Patterns of distress in parents of children undergoing stem cell transplantation

Psychiatric disorders among survivors of childhood acute lymphoblastic leukemia in Denmark and Sweden

BACKGROUND

The diagnosis and treatment of childhood acute lymphoblastic leukemia (ALL) may impact mental health. We investigated the long-term risk of psychiatric disorders among survivors of ALL in a population-based cohort study.

METHODS

We identified patients diagnosed with ALL in Denmark and Sweden before age 20 during 1982-2008. Survivors of ALL (n = 2026), their siblings (n = 3027), and population comparison subjects (n = 9713) were followed for hospital contacts for psychiatric disorders from 5 years after ALL diagnosis (or corresponding index date) until 2017.

RESULTS

By age 30, the absolute risk of psychiatric hospital contacts was 19.9% (95% confidence interval [CI]: 17.9-22.1) for ALL survivors, 18.5% (95% CI: 16.9-20.2) for siblings, and 18.3% (95% CI: 17.3-19.2) for population comparison subjects. Overall, survivors were at higher risk of any psychiatric disorders than siblings (hazard ratio [HR] = 1.25; 95% CI: 1.04-1.50), and population comparison subjects (HR = 1.20; 95% CI: 1.06-1.35). The subgroup of survivors (n = 332) who received a hematopoietic stem cell transplantation (HSCT) and/or had a relapse were at highest risk of psychiatric disorders (HR = 2.07; 95% CI: 1.26-3.41 compared to siblings; HR = 1.67; 95% CI: 1.25-2.23 compared to population comparison subjects).

CONCLUSIONS

The overall absolute risk of psychiatric hospital contacts among ALL survivors was close to that in siblings and population comparison subjects. The modestly increased relative risk was mainly driven by the subgroup of survivors who received HSCT and/or had a relapse. Our findings are reassuring for the large subgroup of ALL survivors without HSCT or relapse, and provide novel insight on both absolute and relative risk of hospital contacts for psychiatric disorders.

The Effect of Psychoeducation on Care Burden Applied to Mothers of Children Who Underwent Allogeneic Bone Marrow Transplantation in Turkey: A Quasi-Experimental Study

OBJECTIVES

The purpose of this study was to examine at the effect of psychoeducation on the care burden for mothers whose children underwent allogeneic bone marrow transplantation (Allo-BMT).

DATA SOURCES

The single group, quasi-experimental study was conducted in a children's BMT unit in the Aegean Region of Turkey. No sampling method was used, and the study sample consisted of 21 mothers who fulfilled the inclusion criteria of turning 18 years old, volunteering for study participation, speaking and understanding Turkish, and having a child who had undergone Allo-BMT. The psychoeducation covered the following topics: (i) Allo-BMT and Child Care After Transplantation, (ii) Feelings Concerning the Disease and the Role of Caregiver, (iii) Stress and Anger Management, and (iv) Family-Spousal and Social Relations. The care burden was measured using the Clinically Adapted Zarit Burden Interview (CA-ZBI). Data analysis was performed on SPSS 20.0 software using repeated measures of analysis of variance (ANOVA) and Bonferroni adjusted post hoc test. After the psychoeducation, a significant difference was found between pretest (26.85 ± 12.9) and posttest (20.42 ± 12.66) care burden of mean scores (P < .05). In addition, a significant difference was found between pretest and follow-up test (20.52 ± 11.49) mean scores of care burden (P < .05).

CONCLUSION

The psychoeducation reduced the care burden experienced by the mothers of the children who underwent Allo-BMT and this positive impact lasted for a month.

IMPLICATIONS FOR NURSING PRACTICE

Nurses, especially consultation liaison psychiatric nurses, can provide similar psychoeducation to caregivers in BMT units, assisting them in protecting their physical and mental health by reducing their care burden.

A meta-ethnographic study of fathers' experiences of caring for a child with a life-limiting illness

BACKGROUND

There is a growing body of qualitative studies examining parents' experiences of caring for a child with a life-limiting condition, coinciding with recent evidence that indicates an increasing incidence of paediatric life-limiting conditions. However, research focusing on fathers' needs remains sparse and is often diluted among a predominant 'mother's voice', raising questions about whether practices in clinical settings meet fathers' needs.

AIM

To provide an in-depth assembly of the current state of knowledge around fathers' experiences of caring for their children diagnosed with life-limiting conditions and understand the implications for healthcare services and policies.

DESIGN

A meta-ethnography was conducted to synthesise findings from existing qualitative studies exploring fathers' experiences of caring.

DATA SOURCES

Four electronic databases (PubMed, PsycINFO, CINAHL and Science Direct) were searched up until April 2020. Qualitative studies exploring fathers' care experience and published in English language were included. The Critical Appraisal Skills Programme (CASP) checklist was employed for study quality appraisal. No temporal limits were used.

RESULTS

Sixty-three studies met the inclusion criteria. Thirty life-limiting conditions were included. Based on responses from 496 fathers, a conceptual model was developed which translates key experiences within the fathers' caregiving journeys. The overarching concepts identified were: the paradox of support, challenges in the caring process, 'nobody thinks of men', impact on family life and the fall of the curtain: an irrevocably altered world. These and associated sub-concepts are discussed, with recommendations for future research and practice provided.

CONCLUSION

The findings indicate the value of a family-oriented approach to develop psychosocial interventions and support channels for fathers, thus empowering them whilst reducing the care-giving burden on the family unit.

The impact of pediatric hematopoietic stem cell transplant timing and psychosocial factors on family and caregiver adjustment

BACKGROUND

The impact of pediatric hematopoietic stem cell transplant (HCT) on family functioning varies, but little is known about how the timing of HCT in children's treatment course contributes to this variability. This study examines how preexisting child, sibling, and family problems, the length of time between diagnosis to HCT, and children's age at HCT are associated with family and caregiver functioning.

PROCEDURE

Caregivers (n = 140) of children (≤18 years old) scheduled to undergo their first HCT completed the Psychological Assessment Tool-HCT and the Impact on Family Scale. Treatment information was extracted from electronic medical records. A bootstrapped multivariate path analysis was used to test the hypotheses.

RESULTS

More preexisting family problems related to greater caregiver perceived negative impact of their child's HCT across family and caregiver functioning domains. Less time between diagnosis and HCT was associated with greater caregiver personal strain, particularly for those with younger children undergoing HCT. Younger child age at HCT was also associated with a larger negative impact on family social functioning.

CONCLUSIONS

Families with preexisting problems are the most at-risk for experiencing negative impacts related to their child's HCT. The timing of a child's HCT within their treatment course and the child's age during HCT may impact families' social functioning and caregiver adjustment. Screening families for preexisting family problems, particularly for families with young children or who are abruptly learning of their child's need for an HCT, may assist providers in identifying families who would benefit from earlier or more intensive psychosocial support.

