A prospective study of anxiety, depression, and behavioral changes in the first year after a diagnosis of childhood acute lymphoblastic leukemia: a report from the Children's Oncology Group

Fear, coping and support- from the perspective of children aged 10-17-year old having acute lymphoblastic leukemia

PURPOSE

To describe experiences of fear, coping, and support in 10-17-year-old children under treatment for acute lymphoblastic leukaemia (ALL).

METHODS

A longitudinal descriptive qualitative design was adopted. Ten children participated in one to three interviews each (24 interviews in all). Interviews were analysed using a matrix-based qualitative method.

RESULTS

The variety of fears described related to uncertainty, pain and medical procedures, bodily changes and loss of control, complications, professionals' attitudes, affected school results, and social isolation. Children used various strategies to deal with fear: some more general, to cope with the whole situation, and others more related to specific events such as treatment and tests. The most reported strategies we labelled Accepting the situation, Positive thinking, and Being an active agent. Less favourable strategies were also reported. Health care professionals, families, and friends offered valuable, but different kinds of, support.

CONCLUSIONS

Children aged 10 to 17 undergoing treatment for ALL experience various fears. Each experience is individual and changes over time, but there are common patterns. Most children used problem-solving or emotional-regulation strategies, but withdrawal was also reported. Even children who can deal with fear need support from their health care professionals, families, and friends.

Resiliency process in the family after childhood leukaemia diagnosis: A longitudinal qualitative study

AIMS

To construct a conceptual framework on the process of family resilience during the first year following childhood leukaemia diagnosis.

DESIGN

A longitudinal qualitative interview study.

METHODS

A longitudinal qualitative study following a grounded theory methodology was employed. Semi-structured interviews were conducted with parents of children with leukaemia in a general hospital. The participants were recruited through purposive and theoretical sampling and longitudinal engagement was achieved by conducting interviews at 1, 3, 6, and 12 months after the leukaemia diagnosis. The core category and categories were saturated following the enrolment of parents of children with leukaemia. Data collection and analyses were performed simultaneously.

RESULTS

Sixteen parents of children with leukaemia participated. The core category of 'families living with childhood leukaemia' refers to the process of family resilience during the first year following childhood leukaemia diagnosis, which includes three phases: (1) destruction and resiliency period; (2) adjustment and consolidation period; and (3) growth and planning period.

CONCLUSION

This study explored the dynamic, complex and continuous processes of resilience among families coping with childhood leukaemia during the first year following diagnosis. Further research should design tailored family interventions that characterise the different phases of family resilience, aiming to support family well-being, integrity and functioning.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Both families and healthcare professionals must create an enabling environment that supports families coping with difficulties. Understanding the different phases of family resilience allows healthcare professionals to provide holistic care that meets the demands of families with childhood leukaemia.

IMPACT

Unique knowledge emerged about the family's resiliency process when facing childhood leukaemia, suggesting a family-led revolution in understanding and managing childhood leukaemia. Therefore, the development of phased, resilience-based family interventions is imperative.

REPORTING METHOD

This study was reported using the COREQ checklist.

PATIENT OR PUBLIC CONTRIBUTION

Patients contributed via study participation.

Prevalence of anxiety, depression, and post-traumatic stress disorder among Omani children and adolescents diagnosed with cancer: a prospective cross-sectional study

BACKGROUND

Children and adolescents diagnosed with cancer often experience psychological distress, encompassing anxiety, depression, and post-traumatic stress disorder (PTSD). This study aimed to evaluate the prevalence of these conditions among Omani children and adolescents diagnosed with cancer, alongside identifying contributing factors.

METHODS

A prospective cross-sectional study was conducted from October 2021 to June 2023 among a cohort of Omani children and adolescents (6-18 years old) diagnosed with cancer at three primary cancer referral centres in Oman. Validated Arabic-language versions of the Screen for Child Anxiety Related Disorders, the Center for Epidemiologic Studies Depression Scale for Children, and the Impact of Event Scale-Revised instruments were used to assess symptoms of anxiety, depression, and PTSD, respectively. An initial assessment (T1) was undertaken within the first 3 months of diagnosis, followed by a second assessment (T2) 3-6 months later.

RESULTS

Of 113 eligible participants, 101 agreed to participate in the study (response rate: 95.6%), with 92 (91.0%) completing both assessments and included in the final analysis. Prevalence rates of anxiety, depression, and PTSD decreased from 43.5%, 56.5%, and 32.6%, respectively, at T1, to 38.0%, 35.9%, and 23.9% at T2. All average scores were below diagnostic cut-off points, except for the depression score at T1. Anxiety and depression scores decreased significantly (p = 0.043 and 0.001, respectively) between T1 and T2, as did the overall prevalence of depression (p = 0.004). At T1, linear regression analysis showed significant correlations between anxiety scores and the child's age and PTSD score (p < 0.05); these variables were also correlated with depression scores (p ≤ 0.001). At T2, significant correlations were observed between anxiety scores and the child's age and PTSD scores (p < 0.001). At both T1 and T2, anxiety, depression, and PTSD scores remained significantly correlated (p < 0.001).

CONCLUSIONS

Omani children and adolescents recently diagnosed with cancer exhibit a high prevalence of anxiety, depression, and PTSD over time. Age-appropriate communication, ongoing support, and mental health services are recommended to help this patient group cope with their diagnosis and manage their emotional wellbeing. There is a need for future research to determine the effectiveness of specific psychological interventions in reducing the frequency of these disorders.

Mental health and neurodevelopmental patient-reported outcome measures (PROMs) for children and young people with epilepsy: A systematic review

Children and young people with epilepsy are at higher risk of mental health disorders and atypical neurodevelopmental outcomes compared to the general population. It is essential to detect such comorbidities early in children with epilepsy and provide appropriate interventions, to improve clinical outcomes. We aimed to identify and evaluate the measurement properties of Patient-Reported Outcome Measures (PROMs) that have been validated specifically to measure mental health and neurodevelopmental outcomes in children and/or young people with epilepsy. We searched Embase, Medline, and PsycINFO in May 2023 for relevant studies. Mental health was defined as psychological symptoms (e.g., anxiety, depression, psychosis) and/or behavioural difficulties (e.g., conduct disorders). Neurodevelopmental outcomes included neurodevelopmental disorder traits such as attention-deficit hyperactivity disorder (ADHD) and autistic spectrum disorders. We assessed methodological quality using Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidance. Twelve papers were identified that psychometrically evaluated 13 relevant PROMs (two epilepsy-specific, eleven generic). The appraisal of the PROMs was limited by the availability of only one or two published articles for each, and incomplete psychometric evaluations in some cases. The tool demonstrating the strongest evidence was The Neurological Disorders Depression Inventory-Epilepsy for Youth. The ADHD Rating Scale-IV and The Paediatric Symptom Checklist -17 demonstrated good evidence in favour of at least two measurement properties. This review identified only a small number of mental health and neurodevelopmental PROMs evaluated specifically in paediatric epilepsy. There is a need for further validation of mental health and neurodevelopmental PROMs in children with epilepsy.

Trajectories of illness perceptions in paediatric cancer patients and their parents and associations with health-related quality of life: Results of a prospective-longitudinal study

OBJECTIVE

In paediatric oncology, little is known about trajectories of illness perceptions and their longitudinal associations with health-related quality of life (HRQoL). Therefore, the aim of this study was to investigate changes in illness perceptions in children and parents over a one-year-period and to investigate predictive value of child's and parent's illness perceptions during acute treatment for child's HRQoL 1 year later.

METHODS

N = 65 child-parent-dyads participated in a longitudinal study (retention rate: 80.2%). Children were 4-18 years of age and underwent acute cancer treatment at baseline. Children and parents reported on their own illness perceptions (Illness-Perception-Questionnaire-Revised), as well as on the child's HRQoL (KINDL-R) at baseline and one-year-follow-up. Paired-samples t-tests were calculated to investigate changes over time. A hierarchical multiple regression analysis was performed to investigate predictive value of child's and parent's illness perceptions for child's HRQoL.

RESULTS

Child's HRQoL t(63) = -6.73, p < 0.001, their perceptions of coherence (i.e. understanding; t(54) = -2.36, p = 0.022) and consequences of their illness (t(54) = 2.86, p = 0.006), and parent's perception of cyclical trajectory (t(61) = 2.06, p = 0.044) improved from baseline to 1-year-follow-up. All other illness perceptions remained stable. Exploratory post-hoc analyses showed differences in the pattern of change in age-, gender-, and diagnosis-specific subgroups. After controlling for baseline levels of HRQoL, child's perceptions of symptoms and consequences were independent predictors of their HRQoL 1 year later (R2 = 0.396, F(2,52) = 10.782, p < 0.001), whereas no parent's illness perceptions added predictive value.

