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

Assessing and Preparing Patients for Hematopoietic Stem Cell Transplant in Canada: An Environmental Scan of Psychosocial Care

Recipients and caregivers of Hematopoietic Stem Cell Transplant (HCT) have extensive physical and psychosocial needs. HCT programs recognize the need to support psychosocial wellbeing. However, evidence-based guidance for pre-HCT psychosocial services is sparse. We conducted a qualitative environmental scan of programs across Canada to better understand how programs evaluate and support patients and caregivers prior to HCT.

METHODS

HCT programs across Canada were contacted with a list of questions about their psychosocial assessment and preparation process with patients and caregivers. They could respond via email or participate in an interview over the phone. Descriptive qualitative content analysis was conducted, using steps outlined by Vaismoradi and colleagues (2013).

RESULTS

Most participants were social workers from hospitals (64%). Four qualitative themes arose: (a) Psychosocial Team Composition. Psychosocial assessment for HCT patients was often provided by social workers, with limited availability of psychologists and psychiatrists. (b) Criteria for assessing select HCT patients. Participants prioritized psychosocial assessments for patients with higher perceived psychosocial needs or risk, and/or according to transplant type. Limited time and high psychosocial staff demands also played into decision-making. (c) Components and Practices of Pre-HCT Psychosocial Assessment. Common components and differences of assessments were identified, as well as a lack of standardized tools. (d) Patient Education Sessions. Many sites provided adjunct patient education sessions, of varying depth.

CONCLUSION

Significant variation exists in the way programs across the country assess their patients' psychosocial pre-transplant needs and assist in preparing patients for the psychosocial aspects of HCT. This environmental scan identified several strategies used in diverse ways. Further in-depth research on program outcomes across Canada could help to identify which strategies are the most successful.

Anxiety and Depression in Parents of Children Undergoing Hematopoietic Stem Cell Transplant (HSCT)

Hematopoietic stem cell transplantation (HSCT) is a well-established therapy tool for several malignant and non-malignant diseases. Parents of children undergoing HSCT experience physiological distress for various reasons such as intensive caregiving, potential complications, and medically intensive process. The purpose of this study was to explore anxiety/depression in parents of children who underwent HSCT and the associated self-reported characteristics.

METHOD AND MATERIAL

In the present study were enrolled 100 parents of children who underwent HSCT. Data were collected by the completion of the "Hospital Anxiety and Depression Scale (HADs)," which also included parents' characteristics. The statistical significance level was p < 0.05.

RESULTS

Of the 100 participants, 81% and 64% of parents experienced anxiety and depression, respectively, based on HADs scores. A statistically significant association was observed between parental anxiety and gender (p = 0.017), frequency of visiting the hospitalized child (p = 0.023), whether they desired family members to remain in hospital (p = 0.033), as well as with the need for participation in daily care (p = 0.023), for help based on personal needs (p = 0.026), for scheduled meetings with parents having same problems (p = 0.006), for contact with hospital after discharge (p = 0.035), and for written information (p = 0.044). In terms of depression, a statistically significant association was observed with difficulties during the hospital stay (p = 0.034), whether they desired other family members to remain in hospital (p = 0.009), as well as with the need for opportunities or time for questions (p = 0.004), for scheduled meetings with parents having the same problems (p = 0.026), and for contact with hospital after discharge (p = 0.038).

CONCLUSION

Anxiety and depression were associated with possibility of family members to remain in the hospital as well as with the need for scheduled meetings with parents having the same problems and for contact after hospital discharge. Based on the findings presented, it is suggested that understanding parents' needs and perceptions is fundamental to the development of appropriate interventions that address their worries.

Matched cohort study of hospitalization in children who have siblings with cancer

BACKGROUND

Health outcomes of children in families affected by cancer are poorly understood. The authors assessed the risk of hospitalization in children who have a sibling with cancer.

METHODS

This was a longitudinal cohort study in which 1600 children who had a sibling with cancer were matched to 32,000 children who had unaffected siblings in Quebec, Canada, from 2006 to 2020. The exposure of interest was having a sibling with cancer. Outcomes included hospitalization for pneumonia, asthma, fracture, and other morbidities any time after the sibling was diagnosed with cancer. The children were followed over time, and Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the impact of having a sibling with cancer on the risk of hospitalization before age 14 years, adjusted for patient characteristics.

