Aggression, antisocial behavior, and substance abuse in survivors of pediatric cancer: possible protective effects of cancer and its treatment

Modifiable Lifestyle Risk Factors in Adult Survivors of Childhood Cancer: A Nationally Representative Study

OBJECTIVE

Given the vulnerable health condition of adult childhood cancer survivors, it is essential that they develop positive health behaviors to minimize controllable health risks. Therefore, we evaluated if adult survivors of non-childhood cancer and childhood cancer differ in the odds of each modifiable risk factor compared with each other and compared with the general population.

METHODS

This nationally representative study leveraged the National Health Interview Survey (NHIS) sample from 2000 to 2018 and the Behavioral Risk Factor Surveillance System (BRFSS) sample from 2016 to 2021. Our study population included adults diagnosed with cancer when they were ≤14 years of age. Outcomes included physical activity, body mass index (BMI), current smoking, ever-smoking, alcohol use, and binge drinking.

RESULTS

Insufficient physical activity was not statistically significant in the BRFSS, but in the NHIS, childhood cancer survivors had significantly more insufficient physical activity compared with non-childhood cancer survivors (aOR 1.29, P=0.038) and the general population (aOR 1.40, P=0.006). Childhood cancer survivors also had a higher likelihood of being significantly underweight (aOR 1.84, P=0.018) and having ever-smoked (aOR 1.42, P=0.001) compared with the general population in the NHIS. There was a significantly higher likelihood of smoking among childhood cancer survivors in the BRFSS (aOR 2.02, P=0.004).

CONCLUSIONS

The likelihoods of many risky behaviors between adult childhood cancer survivors and general population controls were comparable, although rates of physical activity may be decreased, and rates of smoking may be increased among childhood cancer survivors. Targeted interventions are needed to promote healthy behaviors in this vulnerable population.

Burden of Childhood Cancer and the Social and Economic Challenges in Adulthood: A Systematic Review and Meta-Analysis

Importance

Significant advancements in pediatric oncology have led to a continuously growing population of survivors. Although extensive research is being conducted on the short-, medium-, and long-term somatic effects, reports on psychosocial reintegration are often conflicting; therefore, there is an urgent need to synthesize the evidence to obtain the clearest understanding and the most comprehensive answer.

Objective

To provide a comprehensive review and analysis of the socioeconomic attainment of childhood cancer survivors (CCSs) compared with their unaffected peers.

Data Sources

A systematic review and meta-analysis was conducted using data obtained from a comprehensive search of MEDLINE (via PubMed), Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) databases on October 23, 2021; the search was updated until July 31, 2023.

Study Selection

Eligible articles reported on educational attainment, employment, family formation, quality of life (QoL), or health-risk behavior-related outcomes of CCSs, and compared them with their unaffected peers. Study selection was performed in duplicate by 4 blinded independent coauthors.

Data Extraction and Synthesis

Data extraction was performed in duplicate by 4 independent authors following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcome measures were odds ratios (ORs) and mean differences with 95% CIs; data were pooled using a random-effects model.

Results

The search identified 43 913 articles, 280 of which were eligible for analysis, reporting data on a total of 389 502 survivors. CCSs were less likely to complete higher levels of education (OR, 0.69; 95% CI, 0.40-1.18), had higher odds of health-related unemployment (OR, 2.94; 95% CI, 1.90-4.57), and showed lower rates of marriage (OR, 0.72; 95% CI, 0.63-0.84) and parenthood (OR, 0.60; 95% CI, 0.49-0.74) compared with population-based controls.

Conclusion and Relevance

Study findings suggest that CCSs face several socioeconomic difficulties; as a result, the next goal of pediatric oncology should be to minimize adverse effects, as well as to provide lifelong survivorship support aimed at maximizing social reintegration.

Prognosis Communication in Pediatric Oncology: A Systematic Review

BACKGROUND

While communication plays an important role in medicine, it also often represents a challenge when the topic at hand is the prognosis of a high-risk condition. When it comes to pediatric oncology, the challenge becomes even greater for physicians who have to adapt their discourse to both the child and their family.

METHODS

Following the PRISMA guidelines, an advanced search on PubMed, Scopus and the Cochrane Library was performed, from 1 January 2017 to 31 October 2022. Demographic data for caregivers, pediatric patients and physicians were extracted, as well as diagnosis, prognosis, presence at discussion, emotional states and impact on life, trust, decision roles, communication quality and other outcomes.

RESULTS

A total of 21 articles were analyzed. Most studies (17) focused on caregivers, while only seven and five studies were focused on children and physicians, respectively. Most parents reported high trust in their physicians (73.01%), taking the leading role in decision making (48%), moderate distress levels (46.68%), a strong desire for more information (78.64%), receiving high-quality information (56.71%) and communication (52.73%). Most children were not present at discussions (63.98%); however, their desire to know more was expressed in three studies. Moreover, only two studies observed children being involved in decision making. Most physicians had less than 20 years of experience (55.02%) and reported the use of both words and statistics (47.3%) as a communication method.

CONCLUSIONS

Communication research is focused more on caregivers, yet children may understand more than they seem capable of and want to be included in the conversation. More studies should focus on and quantify the opinions of children and their physicians. In order to improve the quality of communication, healthcare workers should receive professional training.

Systematic Review of Substance Use Measurement Tools in Adolescent and Young Adult Childhood Cancer Survivors

Substance use among adolescents and young adults (AYAs) is associated with an increased risk of poor physical and mental health outcomes. For AYA childhood cancer survivors (CCSs), substance use may also increase their likelihood of experiencing late effects. As a result, professional organizations recommend that AYA CCSs be regularly screened for risk behaviors, including substance use. The best methods for assessing these behaviors as part of clinical care for AYA CCSs, however, remain unclear. To begin to address this gap, the purpose of this study was to systematically review written substance use measures that have been used with AYA CCSs and published between 2000 and 2020. A search of PubMed, PsycINFO, and CINAHL using terms related to substance use and AYA CCSs identified 47 articles representing 20 different written substance use measures that evaluated current substance use (i.e., use of alcohol, tobacco, marijuana, prescription medications taken in a manner other than as prescribed, and/or other illicit substances within the 12 months). Measures varied in domains assessed, item formats, and response formats. Results are presented alongside recommendations for selecting screening tools for use with AYA CCS populations in both clinical and research settings.