CONCLUSION

In paediatrics, child's and parent's illness perceptions should be assessed. Our findings highlight the importance of illness perceptions as potential modifiable variables in interventions to improve child's HRQoL.

Portuguese Validation of the TAPQoL: A Health-Related Quality of Life Instrument for Children Aged 0-6 Years

In Portugal, there are few generic and specific instruments to assess health-related quality of life (HRQoL) in children, especially those of preschool age. This study aimed to adapt and validate the Portuguese version of the Preschool Children Quality of Life Questionnaire (TAPQoL) in a community and clinical sample of children aged 0-6 years. The parents of 409 healthy children and 137 children undergoing treatment for burns and acute lymphoblastic leukemia completed the TAPQoL and were assessed on psychological morbidity and family functioning. Exploratory and confirmatory factor analyses were performed, as well as analysis of the psychometric properties as shown by internal consistency measures, convergent validity, and average variance extracted. Confirmatory factor analysis confirmed an 11-factor structure with good psychometric properties. The current version of the TAPQoL is a valid and reliable instrument for assessing HRQoL in Portuguese preschool children in community and clinical settings.

Promoting positive physical activity behaviours in children undergoing acute cancer treatment: feasibility of the CanMOVE intervention

BACKGROUND

Supporting children and adolescents with cancer to be physically active can improve medium- and long-term health outcomes.

OBJECTIVE

To assess the feasibility of CanMOVE, a 10-week complex, theoretically-informed, behaviour change intervention to promote physical activity for children and adolescents undergoing acute cancer treatment.

METHODS

A feasibility study using a single-group, repeated measures, mixed methods design. Participants completed CanMOVE, which included provision of a Fitbit (child/adolescent and carer) and structured support from a physical therapist. Feasibility domains of demand, acceptability, implementation, practicality, limited efficacy, and integration were evaluated. Data sources included service level data, objective assessment of physical activity, physical function, and health-related quality of life; and qualitative data collected via semi-structured interviews with participants and focus groups with staff.

RESULTS

Twenty children/adolescents (median age 13yrs, interquartile-range 9-14) with a mix of cancer diagnoses, 20 parents, and 16 clinicians participated. There was high demand with 95% enrolment rate. CanMOVE was acceptable for participants. All feasibility thresholds set for implementation were met. Under practicality, there were no serious adverse events related to the intervention. Limited efficacy data indicated CanMOVE showed positive estimates of effect in influencing child/adolescent physical activity behaviour, physical function, and health-related quality of life. Positive impacts were also seen in parent and staff attitudes towards physical activity promotion. To improve integration into the clinical setting, it was suggested the duration and scope of CanMOVE could be expanded.

CONCLUSION

CanMOVE was feasible to implement in a paediatric cancer setting. CanMOVE is appropriate to be tested in a large-scale trial.

Music Nursing as Complementary Therapy Improves Anxiety, Fatigue, and Quality of Life in Children with Acute Leukaemia: A Retrospective Study

OBJECTIVE

To explore the effects of music nursing as a complementary therapy on anxiety, fatigue, and quality of life in children with acute leukemia (AL).

METHODS

This study included 150 children with AL admitted to our hospital from August 2021 to August 2023 and divided them into two groups based on treatment: the control (n = 76, received routine nursing) and observation (n = 74, received music nursing on the basis of routine nursing) groups. Comparison of groups was performed in terms of general information, anxiety, fatigue, and quality of life at admission (T0) and 1 month after admission (T1).

RESULTS

No significant differences were observed in the general data between the two groups (P > 0.05). Anxiety, fatigue, and quality of life of the two groups also showed no significant differences at T0 (P > 0.05). The observation group showed significantly lower anxiety than the control group at T1 (P < 0.05). At T1, the observation group exhibited a lower fatigue degree compared with the control group (P < 0.05). At T1, the observation group attained higher scores on physiological and emotional dimensions of the quality of life compared with the control group, and the differences were statistically significant (P < 0.05).

CONCLUSION

Music nursing for AL children, which has a certain clinical application value, can effectively reduce their anxiety and fatigue and improve their quality of life.

A Review of Acute Lymphocytic Leukemia (ALL) in the Pediatric Population: Evaluating Current Trends and Changes in Guidelines in the Past Decade

Acute lymphocytic leukemia (ALL) is a commonly diagnosed cancer in children. Despite technological advancements to improve treatment and survival rates, there has been a steady increase in the incidence of ALL and treatment failures. This paper discusses the pathogenic interaction between genetic and environmental factors leading to childhood ALL. It evaluates the current treatment guidelines and notable obstacles leading to resistance, relapse, and treatment toxicities. The review evaluates a 10-year trend in the management guidelines of pediatric ALL through a systematic literature review of records from 2012 to 2023. Findings show that improvement in the five-year survival rates, notwithstanding rates of relapse and incurable diseases, is still high. Furthermore, several risk factors, including an interplay between genetic and environmental factors, are largely contributory to the outcome of ALL treatments and its overall incidence. Moreover, huge financial costs have remained a significant challenge in outcomes. There remains a need to provide individualized treatment plans, shared decision-making, and goals of care as parts of the management guidelines for the best possible outcomes. We expect that future advancements will increase overall survival rates and disease-free years.

Determining the factors affecting chemotherapy-induced nausea and vomiting in children with cancer

PURPOSE

We evaluated the factors affecting chemotherapy-induced nausea and vomiting (CINV) in children with cancer.

DESIGN AND METHODS

This cross-sectional study was conducted with 62 children aged 9 to 18 years old with a solid tumor who received chemotherapy for the first time, and their parents. Data were collected using a data collection form, the State-Trait Anxiety Inventory for Children, the Beck Anxiety Inventory, the Spielberger State-Trait Anxiety Inventory, and the Baxter Retching Faces Scale. Data were analyzed using Spearman's correlation and logistic regression analyses.

RESULTS

Risk factors related to the child, treatment, and parent were examined. Child-related factors were determined as diagnosis (odds ratio [OR] = 5.5), time since diagnosis (OR = 1.9, OR = 4.7), pretreatment anxiety of the child (r = 0.439, r = 0.422), and past experience of nausea and vomiting before treatment (OR = 1.2). Treatment-related factors involved anti-emetic prophylaxis (OR = 4.9, OR = 9.2). Parent-related factors included pretreatment anxiety of the parent (r = 0.271, r = 0.287), accommodation (OR = 5.5), not eating (OR = 1.2, OR = 1.3), and bad smell (OR = 1.2), which were described amongst parents' as factors that trigger CINV.

CONCLUSIONS

The occurrence of CINV is significantly affected by child-, treatment-, and parent-related risk factors.

PRACTICE IMPLICATIONS

Pediatric nurses should create an environment for children and their parents to reduce their anxiety and provide basic knowledge and skills about the management of CINV.

Application of the National Comprehensive Cancer Network-distress thermometer in pediatric patients during autologous and allogeneic hematopoietic stem cell transplantation and relationship to blood parameters of the stress axis

PURPOSE

Hematopoietic stem cell transplantations (HSCT) are extremely stressful procedures for pediatric patients. The activation of the hypothalamic pituitary adrenocortical axis (HPA) can influence the immune system negatively and therefore the overall outcome. The distress thermometer (DT) is an easy to use tool for the self-assessment of perceived distress.

METHODS

In this prospective study, a DT with an attached problem list was used in 40 pediatric patients undergoing HSCT and in one parent of each patient. The patients were aged 10-18 years. The patients' cortisol, thyroid stimulating hormone, free triiodothyronine and thyroxine levels were measured regularly during the in-patient stay.

RESULTS

After admission to the hospital, the stress levels of the pediatric patients and their parents increased and reached their maximum on the day of HSCT. The overall stress values of the parents were higher than those of their children. There was a significant difference in the parents' stress levels on the day of HSCT, as compared to their stress levels on other days. The mean cortisol values of the pediatric patients also increased after admission, reaching significant elevated levels above the upper normal limit 1 week after HSCT and on discharge day. Although the pediatric patients experienced mainly exhaustion, especially on the day of transplantation, their parents mainly felt worry and anxiety. Interestingly, the rate of worry among children increased in the post-transplant period and reached its maximum on the day of discharge.

CONCLUSIONS

In summary, a significantly increased stress level is shown for both the patients and their parents. This is reflected for the patients both in the DT scores and in the increased cortisol values. For the parents, the focus is primarily on worry and anxiety, for the patients primarily on exhaustion and worry.

The effectiveness of play therapy in children with leukemia: A systematic review

PROBLEM

Leukemia is the most common form of childhood cancer worldwide. Children living with leukemia experience various problems because of the disease's progression, harmful effects of treatment, and prolonged hospitalization process. To increase their well-being and alleviate their problems, these children require ongoing support. One solution that both parents and professionals can use is play therapy. This systematic review aimed to identify the type and effectiveness of play therapy in children living with leukemia.

