Psychiatric aspects of pediatric cancer

Association of Chemotherapy Regimen Intensity and Use of Psychotropic Medications in Pediatric Oncology Patients

OBJECTIVE

Pediatric oncology patients endure treatments that may include chemotherapy, surgery, radiation, and transplant. These treatment modalities often have an effect on a patient's mental health. To date, little is known or published about the association between certain cancer treatment regimens and the use of psychotropic medications. The goal of this study is to identify associations between the use of psychotropic medications in pediatric oncology patients in relation to the intensity of their oncologic treatment regimen.

METHODS

A retrospective chart review was completed for pediatric oncology patients seen between the years of 2009 and 2019 with prescriptions and/or inpatient orders for specific psychotropic medications. The intensity of the oncologic regimen was categorized using the Intensity of Treatment Rating Scale (ITR-3) tool. Association between the intensity of therapy and use of psychotropic medications were compared using Pearson χ2 and Fisher exact tests as appropriate.

RESULTS

There were 172 patients identified as having inpatient and/or outpatient orders for psychotropic medications during the study period. Ninety-one pediatric oncology patients were included in data analysis. It was found that psychotropic medications were used consistently in pediatric oncology patients despite a specific ITR-3 score. There were no statistically significant associations found when comparing ITR-3 scores to psychotropic medication use or to age at diagnosis.

CONCLUSIONS

Significance was not obtained in this study; however, we found that psychotropic medications were used across the spectrum of diagnoses, age, and oncologic treatment intensity. This suggests that all pediatric oncology patients should be evaluated for psychiatric needs throughout their course of oncologic treatment.

Psychopharmacology in the Pediatric Oncology and Bone Marrow Transplant Units: Antidepressant Treatment

Objectives: The aim of this study was to characterize the clinical profiles, tolerability, and efficacy of two groups of antidepressants, selective serotonin reuptake inhibitors (SSRIs), and the atypical antidepressant, mirtazapine, in children and adolescents treated in a large pediatric Hematology-Oncology center. Methods: A review of computerized medical charts of 32 pediatric patients with cancer, from December 2011 to April 2020, was conducted. Efficacy and tolerability of antidepressant medications were retrospectively analyzed. The Clinical Global Impressions-Severity (CGI-S) and Clinical Global Impressions-Improvement (CGI-I) Scales were used to evaluate psychiatric symptoms severity before and following treatment, while the data on adverse events and drug-drug interactions were retrieved from the computerized medical records. Results: Thirty-two children and adolescents with cancer, 2-21 years of age (mean 14.1 ± 4.6 years), were treated with antidepressants. Fourteen patients (44%) received mirtazapine, whereas 18 patients (56%) received SSRIs: sertraline (25%), escitalopram (25%), or fluoxetine (6%). Treatment choice was dictated either by physician preference or informed by potential drug-drug interactions. The most common psychiatric diagnoses were major depressive disorders (47%), anxiety disorders (19%), and medication-induced psychiatric disorders (19%). The most common psychiatric-medical symptoms were depressed mood (94%) and anxiety (62%). CGI-S improved significantly (p < 0.05) between pretreatment and on-treatment assessments, with no statistically significant difference between SSRI and mirtazapine-treated patients. CGI-I scores at reassessment indicated improvement in most patients (84%). Adverse events of treatment were mild in all patients. Conclusions: The antidepressants used in this study, SSRIs and mirtazapine, were effective and well tolerated in children and adolescents with cancer and psychiatric comorbidities. Given the high rates of depression and anxiety in children with cancer, large-scale, multisite, prospective clinical trials of antidepressants are warranted.

Effects of Drawing Therapy on Pediatric Oncology Patients: A Systematic Review

BACKGROUND

A small but significant number of children and adolescents with cancer experience severe physical and psychological distress. Previous studies have shown that drawing therapy positively affects relieving psychological problems. However, the effect of drawing therapy on pediatric oncology patients has not been established by systematic review.