RESULTS

Children who had a sibling with cancer had an increased risk of hospitalization compared with unaffected children (HR, 1.15; 95% CI, 1.02-1.29). Conditions associated with a greater risk of hospitalization included pneumonia, hemangioma, other skin conditions, sleep apnea, and inflammatory bowel disease. The risk of hospitalization was greatest for children whose older sibling had cancer (HR, 1.16; 95% CI, 1.01-1.32) and for children whose sibling had hematopoietic cancer (HR, 1.22; 95% CI, 1.01-1.48).

CONCLUSIONS

Children who have a sibling with cancer are at risk of hospitalization for conditions such as pneumonia, inflammatory bowel disease, and other morbidities. Families affected by childhood cancer may benefit from additional support to facilitate care for all children in the family.

LAY SUMMARY

Little is known about the health of children who have a brother or sister with cancer. The authors studied the types of hospitalization experienced by children who have siblings with cancer. The results indicated that having a sibling with cancer increased the chance of being hospitalized for pneumonia and other conditions that could have been preventable. The results also indicated that children who had an older sibling with cancer or a sibling with blood cancer had a greater chance of being hospitalized. The findings highlight the importance of providing timely care for children in families affected by childhood cancer.

Audit of Psychosocial and Palliative Care Support for Children Having Allogeneic Stem Cell Transplants at the New Zealand National Allogeneic Transplant Centre

Psychosocial and palliative care support during stem cell transplants (SCT) is known to improve outcomes.

AIM

evaluate the support provided to children and families at the New Zealand National Allogeneic Stem Cell Transplant unit (NATC).

METHOD

the psychosocial and palliative care support for children who received SCT between December 2012 and April 2018 was audited.

RESULTS

of the 101 children who received SCT, 97% were reviewed by the social work team (SW) and 82% by the psychiatric consult liaison team (CLT) at least once during their illness. However, pre-transplant psychological assessment only occurred in 16%, and during the SCT admission, only 55% received SW support, and 67% received CLT support. Eight out of eighty-five families (9%) were offered support for siblings. Eight of the sixteen children who died were referred for pediatric palliative care (PPC) with all supported and half the families who experienced a death (n = 8; 50%) received bereavement follow up.

CONCLUSION

although the majority received some social work and psychological support, auditing against the standards suggests the consistency of involvement could be improved. Referrals for PPC were inadequate and largely for end-of-life phase. Sibling support, in particular donor siblings, had insufficient psychological assessment and support. Key recommendations are provided to address this underperformance.

Active Music Engagement and Cortisol as an Acute Stress Biomarker in Young Hematopoietic Stem Cell Transplant Patients and Caregivers: Results of a Single Case Design Pilot Study

This paper reports the results of a single case design pilot study of a music therapy intervention [the Active Music Engagement (AME)] for young children (age 3.51 to 4.53 years) undergoing hematopoietic stem cell transplantation (HCST) and their caregivers. The primary aims of the study were to determine feasibility/acceptability of the AME intervention protocol and data collection in the context of HCST. Secondary aims were to examine caregivers' perceptions of the benefit of AME and whether there were changes in child and caregiver cortisol levels relative to the AME intervention. Results indicated that the AME could be implemented in this context and that data could be collected, though the collection of salivary cortisol may constitute an additional burden for families. Nevertheless, data that were collected suggest that families derive benefit from the AME, which underscores the need for devising innovative methods to understand the neurophysiological impacts of the AME.

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.

Parental experiences in end-of-life decision-making in allogeneic pediatric stem cell transplantation: "Have I been a good parent?"

BACKGROUND

In pediatric hematopoietic stem cell transplantation (HSCT), the end-of-life (EOL) phase and the loss of the child is often characterized by a sudden deterioration of the child following a period of intensive curative treatment. This demands a fast transition for parents. Therefore, an understanding of the parents' perspective on decision-making in such a complex situation is needed. This study aims to gain insight in parental experiences in EOL decision-making in allogeneic pediatric HSCT.

METHODS

A qualitative descriptive study was performed among parents of eight families. Data were thematically analyzed.