Falling Down the Rabbit Hole: Child and Family Experiences of Pediatric Hematopoietic Stem Cell Transplant

Pediatric hematopoietic stem cell transplant (HSCT) is an intensive treatment that can be life-threatening. All family members experience distress. We conducted a grounded theory study using a family systems-expressive arts framework to develop a theoretical understanding of the family experience of HSCT. Six families (15 family members) participated in two interviews, drew an image, and were guided through a "dialoguing with images" process. Participants did not always perceive HSCT as an experience they had lived as a family and were surprised to hear other family members' experiences. While one mother drew, she suddenly understood it was not only her ill child, but the entire family who had "fallen down the rabbit hole." The family experience of HSCT is described across (a) the pre-HSCT trajectory, (b) family fragmentation (hospitalization), and (c) family reintegration. We identified a critical need for targeted family intervention during the transition into HSCT, throughout and following hospitalization.

Parental Efficacy and Control Questionnaire in Hematopoietic Stem Cell Transplant: Preliminary Validation

OBJECTIVE

Develop and evaluate the preliminary validity of a self-report measure of parents' treatment-related efficacy and control, Parental Efficacy and Control Questionnaire-Hematopoietic Stem Cell Transplant (PECQ-HCT), in a pediatric HCT sample.

METHODS

Participants included 185 parents of children (≤12 years old) receiving HCT participating in a larger, longitudinal study. Parents completed the PECQ-HCT as well as measures of social problem-solving skills, collective family efficacy, family beliefs, and parental distress.

RESULTS

Exploratory factor analysis results indicated that a 37-item four-factor model was the best fitting and most theoretically sound, χ2(df = 1,596) = 14,089.95, p < .01, comparative fit index = 0.92, Tucker-Lewis Index = 0.90, and root mean square error of approximation = 0.07. Preliminary subscale scores demonstrated adequate internal consistency as well as good content and criterion-related validity.

CONCLUSIONS

If replicated using a confirmatory factor analysis in a separate sample, these findings suggest that the four-factor PECQ-HCT measure may be useful for measuring HCT-related parental efficacy and perceived control.

Disease-related Parenting Stress in the Post-treatment Phase of Pediatric Cancer

Parenting stress is generally associated with poorer psychological adjustment in caregivers and children with chronic illness. Although parenting stress in pediatric cancer has been previously demonstrated, few studies have investigated this problem when treatments end. The present study aimed to describe disease-related parenting stress in the post-treatment phase of pediatric cancer, and to analyze the role of parents' age and education, family functioning, and perceived child vulnerability in predicting disease-related parenting stress. The study comprised 56 parents of children with cancer, in the post-treatment phase, who completed a clinical and demographic questionnaire, as well as the Pediatric Inventory for Parents, assessing parenting stress, the Child Perceived Vulnerability Scale, and the Family Adaptability and Cohesion Evaluation Scale-Version IV. Results revealed that the level of disease-related parenting stress in the post-treatment phase was still significant. Emotional stress scores were especially high, further showing that parents' concerns in this phase focus mainly on the long-term impact of the disease and treatments, involving intense feelings of fear and uncertainty. A model with four predictors was tested using regression analysis, which explained 57% of parenting stress variance. More specifically, findings indicated that parental age and education significantly predicted parenting stress, accounting for over one-third of the variance in this outcome. Family functioning and perceived child vulnerability explained an additional 18% of parenting stress. Findings of this study suggest that even when treatment ends, there is still the need for continued support in order to assist parents' ability to deal with the implications of having a child who had cancer. Importantly, special attention should be given in clinical practice to the family functioning and to parents' beliefs about their child's vulnerability.

Health-Related Quality of Life and Emotional Health in X-Linked Carriers of Chronic Granulomatous Disease in the United Kingdom

X-linked chronic granulomatous disease (XL-CGD), a rare primary immunodeficiency due to a defect in the gp91^phox NADPH oxidase subunit, results in recurrent, severe infection, inflammation, and autoimmunity. Patients have an absent, or significantly reduced, neutrophil oxidative burst. Due to lyonization, XL-CGD carriers have a dual population of functional and non-functional phagocytes and experience a range of symptoms including increased risk of autoimmunity, fatigue, and infection. Patients with CGD have poorer quality of life (QoL) than normal controls. We evaluated QoL and psychological health in UK XL-CGD carriers. Recruited participants completed the Medical Outcomes Study Short Form 36 version 2 (SF-36 V2), providing an overall score for mental and physical health. Psychological health was assessed using the Hospital Anxiety and Depression Scale (HADS) questionnaire. Seventy-five XL-CGD carriers were recruited from 62 families, median age 43 years (range 3-77). Fifty-six were mothers, 6 grandmothers, and 13 siblings. Sixty-two completed the SF36v2 and had reduced QoL scores compared with adult CGD patients and a UK age-matched female control cohort, indicating a reduced QoL. Sixty-one completed a HADS questionnaire. Over 40% experienced moderate or greater levels of anxiety with only one third being classified as normal. Higher anxiety scores significantly correlated with higher depression scores, lower self-esteem, presence of joint or bowel symptoms, and higher levels of fatigue (p < 0.05). This is the first study to evaluate QoL of XL-CGD carriers, and demonstrates high rates of anxiety and significantly reduced QoL scores. XL-CGD carriers should be considered as potential patients and pro-actively assessed and managed.

The Use of a Video for Discharge Education for Parents After Pediatric Stem Cell Transplantation

Background: Caring for a child at home after hematopoietic stem cell transplant (HSCT) is challenging for parents, and discharge education is critical to ensure parents are prepared. The purpose of this study is to evaluate the feasibility and effectiveness of a discharge video intervention (DVI) as an adjunct to standard discharge teaching (SDT). Method: A two-phase study was conducted at an urban children’s hospital in the western United States. Phase 1 involved SDT alone followed by nurse-administered proficiency testing of parent knowledge in caring for their children at home using a 4-point Likert-type scale of parents of children post-allogeneic HSCT. These results informed the DVI, created in English and Spanish in Phase 2. The DVI content included topics on home cleaning, notifying the medical team, graft-versus-host disease (GVHD), diet and visitor restrictions, and outpatient visits. In Phase 2, the DVI was viewable by parents who also received SDT. Parents’ proficiency was evaluated using the same procedure as in Phase 1. Results: Thirty-four parents participated: 17 in Phase 1 (SDT), 17 in Phase 2 (SDT + DVI). The DVI was viewed by parents in Phase 2 approximately twice prior to discharge. Parents in Phase 2 had higher proficiency scores on home cleaning, signs/symptoms of GVHD, and diet restriction. Parents in Phase 1 had higher proficiency regarding notifying the team. Conclusions: The DVI was feasible and demonstrated incremental increases in parent’s proficiency related to some discharge topics.