OBJECTIVE

The aim of this study was to determine the effect of drawing therapy on the pediatric oncology population.

METHODS

PubMed, EMBASE, MEDLINE, Cochrane, PsycINFO, CINAHL, and Chinese databases including CNKI, Wanfang, VIP, and CBM were searched. Studies published in the English and Chinese languages up to December 2019 were screened, and randomized controlled trials and nonrandomized experimental studies of drawing therapy interventions for pediatric oncology patients were reviewed. Screening was undertaken independently by 2 reviewers. The review protocol was registered with PROSPERO (registration number: CRD42020178365).

RESULTS

Eight studies were included. Three studies were randomized controlled trials, and 5 studies were nonrandomized experimental studies. Seven studies showed that drawing therapy had positive effects on reducing depression and anxiety and improving quality of life. However, 1 study showed a contradictory result, that is, participants had an increased anxiety level after intervention.

CONCLUSIONS

Drawing therapy is effective in improving negative emotions, relieving somatic symptoms, and increasing social communication for pediatric oncology patients.

IMPLICATIONS FOR PRACTICE

Drawing therapy may be considered an adjuvant psychological intervention strategy for pediatric oncology patients. Meanwhile, more rigorous studies are needed to address the deficiencies of small number size and methodological weakness.

Towards objective and reproducible study of patient-doctor interaction: Automatic text analysis based VR-CoDES annotation of consultation transcripts

While increasingly appreciated for its importance, the interaction between health care professionals (HCP) and patients is notoriously difficult to study, with both methodological and practical challenges. The former has been addressed by the so-called Verona coding definitions of emotional sequences (VR-CoDES) - a system for identifying and coding patient emotions and the corresponding HCP responses - shown to be reliable and informative in a number of independent studies in different health care delivery contexts. In the preset work we focus on the practical challenge of the scalability of this coding system, namely on making it easily usable more widely and on applying it on larger patient cohorts. In particular, VR-CoDES is inherently complex and training is required to ensure consistent annotation of audio recordings or textual transcripts of consultations. Following up on our previous pilot investigation, in the the present paper we describe the first automatic, computer based algorithm capable of providing coarse level coding of textual transcripts. We investigate different representations of patient utterances and classification methodologies, and label each utterance as either containing an explicit expression of emotional distress (a `concern'), an implicit one (a `cue'), or neither. Using a data corpus comprising 200 consultations between radiotherapists and adult female breast cancer patients we demonstrate excellent labelling performance.

Mind-Body Therapies in Childhood Cancer

PURPOSE OF REVIEW

Advances in the field of Pediatric Oncology have led to increased survival rates in children with cancer, and addressing the emotional well-being and quality of life of this specific population is a critical component of care. Mind-body therapies (MBTs) are an adjuvant modality of treatment that appears to have a positive impact on patient quality of life, patient mental health, and family perceptions toward illness. In this review, we describe several evidence-based MBTs, such as art therapy, meditation, prayer, music therapy, hypnosis and relaxation techniques, their use, and our personal experience with MBT in our institution.

RECENT FINDINGS

Current data suggests that MBTs have been effective in decreasing symptoms related to oncologic pathology in children. Based on experience in our institution, the administration of these therapies can be expanded with the use of technology and also foster family inclusion in care, which can lead to improved quality of life for the patient and family. Further studies are warranted to ascertain the effects of MBTs in childhood cancer. MBTs are increasingly important in the care of youth with oncologic disease. It is necessary to increase the quantity and quality of research for the selection and inclusion of MBT in this population.

Promotion of Well-being During Treatment for Childhood Cancer: A Literature Review of Art Interventions as a Coping Strategy

BACKGROUND

Scientific literature suggests that art interventions can assist children with cancer cope with physical and psychosocial difficulties associated with cancer treatment. Little is known about how the making of tangible visual art can be helpful and which proposed therapeutic mechanisms are clinically important.