Smoking and Cannabis Use among Childhood Cancer Survivors: Results of the French Childhood Cancer Survivor Study

BACKGROUND

Unhealthy behaviors among childhood cancer survivors increase the risks for cancer treatment adverse effects. We aimed to assess tobacco and cannabis use prevalence in this population and to identify factors associated with these consumptions.

METHODS

This study involved 2,887 5-year survivors from the French childhood cancer survivor study (FCCSS) cohort. Data on health behaviors were compared with those of controls from the general population. Associations of current smoking and cannabis use with clinical features, sociodemographic characteristics, and health-related quality of life (QOL) were investigated using multivariable logistic regressions.

RESULTS

Prevalence for tobacco use was lower in survivors (26%) than in controls (41%, P < 0.001). Among current smokers, survivors smoked more cigarettes per day and started at a younger age than controls. Women, college graduates, older, married, and CNS tumor survivors, as well as those who received chemotherapy and thoracic radiation therapy, were less likely to be smokers and/or cannabis consumers than others. Participants with a poor mental QOL were more likely to smoke.

CONCLUSIONS

Preventive interventions and cessation programs must be carried out as early as possible in survivors' life, especially among young males with low educational level and poor mental health.

IMPACT

This study brings new insights to health behaviors among childhood cancer survivors from a population with high rates of smoking and cannabis use.

Substance use, substance use disorders, and treatment in adolescent and young adult cancer survivors-Results from a national survey

BACKGROUND

Substance use can exacerbate cancer-related morbidity and mortality in adolescent/young adult (AYA) cancer survivors and place them at increased risk for adverse health outcomes. The objective of this study was to assess substance use, misuse, and substance use disorders [SUDs], as well as receipt of treatment for SUDs, among AYA cancer survivors.

METHODS

The authors used data from the National Survey of Drug Use and Health (2015-2018) to identify a nationally representative sample of AYAs aged 12 to 34 years. Outcomes assessed past-year tobacco, alcohol, marijuana, and illicit drug use; misuse of prescription opioids; SUDs; and SUD treatment. Multiple logistic regression was estimated to compare outcomes between 832 AYAs who reported a cancer history (survivors) and 140,826 AYAs who did not, adjusting sequentially for sociodemographic characteristics and health status.

RESULTS

In regressions adjusting for sociodemographic characteristics, survivors were more likely than a noncancer comparison group of peers to use alcohol (6% relative increase; P = .048) and illicit drugs (34% relative increase; P = .012), to misuse prescription opioids (59% relative increase; P < .001), and to have a marijuana (67% relative increase; P = .011), illicit drug (77% relative increase; P < .001), or prescription opioid (67% relative increase; P = .048) SUD. When further adjusting for health status, survivors were still 41% more likely (P < .001) to misuse prescription opioids than noncancer peers. Among those with SUDs, survivors were more likely than peers to receive treatment (unadjusted, 21.5% vs 8.0%; adjusted, P < .05).

CONCLUSIONS

AYA survivors were as likely as or more likely than noncancer peers to report substance use problems. These findings underscore the importance of interventions to reduce substance use and improve SUD treatment among AYA cancer survivors.

LAY SUMMARY

The authors assessed substance use, misuse, and substance use disorders, as well as the receipt of treatment for substance use disorders, among adolescent and young adult (AYA) cancer survivors. In a nationally representative AYA sample, cancer survivors, despite their increased risk for morbidity and early mortality, were as likely as or more likely than peers without cancer to experience substance use problems. In particular, survivors had a significantly higher rate of prescription opioid misuse than peers. However, only 1 in 5 AYA survivors who experienced substance use disorders received treatment. These findings underscore the importance of interventions toward reducing substance use and improving access to treatment among AYA survivors.

Clinic Attendance of Youth With Sickle Cell Disease on Hydroxyurea Treatment

OBJECTIVE

The objective of this study is to describe rates of clinic attendance of youth with sickle cell disease prescribed hydroxyurea and examine potential demographic and medical factors related to consistent clinic attendance.

METHODS

Participants included 148 youth diagnosed with sickle cell disease and prescribed hydroxyurea during a single calendar year. Clinic attendance and potential demographic and medical factors related to attendance were extracted via systematic retrospective medical chart review.

RESULTS

Youth attended 90.3% of scheduled appointments and 85.1% of youth attended at least 80% of scheduled clinic appointments during the study window. Adjusting for other factors, multivariate analysis revealed families with fewer children in the household, families with private insurance, youth experiencing fever, and youth not experiencing pain during the calendar year were more likely to consistently attend clinic visits.

CONCLUSIONS

Adherence to clinic appointments is critical to optimizing health outcomes for youth with sickle cell disease and integral for adequate monitoring of youth prescribed hydroxyurea, in particular. Findings may aid providers in appropriately identifying possible barriers to clinic attendance to develop attendance promotion interventions.

Positive schemas, psychopathology, and quality of life in children with pediatric cancer: A pilot study

PURPOSE

Research in the area of pediatric oncology has shown that although some children and youth diagnosed with this disease cope adaptively after their diagnosis, others continue to have long-term psychosocial difficulties. The potential mechanisms that may protect against the experience of psychopathology and poor quality of life within this population are not well known. The purpose of this pilot study was to utilize a new comprehensive measure of positive schemas to better understand the relationship between positive schemas, quality of life, and psychopathology, for children on active treatment for cancer.

METHODS

Participants were 22 patients, aged 8-18 years, being treated in a pediatric oncology clinic. Patients and parents completed measures of positive schemas, quality of life, and psychopathology.

RESULTS

The mean age at time of initial diagnosis of the patient sample was 11.6 years. Child-reported positive schemas were significantly related to child-reported child quality of life (r = 0.46, p = 0.03).

CONCLUSIONS

This is the first study to examine positive schemas within a pediatric oncology sample. Future research is needed to further explore facets of positive schemas that may be particularly relevant to child psychological functioning in a pediatric oncology population.