Caregiver Perceptions of Music Therapy for Children Hospitalized for a Blood and Marrow Transplant: An Interpretivist Investigation

Background

Despite pharmacological and psychosocial support, pediatric blood and marrow transplant (BMT) recipients typically experience heightened levels of somatic and psychological distress while undergoing transplant. Although clinicians have used psychosocial interventions to target distress, there are gaps in the literature concerning music therapy for children recovering from BMT. This is especially the case among younger children and those affected by rare genetic or metabolic disorders.

Objective

As caregivers are the primary decision makers for minor children, there is a need to understand their preferences and values as this constitutes a component of evidence-informed practice. Therefore, the purpose of this interpretivist investigation was to explore primary caregivers’ perspectives and experiences with music therapy for their children during hospitalization for BMT.

Methods

The researchers conducted semistructured phone interviews with 15 primary caregivers of children who had received music therapy services while hospitalized for BMT. Member checking was used to ensure accuracy of the transcripts and experiences, while trustworthiness was used to verify themes.

Results

Fifteen caregivers of 14 pediatric BMT recipients were interviewed by phone. The following four themes emerged: (1) music therapy motivated patients to physically engage their bodies despite symptoms; (2) music therapy elevated patients’ moods; (3) caregivers benefited from seeing their child engaged in music therapy; and (4) caregivers were appreciative for the opportunity and requested additional music therapy services.

Conclusions

Caregivers perceived music therapy to be a positive and beneficial experience for pediatric patients while hospitalized for BMT. Implications for clinical practice, limitations, and suggestions for future research are provided.

Effect of parental depression level on children's quality of life after haematopoietic stem cell transplantation

PURPOSE

This descriptive cross-sectional study aimed to determine the impact of parental depression level on children's quality of life after haematopoietic stem cell transplantation (HSCT).

METHOD

This study was conducted in a bone marrow transplantation unit of a children's hospital in Ankara, Turkey. The research sample consisted of 82 parents. Children aged 2-18 years and monitored in polyclinics 100 days after HSCT were included in the study. A sociodemographic data form, parent forms of the Pediatric Quality of Life Inventory, and the Beck Depression Inventory (BDI) were used.

RESULTS

Forty (48%) mothers and 42 (51.2%) fathers participated in the study. Of the children, 30 (36.6%) were female and 52 (63.4%) were male, and their mean age was 10.68 [standard deviation (SD) 4.80] years. Twenty-six children (31.7%) had been diagnosed with thalassaemia, and 29 children (35.4%) had undergone HSCT in the previous 25-36 months. The mean total scale score on the Pediatric Quality of Life Inventory was 61.37 (SD 21.85), and the mean parental BDI Score was 14.57 (SD 11.03). Fourteen (17.1%) parents had severe depression and 10 (12.2%) parents had moderate depression. Low statistical correlation was found between the parental BDI score and the total scale score on the Pediatric Quality of Life (r = -0.281; P = 0.011).

CONCLUSION

Parental depression level affects children's quality of life after HSCT. Following transplantation, it is important to evaluate parental depression level and provide support.

The relationship between perceived parental rearing behaviors and school adjustment of adolescent cancer survivors in Korea: A cross-sectional study

Return and adjustment to school in adolescents who have survived cancer have become of increasing interest as the numbers of childhood cancers survivors have grown due to advances in treatments. Perceived parental rearing behavior is an important factor related to school adjustment. This study examined the relationships between maternal and parental rearing practices, general characteristics, and school adjustment in adolescent cancer survivors in Korea. We conducted a descriptive, exploratory study of 84 adolescents with cancer using the Korean version of the Fragebogen zum erinnerten elterlichen Erziehungsverhalten: FEE (Recalled Parental Rearing Behavior) and a school adjustment measurement. Descriptive, Pearson correlational, and multiple regression analyses were used to investigate the data. In bivariate analysis, age (r = -0.358, P < .05), mother's emotional warmth (r = 0.549, P < .01), and father's emotional warmth (r = 0.391, P < .05) were significantly associated with school adjustment. However, the results of multiple regression analysis showed that only mother's emotional warmth (β = .720, P < .05) was significantly associated with school adjustment. Adolescent cancer survivors who reported higher mother's emotional warmth exhibited better school adjustment. This finding indicates that it is important to help parents of adolescent cancer survivors enhance their parental rearing behaviors, such as emotional warmth, to help adolescents adjust to school.

Pilot Study of Parent Psychophysiologic Outcomes in Pediatric Hematopoietic Stem Cell Transplantation

BACKGROUND

Parents of children undergoing hematopoietic stem cell transplantation (HSCT) are at risk for psychological distress. This distress may result in aberrant immune, inflammatory, or endocrine effects. These physiologic outcomes have not been reported previously.

MAIN OBJECTIVE

The aim of this study is to examine the feasibility of longitudinal testing of psychophysiological parameters of stress in parents of children undergoing HSCT.

METHODS

This pilot study was conducted at a large children's hospital in the Midwest and included parents of children who received autologous or allogeneic HSCT. Time points included before the start of HSCT conditioning and day +30, +60, and +100. Outcome variables included parent-perceived stress, lymphocyte subsets, C-reactive protein (CRP), proinflammatory cytokines, salivary cortisol, and salivary amylase. Effect sizes were calculated for each outcome.

RESULTS

Twelve parent-child dyads were enrolled (10 mothers, 2 fathers). Missing data were minimal. Parent-perceived stress significantly increased from pre-HSCT through day +100, and parent CD3+ T-lymphocyte counts decreased from pre-HSCT through day +100. No significant effects were observed for salivary studies, CRP, or proinflammatory cytokines. Effect sizes ranged from 1.23 (perceived stress) to 0.07 (CRP).

CONCLUSION

The results of this study suggest that it is feasible longitudinally measure parent psychophysiologic outcomes in the pediatric HSCT setting. In addition, parent-perceived stress increased linearly from start of conditioning through day +100, whereas parent T-lymphocyte counts decreased concurrently.

IMPLICATIONS FOR PRACTICE

Routine psychological and physical health screening of parents of children undergoing HSCT is needed. Multidisciplinary psychosocial support services should be offered to parents at regular intervals during their child's HSCT.

Different Aspects of Psychological Ill Health in a National Sample of Swedish Parents after Successful Paediatric Stem Cell Transplantation

BACKGROUND

Paediatric hematopoietic stem cell transplantation (HSCT) may have great psychological impact on parents during the intense treatment period as well as many years after a successful transplantation. Since different psychological disorders require different interventions, a differentiation of general distress into specific types of psychological ill health is essential. The aim of this descriptive study was to distinguish anxiety, depression, and burnout, and investigate occurrence and co-occurrence of these in a national Swedish sample of parents of children who had undergone HSCT and survived.

PROCEDURE

Established self-report instruments (Hospital Anxiety and Depression Scale, posttraumatic stress checklist, and Shirom-Melamed Burnout Questionnaire) were used to assess parents' subjective suffering.

INCLUSION CRITERIA

the child had to be alive; ≤18 years of age; >6 months since HSCT.