ELIGIBILITY CRITERIA

We searched PubMed, Scopus, ScienceDirect, and ProQuest databases. Additionally, we performed manual searches on Google Scholar, Google Web, and grey literature. Inclusion criteria comprised: 1) Studies that implemented play therapy on leukemia children, 2) Full-text articles available in English or Indonesian languages from January 2000 to December 2021 and updated until July 2023, and 3) Intervention studies employing quasi-experimental or randomized controlled trial (RCT) designs.

SAMPLE

From 1099 articles, 16 studies were selected. Several forms of play therapy were found, including pretend, music, art, and sand play therapy.

RESULTS

Of the sixteen studies in this systematic review, fifteen demonstrated beneficial effects on psychological issues, particularly anxiety, despair, stress, and physical problems (fatigue and pain).

CONCLUSION

Play therapy effectively alleviates some physical and psychosocial problems in children living with leukemia.

IMPLICATION

Nurses can utilize play therapy as an intervention for children living with leukemia. Additionally, comparative research is recommended with a similar research strategy concerning studies with the same design.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022318549.

Early life cancer and chemotherapy lead to cognitive deficits related to alterations in microglial-associated gene expression in prefrontal cortex

Children that survive leukemia are at an increased risk for cognitive difficulties. A better understanding of the neurobiological changes in response to early life chemotherapy will help develop therapeutic strategies to improve quality of life for leukemia survivors. To that end, we used a translationally-relevant mouse model consisting of leukemic cell line (L1210) injection into postnatal day (P)19 mice followed by methotrexate, vincristine, and leucovorin chemotherapy. Beginning one week after the end of chemotherapy, social behavior, recognition memory and executive function (using the 5 choice serial reaction time task (5CSRTT)) were tested in male and female mice. Prefrontal cortex (PFC) and hippocampus (HPC) were collected at the conclusion of behavioral assays for gene expression analysis. Mice exposed to early life cancer + chemotherapy were slower to progress through increasingly difficult stages of the 5CSRTT and showed an increase in premature errors, indicating impulsive action. A cluster of microglial-related genes in the PFC were found to be associated with performance in the 5CSRTT and acquisition of the operant response, and long-term changes in gene expression were evident in both PFC and HPC. This work identifies gene expression changes in PFC and HPC that may underlie cognitive deficits in survivors of early life exposure to cancer + chemotherapy.

Cognitive disengagement syndrome (sluggish cognitive tempo) and medical conditions: a systematic review and call for future research

Cognitive disengagement syndrome (CDS, previously referred to as sluggish cognitive tempo) is a unique set of symptoms distinct from ADHD inattentive symptoms that appear to be independently associated with neuropsychological and psychosocial outcomes in community and ADHD-specific samples of youth. However, our understanding of CDS in individuals with chronic or complex medical conditions is limited. The current systematic review is the first to summarize the literature on CDS prevalence rates and associations with neurocognitive and functional outcomes in youth with medical conditions, and to discuss areas of future research to guide clinical intervention. We conducted literature searches across four major databases and included studies assessing prevalence estimates, associations with neuropsychological and/or psychosocial functioning, or predictors of CDS in individuals with chronic or complex medical conditions. Twenty-five studies were identified and retained. Fifteen of sixteen studies reported elevations in CDS symptoms, though findings were mixed in studies comparing mean differences to typically developing youth. Seven studies provided inconsistent evidence for CDS being associated with neuropsychological or academic functioning, with six studies demonstrating consistent effects on psychosocial functioning. Finally, nine studies identified biological and sociodemographic factors associated with CDS, though almost all await replication. CDS symptoms are significantly elevated in youth with medical conditions and appear to be particularly linked with psychosocial functioning. Future research is needed to identify prevalence of CDS across a range of medical conditions, examine associations with neuropsychological and psychosocial functioning, and examine whether CDS impacts self-management.

Lifetime Burden of Psychological Symptoms, Disorders, and Suicide Due to Cancer in Childhood, Adolescent, and Young Adult Years: A Systematic Review and Meta-analysis

Importance

A cancer diagnosis and treatment may result in highly traumatic periods with lasting psychological consequences for children, adolescent, and young adult patients with cancer (CYACs). Early identification and management may prevent long-term psychological morbidity and suicide.

Objective

To analyze risk, severity, and risk factors for depression, anxiety, psychotic disorders, and suicide in CYACs and noncancer comparators.

Data Sources

Literature search of PubMed, MEDLINE, Embase, PsycINFO, CINAHL, and PubMed Central from January 1, 2000, to November 18, 2022.

Study Selection

Full-length articles in peer-reviewed journals that measured and reported risk and/or severity of depression, anxiety, psychotic disorders, and suicide mortality in CYACs and a noncancer comparator group.

Data Extraction and Synthesis

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed with prospective PROSPERO registration.

Main Outcomes and Measures

Risk ratios (RRs) were used for dichotomous outcomes, and standardized mean differences (SMDs) were used for continuous outcomes. SMDs were defined as follows: 0.2, small; 0.5, medium; and 0.8, large. Sources of heterogeneity and risk factors were investigated using sensitivity, subgroup, and meta-regression analyses.

Results

From 7319 records, 52 studies were included. Meta-analyses revealed that CYACs were at increased lifetime risk of severe symptoms or a disorder of depression (RR, 1.57; 95% CI, 1.29-1.92), anxiety (RR, 1.29; 95% CI, 1.14-1.47), and psychotic disorders (RR, 1.56; 95% CI, 1.36-1.80) relative to both matched controls and their siblings. Overall suicide mortality was not significantly elevated (RR, 1.63; 95% CI, 0.78-3.40). The mean severity of depression was found to be elevated in CYACs receiving treatment (SMD, 0.44; 95% CI, 0.13-0.74) and long-term survivors (SMD, 0.18; 95% CI, 0.02-0.33). The mean severity of anxiety was found to be elevated only during treatment (SMD, 0.16; 95% CI, 0.03-0.20).

Conclusions and Relevance

Findings of this systematic review and meta-analysis suggest that CYACs may experience lasting psychological burden long into survivorship. Timely identification, preventive efforts, and psycho-oncological intervention for psychological comorbidity are recommended.

Unraveling Dexamethasone-Induced Neurobehavioral and Sleep Problems in Children With ALL: Which Determinants Are Important?

PURPOSE

Dexamethasone, the preferred corticosteroid in most treatment protocols for pediatric acute lymphoblastic leukemia (ALL), can induce undesirable side effects. Neurobehavioral and sleep problems are frequently reported, but the interpatient variability is high. We therefore aimed to identify determinants for parent-reported dexamethasone-induced neurobehavioral and sleep problems in pediatric ALL.

METHODS

Our prospective study included patients with medium-risk ALL and their parents during maintenance treatment. Patients were assessed before and after one 5-day dexamethasone course. Primary end points were parent-reported dexamethasone-induced neurobehavioral and sleep problems, measured with the Strengths and Difficulties Questionnaire and Sleep Disturbance Scale for Children, respectively. Analyzed determinants included patient and parent demographics, disease and treatment characteristics, parenting stress (Parenting Stress Index and Distress Thermometer for Parents), dexamethasone pharmacokinetics, and genetic variation (candidate single-nucleotide polymorphisms rs41423247 and rs4918). Statistically significant determinants identified in univariable logistic regression analyses were incorporated in a multivariable model.

RESULTS

We included 105 patients: median age was 5.4 years (range, 3.0-18.8) and 61% were boys. Clinically relevant dexamethasone-induced neurobehavioral and sleep problems were reported by parents in 70 (67%) and 61 (59%) patients, respectively. In our multivariable regression models, we identified parenting stress as a significant determinant for parent-reported neurobehavioral (odds ratio [OR], 1.16; 95% CI, 1.07 to 1.26) and sleep problems (OR, 1.06; 95% CI, 1.02 to 1.10). Furthermore, parents who experienced more stress before start of a dexamethasone course reported more sleep problems in their child (OR, 1.16; 95% CI, 1.02 to 1.32).

CONCLUSION

We identified parenting stress, and not dexamethasone pharmacokinetics, genetic variation, patient/parent demographics, or disease/treatment characteristics, as a significant determinant for parent-reported dexamethasone-induced neurobehavioral and sleep problems. Parenting stress may be a modifiable target to reduce these problems.

Protocol and biomarker strategy for a multi-site randomized controlled trial examining biological mechanisms and dosing of active music engagement in children with acute lymphoblastic leukemia and lymphoma and parents

BACKGROUND

Music therapy is a standard palliative care service in many pediatric and adult hospitals; however, most research has focused on the use of music to improve psychosocial dimensions of health, without considering biological dimensions. This study builds on prior work examining psychosocial mechanisms of action underlying an Active Music Engagement (AME) intervention, designed to help manage emotional distress and improve positive health outcomes in young children with cancer and parents (caregivers), by examining its effects on biomarkers of stress and immune function.