Substance Use Risk Behaviors and Decision-Making Skills Among Cancer-Surviving Adolescents

The aims of this study were to compare decision making and substance use risk behaviors of a cohort of cancer-surviving adolescents to those of 2 earlier cohorts as well as adolescents in the US general population and to determine the relationship of decision making to substance use risk behaviors. This correlational study used a semistructured interview at the time of the annual clinic visit to obtain data. Teen cancer survivors (N = 76), ages 14-19 years, were recruited from 5 clinics within the United States. Adherence to quality decision-making skills reported by different cancer-surviving adolescent cohorts appears to remain the same over time. However, reported substance use risk behaviors by these teen survivor cohorts have decreased over time. The prevalence rates for lifetime use for the 2004 cohort of teen cancer survivors were 25%, 49%, and 16%, for cigarettes, alcohol, and marijuana use, respectively. These rates are somewhat lower than those in the US general population; yet, they are high given the health vulnerability of cancer-surviving adolescents. Poor-quality decision making was significantly associated with higher levels of substance use risk behaviors for these teen cancer survivors. In conjunction with the statistics related to higher health risks in this vulnerable group of teens, these findings support continued efforts in developing interventions for risk behavior counseling.

Smoking, Binge Drinking, and Drug Use Among Childhood Cancer Survivors: A Meta-Analysis

INTRODUCTION

Childhood cancer survivors are at risk for late effects of therapy, some of which may be exacerbated by smoking, alcohol, or drug use. We undertook a meta-analysis of the literature to determine whether survivors engage in risk-taking behaviors at rates different from their peers/siblings.

METHODS

Studies comparing current engagement in risk-taking behaviors between cancer survivors and siblings or matched peers were identified in MEDLINE (1946-), EMBASE (1947-), PsychINFO (1806-), and the Cochrane Controlled Trials Register. Two reviewers assessed publications for inclusion and extracted data independently. Studies were combined using inverse variance weighting to determine odds ratios (OR) and prevalence rates of risk-taking behaviors in survivors compared to controls.

RESULTS

Fourteen of 1,713 studies satisfied inclusion criteria. Twelve assessed smoking, six binge drinking, and seven drug use. Among survivors, 22% (95% confidence interval 0.19, 0.26) smoked, 20% (0.08, 0.51) were binge drinkers, and 15% (0.10, 0.23) used drugs. Survivors were less likely than siblings to smoke (OR 0.68 [0.49, 0.96]) or binge drink (OR 0.77 [0.68, 0.88]), but similarly likely to use drugs (OR 0.33 [0.03, 3.28]). Survivors were less likely than matched peers to smoke (OR 0.54 [0.42, 0.70]) or use drugs (OR 0.57 [0.40, 0.82]), but equally likely to binge drink (OR 0.97 [0.38, 2.49]).

CONCLUSIONS

Childhood cancer survivors engage in similar or lower rates of risk taking than their siblings/peers. Future studies should identify survivors most likely to benefit from focused interventions, and determine the impact of risk-taking behaviors on the risk for late effects of cancer therapy.

Engagement in High-Risk Behaviors Among Young Adult Survivors of Childhood Cancer Compared to Healthy Same-Age Peers Surveyed in the National Longitudinal Study of Adolescent Health

PURPOSE

This secondary data analysis compared smoking rates, alcohol consumption, and binge drinking, and examined risk factors for engaging in these behaviors among 90 young adult-aged childhood cancer survivors (CSS) with 15,490 young adults in the general population.

METHODS

The sample was drawn from the National Longitudinal Study of Adolescent Health. The sampling distribution of these healthy matched young adults was estimated through the use of bootstrapping, which involved randomly repeated for 10,000 samples of healthy controls.

RESULTS

The findings of repeated sampling analysis revealed that CCS were more likely to smoke daily (34.5% vs. 20.6 healthy matched controls; p = 0.03). The proportion of respondents who had any signs of alcohol abuse symptoms was 72.2% of CCS compared with 81.1% of matched controls (p = 0.16), while CCS with severe alcohol abuse was 51.1% compared with 59.1% of matched controls (p = 0.28). Whether they engaged in binge drinking in the past 12 months was 43.3% for CCS and 46.4% for healthy respondents. Logistic regression analyses were performed to examine predictors of smoking, alcohol use, and binge drinking among CCS. Smoking was very strongly associated with optimism. An optimism score of one unit higher was associated with a 39% reduction in odds of smoking (odd ratio [OR] = 0.61, p < 0.0001). Black CSS were less likely to smoke (OR = 0.15, p < 0.05). CCS in good health were more likely to binge drink (OR = 3.67, p < 0.05).

CONCLUSIONS

Data generated from this secondary data analyses add to the evidence base about the engagement in high risk behaviors among young adult-aged CCS. These findings further emphasize the need for widespread, available effective theory-based screening guidelines and interventions.

Smoking behavior among adult childhood cancer survivors: what are we missing?

PURPOSE

Childhood cancer survivors are a growing population at increased risk for smoking-related health complications. This study compared smoking prevalence, age at smoking initiation, and time trend of smoking prevalence from 1997 to 2010 between adult survivors of childhood cancer and adults without a cancer history (controls) and identified predictors of smoking among these survivors.

METHODS

Data were pooled from the 1997-2010 National Health Interview Survey (survivors, n = 1438; controls, n = 383,805). Smoking prevalence by age group was calculated using weighted least square regression analysis and weighted linear regression of prevalence on year for trend analysis. Logistic regression analyses adjusting for sample weights and design effects were performed to identify predictors of smoking among survivors.

RESULTS

Compared to controls, survivors were significantly more likely to be younger, female, non-Hispanic White, unemployed, with lower income, and to weigh less and smoke more. Survivors initiated smoking earlier than controls. Smoking prevalence among survivors peaked at age 30 and 40 years old, compared to age 25 years in controls. Smoking prevalence decreased consistently from 1997 to 2010 among controls, with larger significant declines in survivors that were subject to more year-to-year variability. Compared to nonsmoking survivors, those who smoke were significantly more likely to be non-Hispanic White, young, uninsured, poor, to have a high school education or less, and to report drinking alcohol.

CONCLUSION

Smoking in adult survivors of childhood cancer continues as a persistent risk factor across socioeconomic groups.

IMPLICATIONS FOR CANCER SURVIVORS

Targeted and tailored smoking cessation/prevention interventions for these survivors are needed.