OBJECTIVE

The purpose of this literature review is to assess and synthesize the research evidence regarding the role of art therapy/art-making interventions for promoting the well-being of children with cancer undergoing treatment.

METHODS

A search of electronic databases (MEDLINE [PubMed], CINAHL, PsycINFO) and EBM Reviews including Cochrane Database of Systematic Reviews (OVID) and manual review of references in articles accessed were undertaken. Inclusion criteria were as follows: research studies of any design; children with cancer undergoing treatment (2-21 years old), and art therapy/art-making intervention. Data extraction and quality appraisal were undertaken. Data were analyzed with an author-developed review sheet and synthesized into a table.

RESULTS

Six articles reporting 6 studies met the inclusion criteria. Studies were based on qualitative (n = 3) and mixed quantitative/qualitative (n = 3) methodologies. Three outcome categories emerged that outline potential therapeutic roles of art interventions.

CONCLUSIONS

Though sparse and developmental in nature, the existing evidence suggests that art interventions may potentially promote the well-being of children undergoing cancer treatment by reducing anxiety, fear, and pain and promoting collaborative behaviors; enhancing communication with the treatment team; and counteracting the disruption of selfhood that cancer treatment evokes.

IMPLICATIONS FOR PRACTICE

Further and higher-quality research is warranted before routinely integrating standardized art interventions into the treatment protocols for children with cancer.

Psychiatric disorders in 130 survivors of childhood cancer: preliminary results of a semi-standardized interview

BACKGROUND

Although psychological sequelae are well known among survivors of childhood cancer, psychiatric sequelae remain inadequately explored. Long-term psychiatric sequelae and their main risk factors in this population were evaluated.

PROCEDURE

Initially, 483 survivors of childhood cancer, except leukemia, were invited to complete a questionnaire assessing their health and quality of life. Of them, 130 completed the survey, subsequently consulted with a pediatric oncologist and an internist, and met with a psychologist for a semi-standardized interview based on the Mini International Neuropsychiatric Interview (MINI), which allowed diagnosis of DSM-IV Axis 1 psychiatric disorders. The collected data were compared with those of the French general population.

RESULTS

Seventy-three of the 130 survivors (56.2%) who completed the MINI interview reported experiencing at least one psychiatric disorder since cancer diagnosis, mostly anxiety (39.2%), mood (27.7%), or major depressive (24.6%) disorders; 46 reported at least one current disorder (35.4%). Agoraphobia (P = 0.02) and psychotic disorders were more common (P = 0.003) and general anxiety disorder less common (P < 0.001) among survivors than the general population. Most disorders correlated significantly with survivors' ratings of lower quality of life. Smoking, cancer type, and treatments significantly influenced the prevalence of psychiatric disorders.

CONCLUSIONS

Results were consistent between the self-questionnaire and MINI interview responses, though time may have biased memory. Vulnerability to and high risk for developing DSM-IV Axis 1 psychiatric disorders of childhood cancer survivors can persist long after diagnosis and treatment. Thus, systematic and general psychological screening of survivors may facilitate long-term psychological restoration.

Treatment of Anxiety and Depression in Adolescents and Young Adults With Cancer

Adolescents and young adults (AYAs) with cancer are a unique population of patients who experience a period of intense and dramatic life changes when they are diagnosed. Overall, AYAs with cancer are resilient; however, their psychosocial needs are often underestimated or unmet. Currently, there are inconsistencies in how AYAs are screened and treated for anxiety and depression. Barriers to treatment include clinicians’ lack of confidence in distinguishing between side effects of treatment and depression/anxiety. Additional barriers include the black box warning for prescribing antidepressants and difficulty partnering with mental health professionals. This article seeks to provide recommendations for pediatric oncology clinicians on how to identify and address anxiety and depression in AYAs and how to partner with mental health professionals in their treatment, and it suggests directions for future research.