METHODS

This two-group randomized controlled trial (R01NR019190) is designed to examine biological mechanisms of effect and dose-response relationships of AME on child/parent stress during the consolidation phase of Acute B- or T-cell Lymphoblastic Leukemia (ALL) and T-cell Lymphoblastic Lymphoma (TLyLy) treatment. Child/parent dyads (n = 228) are stratified (by age, site, risk level) and randomized in blocks of four to the AME or attention control condition. Each group receives one session (30-minutes AME; 20-minutes control) during weekly clinic visits (4 weeks standard risk B-cell ALL; 8 weeks high risk B-cell ALL/T-cell ALL/TLyLy). Parents complete questionnaires at baseline and post-intervention. Child/parent salivary cortisol samples are taken pre- and post-session (sessions 1-4). Child blood samples are reserved from routine draws before sessions 1 and 4 (all participants) and session 8 (high risk participants). We will use linear mixed models to estimate AME's effect on child/parent cortisol. Examining child/parent cortisol as mediators of AME effects on child and parent outcomes will be performed in an ANCOVA setting, fitting the appropriate mediation models using MPlus and then testing indirect effects using the percentile bootstrap approach. Graphical plots and non-linear repeated measures models will be used to examine dose-response relationship of AME on child/parent cortisol.

DISCUSSION

During pediatric cancer treatment there are special challenges that must be considered when measuring cortisol and immune function. In this manuscript we discuss how we addressed three specific challenges through our trial design. Findings from this trial will increase mechanistic understanding of the effects of active music interventions on multiple biomarkers and understanding of dose-response effects, with direct implications for clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04400071.

Severity and Longitudinal Course of Depression, Anxiety and Post-Traumatic Stress in Paediatric and Young Adult Cancer Patients: A Systematic Review and Meta-Analysis

BACKGROUND

A diagnosis of cancer and treatment may constitute a highly traumatic period for paediatric cancer patients (PYACPs). However, no review has comprehensively analysed how the mental health of PYACPs is acutely affected and the longitudinal course.

METHODS

This systematic review followed PRISMA guidelines. Comprehensive searches of databases were conducted to identify studies of depression, anxiety and post-traumatic stress symptoms in PYACPs. Random effects meta-analyses were used for the primary analysis.

RESULTS

From 4898 records, 13 studies were included. Acutely after diagnosis, depressive and anxiety symptoms were significantly elevated in PYACPs. Depressive symptoms only significantly decreased after 12 months (standardised mean difference, SMD = -0.88; 95% CI: -0.92, -0.84). This downward trajectory persisted to 18 months (SMD = -1.862; 95% CI: -1.29, -1.09). Anxiety symptoms similarly only decreased after 12 (SMD = -0.34; 95% CI: -0.42, -0.27) up to 18 months (SMD = -0.49; 95% CI: -0.60, -0.39) after the cancer diagnosis. Post-traumatic stress symptoms showed protracted elevations throughout follow-up. Overall, significant predictors of poorer psychological outcomes included unhealthy family functioning, concomitant depression or anxiety, poor cancer prognosis or experiencing cancer and treatment-related side effects.

CONCLUSIONS

While depression and anxiety may improve over time with a favourable environment, post-traumatic stress may have a protracted course. Timely identification and psycho-oncological intervention are critical.

Effects of a Pretend Play Intervention on Health-Related Quality of Life in Children With Cancer: A Swedish-German Study

Background: Cancer diagnosis can lead to massive physical, emotional, and social burdens on children and their families. Although children have the right to be informed and participate in their care, research shows that children's views are often not considered in care situations. Thus, it is essential to strengthen children's communication and self-efficacy (SE) to convey desires and needs. The present study explores whether a play intervention is associated with improved health-related quality of life (HrQoL) and SE for communication in care situations. We hypothesize that HrQoL and SE for communication will increase from the beginning to after the pretend play intervention. Methods: Children with cancer from Germany and Sweden were enrolled. The pretend play intervention consisted of six to 10 play sessions. A heterogenic selection of questionnaires was used to measure children's HrQoL and SE before the first pretend play session and after the last play intervention. Results: Nineteen families were included in the presented analyses, including 14 self-reports of children and 19 proxy reports of parents. We found improvements in child-reported communication, and emotional and psychosocial well-being using generic and cancer-specific HrQoL measurements. Further, children's SE in care situations improved during the play intervention. Parents also reported minor improvements in the physical dimensions in both generic and chronic-generic HrQoL, along with improvements in independence. Discussion: Overall, the cancer-specific pretend play intervention offers young children with cancer a secure environment and can contribute to their well-being, and communication skills, during or after cancer treatment.

Relationship between Anxiety and Fatigue in Leukemia Patients on Quality of Life with Nausea and Vomiting as an Intervening Factor

AIM: This study aims to identify anxiety and fatigue in children with leukemia on the quality of life. METHODS: Current research was implemented through a descriptive study with a cross-sectional design on children suffering from leukemia and undergoing a series of chemotherapy cycles. Through this design, the researcher measured the dependent variable, independent variable, and mediator variable at the same time with a sample of 82 people. Data collection was further done using PEDSQL 3 for cancer module. Meanwhile, the analysis used is path analysis which involves nausea and vomiting as a mediator. RESULTS: The results showed that the factor that had a direct relationship with the child’s quality of life was nausea and vomiting (p < 0.05) which was then analyzed using Sobel analysis resulting that nausea and vomiting were not a mediator of fatigue and anxiety. Therefore, it is necessary to pay attention to every nursing care practitioner to intervene in order to reduce anxiety and fatigue in children according to their condition. CONCLUSION: Anxiety and fatigue together have a relationship with nausea and vomiting in pediatric patients suffering from leukemia and undergoing chemotherapy. Nausea and vomiting have a significant direct relationship with quality of life. Anxiety and fatigue have a direct relationship with quality of life without being mediated by nausea and vomiting variables.

Promoting positive physical activity behaviors for children and adolescents undergoing acute cancer treatment: Development of the CanMOVE intervention using the Behavior Change Wheel

Background

Increasing participation in physical activity has the potential to improve outcomes for children and adolescents with cancer during treatment and into survivorship. The aim of this study is to outline the theoretical process behind development of CanMOVE, a behavior change intervention designed to increase physical activity for children and adolescents with cancer.

Study design

This study followed a theoretical design process consistent with the Behavior Change Wheel to inform the design of a complex intervention.

Materials and methods

The three stages of the Behavior Change Wheel intervention design process include: (1) understanding physical activity behavior within the pediatric cancer setting, (2) identifying potential intervention functions, and (3) identifying appropriate behavior change and implementation strategies. Qualitative and behavior change literature relevant to the pediatric cancer treatment setting were used to inform each stage.

Results

An individualized and flexible approach to physical activity promotion that considers intrinsic factors specific to the child/adolescent and their environment is required. Fifteen behavioral change strategies were identified to form the intervention components of CanMOVE. Implementation strategies were identified to build motivation, opportunity and capacity toward increasing physical activity behaviors. Key intervention components of CanMOVE include standardized assessment and monitoring (physical activity, physical function, and health-related quality of life), provision of an activity monitor to both child/adolescent and parent, and one-on-one capacity building sessions with a healthcare professional. Capacity building sessions include education, goal setting, an active supervised physical activity session, barrier identification and problem solving, and action planning.

Conclusion

CanMOVE is a novel approach to physical activity promotion in the pediatric cancer treatment setting. The use of a theoretical intervention design process will aid evaluation and replication of CanMOVE when it is assessed for feasibility in a clinical setting. The design process utilized here can be used as a guide for future intervention development.

Longitudinal investigation of suicidal ideation and associated factors during pediatric acute lymphoblastic leukemia chemotherapy

OBJECTIVE

This study describes the prevalence of suicidal ideation (SI) during acute lymphoblastic leukemia (ALL) therapy and investigates the influence of clinical factors and physical symptoms on SI.

METHODS

The Children's Depressive Inventory (CDI-2) was administered to ALL patients (diagnosed 2012-2017) at start of consolidation, delayed intensification (DI), maintenance cycle 1 (MC1), and maintenance cycle 2 (MC2) in a multi-site study. SI was present if patients endorsed the item "I want to kill myself." Logistic regression models evaluated associations between SI and sociodemographic factors; depressive symptoms; and below average, average, and above average symptom clusters identified using latent class analysis of pain, nausea, fatigue, and sleep.