Monitoring and Assessment of Neuropsychological Outcomes as a Standard of Care in Pediatric Oncology

Central nervous system cancers or exposure to CNS-directed therapies increase risk for neuropsychological deficits. There are no accepted guidelines for assessment of neuropsychological functioning in this population. A multifaceted literature search was conducted and relevant literature reviewed to inform the guidelines. Studies of neuropsychological outcomes are widely documented in the pediatric oncology literature. There is strong evidence of need for neuropsychological assessment, but insufficient evidence to guide the timing of assessment, nor to recommend specific interventions. Children with brain tumors and others at high risk for neuropsychological deficits should be monitored and assessed for neuropsychological deficits.

Longitudinal smoking patterns in survivors of childhood cancer: An update from the Childhood Cancer Survivor Study

BACKGROUND

Survivors of pediatric cancer have elevated risks of mortality and morbidity. Many late adverse effects associated with cancer treatment (eg, second cancers and cardiac and pulmonary disease) are also associated with cigarette smoking, and this suggests that survivors who smoke may be at high risk for these conditions.

METHODS

This study examined the self-reported smoking status for 9397 adult survivors of childhood cancer across 3 questionnaires (median time interval, 13 years). The smoking prevalence among survivors was compared with the smoking prevalence among siblings and the prevalence expected on the basis of age-, sex-, race-, and calendar time-specific rates in the US population. Multivariable regression models examined characteristics associated with longitudinal smoking patterns across all 3 questionnaires.

RESULTS

At the baseline, 19% of survivors were current smokers, whereas 24% of siblings were current smokers, and 29% were expected to be current smokers on the basis of US rates. Current smoking among survivors dropped to 16% and 14% on follow-up questionnaires, with similar decreases in the sibling prevalence and the expected prevalence. Characteristics associated with consistent never-smoking included a higher household income (relative risk [RR], 1.16; 95% confidence interval [CI], 1.08-1.25), higher education (RR, 1.32; 95% CI, 1.22-1.43), and receipt of cranial radiation therapy (RR, 1.08; 95% CI, 1.03-1.14). Psychological distress (RR, 0.86; 95% CI, 0.80-0.92) and heavy alcohol drinking (RR, 0.64; 95% CI, 0.58-0.71) were inversely associated. Among ever-smokers, a higher income (RR, 1.17; 95% CI, 1.04-1.32) and education (RR, 1.23; 95% CI, 1.10-1.38) were associated with quitting, whereas cranial radiation (RR, 0.86; 95% CI, 0.76-0.97) and psychological distress (RR, 0.80; 95% CI, 0.72-0.90) were associated with not having quit. The development of adverse health conditions was not associated with smoking patterns.

CONCLUSIONS

Despite modest declines in smoking prevalence, the substantial number of consistent current smokers reinforces the need for continued development of effective smoking interventions for survivors.

Health Behaviors of Childhood Cancer Survivors

There has been a dramatic increase in the number of childhood cancer survivors living to an old age due to improved cancer treatments. However, these survivors are at risk of numerous late effects as a result of their cancer therapy. Engaging in protective health behaviors and limiting health damaging behaviors are vitally important for these survivors given their increased risks. We reviewed the literature on childhood cancer survivors’ health behaviors by searching for published data and conference proceedings. We examine the prevalence of a variety of health behaviors among childhood cancer survivors, identify significant risk factors, and describe health behavior interventions for survivors.

Perceptions of risk among childhood and young adult cancer survivors who smoke

PURPOSE

Despite the fact that childhood and young adult cancer survivors are at increased risk for chronic health problems as a result of their cancer treatment, many use tobacco, thereby increasing their risks. Perceptions of risk related to tobacco use can be targeted for interventions aimed at improving health behaviors for childhood, adolescent, and young adult cancer survivors. Understanding the covariates of perceptions of health risks among young adult survivors who smoke will help to determine targets for intervention.

METHOD

Three hundred seventy-four participants who were diagnosed with cancer prior to age 35, currently between 18 and 55 years of age, and current smokers were recruited as part of a larger smoking cessation study, Partnership for Health-2 (PFH-2). Data were collected by telephone survey.

RESULTS

Overall, women had the highest perception of risk for serious health problems, a second cancer, and heart problems. Additionally, those participants who were dependent on nicotine endorsed that they were at higher risk of serious health problems and second cancers, but not heart problems. Finally, Hodgkin lymphoma survivors reported that they were at increased risk for second cancers and heart problems compared to their “healthy” peers.

CONCLUSION

Young adult cancer survivors who smoke correctly perceived some of their increased health risks. Additional motivation and education is needed for those young adult cancer survivors who perceive their increased health risks yet continue to smoke. Further education is needed for young survivors so they have a fully appropriate sense of risk, especially as it relates to their tobacco use.

The influence of social adjustment on normative and risky health behaviors in emerging adults with spina bifida

OBJECTIVE

To understand the rates of normative and risky health behaviors and the influence of prior and current social adjustment on health risk behaviors in emerging adults with spina bifida (SB).

METHOD

These data are part of a larger longitudinal study of youth with SB; at ages 18-19, 50 emerging adults with SB and 60 typically developing (TD) youth participated. Social adjustment was measured at ages 12/13, 14/15, 16/17, and 18/19. Substance use and sexual activity were self-reported by emerging adults.

RESULTS

The SB group reported similar frequencies (i.e., number of days in the previous month) of cigarette and marijuana use. Fewer individuals with SB reported initiation of both alcohol use (i.e., ever used) and sexual activity (i.e., ever had sex) compared to TD peers. The SB group also reported less frequent alcohol use and fewer sexual partners. Better social adjustment during early adolescence (ages 12/13) predicted more frequent alcohol use and a greater number of sexual partners for all youth. Social adjustment also mediated the effect of group status on health risk behaviors.

CONCLUSIONS

Emerging adults with SB lag behind TD peers in terms of normative initiation of alcohol use and sexual activity. However, this population participates in some risky health behaviors at similar rates compared to their TD peers (e.g., smoking). Youths' health risk behaviors may be influenced by their level of social adjustment. A challenge for future interventions for this population will be finding methods of improving social functioning without increasing the rate of health risk behavior.