Psychosocial distress and functioning of Greek youth with cystic fibrosis: a cross-sectional study

Background

To assess psychosocial functioning and distress of children and adolescents with cystic fibrosis compared to healthy controls.

Methods

Thirty-six patients with cystic fibrosis aged 8–18 years (24 boys, mean age ± SD: 11.5 ± 2.6 years) and 31 sex- and age-matched healthy control subjects (18 boys, mean age ± SD: 12 ± 2.5 years) were enrolled in the study. In order to assess the self-esteem, social adjustment, and family functioning of these young people, the Culture-free Self-esteem Inventory, the Social Adjustment Scale–Self-Report, and the Family Assessment Device were administered. Emotional/ behavioral problems were assessed through the Youth Self Report and the Child Behavior Checklist given to both the subjects and their parents.

Results

No significant differences were found for self-esteem between the two study groups. Regarding social adjustment, children with cystic fibrosis reported significantly worse friendship and overall adjustment (P < 0.05). Moreover, no difference was found in the levels of family functioning between the two groups. No significant differences between the groups were found in emotional/ behavioral problems from the self-reports. On the contrary, parents of children with cystic fibrosis reported significantly higher levels of withdrawal/ depression, thought problems, and delinquent behavior (P ≤ 0.01) as compared to controls.

Conclusions

Children and adolescents with cystic fibrosis appear to be a psychosocially vulnerable group. A biopsychosocial approach should emphasize the assessment and treatment of the psychosocial distress of these patients alongside multiple somatic treatments.

Understanding the perceptions of children battling cancer about self and others through drawing

Background:

Childhood cancer is a stressful experience and may cause a change in the child's perception of himself/ herself, the family and the world around him/ her.

Aims:

This study sought to (a) explore the self-perception of children; and (b) examine the relation of children with others.

Materials and Methods:

The total population of the study consisted of all the children, undergoing cancer treatment at Children Cancer Hospital, located in Karachi. The participants were asked to draw a drawing on self and others. Through qualitative approach (phenomenology), themes and sub-themes were derived.

Results:

Using purposive sampling, the total sample size drawn for this study was 78 children aged 7-12, receiving treatment for cancer (1st stage) at the Children Cancer Hospital, Karachi, Pakistan. The drawings of the children were categorized into facial expressions, self images and family ties. Within each category, there were sub-categories. Under facial expressions, the common emotions reflected were sadness, seriousness, anger; and pain. The self-image pictures uniformly reflected low self-esteem, especially focusing on hair loss, missing body parts. Under the category of family ties, most of the children's drawings reflected their isolation or emotional detachment from or abandonment by their family members.

Conclusions:

The study concludes that the self- image of most of the participants is deteriorated and they are socially isolated. Social and moral support can bring positive emotional development and helps to correct their self-perception.

Predictive factors of internalized and externalized behavioral problems in children treated for acute lymphoblastic leukemia

BACKGROUND

Pediatric cancer survivors are at increased risk of various neurological and psychological problems. The prevalence of behavioral problems was assessed in a longitudinal study in pediatric patients with an acute lymphoblastic leukemia (ALL). Multilevel modeling was used to identify associated predictive factors.

PROCEDURE

ALL patients and their parents (n = 138) took part to this study. Patients were treated according to the Dana-Farber Cancer Institute (DFCI) consortium protocols 91-01 or 95-01. Mothers filled out questionnaires providing a measure of behavioral problems for their child at diagnosis and during the subsequent 4 years, and of their perceived familial stress at diagnosis and post-induction.

RESULTS

Prevalence of internalized behavioral problems at diagnosis was increased [42% above 1 standard deviation (SD); P < 0.001], but it normalized over time. Internalized problems resolved more slowly in the presence of medical variables associated with increased stress related to the disease (hospitalization duration, P < 0.001; relapse risk at diagnosis, P < 0.001). Externalized behavioral problems were within the expected normal range, but more sustained over time with the 95-01 than with the 91-01 treatment protocols (P < 0.05), likely due to the type of corticosteroid (CS) used (dexamethasone vs. prednisone).