RESULTS

Participants (n = 175) were 51% male, 75% high-/very high-risk disease, with a median age of 11.2 years at diagnosis (range: 7-18 years). Overall, 14.9% of patients (75% under age 12 years) endorsed SI during treatment, including 4% at start of consolidation, 9% at DI, 8% at MC1, and 4% at MC2. Non-Hispanic Other patients were 10.9-times (95% CI: 2.30-53.40) more likely than non-Hispanic Whites to endorse SI (p = 0.003). The frequency of SI was higher in patients experiencing above average (53.3%) compared to below average (4.1%, p = 0.003) symptoms. Depressive symptoms were consistently associated with SI.

CONCLUSIONS

SI during the initial year of childhood ALL was more prevalent in children under the age of 12 years, from ethnic groups not typically associated with increased risk, and who endorsed increased physical and depressive symptoms. Findings highlight the need for improved screening of mental health problems to mitigate symptoms of distress.

A qualitative examination of the benefits and challenges of a psychosocial screening intervention in pediatric oncology: "Support comes to us"

BACKGROUND

Pediatric cancer diagnosis and treatment can have detrimental mental health effects on parents (caregivers) and their children/adolescents (youth). Psychosocial screening and intervention have been recognized as standards of care in pediatric oncology. The most effective psychosocial interventions to support those in need post screening have not been determined.

AIMS

This qualitative study aimed to investigate the perceived benefits and challenges for caregiver and youth participants in the screening-intervention arm of an Enhanced Psychosocial Screening Intervention (EPSI) pilot study.

METHODS

EPSI consists of a psychosocial navigator (PSN) who shares screening results conducted near diagnosis (T1) and monthly for 1 year (T2) with treating teams and families. All 17 caregiver-youth dyads who had completed EPSI were invited to participate in a semi-structured interview.

RESULTS

Ten caregivers and nine youth participated. Identified themes were grouped into benefits and challenges of EPSI: feeling supported and cared for (support comes to us regularly, having someone to talk to); and feeling empowered through knowledge of resources and services were perceived as benefits. Caregivers were challenged by feeling overwhelmed, and youth by screening questions perceived as too repetitive.

CONCLUSIONS

Regular monthly contacts for a year by the PSN with screening results and recommendations were perceived as beneficial by youth newly diagnosed with cancer and their caregivers who participated in EPSI. Feeling that support came to them and they had someone to talk to was a critical component. While information about psychosocial resources was not always used right away, it did evoke feelings of being empowered.

Recommendations for the surveillance of mental health problems in childhood, adolescent, and young adult cancer survivors: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group

Survivors of childhood, adolescent, and young adult (diagnosed when <25 years of age) cancer are at risk of mental health problems. The aim of this clinical practice guideline is to harmonise international recommendations for mental health surveillance in survivors of childhood, adolescent, and young adult cancer. This guideline was developed by a multidisciplinary panel of experts under the sponsorship of the International Guideline Harmonization Group. We evaluated concordance among existing survivorship clinical practice guidelines and conducted a systematic review following evidence-based methods. Of 7249 studies identified, 76 articles from 12 countries met the inclusion criteria. Recommendations were formulated on the basis of identified evidence in combination with clinical considerations. This international clinical practice guideline strongly recommends mental health surveillance for all survivors of childhood, adolescent, and young adult cancers at every follow-up visit and prompt referral to mental health specialists when problems are identified. Overall, the recommendations reflect the necessity of mental health surveillance as part of comprehensive survivor-focused health care.

Prevalence of Anxiety, Depression, and Post-Traumatic Stress Disorder among Children and Adolescents with Cancer: A Systematic Review and Meta-Analysis

Assessment of psychological and emotional disorders is an important indicator of well-being among children and adolescents with cancer. This review aimed to determine the prevalence rates of three major psychological disorders in this population, including anxiety, depression, and post-traumatic stress disorder (PTSD). Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Various databases were searched to identify cross-sectional studies assessing anxiety, depression, and PTSD among children and adolescents with cancer. The Joanna Briggs Institute checklist was used to assess research quality. Of the 40 studies included in the literature review, 33 measured anxiety, 28 focused on depression, and nine assessed PTSD. A total of 18 studies were incorporated into the meta-analysis, with pooled prevalence rates of anxiety, depression and PTSD found to be 13.92% (n  =  1,971; 95% confidence interval [CI]  =  10.23-18.07%), 20.43% (n  =  1,990, 95% CI  =  13.85-27.93%), and 20.90% (n  =  755, 95% CI  =  13.28-29.73%), respectively. Mental health and psychological interventions are essential for children and adolescents diagnosed with cancer. Future work should be undertaken in different regions, such as the Middle East or Africa, or South America when assessing the prevalence of psychological disorders in children and adolescents diagnosed with cancer.

Psychiatric disorders among children with acute lymphoblastic leukemia in South Korea: a nationwide population-based longitudinal study

Objective

Children with acute lymphoblastic leukemia (ALL) may be at increased risk of psychiatric disorders. This study analyzed the incidence of psychiatric disorders in children with ALL in South Korea.

Methods

Using nationwide claims data for January 2009 to March 2016, we identified three major psychiatric disorders (depression, anxiety and stress/adjustment disorder) among children diagnosed with ALL. We analyzed the incidence of psychiatric disorders before and after ALL diagnosis.

Results

Overall, 2160 children diagnosed with ALL were identified. Seventy-five children (3.5%) were diagnosed with at least one major psychiatric disorder from 1 year before ALL diagnosis to the last follow-up point (range: 42.5–111.5 months). Of these, 70 (93.3%) patients were identified after ALL diagnosis, with the incidence peaking 1 year after ALL diagnosis. Depression, anxiety and stress/adjustment disorders were diagnosed in 30 (1.4%), 15 (0.7%) and 30 (1.4%) patients, respectively.

Conclusions

Among pediatric patients with ALL, most psychiatric disorders were identified after the diagnosis of leukemia, and psychiatric disorder incidence differed according to patient age and time since ALL diagnosis. Timely screening for and proper management of mental disorders are needed during all stages of ALL treatment.

The Psychosocial Burden of Families with Childhood Blood Cancer

Cancer is the second leading cause of death for children, and leukemias are the most common pediatric cancer diagnoses in Chile. Childhood cancer is a traumatic experience and is associated with distress, pain, and other negative experiences for patients and their families. Thus, psychosocial costs represent a large part of the overall burden of cancer. This study examines psychosocial experiences in a sample of 90 families of children with blood-related cancer in Chile. We provide a global overview of the family experience, focusing on patients, caregivers, and siblings. We find that most families report a negative impact upon diagnosis; disruptions in family dynamics; a range of negative feelings of the patient, such as depression, discouragement, and irritability; and difficulty with social lives. Additionally, they report negative effects in the relationship between the siblings of the patient and their parents, and within their caregivers' spouse/partner relationship, as well as a worsening of the economic condition of the primary caregiver. Furthermore, over half of the families in the sample had to move due to diagnosis and/or treatment. Promoting interventions that can help patients, siblings, and parents cope with distress and promote resilience and well-being are important.

Young children's experiences of support when fearful during treatment for acute lymphoblastic leukaemia-A longitudinal interview study

AIM AND OBJECTIVES

To describe young children's experiences of valuable support in managing their fears about treatment for acute lymphoblastic leukaemia. The focus was specifically on support from parents and healthcare professionals.

DESIGN

The study had a qualitative descriptive longitudinal design.

METHODS

The study analysed 35 interviews with 13 children at three different times during their treatment period. Data were analysed using a matrix-based method. The Consolidated criteria for reporting qualitative research (COREQ) guidelines have been followed.

RESULTS

Parents and healthcare professionals provide important support to children undergoing treatment for acute lymphoblastic leukaemia, although their roles differ. Children valued their parents' closeness and advocacy, being able to participate in their own care, and being given pain relief during procedures known to create pain. Valued support from healthcare professionals changed over time, from providing information and showing the tools that would be used in procedures, to paying attention to the child's needs and desires. It was more important for children to be able to choose between different alternatives in medical procedures than deciding on major treatment issues.

Translationally relevant mouse model of early life cancer and chemotherapy exposure results in brain and small intestine cytokine responses: A potential link to cognitive deficits

Survivors of acute lymphoblastic leukemia (ALL), the most common childhood cancer, are at increased risk for long-term cognitive problems, including executive function deficits. The chemotherapeutic agent methotrexate (MTX) is used to treat most ALL patients and is closely associated with cognitive deficits. To address how early life cancer chemotherapy leads to cognitive deficits, we developed a translationally relevant mouse model of leukemia survival that exposed mice to leukemic cells and chemotherapeutic drugs (vincristine and MTX, with leucovorin rescue) in early life. Male and female mice were tested several weeks later using novel object recognition (recognition memory) and 5-choice serial reaction time task (executive function). Gene expression of proinflammatory, white matter and synapse-associated molecules was assessed in the prefrontal cortex and small intestine both acutely after chemotherapy and chronically after cognitive testing. Early life cancer-chemotherapy exposure resulted in recognition memory and executive function deficits in adult male mice. Prefrontal cortex expression of the chemokine Ccl2 was increased acutely, while small intestine expression of the proinflammatory cytokine tumor necrosis factor-alpha was elevated both acutely (both sexes) and chronically (males only). Inflammation in the small intestine was correlated with prefrontal cortical proinflammatory and synaptic gene expression changes, as well as to executive function deficits. Collectively, these data indicate that the current protocol results in a robust mouse model in which to study cognitive deficits in leukemia survivors, and suggest that small intestine inflammation may represent a novel contributor to adverse CNS consequences of early life chemotherapy.

