Temperament, personality, and quality of life in pediatric cancer patients

The effect of drama on psychosocial problems and emotional states of hospitalized children with cancer

BACKGROUND AND PURPOSE

Hospitalization is a traumatic experience for children. Especially in the case of childhood cancers that require long-term hospitalization, children need psychosocial support. The study aimed to examine the effectiveness of drama in reducing psychosocial problems in hospitalized paediatric children diagnosed with cancer.

METHODS

The study used a mixed method approach, combining both qualitative and quantitative methods with a single group. Drama sessions prepared according to the Tasks and Skills Model were used to support their psychosocial conditions. The Facial Expression Form, The Assessment Scale for Psychosocial Symptoms in Hospitalized Children, and the Drawing and Writing Technique were used before and after the drama sessions.

RESULTS

This study differs from others in its use of drama intervention to reduce psychosocial problems in children undergoing cancer treatment. As a result of the study, it was found that there was a decrease in anxiety, hopelessness, anger-aggression and communication difficulties among psychosocial problems and a change in mood towards feeling happy. The study suggests that drama sessions were effective in relieving emotional distress in paediatric cancer patients.

CONCLUSION

The study suggests that drama sessions were effective in relieving emotional distress in paediatric cancer patients.

PRACTICE IMPLICATIONS

Applying drama to children undergoing long-term hospital treatment can help alleviate psychosocial problems by reducing stress, emotional suppression, and compensating for trauma.

Behavioral Management as a Coping Strategy for Managing Stressors in Primates: The Influence of Temperament and Species

Primates involved in biomedical research experience stressors related to captivity, close contact with caregivers, and may be exposed to various medical procedures while modeling clinical disease or interventions under study. Behavioral management is used to promote behavioral flexibility in less complex captive environments and train coping skills to reduce stress. How animals perceive their environment and interactions is the basis of subjective experience and has a major impact on welfare. Certain traits, such as temperament and species, can affect behavioral plasticity and learning. This study investigated the relationship between these traits and acquisition of coping skills in 83 macaques trained for cooperation with potentially aversive medical procedures using a mixed-reinforcement training paradigm. All primates successfully completed training with no significant differences between inhibited and exploratory animals, suggesting that while temperament profoundly influences behavior, training serves as an important equalizer. Species-specific differences in learning and motivation manifested in statistically significant faster skill acquisition in rhesus compared with cynomolgus macaques, but this difference was not clinically relevant. Despite unique traits, primates were equally successful in learning complex tasks and displayed effective coping. When animals engage in coping behaviors, their distress decreases, improving welfare and reducing inter- and intra- subject variability to enhance scientific validity.

Temperament and Health-Related Quality of Life in Newly Diagnosed Pediatric Inflammatory Bowel Disease

OBJECTIVE

Health-related quality of life (HRQOL) is typically examined from a deficit standpoint, meaning that little is known about factors associated with higher HRQOL in pediatric illness samples. The aim of the current study was to investigate demographic, disease, and temperamental factors associated with child and parent-report of HRQOL in youth newly diagnosed with inflammatory bowel disease (IBD).

METHODS

Participants included 52 youth ages 8-17 diagnosed with IBD and their caregivers who each completed ratings of the child's HRQOL. Parents rated their child's emotional reactivity, conceptualized as a temperamental risk factor, and adaptability, conceptualized as a temperamental protective factor. Disease symptoms were rated by youth, and physician global assessment of disease activity was obtained.

RESULTS

HRQOL was rated lower by children and their parents as self-reported disease symptoms and parent-rated emotional reactivity increased. Conversely, total HRQOL was higher for children with higher parent-ratings of adaptability. In multiple regression analyses, higher levels of adaptability along with male sex and lower child-reported disease symptoms were associated with higher child and parent-reported HRQOL.