CONCLUSIONS

Assessment of both internalized and externalized problems is required in this population. The impact of pharmacological variables on externalized behavioral problems is likely related to CS use.

Application of the verona coding definitions of emotional sequences (VR-CoDES) on a pediatric data set

OBJECTIVE

Adult patients present concerns as defined in the Verona Coding Definitions of Emotional Sequences (VR-CoDES), but we do not know how children express their concerns during medical consultations. This study aimed to evaluate the applicability of VR-CoDES to pediatric oncology consultations.

METHODS

Twenty-eight pediatric consultations were coded with the Verona Coding Definitions of Emotional Sequences (VR-CoDES), and the material was also qualitatively analyzed for descriptive purposes. Five consultations were randomly selected for reliability testing and descriptive statistics were computed.

RESULTS

Perfect inter-rater reliability for concerns and moderate reliability for cues were obtained. Cues and/or concerns were present in over half of the consultations. Cues were more frequent than concerns, with the majority of cues being verbal hints to hidden concerns or non-verbal cues. Intensity of expressions, limitations in vocabulary, commonality of statements, and complexity of the setting complicated the use of VR-CoDES. Child-specific cues; use of the imperative, cues about past experiences, and use of onomatopoeia were observed.

CONCLUSION

Children with cancer express concerns during medical consultations. VR-CoDES is a reliable tool for coding concerns in pediatric data sets.

PRACTICE IMPLICATIONS

For future applications in pediatric settings an appendix should be developed to incorporate the child-specific traits.

Tumor locus moderates anxiety symptoms in a pediatric neuro-oncologic sample

Despite the prevalence of pediatric Central Nervous System (CNS) solid tumors, little is understood about patients' disease-related anxiety experience. Data from 25 remitted pediatric CNS tumor patients posttreatment were collected. Significant symptoms of anxiety were reported by 32% of patients. MRI studies showed all anxious patients had right cortical tumors or left cerebellar tumors. Confound analyses suggest these results are not better accounted for by demographic, disease, or treatment variables. These results evidence the risk some pediatric neuro-oncologic patients face for developing significant anxiety symptoms.

Challenge by choice: adventure-based counseling for seriously ill adolescents

Adventure-based programming, a component of adventure therapy, is an intentional practice used in summer camps, community-based youth agencies, and other organizations to promote inter- and intrapersonal growth and change. This programming has gained popularity in addressing personal growth, as well as specific problems, including substance abuse, juvenile delinquency, and other life challenges. Adventure-based programming addresses the developmental needs of seriously ill adolescents on several levels. This article describes adventure-based programming in the context of its effectiveness and utility in a summer camp program for children who have life-threatening illnesses.

A process to facilitate decision making in pediatric stem cell transplantation: the individualized care planning and coordination model

Providers of care for children undergoing stem cell transplantation (SCT) skillfully combine the roles of scientist and clinician. As scientists, they apply scientific methods and disease theory in the creation and testing of new therapies and in the careful observation and exploration of treatment outcomes. As clinicians, they are capable of intuitively delivering care in a patient- and family-centered context of meaning and life values. The specialty of SCT has inherent aspects that make treatment decision making complex and potentially contentious. Having a strategy ready to implement in advance or at the time when treatment decisions need to be made will facilitate and enhance the decision making process for both the health care team and family members. Here we introduce the individualized care planning and coordination (ICPC) model as a practical approach to facilitate ethical and effective decision making in pediatric SCT settings. The ICPC is a 3-step model comprising (1) relationship--understanding the illness experience from the perspective of the patient and family, sharing relevant information, and assessing ongoing needs; (2) negotiation--prognosticating, establishing goals of care, and discussing treatment options; and (3) plan--generating a comprehensive plan of care that includes life and medical plans. Based on a foundation of a care of competence, empathy, compassion, communication, and quality, the ICPC model aims to diminish contentious family-staff interactions that can lead to mistrust and help guide treatment decision making. The ICPC model enhances communication among patients, families, and clinicians by revealing patient and family values and medical and quality-of-life priorities before reaching or even during critical decision points in the transplantation process.