Online patient portal use by caregivers in pediatric oncology: Are we widening sociodemographic disparities?

BACKGROUND

Financial and regulatory incentives have encouraged and increased the availability of online patient portals that provide caregivers access to their child's electronic health records (EHR). Such access is believed to promote better engagement and outcomes of care. Little is known about the use of portals by caregivers of children with cancer. This study sought to examine whether sociodemographic and clinical care variables are associated with portal activation in a pediatric oncology sample.

METHODS

Sociodemographic and clinical characteristics were extracted from the EHR of pediatric oncology patients treated for their first cancer in the Nemours Center for Cancer and Blood Disorders between 2012 and 2017. A Child Opportunity Index (COI) was calculated based on home zip code. Characteristics of children whose caregivers did and did not activate the portal were compared.

RESULTS

Sixty-six percent of caregivers activated a portal account with a peak within 90 days of diagnosis. In logistic regression, caregivers with a younger aged child, spoke English, lived closer to the hospital, lived in higher COI area, with longer treatment length, and more radiology tests had greater odds of portal activation. Those with private health insurance or White race were overrepresented among those who activated an account in univariate analysis.

CONCLUSION

The majority of caregivers of children with cancer activate portal accounts; however, differences in sociodemographic and clinical variables across those who did and did not activate accounts emerged. As portals become ubiquitous, we must understand how they are used and mitigate widening inequities caused by disparate portal use.

Acculturation discrepancy and mental health associations among Hispanic childhood cancer survivors and their parents

OBJECTIVE

Acculturation discrepancy occurs when the rate of host culture acquisition and/or heritage culture retention between non-native parents and their children diverges. The resulting conflict may exacerbate mental health conditions in already vulnerable populations. The present study examined discrepancies between Hispanic and Anglo-American acculturation, as two separate constructs, and mental health symptomology in Hispanic childhood cancer survivors (HCCS) and their parents.

METHODS

Participants were 68 matched parent-child dyads (HCCS (M_age  = 19.4 (2.77) years., 50.0% female); and parent (M_age  = 46.3 (6.07) years., 89.7% female)). Study variables were HCCS posttraumatic-growth (PTG) and quality-of-life (PedsQL); parent posttraumatic stress (PTSD); and parent/HCCS depressive symptoms (CESD) and acculturation orientations. Discrepancy was calculated as the dyadic difference between like acculturation measures.

RESULTS

After controlling for covariates, Hispanic acculturation discrepancy and HCCS psychosocial health (a subset of PedsQL) was negatively correlated (r = -0.26, p < 0.5); while Anglo-American acculturation discrepancy was positively associated with HCCS PTG (r = 0.34, p < 0.01) and overall PedsQL (r = 0.24, p < 0.05), and moderated the relationship between parent CESD and HCCS PedsQL.

CONCLUSION

The findings suggest that the two acculturation discrepancy constructs have opposite effects. HCCS losing their heritage culture while their parents simultaneously retain it appears to be a deleterious process; whereas, HCCS learning the US culture more rapidly than parents may have protective benefits. This study has important implications for mental health interventions among HCCS. Findings should be used to inform the survivorship clinical community of the value of acculturation timing and parent/child discrepancy.

Pilot randomized psychosocial trial of a screening intervention in pediatric oncology

OBJECTIVE

Psychosocial screening is a standard of care in pediatric oncology, but there is limited information about how to intervene after screening. This pilot trial aimed to determine feasibility of the novel Enhanced Psychosocial Screening Intervention (EPSI) and explore its preliminary efficacy outcomes. We examined rates of recruitment, retention, intervention acceptability, and monthly distress screening completion, as well as exploratory efficacy outcomes (Patient-Reported Outcomes Measurement Information System: depression, anxiety and fatigue; distress thermometer, pain and sleep).

METHODS

Parallel-group randomized pilot trial: Caregiver-youth (10-17 years at enrollment, newly diagnosed with cancer) dyads were randomly allocated to either EPSI or standard care with 1:1 ratio allocation. EPSI consists of having a Psychosocial Navigator who shares screening results conducted near diagnosis and monthly for one year with treating teams and families, and provides recommendations tailored to screening results.

RESULTS

Enrollment rate was 54% (38 dyads); retention was 90% and acceptability 86% (caregivers) and 76% (youth). Exploratory symptoms of depression, anxiety, distress and fatigue outcomes consistently improved mainly for caregivers.

CONCLUSIONS

Results suggest EPSI is feasible and acceptable and exploratory mental and physical efficacy outcomes are promising for use in a future confirmatory multisite efficacy trial.

Social Support in Parents of Children With Cancer: A Systematic Review

OBJECTIVES

Parents of children with cancer (PCCs) experience stress as they navigate managing their child's illness. Arguably, social support is critical to PCCs' well-being. This review examines the literature on social support in PCCs.

METHODS

Studies of social support in PCCs were collected from PsycINFO, CINHAL, and MEDLINE. Data were extracted from 37 studies published between January 2010 and May 2021 related to the conceptualization, measurement, and availability of social support in PCCs. Relationships between PCCs' social support, well-being, and unique parent and child factors were also synthesized. Risks of biases were assessed using domains of the Effective Public Health Practice Project.

RESULTS

Social support in PCCs is conceptualized as (a) perceived availability and satisfaction with social support and (b) social support seeking as a coping strategy. Parents of children with cancer report receiving as much or more support than typical adults, but PCCs engage in less social support seeking. Family and significant others are the most prevalent sources of support, and emotional support is the most received type of social support. Social support is positively related to well-being and negatively related to distress, anxiety, and posttraumatic stress. Findings related to social support differences based on parent and child unique factors were minimal and present opportunities for future research. The risk of bias was generally low, with caution that most studies cannot demonstrate directionality of findings due to cross-sectional study designs.

CONCLUSIONS

Given the consistent positive association between social support and well-being in PCCs, clinicians should assess and encourage social support for this vulnerable population.

Pediatric lymphoma patients in Malawi present with poor health-related quality of life at diagnosis and improve throughout treatment and follow-up across all Pediatric PROMIS-25 domains

BACKGROUND

Patient-reportedoutcomes (PROs) that assess health-related quality of life (HRQoL) are increasingly important components of cancer care and research that are infrequently used in sub-Saharan Africa (SSA).

METHODS

We administered the Chichewa Pediatric Patient-Reported Outcome Measurement Information System Pediatric (PROMIS)-25 at diagnosis, active treatment, and follow-up among pediatric lymphoma patients in Lilongwe, Malawi. Mean scores were calculated for the six PROMIS-25 HRQoL domains (Mobility, Anxiety, Depressive Symptoms, Fatigue, Peer Relationships, Pain Interference). Differences in HRQoL throughout treatment were compared using the minimally important difference (MID) and an ANOVA analysis. Kaplan-Meier survival estimates and Cox hazard ratios for mortality are reported.

RESULTS

Seventy-five children completed PROMIS-25 surveys at diagnosis, 35 (47%) during active treatment, and 24 (32%) at follow-up. The majority of patients died (n = 37, 49%) or were lost to follow-up (n = 6, 8%). Most (n = 51, 68%) were male, median age was 10 (interquartile range [IQR] 8-12), 48/73 (66%) presented with advanced stage III/IV, 61 (81%) were diagnosed with Burkitt lymphoma and 14 (19%) Hodgkin lymphoma. At diagnosis, HRQoL was poor across all domains, except for Peer Relationships. Improvements in HRQoL during active treatment and follow-up exceeded the MID. On exploratory analysis, fair-poor PROMIS Mobility <40 and severe Pain Intensity = 10 at diagnosis were associated with increased mortality risk and worse survival, but were not statistically significant.

CONCLUSIONS

Pediatric lymphoma patients in Malawi present with poor HRQoL that improves throughout treatment and survivorship. Baseline PROMIS scores may provide important prognostic information. PROs offer an opportunity to include patient voices and prioritize holistic patient-centered care in low-resource settings.

Trajectories and risk factors for anxiety and depression in children and adolescents with cancer: A 1-year follow-up

BACKGROUND

There is limited data on the longitudinal trajectories of psychiatric disorders in children with cancer and risk factors for their persistence. The current study aimed to longitudinally assess the trajectories and risk factors for anxiety and depressive symptoms and disorders in children and adolescents with cancer.