CONCLUSIONS

Higher HRQOL at time of diagnosis in pediatric IBD is associated with greater adaptability when accounting for variability due to child sex and disease symptoms. Consideration of temperament, including emotional reactivity and adaptability, may offer insight into patients' typical ways of responding when stressed and provide preliminary information about factors related to post-diagnosis HRQOL. Attention should be given to both protective and risk factors to inform future intervention development, including strengths-based approaches.

The Influence of Early Childhood Temperament on Later Social-Emotional Functioning in Youth with Cancer

OBJECTIVE

One of the peak incidences of childhood cancer is during the early childhood years. This is also an important time for psychosocial and personality development, and it is well known that early childhood temperament influences later psychosocial functioning. However, this association has not been examined in young children with cancer.

METHODS

Parents of children with cancer (N = 39) and healthy comparisons (N = 35) completed an indicator of temperament (Children's Behavior Questionnaire) when children were young (Mage=4.99 ± 1.05 years). Five years later, parents and youth completed measures of psychosocial functioning (Mage=10.15 ± 1.10 years; Behavior Assessment Scale for Children, 2nd edition and Social Emotional Assets and Resilience Scale).

RESULTS

Parents of healthy comparisons reported that their children demonstrated greater surgency than youth with cancer; there were no differences in negative affect or effortful control. Children with cancer and healthy comparisons were rated similarly on measures of psychosocial functioning. Health status was not a significant predictor of later functioning, but socioeconomic status and temperament were. The influence of temperament was stronger for strengths-based functioning (e.g., social competence, adaptive functioning) versus distress (internalizing and externalizing problems).

CONCLUSIONS

Early childhood temperament is a strong predictor of later psychosocial functioning, regardless of health status. Findings highlight the need to consider temperament in the clinical assessment of psychosocial functioning in children with cancer. Additional research is needed to specifically assess how a diagnosis of cancer in early childhood influences temperament over time.

Temperament and the Impact of Stuttering in Children Aged 8-14 Years

Purpose The goal of this study was to evaluate possible associations between child- and mother-reported temperament, stuttering severity, and child-reported impact of stuttering in school-age children who stutter. Method Participants were 123 children who stutter (94 boys and 29 girls) who were between 9;0 and 14;10 (years;months) and their mothers. Temperament was assessed with the revised child and parent version of the Early Adolescent Temperament Questionnaire-Revised (Ellis & Rothbart, 2001). The Overall Assessment of the Speaker's Experience of Stuttering (Yaruss & Quesal, 2006) was used to evaluate the stuttering impact. Results Child- and mother-reported Early Adolescent Temperament Questionnaire-Revised temperament factors correlated moderately. No statistically significant associations were found between temperament and stuttering severity. The temperament factors of Surgency (both child- and mother-reported) and Negative Affect (only child-reported) correlated moderately with the Overall Impact and several subsections (i.e., Speaker's Reactions, Daily Communication, and/or Quality of Life) of the Overall Assessment of the Speaker's Experience of Stuttering. Conclusions More extraverted and less fearful/shy children experience a lower overall impact of their stuttering. Children with higher levels of irritability and frustration experience a higher overall impact of their stuttering. Since children's ratings of temperament were more sensitive to these associations than mothers, this study supports the inclusion of child-reported temperament questionnaires in future research.

Temperament in preschool children with sickle cell anaemia

AIMS

Few studies have investigated the potential impact of sickle cell anaemia (SCA) on temperament. The aim of the current study was to investigate temperament in preschool children with SCA and to establish the reliability of the Children's Behaviour Questionnaire (CBQ) in this population.

METHODS

The CBQ, a parent-report measure of temperament, was completed by parents of 21 preschool children with SCA and a control group of parents of typically developing children, matched for age, ethnicity and socioeconomic status.

RESULTS

A significant difference between groups was identified for the dimension of negative affectivity only, with specific differences observed in the discomfort subdomain. Patients with a greater number of hospital admissions in the previous year were reported to have higher levels of discomfort.

CONCLUSIONS

Preschool children with SCA are reported to have higher rates of negative affectivity, particularly discomfort. Future research is required to investigate the potential influence of dysregulated negative emotions and discomfort on disease management and quality of life throughout childhood.