RESULTS

Four hundred twenty-one eligible parents (220 mothers and 201 fathers) were identified, of whom 284 choose to participate (response rate 67%). In total, 134 parents (87 mothers, 47 fathers) reported clinically relevant levels of one or more of the assessed types of psychological ill health, representing 48% of the responding participants and 32% of the entire national population of parents of children who had undergone HSCT and survived. Anxiety and/or burnout were reported most frequently. A majority reported more than one type of psychological ill health. Depression only was rare.

CONCLUSIONS

The findings underscore the importance of recognizing-in research as well as in clinical practice-that different types of psychological ill health may affect parents after successful HSCT. When parents present with psychological suffering, a referral for qualified assessment is warranted to obtain the proper treatment.

A randomized clinical trial of a parent-focused social-cognitive processing intervention for caregivers of children undergoing hematopoetic stem cell transplantation

OBJECTIVE

Providing care to one's child during and after a hematopoietic stem cell transplant (HSCT) is a universally stressful experience, but few psychological interventions have been developed to reduce caregiver distress. The goal of this study was to test the efficacy of a brief cognitive-behavioral intervention delivered to primary caregivers.

METHOD

Two hundred eighteen caregivers were assigned either best-practice psychosocial care (BPC) or a parent social-cognitive intervention program (P-SCIP). The 5 session P-SCIP was delivered during the HSCT hospitalization. Caregivers completed measures of distress, optimism, coping, and fear appraisals preintervention, 1, 6 months, and 1 year.

RESULTS

P-SCIP reduced caregiver's distress significantly more than BPC between the pretransplant assessment (Time 1) and 1-month follow-up assessment (Time 2). P-SCIP had a stronger effect than BPC among caregivers who began the hospitalization reporting higher depression and anxiety, and among caregivers whose children developed graft-versus-host disease (GvHD). Long-term treatment effects of P-SCIP were seen in traumatic distress among caregivers who reported higher anxiety pretransplant as well as among caregivers whose children had GvHD at HSCT discharge.

CONCLUSIONS

Screening caregivers for elevations in pretransplant anxiety and targeting interventions specifically to these caregivers, as well as targeting caregivers to children who develop GvHD, may prove beneficial.

Identifying unmet informational needs in the inpatient setting to increase patient and caregiver engagement in the context of pediatric hematopoietic stem cell transplantation

BACKGROUND

Patient-centered care has been shown to improve patient outcomes, satisfaction, and engagement. However, there is a paucity of research on patient-centered care in the inpatient setting, including an understanding of unmet informational needs that may be limiting patient engagement. Pediatric hematopoietic stem cell transplantation (HSCT) represents an ideal patient population for elucidating unmet informational needs, due to the procedure's complexity and its requirement for caregiver involvement.

METHODS

We conducted field observations and semi-structured interviews of pediatric HSCT caregivers and patients to identify informational challenges in the inpatient hospital setting. Data were analyzed using a thematic grounded theory approach.

RESULTS

Three stages of the caregiving experience that could potentially be supported by a health information technology system, with the goal of enhancing patient/caregiver engagement, were identified: (1) navigating the health system and learning to communicate effectively with the healthcare team, (2) managing daily challenges of caregiving, and (3) transitioning from inpatient care to long-term outpatient management.

DISCUSSION

We provide four practical recommendations to meet the informational needs of pediatric HSCT patients and caregivers: (1) provide patients/caregivers with real-time access to electronic health record data, (2) provide information about the clinical trials in which the patient is enrolled, (3) provide information about the patient's care team, and (4) properly prepare patients and caregivers for hospital discharge.

CONCLUSION

Pediatric HSCT caregivers and patients have multiple informational needs that could be met with a health information technology system that integrates data from several sources, including electronic health records. Meeting these needs could reduce patients' and caregivers' anxiety surrounding the care process; reduce information asymmetry between caregivers/patients and providers; empower patients/caregivers to participate in the care process; and, ultimately, increase patient/caregiver engagement in the care process.

Barriers to psychological care among primary caregivers of children undergoing hematopoietic stem cell transplantation

PURPOSE

This substudy of an intervention trial aimed to describe barriers to participation in psychological care among primary caregivers of children who were about to undergo a hematopoietic stem cell transplantation (HSCT), including demographic and medical correlates.

METHOD

Three hundred and twelve primary caregivers of children undergoing HSCT who were approached to participate in a psychological intervention trial (n = 218 enrollees and 94 decliners) completed a measure of barriers to psychological care.

RESULTS

The most frequently endorsed barriers to care were focusing on the child as priority, not wanting to leave the child's bedside, and already having adequate psychosocial support. The least frequently endorsed barriers were location, wait times, and stigma around seeking psychological care.

CONCLUSIONS

Results suggest that explaining how psychological care for a primary caregiver can positively affect their ill child may reduce barriers to seeking needed support services. Certain practical barriers to care may be irrelevant in inpatient settings where psychological support is offered.

A Novel Health Information Technology Communication System to Increase Caregiver Activation in the Context of Hospital-Based Pediatric Hematopoietic Cell Transplantation: A Pilot Study

BACKGROUND

Pediatric hematopoietic cell transplantation (HCT), commonly referred to as blood and marrow transplantation (BMT), is an intense treatment modality that requires the involvement of engaged caregivers during the patient's (child's) prolonged hospitalization. The ubiquity of electronic health records (EHRs) and a trend toward patient-centered care could allow a novel health information technology (IT) system to increase parental engagement. The paucity of research on acute care, hospital-based (inpatient) health IT applications for patients or caregivers provides an opportunity for testing the feasibility of such applications. The pediatric BMT population represents an ideal patient group to conduct an evaluation due to the lengthy inpatient stays and a heightened need for patient activation.

OBJECTIVE

The primary objective of this study is to assess the feasibility of implementing the BMT Roadmap in caregivers as an intervention during their child's inpatient hospitalization. The BMT Roadmap is an inpatient portal prototype optimized for tablet with a user-centered design. It integrates patient-specific laboratory and medication data from the EHR in real-time and provides support in terms of discharge goals, home care education, and other components. Feasibility will be proven if (1) the BMT Roadmap functions and can be managed by the study team without unexpected effort, (2) the system is accessed by users at a defined minimum threshold, and (3) the qualitative and quantitative research conducted provides quality data that address the perceived usefulness of the BMT Roadmap and could inform a study in a larger sample size.

METHODS

This will be a single-arm, nonrandomized feasibility study. We aim to enroll 10 adult caregivers (age ≥ 18 years) of pediatric patients (aged 0-25 years) undergoing autologous (self-donor) or allogeneic (alternative donor) BMT. Assenting minors (aged 10-18) will also be invited to participate. Recruitment of study participants will take place in the outpatient pediatric BMT clinic. After signing an informed consent, the research study team will provide participants with the BMT Roadmap, available on an Apple iPad, which will used throughout the inpatient hospitalization. To measure the study outcomes, approximately 6-8 semistructured qualitative interviews will be conducted periodically from pre-BMT to 100 days post-BMT and an additional 15-20 semistructured interviews will be conducted among BMT health care providers to assess perceived usefulness and usability of the system, as well as any associated workflow impacts. Quantitative survey instruments will only be administered to adult participants (age ≥ 18 years).