RESULTS

All parents were aware of their child's deterioration. Six families were confronted with a rapid deterioration, while two families experienced a gradual realization that their child would not survive. Parental EOL decision-making in pediatric HSCT shows a reflective perspective on the meaning of parenthood in EOL decision-making. Two central themes were identified: "survival-oriented decision-making" and "struggling with doubts in hindsight." Six subthemes within the first theme described the parents' goal of doing everything to achieve survival.

DISCUSSION

Parents experienced EOL decision-making mainly as a process guided by health care professionals (HCPs) based on the child's condition and treatment possibilities. The decision-making is characterized by following opportunities and focusing on hope for cure. In hindsight parents experienced doubts about treatment steps and their child's suffering. HCPs can strengthen the parental role by an early integration of palliative care, providing timely support to parents in the process of imminent loss. Advance care planning can be used to support communication processes, defining preferences for future care.

Impact of Race and Socioeconomic Status on Psychologic Outcomes in Childhood Cancer Patients and Caregivers

Complex relationships between race and socioeconomic status have a poorly understood influence on psychologic outcomes in pediatric oncology. The Family Symptom Inventory was used to assess symptoms of depression and anxiety in pediatric patients with cancer and their caregivers. Separate hierarchical linear regression models examined the relationship between demographic variables, cancer characteristics, socioeconomic status, and access to care and patient or caregiver depression/anxiety. Participants included 196 pediatric patients with cancer (mean age, 11.21 y; 49% African American) and their caregivers. On average, caregivers reported low levels of depression/anxiety. Symptoms of depression and anxiety in patients were correlated with poorer mental health in caregivers (r=0.62; P<0.01). Self-reported financial difficulty (β=0.49; P<0.001) and brain cancer diagnosis for their child (β=0.42; P=0.008) were significantly associated with depression and anxiety in caregivers. Analysis did not reveal significant associations between race, household income, or access to care and patient or caregiver depression/anxiety. Perception of financial hardship can adversely impact mental health in caregivers of children with cancer. Psychosocial assessment and interventions may be especially important for caregivers of patients with brain tumors and caregivers who report feeling financial difficulty.

Predictors of parental distress during acute phase of pediatric hematopoietic stem cell transplantation in Japan: A multicenter prospective study

Objective

The purposes of this study were (1) to describe the levels of anxiety and depressive symptoms in parents of children undergoing hematopoietic stem cell transplantation (HSCT) before (Time 1 [T1]) and one month after transplantation (Time 2 [T2]), and (2) to identify the pre-HSCT factors that predict anxiety and depressive symptoms in fathers and mothers one month after transplantation.

Methods

A prospective quantitative study was conducted at four children's hospitals between June 2015 and September 2016 using self-administered questionnaires and medical records. Parents from 23 families, including 19 fathers and 23 mothers, completed the Hospital Anxiety and Depression Scale (cutoff score: 8) and provided information regarding their stress appraisal, coping strategies, family functioning, demographic characteristics, and children's health-related quality of life. Hierarchical multiple regression analysis was performed to identify the variables that predicted T2 paternal and maternal anxiety and depressive symptoms.

Results

Among the parents, 15 fathers (79%) and 11 mothers (48%) reported anxiety symptoms, and 13 fathers (68%) and 9 mothers (39%) reported depressive symptoms above the cutoff level for clinical relevance at T1. Similarly, 11 fathers (58%) and 6 mothers (26%) reported anxiety symptoms, and 10 fathers (53%) and 9 mothers (39%) reported depressive symptoms above the cutoff level at T2. Overall, parents' anxiety and depressive symptoms did not differ significantly between T1 and T2. For fathers, both T1 depressive symptoms and the understanding of their children's medical situation through communication with other parents and consultation with medical staff predicted T2 paternal depressive symptoms. For mothers, T1 maternal anxiety symptoms and marital satisfaction predicted T2 anxiety symptoms.

Conclusions

The medical staff should understand that parents of children undergoing HSCT experience considerable psychological distress throughout the treatment process, and therefore, they should adopt unique approaches to reduce such distress.

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.