METHODS

Children and adolescents with cancer and their parents completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Depression and Anxiety Module and were interviewed by the semi-structured Affective and Anxiety Modules of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), at 4 time points, 1, 4, 7, and 12 months following the diagnosis of cancer.

RESULTS

Of the 99 patients enrolled, 48% met criteria for anxiety and/or depressive disorders at least once during the follow-up period. There was a significant decrease in PROMIS pediatric and parent anxiety and depression scores (all p's < 0.01) and in the rate of depressive disorders over time (p = 0.02), while rates of anxiety disorders remained stable. Anxiety PROMIS pediatric and parent scores at baseline, having brain tumors and being in the acute treatment phase significantly predicted the presences of anxiety disorders at endpoint.

CONCLUSIONS

Our results highlight the importance of screening for anxiety and disorders in children with cancer, especially among those with brain tumors and at the acute phase of treatment.

Protocol for mapping psychosocial screening to resources in pediatric oncology: a pilot randomized controlled trial

Background

A pediatric cancer diagnosis and its treatment can have a detrimental effect on the mental health of children and their families. Screening to identify psychosocial risk in families has been recognized as a standard of care in pediatric oncology, but there has been limited clinical application of this standard thus far. A significant impediment to the implementation of psychosocial screening is the dearth of information on how to translate psychosocial screening to clinical practice, and specifically, how to follow-up from screening results. This manuscript aims to describe a protocol of a new intervention examining the feasibility and acceptability of mapping via a Psychosocial Navigator (PSN) psychosocial screening results to specific recommendations of resources for families based on measured risk for psychosocial distress and mental health symptoms.

Methods

The pilot randomized control trial (RCT) consists of dyads of youth (10–17 years) newly diagnosed with cancer and their primary caregiver. This RCT includes two arms (intervention and control group), with each group completing measurements near diagnosis and 1 year later. After the initial assessment, dyads in the intervention group receive monthly screening results and recommendations from the study PSN that are tailored to these results. The patient’s primary healthcare team (nurse, social worker, oncologist) also receive the risk, distress, and mental health results as well as the recommendations from the PSN.

Discussion

This study addresses a significant barrier to the implementation of psychosocial screening in pediatric oncology: specifically, the limited knowledge of how to follow-up from screening results. Findings from this pilot will inform a future definitive RCT to test the effectiveness of the intervention on patient and family mental health outcomes. This project has implications for enhancing clinical care in pediatric oncology, as well as other pediatric populations.

Strengths and limitations of this study

This is the first study of screening and follow-up using a psychosocial navigator.

This study involves both patient and caregiver report.

The small sample size necessitates a future larger study to investigate the effects of intervention.

Trial registration

NCT04132856, Registered 10 October 2019—retrospectively registered.

Risk factors for steroid-induced adverse psychological reactions and sleep problems in pediatric acute lymphoblastic leukemia: A systematic review

OBJECTIVE

Steroids play an essential role in treating pediatric acute lymphoblastic leukemia (ALL). The downside is that these drugs can cause severe side effects, such as adverse psychological reactions (APRs) and sleep problems, which can compromise health-related quality of life. This study aimed to systematically review literature to identify risk factors for steroid-induced APRs and sleep problems in children with ALL.

METHODS

A systematic search was performed in six databases. Titles/abstracts were independently screened by two researchers. Data from each included study was extracted based on predefined items. Risk of bias and level of evidence were assessed, using the Quality in Prognosis Studies tool and the Grading of Recommendations Assessment, Development and Evaluation tool, respectively.

RESULTS

Twenty-four articles were included. APR measurement ranged from validated questionnaires to retrospective record retrieval, sleep measurement included questionnaires or actigraphy. Overall, quality of evidence was very low. Current evidence suggests that type/dose of steroid is not related to APRs, but might be to sleep problems. Younger patients seem at risk for behavior problems and older patients for sleep problems. No studies describing parental stress or medical history were identified. Genetic susceptibility associations remain to be replicated.

CONCLUSIONS

Based on the current evidence, conclusions about risk factors for steroid-induced adverse psychological reactions or sleep problems in children with ALL should be drawn cautiously, since quality of evidence is low and methods of measurement are largely heterogeneous. A standardized registration of steroid-induced APRs/sleep problems and risk factors is warranted for further studies in children with ALL.

Few guidelines offer recommendations on how to assess and manage anxiety and distress in children with cancer: a content analysis

PURPOSE

To (1) describe and compare, across all eligible guidelines, recommendations that address any aspect of clinical assessment or management of anxiety and distress experienced by children and adolescents undergoing cancer treatment or hematopoietic stem cell transplantation (HSCT), and (2) assess guideline characteristics that influence identified recommendations.

METHODS

We searched five databases for relevant guidelines and conducted a grey literature search. Guidelines had to refer to children 0-18 years old who were undergoing cancer treatment or HSCT, describe any aspect of clinical assessment or management of symptoms of anxiety and distress, and be publicly accessible and published in English on or after 2000.

RESULTS

We identified 118 guidelines on pediatric cancer of which 13 mentioned clinical assessment or management of anxiety and distress. Six contained ≥ 1 recommendation addressing assessments of symptoms of which only two recommended specific screening instruments. Ten contained ≥ 1 recommendation addressing interventions for symptoms, of which six described specific interventions such as distraction and medication. Psychologists and nurses were the most common panel members and three guideline panels included a patient advocate. Only two guidelines received overall quality ratings > 80.0%.

CONCLUSION

We identified no guidelines that were specific to clinical assessment or management of anxiety and distress among children and adolescents undergoing cancer treatment or HSCT, and thus, clinicians lack evidence-informed guidance on how to manage these specific symptoms. Future research should establish high-quality guidelines that offer recommendations specific to clinical assessment and management of anxiety and distress in pediatric oncology and HSCT.

Relationships between parent and adolescent/young adult mental health among Hispanic and non-Hispanic childhood cancer survivors

PURPOSE

To examine associations between parents and adolescent and young adult (AYA) childhood cancer survivors' (CCS) mental health, and differences by Hispanic ethnicity.

SAMPLE

Participants were 129 CCS (Mage = 19.5 yrs.; 49.9% female) and their parents (Mage = 49.0 yrs.; 87.6% female); 52.7% identified as Hispanic.

METHODS

CCS completed assessments of Depressive Symptoms (CES-D), Posttraumatic Growth (PTG) and Pediatric Quality of Life (PedsQL), while parents completed CES-D, Perceived Stress (PSS) and Posttraumatic Stress Disorder (PTSD) measures.

RESULTS

After controlling for covariates, all three negative parental mental health measures (Parent CES-D, PSS, and PTSD), were positively associated with CCS CES-D indicating that higher depressive symptoms and stress in parents was associated with higher depressive symptoms in CCS. Parent CES-D was negatively associated with CCS PedsQL and parent PSS was negatively associated with CCS PTG. Moderation analysis revealed parent PSS to be negatively associated with PedsQL and positively related to CES-D among Hispanic families only.

CONCLUSION

Higher parental negative mental health measures may adversely affect CCS levels of depression, while lower values for parental negative health measures were associated with positive CCS mental health outcomes in AYA. Hispanic parents experience more associations with stress than non-Hispanics.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

Long-term survivorship follow-up care guidelines should address the mental health needs of both parents and CCS, paying particular attention to perceived stress in Hispanic families.

Path analysis of the effects of social support, self-efficacy, and coping style on psychological stress in children with malignant tumor during treatment

The aim of this study was to explore the relationship between social support, self-efficacy, coping style, and psychological stress in children with malignant tumors during the treatment, and to clarify the mediating effects.From May 2019 to August 2019, selected by convenience sampling method, 141 children with malignant tumors in the treatment period were evaluated using the Social Support Questionnaire, General Self-efficacy Scale, Simplified Coping Style Questionnaire, and Depression-Anxiety-Stress Scale.The results of correlation analysis showed that depression was negatively correlated with coping style, self-efficacy, affirmation and support, satisfaction, company, and intimacy, but positively correlated with conflict and punishment; both anxiety and stress were significantly negatively correlated with coping style, self-efficacy, affirmation and support, company, and intimacy. The results of the model indicated that gender, social support, self-efficacy, and coping style could directly predict the psychological stress of children with malignant tumors in the treatment period, social support and self-efficacy could indirectly predict the psychological stress of children with malignant tumors, and the total effect of self-efficacy on the psychological stress of children was the largest. Through 2000 bootstrap tests of mediating effect, it not only confirmed the mediating effect of self-efficacy and coping style but also had a chain-mediating effect.Appropriate social support can improve the self-efficacy of children with malignant tumors in the treatment period and encourage them to take a positive response to the disease, thereby effectively preventing or reducing the occurrence of psychological stress.