RESULTS

Recruitment will begin in September 2015, and preliminary findings are expected in 2016.

CONCLUSIONS

This protocol offers a framework for the design and analysis of a personalized health IT system that has the potential to increase patient and caregiver engagement in acute care, hospital-based contexts.

User-Centered Design Groups to Engage Patients and Caregivers with a Personalized Health Information Technology Tool

Health information technology (IT) has opened exciting avenues for capturing, delivering and sharing data, and offers the potential to develop cost-effective, patient-focused applications. In recent years, there has been a proliferation of health IT applications such as outpatient portals. Rigorous evaluation is fundamental to ensure effectiveness and sustainability, as resistance to more widespread adoption of outpatient portals may be due to lack of user friendliness. Health IT applications that integrate with the existing electronic health record and present information in a condensed, user-friendly format could improve coordination of care and communication. Importantly, these applications should be developed systematically with appropriate methodological design and testing to ensure usefulness, adoption, and sustainability. Based on our prior work that identified numerous information needs and challenges of HCT, we developed an experimental prototype of a health IT tool, the BMT Roadmap. Our goal was to develop a tool that could be used in the real-world, daily practice of HCT patients and caregivers (users) in the inpatient setting. Herein, we examined the views, needs, and wants of users in the design and development process of the BMT Roadmap through user-centered Design Groups. Three important themes emerged: 1) perception of core features as beneficial (views), 2) alerting the design team to potential issues with the user interface (needs); and 3) providing a deeper understanding of the user experience in terms of wider psychosocial requirements (wants). These findings resulted in changes that led to an improved, functional BMT Roadmap product, which will be tested as an intervention in the pediatric HCT population in the fall of 2015 (ClinicalTrials.govNCT02409121).

Parent Outlook: How Parents View the Road Ahead as They Embark on Hematopoietic Stem Cell Transplantation for Their Child

Pediatric hematopoietic stem cell transplantation (HSCT) offers cure for high-risk malignancies and other conditions, but carries a risk of complications. Parental outlook regarding their child's transplantation course and future health has been largely unexplored. This report presents the Parent Outlook Scale, describes its properties, and examines the outlook of parents embarking on their child's transplantation course and the associated variables. Parents of children scheduled to undergo HSCT (n = 363) at 8 US transplantation centers completed the Parent Outlook Scale, comprising 4 items assessing frequency of the parent's thoughts about the potential difficulty of the child's transplantation (Transplant Difficult subscale) and worsened health (Health Worse subscale). Item responses were rated on a 5-point Likert scale (ranging from "none" to "all of the time") and, along with scale/subscale scores, transformed to 100-point scales, with higher scores connoting greater thought frequency. Psychometrics were explored. Multivariable models identified personal and clinical characteristics associated with scale and subscale scores. The Parent Outlook Scale (α = 0.75) and subscales were found to have sound psychometric properties. Factor loading supported the single scale with 2 subscales representing distinct aspects of overall outlook. Mean scores (Parent Outlook, 52.5 ± 21.7; Transplant Difficult, 64.4 ± 25.6; Health Worse, 40.7 ± 25.7) revealed variability within and across scale/subscales. Significantly different mean subscale scores (P < .001) indicated more frequent Transplant Difficult thoughts than Health Worse thoughts. Clinical factors (solid tumor diagnosis and unrelated donor transplant) and a parent factor (worse emotional functioning) were associated with higher scale and subscale scores. Our findings show that the outlook of parents embarking on their child's HSCT course is varied and not solely a product of clinical factors readily apparent to clinicians. Referring and transplantation clinicians should create opportunities to explore with parents their perspectives and concerns before and during the course of HSCT.

The impact of pediatric blood and marrow transplant on parents: introduction of the parent impact scale

BACKGROUND

Parents often experience stress-related complications when their child requires blood and marrow transplant (BMT). Previous studies have described the emotional toll BMT places on parents during the acute phase of care and within the context of clinical complications. In this paper we introduce the Parent Impact Scale (PARimpact), designed to capture physical and emotional challenges of the child's health on the parent. The primary aim of this paper is to examine psychometric properties of PARimpact, and the secondary aim is to explore factors associated with PARimpact scores for further hypothesis generation.

METHODS

This analysis used a merged dataset of two longitudinal studies. Accompanying parents (n = 363) of children undergoing BMT were surveyed up to six times from pre-BMT baseline to one year after their child's BMT. For this analysis, pre-BMT baseline responses to PARimpact were used to examine the factor structure with Principal Component Analysis (PCA) and Exploratory Factor Analysis (EFA). Construct validity was assessed, and multivariable regression was used to examine relationships between PARimpact and BMT clinical variables.

RESULTS

PCA and EFA revealed a one-factor solution with acceptable item loading; Cronbach's α was 0.83 at baseline. Hypothesized differences in known groups were detected for BMT complications with significantly higher PARimpact scores for those with vs. without each complication. In the adjusted multivariable regression models, acute graft versus host disease (b = 5.3; p = 0.03), end organ toxicity (b = 5.9; p < 0.01), and systemic infection (b = 9.1; p < 0.01) were associated with significantly higher mean PARimpact scores in the first 3 months following transplant. After the first 3 months to 1 year post BMT, systemic infection was associated with increased mean PARimpact scores (b = 19.2; p < 0.01).

CONCLUSIONS

Initial results suggest that the PARimpact is valid and reliable. Our finding that clinical complications increase the impact of BMT on the caretaking parent indicates the need for BMT healthcare professionals to identify these events and help parents navigate the BMT course. Clinical application of the PARimpact scale should be considered to identify high-risk families and provide targeted interventions to augment care.

Posttraumatic growth and support among parents whose children have survived stem cell transplantation

In the current study, we investigated the occurrence of posttraumatic growth (PTG) among parents whose children had had stem cell transplantation (SCT) and survived. Although SCT is well established, it remains stressful and dangerous, and SCT is only performed if there is no other choice of treatment to be considered. A questionnaire batteries including the Post-Traumatic Stress Disorder (PTSD) Check List-Civilian version and the Post-Traumatic Growth Inventory were sent out to a cross-sectional national sample of parents of children who had had SCT six months or more before the study. The response rate was 66% (n = 281). The data were analyzed in relation to parents' appraisal of the event, gender, and perceived social support. The results confirm that SCT in childhood is an event of extreme adversity for the parents. Indications of PTSD were found among an important minority of the parents. Nevertheless, a large proportion of the parents had experienced growth as a consequence of the child's illness. Appreciation of life and personal strength were the domains with the highest scores. Moreover, a higher level of PTG was correlated with a higher level of posttraumatic stress and with an experience of the trauma as more severe. In summary, the study indicates that PTG is a relevant concept for this group of parents.