Post-traumatic stress disorder and health-related quality of life in the siblings of the pediatric bone marrow transplantation survivors and post-traumatic stress disorder in their mothers

Although BMT is lifesaving in many childhood diseases, it was found to be related to anxiety, depression, and PTSD in parents, and PTSD, anxiety and overall low self-esteem in siblings. Research on siblings' HRQoL is limited. The aim of this study was to investigate PTSD and HRQoL in siblings (donor and non-donor) of pediatric BMT survivors and PTSD in their mothers, compared to the healthy controls. Thirty-five siblings and their mothers and 35 healthy peers and their mothers were recruited as the study group and as the comparison group, respectively. In children, Child PTSD-Reaction Index for PTSD and PedsQL for HRQoL were used. PTSD Checklist-Civilian Version was used for PTSD in mothers. The study group, both children and mothers, obtained significantly higher PTSD rates than the control group. Children in the study group also reported significantly poorer HRQoL than the control group in all scales. As a novel finding, there was a significant negative correlation between siblings' and mothers' PTSD scores and siblings' PedsQL scores, indicating that PTSD symptoms in siblings and mothers significantly led to impairment in siblings' HRQoL or vice versa. Thus, the identification and treatment of siblings and mothers with PTSD seems imperative.

National Institutes of Health Hematopoietic Cell Transplantation Late Effects Initiative: The Patient-Centered Outcomes Working Group Report

In 2015, the National Institutes of Health convened six working groups to address the research needs and best practices for late effects of hematopoietic stem cell transplantation survivors. The Patient-Centered Outcomes Working Group, charged with summarizing the HRQOL evidence base, used a scoping review approach to efficiently survey the large body of literature in adult and pediatric HCT survivors over 1 year after transplantation. The goals of this paper are to (1) summarize the current literature describing patient-centered outcomes in survivors, including the various dimensions of health-related quality of life affected by HCT, and describe interventions tested to improve these outcomes; (2) highlight areas with sufficient evidence allowing for integration into standard practice; (3) address methodological issues that restrict progress in this field; (4) identify major gaps to guide future research; and (5) specify priority research recommendations. Patient-centered outcomes were summarized within physical, psychological, social, and environmental domains, as well as for adherence to treatment, and health behaviors. Interventions to improve outcomes were evaluated for evidence of efficacy, although few interventions have been tested in long-term HCT survivors. Methodologic issues defined included lack of consistency in the selection of patient-centered outcome measures, along with the absence of a standard for timing, frequency, and mode of administration. Recommendations for HCT survivorship care included integration of annual screening of patient-centered outcomes, use of evidence-based practice guidelines, and provision of treatment summaries and survivorship care plans after HCT. Three priority research recommendations included the following: (1) design and test risk-targeted interventions with dose-intensity modulation matching the needs of HCT survivors with priority domains, including sexual dysfunction, fatigue, sleep disruption, nonadherence to medications and recommended health care, health behaviors including physical inactivity and healthy eating, and psychological dysfunction, with particular consideration of novel technologies to reach HCT survivors distant from their transplantation centers; (2) design a consensus-based methodologic framework for outcomes evaluation; and (3) evaluate and compare existing practices for integrating patient-centered outcome screening and interventions across HCT survivorship programs.

Effectiveness of a relaxation intervention (progressive muscle relaxation and guided imagery techniques) to reduce anxiety and improve mood of parents of hospitalized children with malignancies: A randomized controlled trial in Republic of Cyprus and Greece

PURPOSE

To explore the effect of Progressive Muscle Relaxation (PMR) and Guided Imagery (GI),in reducing anxiety levels among parents of children diagnosed with any type of malignancy receiving active treatment at a Paediatric Oncology Unit in Republic of Cyprus and in Greece.

METHOD

A randomized non-blinded control trial was conducted between April 2012 to October 2013, at two public paediatric hospitals. Fifty four eligible parents of children hospitalized with a malignancy were randomly assigned to the intervention (PMR and GI) (n = 29) and a control group (n = 25). The study evaluated the changes in anxiety levels(HAM-A) and mood changes(POMSb).

RESULTS

There was a statistically significant difference in the mean scores of the subjects in the intervention group in HAM-A scale between the T0 (14.67 ± 9.93) and T1 (11.70 ± 8.15) measurements (p = 0.008) compared to the control group in which a borderline difference (16.00 ± 11.52 vs 13.33 ± 8.38) was found (p = 0.066). The effect size for the intervention group was low to moderate (0.37). Regarding mood changes, there was a statistically significant difference in tension for parents in the intervention group between T0 and T1 (11.15 ± 5.39 vs 9.78 ± 4.26), (p = 0.027). Furthermore, the parents in the intervention group were significantly less sad following the intervention (T1) (2.81 ± 1.07 vs 2.19 ± 1.21), (p = 0.001), and felt significantly less tense (2.93 ± 0.91 vs 2.26 ± 0.90), (p = 0.001) and anxiety (2.63 ± 1.21 vs 2.19 ± 1.07), (p = 0.031) compared to those in the control group.