Risky health behavior among adolescents in the childhood cancer survivor study cohort

OBJECTIVE

To report the prevalence and comparison of cancer-linked health behaviors and identify risk factors associated with unhealthy behavior among adolescent siblings and cancer survivors.

METHODS

The Child Health and Illness Profile--Adolescent Edition (CHIP--AE) was completed by 307 survivors and 97 sibling controls 14-20 years of age.

RESULTS

Risky behavior ranged from 0.7% to 35.8% for survivors and 1.0% to 41.2% for siblings. Comparisons of sexual behavior, tobacco, alcohol, or illicit drug use utilizing continuous data revealed no differences between groups. Categorically, survivors were less likely to report past smokeless tobacco use or current use of beer/wine or binge drinking (p-values range from .01 to .04). Survivors with better mental health were at lower risk for poor behavioral outcomes.

CONCLUSIONS

Adolescent survivors engage in risky health behaviors at rates generally equivalent to their siblings. Aggressive health education efforts should be directed toward this high-risk population.

Adolescent cancer survivors' smoking intentions are associated with aggression, attention, and smoking history

INTRODUCTION

The present study examines behavioral and psychosocial factors associated with smoking intentions and experimentation among adolescent survivors of pediatric cancer.

METHODS

Adolescent survivors of brain tumor and acute lymphoblastic leukemia (n  =  99) provided information about their smoking histories and their intentions to smoke in the future. Behavior rating scales were completed by survivors, parents, and teachers.

RESULTS

Past experimentation with smoking and higher levels of self-reported aggression were associated with intentions to smoke in the future (OR  =  4.18, 95% CI 1.02-17.04, and OR  =  1.08, 95% CI 1.01-1.15, respectively), while teacher-ratings of inattention in the classroom were negatively associated with intentions to smoke (OR  =  0.94, 95% CI.88-.99), all p  < .05. Experimentation with smoking was more likely among older survivors (OR  =  1.76, 95% CI 1.16-2.66, p  < .01) and those whose parents had divorced (OR  =  4.40, 95% CI 1.21-16.06, p  < .05).

DISCUSSION

A concerning minority of adolescent survivors have clear intentions to smoke, a behavior that adds to their overall health risk. Smoking intentions and experimentation are important precursors to regular smoking. Prevention efforts are needed to interrupt the progression from intentions and experimentation to established smoking and nicotine dependence in this medically vulnerable population.

IMPLICATIONS FOR CANCER SURVIVORS

Assessment of an adolescent's history of parental divorce, past experimentation with smoking, and aggressive behavior will identify those survivors who are likely to consider smoking in the future. Screening for these characteristics will allow clinicians to be more vigilant in health promotion.

Attentional and executive dysfunction as predictors of smoking within the Childhood Cancer Survivor Study cohort

INTRODUCTION

Previous research has suggested that childhood cancer survivors initiate smoking at rates approaching those of healthy individuals, even though smoking presents unique risks to survivors. The present study explores whether the attentional and executive functioning (EF) deficits associated with cancer and treatment place survivors of childhood cancer at increased risk for smoking.

METHODS

Data from the Childhood Cancer Survivor Study were examined to identify concurrent and longitudinal correlates of tobacco use. We explored whether childhood attention problems and adulthood executive dysfunction were associated with smoking among adult survivors of childhood cancer.

RESULTS

Childhood attention problems emerged as a striking predictor of adult smoking nearly a decade later on average. Nearly half (40.4%) of survivors who experienced attention problems in childhood reported a history of smoking, a significantly higher rate of ever smoking, than reported by those without childhood attention problems (relative risk [RR] = 1.53, 95% CI = 1.31-1.79). Furthermore, they were nearly twice as likely to be current smokers in adulthood compared with those without childhood attention problems (RR = 1.71, 95% CI = 1.38-2.11). Similar associations were found between components of adult executive dysfunction and adult smoking.

DISCUSSION

Childhood cancer and treatment are associated with subsequent deficits in attention and EF. Early detection of these deficits will allow clinicians to identify patients who are at increased risk for smoking, an important step in promoting and maintaining health in this medically vulnerable population.

Anti-Smoking Communication to Preadolescents with and without a Cancer Diagnosis: Parents and Healthcare Providers as Important Communicators

A cancer diagnosis does not prevent smoking among pediatric oncology patients, and anti-smoking communications among parents and health care providers have been proposed as influencing smoking outcomes in this group. Anti-smoking communications were compared among 93 preadolescents with cancer and 402 controls. After adjusting for demographics and covariates, preadolescents with cancer were less likely than control participants to report receipt of anti-smoking messages from physicians and parents, and recalled more messages >/= 4 months post-diagnosis as compared to 1-3 months. Should anti-tobacco communications prove to influence smoking outcomes, parents and physicians may be uniquely positioned to provide smoking prevention interventions to these patients.

Survivors of childhood cancer and comparison peers: the influence of peer factors on later externalizing behavior in emerging adulthood

OBJECTIVE

To examine group differences and predictors of externalizing behavior and substance use during the transition to emerging adulthood (i.e., ages 18-25) among survivors of childhood cancer and comparison peers.

METHODS

Peer acceptance and social behavior were assessed in classrooms of 55 children (ages 8-15) during cancer treatment. Children with cancer, comparison peers (n = 60), and parents completed measures of externalizing behavior and/or substance use during an initial home visit and soon after participants turned 18.

RESULTS

At follow-up, survivors and peers exhibited similar externalizing behaviors and substance use, except peers were more likely to use marijuana. Substance use was associated with earlier peer acceptance and social behavior. Survivors who were older at diagnosis were at greater risk for later externalizing behavior and substance use.

CONCLUSIONS

Mean externalizing behaviors and substance use generally fell within normative ranges for both survivors and peers. Some survivors may benefit from interventions to reduce risk behavior.

Prevalence of multiple health-related behaviors in adolescents with cancer

OBJECTIVE

This preliminary study investigated prevalence rates of multiple health-related behaviors (ie, tobacco, alcohol, and other drug use; sexual risk-taking; nutrition/physical activity; overweight and dietary behaviors; sun safety) among 42 adolescents on active treatment for cancer, as compared with healthy adolescent norms.