Psychological distress and psychiatric diagnoses among primary caregivers of children undergoing hematopoietic stem cell transplant: an examination of prevalence, correlates, and racial/ethnic differences

OBJECTIVE

The aims of the study were to examine the prevalence of self-reported psychological distress, examine the prevalence of interview-rated psychiatric diagnoses, identify correlates of psychological distress and psychiatric diagnosis and examine racial/ethnic group differences on measures of psychological distress among primary caregivers of children preparing to undergo hematopoietic stem cell transplant (HSCT).

METHODS

Caregivers (N = 215) completed the Beck Anxiety Inventory, Beck Depression Inventory (BDI), Impact of Events Scale, and a psychiatric interview assessing major depressive disorder, generalized anxiety disorder and panic disorder. Regression analyses examined correlates of distress and psychiatric diagnosis. Comparisons were made between racial/ethnic groups.

RESULTS

Posttraumatic stress symptoms were reported by 54% of caregivers during the time preparing for the child's HSCT. Twenty-seven percent of caregivers met diagnostic criteria for at least one of the psychiatric diagnoses during this time. Few factors were associated with distress or psychiatric diagnosis, except the child scheduled for allogeneic transplant, being married and prior psychological/psychiatric care. Sociodemographic factors accounted for racial/ethnic group differences, except that Hispanic/Latino caregivers reported higher BDI scores than non-Hispanic white caregivers.

CONCLUSION

Caregivers may be at greater risk of posttraumatic stress symptoms than anxiety or depression. Prior psychological/psychiatric treatment is a risk factor for greater psychological distress and psychiatric diagnosis during this time. Racial differences are mostly due to sociodemographic factors.

The role of social and cognitive processes in the relationship between fear network and psychological distress among parents of children undergoing hematopoietic stem cell transplantation

The current study examined whether cognitive and social processing variables mediated the relationship between fear network and depression among parents of children undergoing hematopoietic stem cell transplant (HSCT). Parents whose children were initiating HSCT (N = 179) completed survey measures including fear network, Beck Depression Inventory, cognitive processing variables (positive reappraisal and self-blame) and social processing variables (emotional support and holding back from sharing concerns). Fear network was positively correlated with depression (p < .001). Self-blame and holding back emerged as individual partial mediators in the relationship between fear network and depression. Together they accounted for 34.3% of the variance in the relationship between fear network and depression. Positive reappraisal and emotional support did not have significant mediating effects. Social and cognitive processes, specifically self-blame and holding back from sharing concerns, play a negative role in parents' psychological adaptation to fears surrounding a child's HSCT.

Patterns of psychological responses in parents of children that underwent stem cell transplantation

OBJECTIVE

Hematopoietic stem cell transplantation (HSCT) is curative in several life-threatening pediatric diseases but may affect children and their families inducing depression, anxiety, burnout symptoms, and post-traumatic stress symptoms, as well as post-traumatic growth (PTG). The aim of this study was to investigate the co-occurrence of different aspects of such responses in parents of children that had undergone HSCT.

METHODS

Questionnaires were completed by 260 parents (146 mothers and 114 fathers) 11-198 months after HSCT: the Hospital Anxiety and Depression Scale, the Shirom-Melamed Burnout Questionnaire, the post-traumatic stress disorders checklist, civilian version, and the PTG inventory. Additional variables were also investigated: perceived support, time elapsed since HSCT, job stress, partner-relationship satisfaction, trauma appraisal, and the child's health problems. A hierarchical cluster analysis and a k-means cluster analysis were used to identify patterns of psychological responses.

RESULTS

Four clusters of parents with different psychological responses were identified. One cluster (n = 40) significantly differed from the other groups and reported levels of depression, anxiety, burnout symptoms, and post-traumatic stress symptoms above the cut-off. In contrast, another cluster (n = 66) reported higher levels of PTG than the other groups did.

CONCLUSIONS

This study shows a subgroup of parents maintaining high levels of several aspects of distress years after HSCT. Differences between clusters might be explained by differences in perceived support, the child's health problems, job stress, and partner-relationship satisfaction.

Adjustment in parents of children undergoing stem cell transplantation

Pediatric stem cell transplantation (SCT) is a demanding procedure for children and parents. Interventions to promote positive adjustment of parents in this setting are needed. A total of 171 patient-parent dyads from 4 sites received 1 of 3 interventions to reduce SCT-related distress: a child intervention with massage and humor therapy, an identical child intervention plus a parent intervention with massage and relaxation/imagery, or standard care. Parents completed weekly self-report measures of distress and positive affect during the acute phase of treatment (weeks -1 through +6); and measures of depression, posttraumatic stress (PTSD), and benefit finding at baseline and week +24. No significant differences across treatment arms were observed on repeated measures of parental distress. There was a marginally significant effect of the child intervention on parental positive affect. Over time, parental distress decreased significantly and positive affect increased significantly in all groups. Similarly, there were no significant intervention effects on the global adjustment outcomes of depression, PTSD, and benefit finding. However, reports of depression and PTSD decreased significantly and reports of benefit finding increased significantly from baseline to week +24 for all groups. Across all study arms, parent adjustment improved over time, suggesting that parents demonstrate a transient period of moderately elevated distress at the time of their child's admission for transplantation, followed by rapid improved to normative levels of adjustment. Similar to results previously reported for their children, these parents appear resilient to the challenges of transplantation.

The use of haematopoietic stem cell transplantation in Fanconi anaemia patients: a survey of decision making among families in the US and Canada

BACKGROUND

Fanconi anaemia (FA) is a rare genetic disorder associated with bone marrow failure (BMF), congenital anomalies and cancer susceptibility. Stem cell transplantation (SCT) offers a potential cure for BMF or leukaemia, but incurs substantial risks. Little is known about factors influencing SCT decision making.

OBJECTIVE

The study objective was to explore factors influencing patients' with FA and family members' decision making about SCT.

DESIGN

Using a mixed-methods exploratory design, we surveyed US and Canadian patients with FA and family members who were offered SCT.

MAIN VARIABLES STUDIED

Closed-ended survey items measured respondents' beliefs about the necessity, risks and concerns regarding SCT; multivariable logistic regression was used to examine the association between these factors and the decision to undergo SCT. Open-ended survey items measured respondents' perceptions of factors important to the SCT decision; qualitative analysis was used to identify emergent themes.

RESULTS

The decision to undergo SCT was significantly associated with greater perceived necessity (OR = 2.81, P = 0.004) and lower concern about harms of SCT (OR = 0.31, P = 0.03). Qualitative analysis revealed a perceived lack of choice among respondents regarding the use of SCT, which was related to physician influence and respondent concerns about patients' quality of life.

