of child psychiatric consultation in medical settings were reviewed.

RESULTS

Information related to clinical issues was organized into categorical (disease-oriented), noncategorical, and family studies. Newer articles on ethical considerations in caring for medically ill children are summarized.

CONCLUSIONS

Research has continued to focus on and reflect the importance of the emotional and behavioral needs of children in pediatric settings and the adaptation and stress within families who care for chronically ill children. Given the increased complexity and demands of medical care, the training and skills of a child psychiatrist in pediatric consultation remain a valuable component of comprehensive care for children.

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.

Anxiety and depression in adolescent cancer: findings in patients and parents at the time of diagnosis

Adolescent cancer is uncommon and presents an exceptional stress for the young patient and their parents. The emotional needs of adolescents with cancer are a major factor in the recommendation for the establishment of adolescent cancer units in major cancer centres in the U.K. However, there have been no prospective, longitudinal studies assessing the psychological impact of a diagnosis of cancer on the adolescent patient and their family. In 1994 we began a longitudinal study of the emotional impact of the diagnosis of cancer in patients and their families presenting to an adolescent cancer unit and of the coping strategies they employ. This first report presents the results of the study at the time of diagnosis in 42 adolescents, 34 mothers and 27 fathers. The Beck Depression Inventory (BDI) was used to assess depression and anxiety levels were measured using Spielberger's State Trait Anxiety Inventory (STAI). Adolescents and their parents completed the questionnaires on first admission to the adolescent cancer unit. The median time since cancer diagnosis was approximately 3 weeks. To provide normative data for the U.K. adolescent population, control values were obtained from 173 pupils of the same age and background. The results showed that, contrary to expectation, adolescents with cancer were no more anxious or depressed than the control adolescent population. Nevertheless, a substantial minority of patients and controls had elevated anxiety or depression scores. Girls were significantly more anxious (P = 0.011) and depressed (P < 0.0001) than boys. Mothers were the most anxious family members and were significantly more anxious than fathers (P = 0.038). Parental anxiety scores, especially mothers, were much higher than reported norms. There was no significant difference between mothers' and fathers' depression scores. Although at the time of diagnosis adolescent cancer patients are not more anxious or depressed than their healthy peers, many adolescents without cancer are anxious or depressed. Staff on adolescent cancer units should therefore be aware of the frequency of emotional disturbance in this population. Mothers are the most anxious family members. Although the findings are relatively reassuring at the time of diagnosis, follow-up data from this cohort will show whether anxiety and depression change with treatment involving intensive chemotherapy, surgery and radiotherapy and will indicate the coping strategies which patients and their families adopt in dealing with both the disease and its treatment.

School age children's coping with sexual abuse: abuse stresses and symptoms associated with four coping strategies

Strategies used by 84 sexually abused children, ages 7 to 12, to cope with their abuse were evaluated, along with child abuse-related symptoms, parent-reported behavioral symptoms, and teacher-reported behavioral symptoms. Principal components analysis of coping yielded four strategies that were labeled avoidant coping, internalized coping, angry coping, and active/social coping. Each coping strategy was found to be associated with a unique set of abuse characteristics, abuse-related social environment, and symptoms. In contrast to findings with adult survivors and adolescents, use of avoidant coping strategies among school-age children was found to be related to fewer behavioral problems, although it was also associated with greater sexual anxieties. Internalized coping was found to be associated with increased guilt and PTSD hyperarousal symptoms. Active/social coping was the only strategy found to be unrelated to symptoms, but neither was it associated with measured benefits. In contrast to some clinical opinion that externalizing blame and venting anger is a helpful strategy, angry coping was found to be associated with a wide range of behavioral and emotional problems as rated by the child's home-room school teacher. Results are discussed in terms of a proposed mediational model.

Psychiatric sequelae in seriously ill children and their families

Going through a life-threatening illness as a child or adolescent is a tremendously stressful experience for the entire family. Although the majority of survivors do go on to adjust and function well, some have ongoing problems. These problems include evidence of posttraumatic stress, learning difficulties, depression, and anxiety. Their parents appear to be even more severely affected, possibly because they had a better appreciation at the time of the true dangers posed by the illness and the treatment. Little is yet known about their siblings, although it is clear that the acute stage of illness and treatment effects the entire family. Areas needing study include the long-term sequelae on siblings of survivors, as well as a better understanding of the precipitants and mediators of the problems noted in survivors and parents. Only then can interventions and preventative measures be undertaken and tested. Also needed is a better understanding of the impact of cultural differences on precipitants, mediators, and symptoms.

A comparison of measures of adjustment, symptoms, and impairment among children with chronic medical conditions

OBJECTIVE

To examine the concurrent and criterion validity of three instruments used to measure emotional and behavioral problems among children with chronic illness.

METHOD

The Personal Adjustment and Role Skills Scale (PARS III), Child Behavior Checklist (CBCL), and Columbia Impairment Scale (CIS) were compared with each other and with structured interview-derived psychiatric diagnoses in 116 chronically ill children, aged 9 to 18 years. Three cutoff scores were used for each measure.

RESULTS

The measures had good concurrent validity despite only moderate agreement with each other. Their criterion validity was only fair: levels of sensitivity were fair at low cutoffs and poor at standard and high cutoffs; specificity and positive predictive values rose from moderate at low cutoffs to high at standard and high cutoffs. The agreement between the scales and a mental disorder diagnosis was only moderate at any of the cutoff points.

CONCLUSIONS

Each of these measures has significant limitations. Both the CBCL and the PARS III appear to measure similar constructs but are likely to underidentify medically ill children with comorbid psychiatric problems. Consideration of global functioning across domains, with a measure such as the CIS, might provide an alternative approach to behavioral and symptom checklists in the assessment and management of children with chronic conditions.