METHODS

Health-related behaviors were assessed using the 2005 National Youth Risk Behavior Survey, for which healthy adolescent norms were publicly available.

RESULTS

Adolescents with cancer reported significantly lower current and lifetime rates of tobacco, alcohol, and other drug use; fruit/vegetable consumption; physical activity; and dietary behavior, in addition to lower rates of lifetime sexual intercourse, early-onset sexual intercourse, and alcohol/drug use before last sexual intercourse, compared with healthy peers. Among those who have previously engaged in sexual intercourse, there appeared to be a trend toward increased partners, current sexual activity, and lack of protection at last episode of sexual intercourse. Adolescents with cancer also reported significantly higher rates of television watching compared with healthy peers.

CONCLUSIONS

Adolescents on active treatment for cancer are engaging in multiple health-risk behaviors, including sedentary behavior, poor nutrition, lack of sun safety, and sexual risk-taking (eg, multiple partners, lack of protection at last sexual intercourse). Health promotion interventions are needed during active treatment to facilitate the acquisition of good health practices as adolescents transition into survivorship.

Factors influencing long-term follow-up clinic attendance among survivors of childhood cancer

INTRODUCTION

Attendance at long-term follow-up clinic is necessary for survivors of childhood cancer to facilitate education about cancer-related health risks, early detection of treatment-related morbidity, and implementation of health-promoting interventions. Despite the need for continued care, barriers to clinic attendance exist. The purpose of this prospective study was to identify the demographic, medical, and logistic factors impacting clinic attendance and long-term follow-up care among survivors of childhood cancer.

METHODS

Adherence to clinic attendance was monitored among 941 long-term childhood cancer survivors scheduled for evaluation. Patients were classified as "attenders" or "non-attenders" based on the outcome of their first scheduled clinic appointment over a one year period. Social work staff contacted non-attenders by telephone to determine reasons for missed appointments.

RESULTS

Nearly 15% of survivors were classified as non-attenders. Univariate findings revealed that older age, lower SES, being non-white, less medically insured, traveling by car, living shorter distance from clinic, having a scheduled social work consultation, and entering or exiting survivorship clinic were associated with clinic non-attendance (all p values < 0.05). The final multivariate model indicated that non-whites (OR = 1.88, 95% CI = 1.19-2.97), patients without insurance (OR = 2.36, 95% CI = 1.98-3.79), those traveling by car (OR = 12.74, 95% CI = 3.97-40.86), and those who have not experienced secondary cancer events (OR = 1.76, 95% CI = 0.94-3.28) were more likely to be non-attenders. Work or school conflicts were the primary reasons cited for missed appointments.

DISCUSSION/CONCLUSIONS

Despite mechanisms designed to reduce financial burdens associated with attending survivorship clinic at our institution, demographic, medical, and logistic barriers exist which impact participation in long-term follow-up. IMPLICATIONS FOR CANCER SURVIVORS AND PROVIDERS: These results highlight the importance of developing tailored outreach strategies for survivors of childhood cancer at-risk for clinic non-attendance, particularly among underserved populations.

Smoking and binge drinking among Canadian survivors of childhood and adolescent cancers: a comparative, population-based study

BACKGROUND

Objectives of this study were to describe the prevalence of smoking and binge drinking among survivors of childhood and adolescent cancer compared to controls who had never had cancer, and to identify factors associated with these behaviors.

PROCEDURE

Data came from a national, multi-centre, population-based study of survivors of childhood and adolescent cancer (n = 1,263) aged 16 to 37 years and an age and gender matched control group (n = 1,422). Logistic regression analyses were performed to determine the likelihood and predictors of current smoking and binge drinking.

RESULTS

Survivors were less likely to be current smokers (OR(adj) = 0.65, 95% CI = 0.54-0.77) and binge drinkers (OR(adj) = 0.66, 95% CI = 0.55-0.78) than the controls. Still, a substantial proportion of survivors reported smoking (23%) and binge drinking (25%). Survivors' smoking and binge drinking did not vary substantially by the clinical factors assessed. Survivors who received therapy associated with cardiac and/or pulmonary toxicity were as likely to smoke as non-exposed survivors. For both the survivors and controls current smoking and binge drinking were associated with lower education and higher reported stress. Binge drinking was also associated with being male and life dissatisfaction in both groups.

CONCLUSIONS

This study indicates a need to reduce smoking and binge drinking among survivors of childhood and adolescent cancer and to design interventions addressing the underlying reasons for adopting unhealthy behaviors despite their risk for late effects. We identified factors related to smoking and binge drinking among survivors: being male, lower educational attainment, life dissatisfaction and high stress, which should help inform intervention development.

Alcohol consumption patterns and risk factors among childhood cancer survivors compared to siblings and general population peers

AIMS

This study describes alcohol consumption among adult survivors of pediatric cancer compared to sibling controls and a national sample of healthy peers. Risk factors for heavy drinking among survivors are described.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional data were utilized from the Childhood Cancer Survivor Study including adult survivors of pediatric cancer (n = 10 398) and a sibling cohort (n = 3034). Comparison data were drawn from the National Alcohol Survey (n = 4774).

MEASUREMENT

Alcohol consumption, demographic, cancer diagnosis, treatment and psychosocial factors were measured.

FINDINGS

Compared to peers, survivors were slightly less likely to be risky [adjusted odds ratio (ORadj) = 0.9; confidence interval (CI) 0.8-1.0] and heavy drinkers (ORadj = 0.8; CI 0.7-0.9) and more likely to be current drinkers. Compared to siblings, survivors were less likely to be current, risky and heavy drinkers. Risk factors for survivors' heavy drinking included being age 18-21 years (ORadj = 2.0; 95% CI 1.5-2.6), male (ORadj = 2.1; 95% CI 1.8-2.6), having high school education or less (ORadj = 3.4; 95% CI 2.7-4.4) and drinking initiation before age 14 (ORadj = 6.9; 95% CI 4.4-10.8). Among survivors, symptoms of depression, anxiety or somatization, fair or poor self-assessed health, activity limitations and anxiety about cancer were associated with heavy drinking. Cognitively compromising treatment, brain tumors and older age at diagnosis were protective.