CONCLUSIONS

Overall, study results emphasize the importance of the delicate interplay between provider recommendation of a medical procedure and patient/parental perceptions and decision making. Findings can help providers understand the need to acknowledge family members' perceptions of SCT decision making and offer a comprehensive discussion of the necessity, risks, benefits and potential outcomes.

Parental perspectives on a behavioral health music intervention for adolescent/young adult resilience during cancer treatment: report from the children's oncology group

PURPOSE

This article describes parental perspectives on the helpfulness and meaningfulness of a behavioral health music therapy intervention targeted to adolescents/young adults (AYA) with cancer undergoing stem cell transplantation. We demonstrate how qualitative methods may be used to understand critical aspects of an intervention and mechanisms by which the intervention impacts the target AYA outcomes of resilience and quality of life.

METHODS

A qualitative descriptive design was used to obtain parents' perspectives. A maximum-variation purposive sampling technique was used to sample 16 parents whose AYA had been randomized to the intervention group. A semistructured open-ended interview was conducted between 100 and 160 days after the AYA's transplant.

RESULTS

Results were grouped into three categories: (1) helpfulness and meaningfulness of the intervention to AYA adjustment to the transplantation experience; (2) helpfulness and meaningfulness of the intervention for parents; and (3) AYA ability to participate in the intervention during the acute phase of transplant.

CONCLUSIONS

Parents observed and interacted with their AYA who participated in a targeted behavioral intervention. Thus, parents were able to describe mechanisms through which the intervention was helpful and meaningful for the AYA and indirect personal benefits for themselves. The results suggest the importance of the targeted outcomes identified in the Resilience in Illness Model and mechanisms of action in the Contextual Support Model of Music Therapy, and identify approaches for future study.

Socially disadvantaged parents of children treated with allogeneic haematopoietic stem cell transplantation (HSCT): report from a supportive intervention study, Denmark

PURPOSE

This study was undertaken to test a daily Family Navigator Nurse (FNN) conducted intervention program, to support parents during the distressful experience of their child's Allogeneic Haematopoietic Stem Cell Transplantation (HSCT).

METHODS

A qualitative analysis of the supportive intervention program for parents whose child is under HSCT treatment while hospitalized. Parents to 25 children were included in the intervention group. Twenty-five parents were included in a participant observational study and 21 of these completed a semi-structured interview 100 days following HSCT.

RESULTS

Three main problems faced by all parents included 1) the emotional strain of the child's HSCT; 2) re-organizing of the family's daily life to include hospitalization with the child; and 3) the financial strain of manoeuvring within the Danish welfare system. The FNN performed daily intervention rounds to ease each of these problems during the study period. Having the following pre-existing risk factors, negatively influenced the parents' ability to address these problems: 1) being a single parents; 2) low-level income; 3) low-level education; 4) low-level network support: 5) being a student or unemployed; 6) physical/psychiatric illness; and 7) ethnicity. Six families with 4 or more risk factors had complex emotional, social and financial problems that required extensive intervention by the FNN and that impacted their ability to provide care for the child.

CONCLUSION

The parents' pre-existing risk factors were further complicated by their children's HSCT. A recommendation for clinical practice is to identify families with multiple interrelated problems and allocate resources to support these families.

Parental caregiving of children prior to hematopoietic stem cell transplant

Using the Caregiver Reaction Assessment (CRA), we assessed positive reactions and burdens of the caregiving experience among parental caregivers (n = 189) of children scheduled to undergo hematopoietic stem cell transplant. Although widely used in non-parental caregivers, the CRA has not been used in parents of pediatric patients. Reliability (Cronbach's alpha: .72-.81 vs. .63) and concurrent validity (correlation: .41-.61 vs. .28) were higher for negatively framed than positively framed subscales. Results indicate that the caregiving experience is complex. The parents experienced high caregiver's esteem and moderate family support, but also negative impacts on finances and schedule, and to a lesser degree, health. Compared to non-parental caregivers, parental caregivers experienced higher esteem and more impact on finances and schedule.

Peritransplant psychiatric evaluation of patients with fanconi anemia

Patients with Fanconi anemia (FA) referred for stem cell transplantation (SCT) have multiple psychosocial risk factors and often present in distress in the peritransplant period. Twenty-two patients with FA were referred for psychiatry consultation before, during, or after SCT, across a 13-year period at Memorial Sloan-Kettering Cancer Center. The most common diagnoses were mood (50%), adjustment (46%), and anxiety (23%) disorders and delirium (23%); the most common psychiatric symptoms were anxious/depressed (86%), withdrawn (64%), and aggressive (59%) symptoms. Etiology of the diagnoses and symptoms included: chronic childhood illness, physical and/or neurodevelopmental disability, presence of a genetic syndrome, presence of a cancer predisposition syndrome, exposure to therapeutic androgens, and exposure to pediatric SCT. However, the degree of influence of the different factors could not be determined. In addition, other factors such as impact of sibling illness or loss, extent of treatment nonadherence, level and significance of neurodevelopmental pathologies were identified. Future prospective and possibly multicenter studies will need to be generated for a better understanding and more complete factor analysis.

Differences in mothers' and fathers' psychological distress after pediatric SCT: a longitudinal study

The purpose of this study was to examine longitudinally psychological distress and its correlates in mothers and fathers of children who undergo SCT, up to 2 years post SCT. A total of 111 parents of patients diagnosed mainly with leukemia completed standardized measures of depression and anxiety symptoms as indicators of psychological distress, 85 at 1 year pre-SCT and 81 at 2 years post SCT. Parents' age and gender, child's age, diagnosis, radiation history, behavior and physical health were examined as potential related factors. Linear mixed models for repeated measures with appropriate covariance structure were used in the analysis. Depression and anxiety scores significantly decreased by 2 years for mothers and fathers. Mothers reported significantly more depression symptoms than did fathers, but reported comparable symptoms of anxiety. Pre-SCT depression and anxiety scores, mother's age (younger), child's behavior problems, radiation history and diagnosis of neuroblastoma predicted maternal distress 2 years post SCT; pre-SCT depression and anxiety scores, father's age (older) and child's diagnosis predicted father's distress. This study highlights differences and similarities in mothers' and fathers' psychological distress and identifies related risk factors. The results can guide interventions for mothers and fathers whose children undergo SCT based on their pre-SCT psychosocial risk.

Complementary therapies for children undergoing stem cell transplantation: report of a multisite trial

BACKGROUND

Children undergoing stem cell transplant (SCT) experience high levels of somatic distress and mood disturbance. This trial evaluated the efficacy of complementary therapies (massage, humor therapy, relaxation/imagery) for reducing distress associated with pediatric SCT.