CONCLUSIONS

These findings provided evidence on the positive effect of the combination of PMR and GI in reducing anxiety and improving mood states in parents of children with malignancy.

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.

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.

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.

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.

Children's lived experiences of hematopoietic stem cell transplantation

Although hematopoietic stem cell transplantation is a valuable treatment in many life-threatening pediatric disorders, a large number of children who receive hematopoietic stem cell transplantation are faced with a variety of physical and psychological problems throughout this process. In this study, we explored the lived experiences of these children during their treatment to provide a better understanding of their main concerns, emotions, and expectations. The participants were six children, aged between 6 and 17 years, who underwent hematopoietic stem cell transplantation. Data were collected through individual, in-depth, and semistructured interviews. Using interpretive phenomenological analysis, the findings revealed that the children experienced "transplantation rejoicing" in this "difficult passage", which was associated with "deepening of family ties". Awareness of these experiences, feelings, and concerns can help in the development of more professional interventions to provide children with holistic care during their hospitalization.

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 emotional functioning declines with occurrence of clinical complications in pediatric hematopoietic stem cell transplant

PURPOSE

Parents' stress levels are high prior to their child's hematopoietic stem cell transplant (HSCT) and during transplant hospitalization, usually abating after discharge. Nevertheless, a subgroup of parents continues to experience frequent anxiety and mood disruption, the causes of which are not well understood. The purpose of this study was to assess whether clinical complications of HSCT could explain variation in parents' recovery of emotional functioning.

METHODS

Pediatric HSCT recipients (n = 165) aged 5-18 and their parents were followed over the first year post-transplant. Health-related quality of life assessments and medical chart reviews were performed at each time period (baseline, 45 days, 3, 6, and 12 months). We tested the association between clinical complications [acute and chronic graft versus host disease (aGVHD and cGVHD), organ toxicity, and infection] and longitudinally measured parental emotional functioning, as assessed by the Child Health-Ratings Inventories. The models used maximum likelihood estimation with repeated measures.

RESULTS

In adjusted analyses covering the early time period (45 days and 3 months), aGVHD grade ≥2, intermediate or poor organ toxicity, and systemic infection were associated with decreases in mean parental emotional functioning of 5.2 (p = 0.086), 5.8 (p = 0.052), and 5.1 (p = 0.023) points, respectively. In the later time period (6 and 12 months), systemic infection was associated with a decrease of 20 points (p < 0.0001). cGVHD was not significantly associated.

CONCLUSIONS

When children experience clinical complications after HSCT, parental emotional functioning can be impacted. Intervening at critical junctures could mitigate potential negative consequences for parents and their children.

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.

Differences in mothers' and fathers' health-related quality of life after pediatric SCT: a longitudinal study

The purpose of this study was to examine longitudinally health-related quality of life (HRQOL) and related factors in mothers and fathers of children who undergo SCT, before, and 1 and 2 years after SCT. A total of 84 parents (49 mothers/35 fathers) of patients diagnosed mainly with leukemia completed a HRQOL measure before SCT, 46 at 1 year (26 mothers/20 fathers) and 50 parents (31 mothers/19 fathers) at 2 years post SCT. Physical and psychosocial HRQOL summary scores are reported. Parents' age and gender, child's diagnosis, radiation history, age, behavior and physical health were examined. Linear mixed models for repeated measures with a covariate structure were used for analysis. Physical HRQOL did not differ between mothers and fathers or over time. Maternal and paternal psychosocial HRQOL scores improved by 2 years post SCT. Child's behavior problems and poor health, and maternal age (younger) predicted poor maternal psychosocial HRQOL 2 years post SCT. Child's behavior problems, diagnosis and treatment severity predicted poor paternal psychosocial HRQOL. These findings identify similar (child's poor behavior) and differential risk factors (parental young age, disease and treatment severity, and child's poor health status) for poor HRQOL for mothers and fathers. These findings can guide comprehensive family-care interventions before, during and after pediatric SCT.