Assessing resiliency in paediatric rehabilitation: A critical review of assessment tools and applications

BACKGROUNDS

Resiliency has attracted a growing interest in paediatric rehabilitation as a key capacity for disabled children and their families to thrive. This study aimed to identify measures used to assess resiliency of disabled children/youth and their families and critically appraise the current use of resiliency measures to inform future research and practice.

METHODS

A two-stage search strategy was employed. First, systematic reviews of resiliency measures published since 2000 were searched. Second, full names of measures identified in at least two systematic reviews were searched across four electronic databases. Included studies assessed resiliency among children/youth (0-18 years old) with chronic health conditions and/or disabilities and their families. Identified articles were then analysed to discern the study's definition of resiliency, authors' rationales for measurement selection, and types of perceived adversities facing the study participants.

RESULTS

From an initial yield of 25 measures identified in five systematic reviews, 11 were analysed in two or more reviews. The second stage yielded 41 empirical studies published between 2012 and 2018, which used 8 of the 11 resiliency measures searched by name. Of 41, 17 studies measured resiliency of disabled children/youth, 23 assessed resiliency within family members, and 1 studied both children/youth and their families. Our critical appraisal identified inconsistencies between the studies' definition of resiliency and chosen measures' operationalization, implicit assumption of disabilities as a developmental risk that automatically results in life adversities, and the tendency among family studies to reduce resiliency down to stress coping skills. Research that encompasses contextual factors and developmental influences is lacking.

CONCLUSIONS

There is a need for a situated measurement approach that captures multiple interacting factors shaping resiliency over one's life course. Resiliency measures would benefit from a greater focus on a person-environment transaction and an alternative definition of resiliency that accounts for multiple capacities to navigate through disabling environments.

Understanding differences in the long-term psychosocial adjustment of pediatric cancer patients and their parents: an individual differences resources model

The experience of childhood cancer is a major life stressor for children and their parents. There is substantial variability among pediatric cancer patients and their parents in their ability to cope with the cancer. Although other models typically focus on the psychological resources families use to broadly cope with a diagnosis of pediatric cancer, we present a model that focuses specifically how parents and children cope with the stress of invasive and often painful treatment episodes. Our resources model is further distinct with its focus on individual differences in personal (e.g., personality traits) and social (e.g., social support) resources and the role these differences may play in psychosocial adjustment of families confronting pediatric cancer. We use findings from the broader pediatric cancer research literature and our own 15-year program of research on individual differences in psychological resources and parents and children's responses to treatment episodes to provide empirical support for our model. Support was found for the six premises of the model: (a) parent resources influence their longer-term psychosocial adjustment, (b) parent resources influence children's responses to treatment episodes, (c) parent resources indirectly influence their longer-term psychosocial adjustment through their responses to treatment episodes, (d) children's personal resources influence how parent responses to treatment episodes, (e) children's resources influence their longer-term psychosocial adjustment, and (f) children's resources indirectly influence their longer-term psychosocial adjustment through their responses to treatment episodes. Understanding how the availability of resources influences parents and children confronting cancer provides a foundation for future research on individual differences in resources and offers other avenues through which clinicians can assess and treat families at risk for poor psychosocial adjustment during treatment and in their life beyond cancer treatments.

The Relationship Between Parent Distress and Child Quality of Life in Pediatric Cancer: A Meta-Analysis

PROBLEM

Pediatric cancer places both parents and children at risk for psychosocial difficulties, including a specific risk for diminished quality of life. Previous research has identified relationships between parent and child psychosocial adjustment outcomes (e.g., depression, anxiety), yet the relationships between parent adjustment and child quality of life have yet to be comprehensively evaluated via meta-analysis.

ELIGIBILITY CRITERIA

A systematic review and meta-analysis were conducted using EBSCO, with PsychINFO, MEDLINE, Academic Search Premiere, and Health Source: Nursing/Academic Edition.