METHODS

Across 4 sites, 178 pediatric patients scheduled to undergo SCT were randomized to a child-targeted intervention involving massage and humor therapy, the identical child intervention plus a parent intervention involving massage and relaxation/imagery, or standard care. Randomization was stratified by site, age, and type of transplant. The interventions began at admission and continued through SCT Week +3. Primary outcomes included patient and parent reports of somatic distress and mood disturbance obtained weekly from admission through Week +6 using the Behavioral, Affective, and Somatic Experiences Scales. Secondary outcomes included length of hospitalization, time to engraftment, and usage of narcotic analgesic and antiemetic medications.

RESULTS

A mixed model approach was used to assess longitudinal trends of patient and parent report outcomes and to test differences between groups on these measures. Significant changes across time were observed on all patient and parent report outcomes. However, no significant differences between treatment arms were found on the primary outcomes. Similarly, no significant between-group differences were noted on any of the medical variables as secondary outcomes.

CONCLUSIONS

Results of this multisite trial failed to document significant benefits of complementary interventions in the pediatric SCT setting.

Parents' experiences one year on from their child's hematopoietic stem cell transplant for primary immunodeficiency

This study explored parental experience one year after hematopoietic stem cell transplant for primary immunodeficiency. Eight parents whose child had undergone transplant were interviewed one year after their child's transplant. Transcripts were analysed using interpretative phenomenological analysis. Four themes emerged: parents' paradoxical existence within an 'abnormal normality'; isolation felt by parents; gender differences between mothers and fathers; and the 'positive growth' parents attribute to their experience. As well as describing stressful or traumatic experiences they identified aspects of post-traumatic growth. The methodology used allowed contrasting experiences to emerge and highlights the importance of follow-up for parents as well as children.

Parental stress and perceived vulnerability at 5 and 10 years after pediatric SCT

With the aim of assessing parental stress after SCT, 73 parents of children and adolescents who underwent SCT 5 or 10 years ago responded to questionnaires on general distress (General Health Questionnaire (GHQ)), disease-related stress (Pediatric Inventory for Parents-short form (PIP-SF)) and perceptions of child vulnerability (Child Vulnerability Scale (CVS)). General distress scores were comparable with the reference groups, but 40% of the mothers at 5 years after SCT reported increased stress levels as compared with 26% in the community-based reference group. Disease-related stress was comparable with the reference group of parents of children who were just off cancer treatment, 5 years after SCT. At 10 years after SCT, scores were lower than the reference group. Perceived child vulnerability did diminish over time, but remained high in parents of SCT survivors, compared with parents of healthy children: 96% of the parents at 5 years after SCT and 76% of the parents at 10 years after SCT scored above the cutoff point. Perceived vulnerability was found to be a predictor for parental disease-related stress. To conclude, although most parents of SCT survivors are resilient, the majority of parents perceive their child to be much more vulnerable as compared with parents of healthy children. This perception is associated with disease-related stress and may induce overprotective parenting.

Parental stress before, during, and after pediatric stem cell transplantation: a review article

Goals of work

Pediatric stem cell transplantation (SCT) is a stressful treatment for children with relapsed or high-risk malignancies, immune deficiencies and certain blood diseases. Parents of children undergoing SCT can experience ongoing stress related to the SCT period. The aim of this article was to present a literature review of articles on parental distress and adaptation before, during, and after SCT and to identify risk and protective factors.

Materials and methods

The review was conducted systematically by using PubMed, Web of Science, PsychInfo, and Picarta databases. Eighteen articles met our inclusion criteria: publishing date between January 1, 1990 and January 1, 2009; studies concerning parents of children undergoing SCT; studies examining the psychological adjustment and/or stress reactions of parents as primary outcomes and studies available in English.

Main results

Highest levels of parental stress are reported in the period preceding SCT and during the acute phase. Stress levels decrease steadily after discharge in most parents. However, in a subgroup of parents, stress levels still remain elevated post-SCT. Parents most at risk in the longer term display highest levels of stress during the acute phase of the SCT.

Conclusions

Psychosocial assessment before SCT, during the acute phase and in the longer term, is necessary to identify parents in need for support and follow-up care.

Validity and consequence of informed consent in pediatric bone marrow transplantation: The parental experience

BACKGROUND

Conditions supporting a high quality of consent for pediatric bone marrow transplantation (BMT) are suboptimal given the complexity of the procedure, lack of options, and parent emotional duress. We studied if parents perceived choice when consenting to BMT, if they felt the consent provided was valid, and how the consent process affected them.

METHODS

Telephone or face-to-face interviews were recorded using a semi-structured interview outline. Interview transcripts were anonymized, and independently analyzed by three reviewers.

RESULTS

Twenty parents of twelve children participated, including five bereaved parents. There were no differences in patient transplant characteristics between the eligible and study groups. Divorced or separated parents were underrepresented in the participant group. Fifteen parents felt personally compelled to consent; most (18) denied feeling external medical pressure to do so. All parents felt their consent was valid and most reported adequate levels of freedom, capacity, and information. Expectations formulated during the consent process strongly influenced parents' experience post-BMT. Good communication during consent contributed to trust and therapeutic alliance with physicians following BMT. Late parental stress and anxiety were periodic, but very high in some families.

CONCLUSIONS

Parents feel consent for pediatric BMT is valid, despite feeling personally compelled to consent. Strategies aimed at nurturing hope and realistic expectations may assist in improving the consent process, while diminishing long-term stressors.

Having a child to save a sibling: reassessing risks and benefits of creating stem cell donors

This manuscript assesses the risks, benefits, and ethical concerns regarding the use of assisted reproductive techniques (ART) to create a new donor for stem cell transplantation. We address ethical literature, the medical and psychosocial impact on patient, donor, family, and medical caregivers, and the appropriate decision-making process. We conclude that the use of ART to create a stem cell donor can be ethically acceptable. The decision to conceive a donor has medical and psychosocial implications. The family is the appropriate decision-maker and must consider risks and benefits to all parties with input from medical caregivers.

Psychosocial Functioning in Pediatric Cancer

OBJECTIVE

To describe the emergence of pediatric psycho-oncology and to summarize research on psychosocial aspects of childhood cancer and survivorship.

METHODS

To review research into illness communication and informed consent, procedural pain, late effects, psychological distress, coping and adjustment, and special risk populations. Methodological challenges, appropriate methodology, and directions for future research are discussed.

RESULTS

The past 30 years have seen change from avoidance of communication about cancer to an emphasis on straightforward discussion of diagnosis and prognosis. Behavioral research has led to interventions to reduce procedural distress. Late effects have been observed in social functioning. Although average levels of distress in survivors of pediatric cancer are typical, subsets of more vulnerable patients and family members exist. Factors predicting positive and negative coping have been identified.

CONCLUSIONS

As the numbers of pediatric cancer survivors increase, psychosocial researchers will be better able to conduct longitudinal studies not only of adjustment and its predictors but also of the impact of the emerging medical treatments and interventions to ameliorate late effects of treatment. Additional funding, improving methodology, and multi-institutional cooperation will aid future pediatric psycho-oncology investigators.