Prescribing practices of selective serotonin reuptake inhibitors (SSRIs) among pediatric oncologists: a single institution experience

Although children and adolescents with cancer often experience symptoms of anxiety and depression, there are no published data regarding the use of selective serotonin reuptake inhibitors (SSRIs) for treating depression in the pediatric oncology population. The goal of this study was to characterize SSRI prescribing practices among pediatric oncologists. A brief (14 item) written survey was distributed to all attending and fellow physicians at a large center with an 85% response rate (N = 40). Half of the respondents prescribed SSRIs for patients, and the most common triggers for prescription include oncologist perceptions of the patient's general sadness, major depressive disorder, and anxiety. The majority of oncologists in the sample (70%) used more than one SSRI. Most physicians prescribe during the first year of therapy and 50% feel that their practice will be influenced by the Federal Drug Administration (FDA) warnings governing the use of SSRIs in the pediatric population. Some physicians consult hospital psychologists, while fewer consult psychiatrists prior to prescribing for these patients. The information gathered from this survey demonstrates that pediatric oncologists are prescribing SSRIs for their patients for a variety of indications. Prospective clinical trials that involve screening patients for depression and anxiety prior to and following SSRI therapy may be helpful in determining whether they result in amelioration of symptoms. It would also be important to evaluate the benefits of a concurrent psychological intervention with medication.

The prevalence and use of antidepressant medication in pediatric cancer patients

BACKGROUND

During the period of cancer diagnosis and active treatment, several small case series have revealed high rates of psychiatric difficulty in pediatric patients. However, due to the methodological limitations in these studies, it remains impossible to determine accurately the true prevalence of mood disorders in pediatric cancer patients receiving cancer treatment. To date, no study has reported rates of antidepressant treatment in this population.

OBJECTIVES

The aims of this study were: (1) To determine the prevalence of the use of antidepressant medication (ADM) in children with cancer; (2) to identify a group of children being treated for cancer, that are likely to receive ADM, and who therefore may be eligible for a prospective observational or interventional clinical trial of depression during cancer therapy.

METHODS

We reviewed the medical records of 224 pediatric patients suspected for cancer in 2003 at the Children's Medical Center of Dallas. Of these, 6 proved non-oncologic and 2 were lost to follow up, leaving 216 charts for review.

RESULTS

Within 1 year of diagnosis, 29 patients (13%) had received a psychiatric consultation. Twenty-two patients (10.2%) received ADM within 1 year of cancer diagnosis. Children >/= 12 years, children with acute lymphoblastic leukemia, and children receiving radiotherapy or opiate analgesics were more likely to receive ADM by multivariate analysis. Race, sex, bone marrow transplant, and surgery were not significantly associated with ADM use.

CONCLUSIONS

The prevalence of ADM use in pediatric cancer patients (10.2%) was higher than the reported rates of depression (4-8%) and ADM treatment (1%) in the general pediatric population. Teenagers and those who received opiate analgesic medications during their cancer therapy represent a subgroup of children in whom further study of depression and cancer therapy may be valuable.

The adolescent with a chronic illness

The primary care clinician can play an important role in enhancing the quality of life for the adolescent with chronic illness through developmentally appropriate, individualized and compassionate coordination of care (Sidebar 2). Special attention to the process of adolescence, family, and psychological issues are required for successful management. Transition of care to adult services should be planned carefully with a multidisciplinary team.

Depression in paediatric cancer: an overview

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