SAMPLE

Fourteen studies met inclusion criteria.

RESULTS

Fourteen correlations from 1646 parents of children with cancer were evaluated, resulting in a medium-magnitude correlation between parent psychosocial adjustment and child quality of life (r = 0.23, p < .001). Additional analyses evaluating the relationship between parent psychosocial adjustment and child social/emotional quality of life resulted in a medium-magnitude correlation (r = 0.24, p < .001).

CONCLUSIONS

A significant relationship exists between parent psychosocial adjustment and child quality of life. However, this relationship appears slightly less strong than those found in meta-analyses evaluating other child psychosocial adjustment outcomes.

IMPLICATIONS

Parent distress is an important factor to evaluate in the context of pediatric cancer, as it appears to have implications for child quality of life, in addition to other child psychosocial adjustment outcomes.

Neurodevelopmental consequences of pediatric cancer and its treatment: applying an early adversity framework to understanding cognitive, behavioral, and emotional outcomes

Today, children are surviving pediatric cancer at unprecedented rates, making it one of modern medicine's true success stories. However, we are increasingly becoming aware of several deleterious effects of cancer and the subsequent "cure" that extend beyond physical sequelae. Indeed, survivors of childhood cancer commonly report cognitive, emotional, and psychological difficulties, including attentional difficulties, anxiety, and posttraumatic stress symptoms (PTSS). Cognitive late- and long-term effects have been largely attributed to neurotoxic effects of cancer treatments (e.g., chemotherapy, cranial irradiation, surgery) on brain development. The role of childhood adversity in pediatric cancer - namely, the presence of a life-threatening disease and endurance of invasive medical procedures - has been largely ignored in the existing neuroscientific literature, despite compelling research by our group and others showing that exposure to more commonly studied adverse childhood experiences (i.e., domestic and community violence, physical, sexual, and emotional abuse) strongly imprints on neural development. While these adverse childhood experiences are different in many ways from the experience of childhood cancer (e.g., context, nature, source), they do share a common element of exposure to threat (i.e., threat to life or physical integrity). Therefore, we argue that the double hit of early threat and cancer treatments likely alters neural development, and ultimately, cognitive, behavioral, and emotional outcomes. In this paper, we (1) review the existing neuroimaging research on child, adolescent, and adult survivors of childhood cancer, (2) summarize gaps in our current understanding, (3) propose a novel neurobiological framework that characterizes childhood cancer as a type of childhood adversity, particularly a form of early threat, focusing on development of the hippocampus and the salience and emotion network (SEN), and (4) outline future directions for research.

Motor skill delays in pre-school children with leukemia one year after treatment: Hematopoietic stem cell transplantation therapy as an important risk factor

CNS-directed therapies for the treatment of leukemia can adversely affect the acquisition of new skills, such as reading/writing and math. Two years after the end of treatments, children show gross and fine motor skill delays that may persist even when patients are considered healed. The goal of the present study was to assess motor skills difficulties in pre-school children with leukemia one year after treatment. Particular attention has been paid to those patients who had undergone Hematopoietic Stem Cell Transplantation (HSCT) and to the relationship between motor delays and age bands. Participants were 60 children (median age of 5; inter quartile range: 3.07–5.76), including 31 females and 29 males, 91.7% of them were affected by acute lymphoblastic leukemia (ALL), and 8.3% by acute myeloid leukemia (AML). Five children had undergone HCST. Parents were interviewed by Vineland Adaptive Behavior Scales (VABS) on children’s motor skills and filled in the Italian Temperament Questionnaire (QUIT). VABS’s total scores were converted into equivalent mental age scores (EMA). A score difference of at least three months between current age and equivalent mental age was considered a developmental delay. Non-parametric analyses were run to understand if HSCT treatment and a specific age band influence children’s motor skills. Significant delays were found in global motor skills (56.7%) as well as in fine and gross motor domains. Mann Whitney U tests showed that children with HSCT were reported to have lower gross motor mean ranks (U = 62; p = 0.004; Mean rank = 15.40) than peers without HSCT (Mean rank = 31.87) and lower mean rank values on motor temperament scale (U = 9; p = 0.003; HSCT Mean rank = 4.75 versus no HSCT Mean rank = 27.81). Kruskal Wallis’ tests identified the high risk treatment showing that HSCT experience negatively impacted the motor skills and temperamental motor activity of pre-school children one year after the diagnosis of leukemia.