CONCLUSIONS

Adult survivors of childhood cancer show only a modest reduction in alcohol consumption compared to peers despite their more vulnerable health status. Distress and poorer health are associated with survivor heavy drinking. Screening for alcohol consumption should be instituted in long-term follow-up care and interventions among survivors and siblings should be established to reduce risk for early drinking.

Parent report of attention problems predicts later adaptive functioning in children with brain tumors

Children with brain tumors are at risk for psychological and behavioral difficulties. This study examined the ability of parent report of attention problems, withdrawal, anxiety, and depression, as well as IQ, to predict later adaptive functioning in 42 children treated for brain tumors. Age at diagnosis, SES, gender, and scores on the Neurological Predictor Scale (NPS) also were examined as predictors. Parent report of attention problems, SES, and NPS were significant predictors of later adaptive functioning across domains. This finding highlights the ability of parent report of attention problems to predict later adaptive functioning in children treated for brain tumors.

A comparison of emotional/behavioural problems between Taiwanese children with cancer and healthy controls

AIMS

The purpose of this study was to compare children, diagnosed with cancer, who were attending school, with their healthy peers on emotional and behavioural problems.

BACKGROUND

Children who suffer from cancer experience severe side effects from their treatment protocols and from the uncertainty associated with their disease. We were seeking to find out if these children subsequently experienced more emotional and behavioural problems than their healthy peers.

METHODS

Parents and teachers of paediatric oncology patients and their healthy schoolmates were recruited. The ratio was one patient to two schoolmates. The Child Behaviour Checklist (CBCL) was used to collect data from the parents and teachers of 23 paediatric cancer patients and 46 healthy controls. Children were matched on enrollment in the same grade and socioeconomic status of their families. Paired-t tests were used to compare the differences between the emotional/behavioural scores of both groups of children.

RESULTS

The findings of the study indicated that children with cancer had statistically higher scores on the following items of the CBCL: withdrawn/depressed, somatic complaints, social problems, thought problems, hyperactivity/impulsivity, rule-breaking behaviours and aggressive behaviours.

CONCLUSIONS

School children with cancer in Taiwan did have more emotional/behavioural problems than their peers. Findings from this study suggest that Taiwanese paediatric oncology patients who are able to return to school and their families may need more psychosocial care.

RELEVANCE TO CLINICAL PRACTICE

Healthcare professionals may need to extend their professional services to school settings to decrease long-term emotional and behavioural problems in children with cancer.

Health behaviours in childhood cancer survivors: a systematic review

AIM

To review (1) prevalence and predictors of risk behaviours especially smoking and (2) values of interventions to reduce risk behaviours in childhood cancer survivors.

METHOD

A systematic search of four databases (OVID Medline (1966 to May week 2, 2006), CINAHL, EMBASE, and Pubmed (US Library of Medicine and National Institute of Health)) for articles published between January 1990 and May 2006.

RESULTS

Twenty-three eligible articles. Incidence of risk behaviours are comparable with, or lower than the general population and controls. Socio-demographic (age, socio-economic status, diagnosis, ethnic group) and psychological variables (perceived vulnerability) predict risk behaviour. Improved knowledge and awareness of vulnerability have been found after interventions, but no changes in health behaviours.

CONCLUSION

This review illustrates an optimistic picture of low participation in substance use amongst survivors, although based mainly on smoking. However, smoking might not be the major problem for survivors and attention must also be directed to other health behaviours including exercise and healthy diet.

Young adult patients with a history of pediatric disease: impact on course of life and transition into adulthood

PURPOSE

To assess the course of life of young adults who grew up with a chronic or life-threatening disease, and to compare their course of life with that of peers from the general population. Optimal transition from pediatric to adult health care requires knowledge of the psychosocial history of patients grown up with a pediatric disease.

METHODS

A total of 508 young adults from the general Dutch population and 650 patients, aged 18-30 years, participated: 348 survivors of childhood cancer, 93 patients with anorectal malformations, 72 patients with Hirschsprung's disease, 61 patients with oesophageal atresia, 76 patients with end-stage renal disease. They completed the Course of Life Questionnaire, which retrospectively assesses the achievement of developmental milestones (autonomy, psychosexual and social development), and risk behavior (antisocial behavior, substance use and gambling).

RESULTS

The young adults grown up with a chronic or life-threatening disease proved to have achieved significantly fewer milestones, or at older age than their peers, in all course-of-life domains. The course of life of young adults grown up with esophageal atresia was not delayed compared with that of their peers, whereas that of survivors of childhood cancer and patients with end-stage renal disease was delayed most.

CONCLUSIONS

Health care providers should help to minimize the harm for children who grow up with a chronic or life-threatening disease by encouraging parents to stimulate social contacts and autonomy. Attention should especially be directed at children and adolescents growing up with childhood cancer or with end-stage renal disease.

Predicting and modifying substance use in childhood cancer survivors: application of a conceptual model

PURPOSE/OBJECTIVES

To identify factors that predict or modify substance use in childhood cancer survivors and to describe how a risk-counseling intervention reduced young survivors' substance use.

DESIGN

Secondary analysis of clinical trial data and primary analysis of medical record data.

SETTING

Outpatient clinic.

SAMPLE

149 females and 118 males 12-18 years of age whose cancer had been in remission for at least two years were randomly assigned to intervention (n = 132) and standard care (n = 135) groups.

METHODS

Self-report questionnaires, abstracted medical record data, confirmatory factor analysis, and structural equation modeling.

MAIN RESEARCH VARIABLES

Smoking, alcohol consumption, knowledge, risk perceptions, motivation, and worry about cancer and treatment effects.

FINDINGS

Three factors directly predicted substance use at baseline: being in a higher grade in school (independent of age), feelings of being more susceptible to late effects of cancer therapy, and worrying more about cancer and its treatment. At follow-up a year later, grade in school and worry predicted increased substance use. In addition, a desire to change health behavior, influenced by the intervention and gender, predicted decreased substance use. The mechanism of influence of the intervention was evident: The intervention led to a need to change, which precipitated a desire to change and ultimately resulted in decreased substance use.

CONCLUSIONS

Young survivors' worries and concerns about their cancer and treatment-related late effects are a new intervention target. Motivation is sensitive to behavioral change interventions and positively affects risk reduction.