Promoting Emotional Well-being in Hospitalized Children and Adolescents With Virtual Reality: Usability and Acceptability of a Randomized Controlled Trial

The aim of this study was to describe and compare small-sized preliminary data on the usability and acceptability of a randomized controlled trial. This study compares a one-to-one cognitive-behavioral treatment and a virtual reality treatment for children and adolescents hospitalized for long-term physical conditions. The final sample was composed of 19 children and adolescents with chronic illness who were hospitalized. The sample was randomly allocated to two intervention groups: cognitive-behavioral usual treatment and virtual reality-based treatment. Participants in the virtual reality group demonstrated higher perceived efficacy scores for every treatment component than for traditional treatment. Statistically significant differences were found for the total usability and acceptability scores. Participants in the virtual reality group show high acceptability of all the virtual environments. The components and environments of virtual reality were well accepted. The virtual reality program received high scores in immersion, feasibility of use, and sense of reality. Technology-based treatments, that is, virtual reality, can provide motivational benefits in relation to traditional treatments.

Interventions to improve the mental health of children and young people with long-term physical conditions: linked evidence syntheses

BACKGROUND

Although mental health difficulties can severely complicate the lives of children and young people (CYP) with long-term physical conditions (LTCs), there is a lack of evidence about the effectiveness of interventions to treat them.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of interventions aiming to improve the mental health of CYP with LTCs (review 1) and explore the factors that may enhance or limit their delivery (review 2).

DATA SOURCES

For review 1, 13 electronic databases were searched, including MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Science Citation Index. For review 2, MEDLINE, PsycINFO and CINAHL were searched. Supplementary searches, author contact and grey literature searches were also conducted.

REVIEW METHODS

The first systematic review sought randomised controlled trials (RCTs) and economic evaluations of interventions to improve elevated symptoms of mental ill health in CYP with LTCs. Effect sizes for each outcome were calculated post intervention (Cohen's d). When appropriate, random-effects meta-analyses produced pooled effect sizes (d). Review 2 located primary qualitative studies exploring experiences of CYP with LTCs, their families and/or practitioners, regarding interventions aiming to improve the mental health and well-being of CYP with LTCs. Synthesis followed the principles of metaethnography. An overarching synthesis integrated the findings from review 1 and review 2 using a deductive approach. End-user involvement, including topic experts and CYP with LTCs and their parents, was a feature throughout the project.

RESULTS

Review 1 synthesised 25 RCTs evaluating 11 types of intervention, sampling 12 different LTCs. Tentative evidence from seven studies suggests that cognitive-behavioural therapy interventions could improve the mental health of CYP with certain LTCs. Intervention-LTC dyads were diverse, with few opportunities to meta-analyse. No economic evaluations were located. Review 2 synthesised 57 studies evaluating 21 types of intervention. Most studies were of individuals with cancer, a human immunodeficiency virus (HIV) infection or mixed LTCs. Interventions often aimed to improve broader mental health and well-being, rather than symptoms of mental health disorder. The metaethnography identified five main constructs, described in an explanatory line of argument model of the experience of interventions. Nine overarching synthesis categories emerged from the integrated evidence, raising implications for future research.

LIMITATIONS

Review 1 conclusions were limited by the lack of evidence about intervention effectiveness. No relevant economic evaluations were located. There were no UK studies included in review 1, limiting the applicability of findings. The mental health status of participants in review 2 was usually unknown, limiting comparability with review 1. The different evidence identified by the two systematic reviews challenged the overarching synthesis.

CONCLUSIONS

There is a relatively small amount of comparable evidence for the effectiveness of interventions for the mental health of CYP with LTCs. Qualitative evidence provided insight into the experiences that intervention deliverers and recipients valued. Future research should evaluate potentially effective intervention components in high-quality RCTs integrating process evaluations. End-user involvement enriched the project.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001716.

FUNDING

The National Institute for Health Research (NIHR) Health Technology Assessment programme and the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

The Gut Microbiome and Pediatric Cancer: Current Research and Gaps in Knowledge

The human microbiome consists of trillions of microbial cells that interact with one another and the human host to play a clinically significant role in health and disease. Gut microbial changes have been identified in cancer pathogenesis, at disease diagnosis, during therapy, and even long after completion of treatment. Alterations in the gut microbiome have been linked to treatment-related toxicity and potential long-term morbidity and mortality in children with cancer. Such alterations are plausible given immune modulation due to disease as well as exposure to cytotoxic chemotherapy, infections, and antibiotics. The following review presents our current scientific understanding on the role of the gut microbiome in pediatric cancer, identifies gaps in knowledge, and suggests future research goals.

New Technologies to Improve Pain, Anxiety and Depression in Children and Adolescents with Cancer: A Systematic Review

Pain, anxiety, or depression are very prevalent in children and adolescents with cancer, which is a great challenge for health professionals. Several studies pointing out the positive effect of technology on the management of symptoms have been published in recent years. Considering these studies is important in order to reduce the negative impact on the quality of life of this population. This study aimed to analyze the available evidence and to describe the benefits of the new technologies in the treatment of pain, anxiety, and depression in children and adolescents with cancer. A systematic search using six electronic databases was conducted to identify studies using technological interventions with a focus on pain, anxiety, and depression that were published from 2008 to 2018 including oncology patients from 0–18 years old. Out of the 1261 studies that were identified, five studies met the inclusion criteria for this systematic review. Robots were used in two studies, providing amusement and social interventions that showed significant improvements. Virtual reality, a mobile application, and a videogame were used in three studies and obtained beneficial results in pain and anxiety. The studies included in this review suggest that new technologies can be used as an innovative form of non-pharmacological intervention with therapeutic benefits.

Brief version of the coping health inventory for parents (CHIP) among family caregivers of children with chronic diseases

Background

The Coping Health Inventory for Parents (CHIP) has demonstrated good psychometric properties in several language forms and has been used to assess the coping behaviors of families facing disease. However, the CHIP has not been validated in Mexico among families of children with chronic conditions, where it could be useful for research and intervention. The objectives of this instrumental study were to obtain a version of the CHIP for the Spanish language in Mexico, establish the factor structure of the Mexican version of the CHIP, probe its internal consistency reliability, and assess its concurrent construct validity.

Methods

A nonprobability sample of 405 family caregivers of children with chronic diseases responded to a battery of measurement instruments that included the CHIP, the Beck Anxiety Inventory, and the Beck Depression Inventory. The sample was randomly divided into two parts. In one subsample (190 participants), an exploratory factor analysis was performed using a principal component analysis and oblique rotation. In the second subsample (215 participants), a confirmatory factor analysis was performed using maximum likelihood estimation.

Results

The scale was reduced to 16 items (CHIP-16) with factorial loads greater than .50. The empirical criteria used to determine the number of factors converged on the following five factors: belief and trust (McDonald ω = .85), spouse/partner relationship (ω = .79), home care (ω = .77), family involvement (ω = .75), and security/stability (ω = .79). The overall internal consistency was good (ω = .88). The five-factor model showed acceptable fit indices and high parsimony. The mean CHIP-16 scores and the Spouse/partner relationship scores among the caregivers with anxiety were greater than those among the caregivers without anxiety. The mean home-care scores among the women were greater than those among men.

Conclusions

The 16-item version of the CHIP showed good internal consistency and construct validity; thus, the CHIP-16 is a useful instrument for measuring and assessing coping in family caregivers of children with chronic diseases.

Emotional symptoms and family functioning in caregivers of children with newly diagnosed leukemia/lymphomas and solid tumors: Short-term changes and related demographic factors

BACKGROUND

Pediatric oncology diagnoses are distressing to caregivers. However, researchers have not investigated the impact that the type of cancer diagnosis has on caregiver anxiety, depression, distress, and family functioning. The purpose of this study was to longitudinally investigate the early trajectory of caregiver psychological symptoms of anxiety, depression, distress, and family functioning near diagnosis and 6 months later by cancer type, and to examine the demographic factors that may be associated with caregiver emotional and family functioning outcomes.

METHODS

Caregivers (n = 122) of children with a recent diagnosis of leukemia/lymphoma or solid tumor completed self-report measures of psychological and family functioning (Hospital Anxiety and Depression Scale, Distress Thermometer, and Family Environment Scale).

RESULTS

In general, caregivers endorsed elevated psychological symptoms at the time of diagnosis, which decreased 6 months later. Caregivers of children with solid tumors endorsed greater anxiety across time than caregivers of children with leukemia/lymphoma did. In addition to caring for a child with a solid tumor, female sex, non-White ethnicity, and non-English language spoken in the home were factors associated with anxious and depressive symptoms and poorer family functioning.

CONCLUSION

When creating psychosocial interventions for families of children with cancer, the unique demands of solid tumor treatments, the caregiver's sex, and cultural characteristics must be considered to promote coping, resiliency, and problem-solving skills around the time of diagnosis, particularly in more vulnerable families.