Health-related quality of life after completion of successful treatment for childhood cancer

BACKGROUND

Previous studies have assessed health-related quality of life (HRQOL) during several treatment stages in children with cancer, but there is limited knowledge about HRQOL shortly after completing therapy. This study determined HRQOL of children with cancer shortly after the end of successful treatment compared with normative values.

PROCEDURE

Several age-specific HRQOL questionnaires were administered: the ITQOL (generic, proxy-report, 0-4 years), CHQ PF 50 (generic, proxy-report, 5-7 years), Kidscreen (generic, self-report, 8-18 years) and Disabkids (chronic generic, self-report, 8-18 years).

RESULTS

Children with cancer (N = 191, mean age 9.25, SD 5.06, 47.1% female) participated. Physical well-being was affected for all ages. Compared to normative values 0- to 7-year-olds were rated significantly lower on the majority of the scales. In addition, 12- to 18-year-olds had significantly better HRQOL than the norm on social scales. Compared to chronically ill norms, 8- to 18-year-olds demonstrated no differences, except for 12- to 18-year-olds who experienced significantly more physical limitations. Additionally, we found that HRQOL of parents of 0- to 7-year-olds was poorer than the norm.

CONCLUSION

HRQOL in children with cancer and their parents can be impaired compared with the norm. Therefore, HRQOL should be monitored in clinical practice to make paediatric oncologists aware of these problems. For young children, we recommend checking whether certain HRQOL problems can be explained by parental worries. For older children and adolescents, paediatric oncologists need to consider social desirability and the child's adaptive style.

An analysis of parental roles during haematopoietic stem cell transplantation of their offspring: a qualitative and participant observational study

AIM

The aim of this study was to investigate the parents' experiences and reflections on their parental role while taking care of their child.

BACKGROUND

Parents of children undergoing treatment with allogeneic haematopoetic stem cell transplantation for life threatening diseases in protective isolation, experience distress related to the child's care. Parents struggle to cope with the stress related to the child's disease, treatment and survival possibilities.

METHODS

During the period 2007-2009, eight participant studies and 16 in-depth interviews were performed and analysed using a theoretical ideal type construction and an interactionistic approach.

RESULTS

Three ideal types of approaches were identified (1) expertise-mindedness, (2) dialogue-mindedness and (3) the approach of the socially challenged parents. Expertise-minded parents base their rationality for care and interactions on medical knowledge. It is important for dialogue-minded parents that emotions are included in the rationality for care. Being able to manage these two approaches requires emotional work in the form of both surface- and deep acting from the parents. Socially challenged parents fail to adapt to either of the two approaches since they often fail to manage the required emotional work.

CONCLUSION

The three described ideal types give a new perspective on the complex interactions that occur between parents, child and staff during treatment with haematopoetic stem cell transplantation. Understanding the rationality behind the different approaches adopted by parents may assist medical staff to understand the parents' rationality for care of their child and to identify socially challenged parents who need help in managing the care of their child.

Hematopoietic stem cell transplantation in children with cancer and the risk of long-term psychological morbidity in the bereaved parents

We have investigated whether hematopoietic stem cell transplantation (HSCT) before the death of children with cancer has a long-term effect on the physical and psychological well-being of the parents. A nationwide questionnaire was sent out to all bereaved parents in Sweden who had lost a child due to a malignancy from 1992 to 1997. Self-reported levels of anxiety, depression and quality of life as well as overall psychological and physical well-being in bereaved parents of children who underwent HSCT were compared with bereaved parents whose children did not receive a transplant. Bereaved parents whose children underwent HSCT had, according to a visual digital scale, an increased relative risk (RR) of long-term anxiety (RR 1.5; 95% confidence interval (CI) 1.0-2.1), poor psychological well-being (RR1.3; 95% CI 1.1-1.5), low quality of life (RR 1.4; 95% CI 1.2-1.7) and poor physical health (RR 1.3; 95% CI 1.1-1.5), whereas the State-Trait Anxiety Inventory and 'The Göteborg Quality of Life Instrument' were non-significantly increased (RR 1.3; 95% CI 0.8-2.3 and RR 1.7; 95% CI 0.9-3.3, respectively). The risks of these consequences were further augmented in case of multiple HSCT. We suggest that bereaved parents of children undergoing HSCT may be at greater risk of decreased psychological well-being than other bereaved parents of children with cancer.