IMPLICATIONS FOR NURSING

Two new intervention strategies to address the impact of survivors' concerns about their cancer and its treatment are implied: (a) Replace substance use with new coping methods to reduce fear and anxiety, and (b) tailor motivation-based interventions to age and gender to communicate graphically and realistically to survivors the personal importance of behavioral change in modifying the risks of late effects.

Health-risk behaviours among adolescent survivors of childhood cancer

BACKGROUND

The purpose of the study was to investigate smoking, alcohol use, illicit drug use and sexual risk taking among adolescent survivors of childhood cancer treated in Australia.

PROCEDURE

A comparison study selecting on exposure (cancer vs. healthy) and administering a branched computerised questionnaire assessing health-risk behaviour, predominately by telephone interview. One hundred fifty-three adolescent survivors of childhood cancer were compared with age matched healthy adolescents drawn from one of two Australian population based surveys of adolescent health. Behaviours assessed were tobacco use, alcohol use, binge drinking, cannabis use, pain reliever use, other illicit drug use and unprotected sex.

RESULTS

Compared to their healthy peers, younger survivors (13- to 17-years) were at an increased risk of reporting pain reliever use (OR = 2.1) for non-medical purposes, but lower risk of binge drinking (OR = 0.20), cannabis use (OR = 0.25), other illicit drug use (OR = 0.31), tobacco use (OR = 0.38) and alcohol use (OR = 0.44). Older survivors (18- to 24-years) were at an increased risk of reporting alcohol use (OR 1.5), but at lower risk of reporting cannabis use (OR = 0.27), other illicit drug use (OR = 0.44) and tobacco use (OR = 0.47). Survival analysis using the full adolescent survivor cohort (13- to 24-years) showed that the age of onset of tobacco use was later for cancer survivors (hazard ratio HR = 0.65).

CONCLUSION

Adolescent cancer survivors show reduced involvement in most health-risk behaviours, with the exception of pain reliever use among younger survivors and alcohol use among the older survivors. Although risks were reduced a substantial proportion of survivors engage in these behaviours.

The course of life of survivors of childhood cancer

The developmental consequences in adulthood of growing up with childhood cancer are not well understood. The Course of life questionnaire was developed to assess the attainment of developmental milestones retrospectively and socio-demographic outcomes in young adulthood. The aim of this study was to assess the course of life and socio-demographic outcomes in young adult survivors of childhood cancer. Knowledge about possible gaps in the course of life could enable health care providers to aim for the most favourable course of life. A total of 353 Dutch survivors and a comparison group of 508 peers without a history of cancer, all aged between 18 and 30, filled in the Course of life questionnaire. The course of life of the survivors was found to be hampered. The young adult survivors of childhood cancer in the Netherlands turned out to have achieved fewer milestones than their peers with respect to autonomy development, social development, and psycho-sexual development, or to have achieved the milestones when they were older than their peers. In addition, survivors displayed less risk behaviour than the comparison group. The survivors and the comparison group also differed on some socio-demographic issues. A considerably lower percentage of survivors than peers in the comparison group were married or living together, and/or employed. Their educational level, on the other hand, was as high as that of their peers.

Factor Analysis and Validity of the Conners Parent and Teacher Rating Scales in Childhood Cancer Survivors

OBJECTIVE

To examine the factor structure of the Conners Parent Rating Scale-Revised: Short Form (CPRS-R:S) and the Conners Teacher Rating Scale-Revised: Short Form (CTRS-R:S) in children who are long-term survivors of acute lymphocytic leukemia (ALL) or brain tumors (BT)and who have received central nervous system directed treatment.

METHOD

Parents and teachers of 150 long-term survivors completed the CPRS-R:S or CTRS-R:S as part of a screening battery. The data were submitted to a maximum likelihood confirmatory factor analysis to test the construct validity of the scales and the forms were compared. The CPRS-R:S was also compared to selected subscales of the Achenbach Child Behavior Checklist (CBCL) for further validation.

RESULTS

The analyses demonstrated an adequate fit of the original three-factor structure of the CTRS-R:S [oppositional, cognitive problems/inattention, hyperactivity]. The analyses of the CPRS-R:S suggested a less adequate fit of the original three-factor structure but principal components factor analysis yielded a three-factor solution with factors similar to those of Conners' original factor structure. Significant correlations were found between the CPRS-R:S and the selected subscales of the CBCL.

CONCLUSIONS

These findings support the similar construct validity of the original CTRS-R:S and CPRS-R:S. Although significantly correlated, the CPRS-R:S and CTRS-R:S are not interchangeable in the assessment of survivors of childhood cancer.

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.

Competence of and Emotional/Behavioral Problems in Pediatric Oncology Patients in Taiwan

The objective of this study was to examine the factor structure of Achenbach's Child Behavior Checklist, using confirmatory factor analysis, in a group of pediatric oncology patients in Taiwan and to compare the competence and behavioral/emotional problems scores of these children with normative scores to assess competence and emotional/behavioral problems of Taiwanese children with cancer. Subjects included parents (124 mothers and 22 fathers) of 146 pediatric oncology patients who completed the measures. Factor loadings of the overall fit indices for the study subjects yielded or approached satisfactory results for all syndromes, except for aggressive behavior. The indices for both internalizing and externalizing syndromes also showed good model fit. Taiwanese children with cancer had significantly lower competence scores on the Child Behavior Checklist/4-18 than did Achenbach's sample, except Taiwanese girls with cancer, who had higher activity competence scores, but these scores were not statistically significant. Taiwanese boys with cancer had significantly higher scores on all of the emotional/behavioral problems, but had lower delinquent behavior, aggressive behavior, and externalizing syndrome scores. In contrast, girls with cancer had significantly higher scores on somatic complaints and internalizing syndrome, but significantly lower aggressive behavior and externalizing syndrome scores. Taiwanese adolescents with cancer had significantly lower competence scores compared with normative scores, with the exception being that the adolescents in the current study had significantly higher school competence scores. These adolescents also had significantly fewer attention problems but tended to have more somatic complaints. These findings clearly indicate that healthcare for children with cancer should include psychological services to prevent long-term emotional/behavioral problems.

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

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