Resilience in Adolescents with Cancer: Association of Coping with Positive and Negative Affect

OBJECTIVE

To examine the prospective association between adolescents' coping with cancer-related stress and observed positive and negative affect during a mother-adolescent interaction task involving discussion of cancer-related stressors.

METHODS

Adolescents (age 10-15 years) self-reported about their coping and affect approximately 2 months after cancer diagnosis. Approximately 3 months later, adolescents and mothers were video recorded having a discussion about cancer, and adolescents were coded for expression of positive affect (positive mood) and negative affect (sadness and anxiety).

RESULTS

Adolescents' use of secondary control coping (i.e., acceptance, cognitive reappraisal, and distraction) in response to cancer-related stress predicted higher levels of observed positive affect, but not negative affect, over time.

CONCLUSION

Findings provide support for the importance of coping in the regulation of positive emotions. The potential role of coping in preventive interventions to enhance resilience in adolescents facing cancer-related stress is highlighted.

Impact of Ego-resilience and Family Function on Quality of Life in Childhood Leukemia Survivors

BACKGROUND

This study aimed to examine the impact of ego-resilience and family function on quality of life in childhood leukemia survivors.

METHODS

This study targeted 100 pediatric leukemia survivors, who visited the Pediatric Hemato-Oncology Center in South Korea from Aug to Dec 2011. A structured questionnaire of ego-resilience, family function and quality of life used to collect data through direct interview with the pediatric patients and their parents. The correlation between the study variables analyzed using the Pearson's correlation coefficient, and the impact on quality of life analyzed using a stepwise multiple regression.

RESULTS

Ego-resilience (r = 0.69, P<0.001) and family function (r =0.46, P< 0.001) had a positive correlation with quality of life and all the sub-categories of quality of life. Ego-resilience was a major factor affecting quality of life in childhood leukemia survivors, with an explanatory power of 48%. The explanatory power for quality of life increased to 53% when age and family function were included.

CONCLUSION

Ego-resilience, age, and family function affect quality of life in childhood leukemia survivors. Hence, strategies are required to construct age-matched programs to improve quality of life, in order to help restore the necessary ego-resilience and to strengthen family function in childhood leukemia survivors.

Children with minimal chance for cure: parent proxy of the child's health-related quality of life and the effect on parental physical and mental health during treatment

To assess health-related quality of life (HRQOL) from the time of diagnosis until disease progression in a cohort of children with diffuse intrinsic pontine glioma (DIPG). The assessment was collected from the perspectives of the child and their parents and evaluated the effect of the child's HRQOL on their parents' physical and mental well-being, thus providing insight into the optimal timing of palliative consultation, including anticipatory grief and bereavement services. This longitudinal study assessed 25 parents and their children, ages 2-17 years of age with DIPG across five time-points, baseline and weeks 2, 4, 6, 16, 24. Assessments included the PedsQL 4.0 Core Scales, PedsQL 3.0 Brain Tumor Scale, and Short-Form 36. HRQOL instruments were completed by the child (age ≥5 years) and parent-proxy (ages 2-17 years), with the parent completing the SF-36. Children's reports and parents' proxy of their child's HRQOL indicated poor physical functioning and increased anxiety at the initiation of therapy. A trending improvement in the children's HRQOL was reported by children and parents from baseline to week 6, with a decline at week 16. The childs' parent proxy reported cognitive problems, procedural anxiety and lower overall brain tumor HRQOL were assoicated with poorer self-reported parental mental status. Palliative care consultation should be initiated at the time of diagnosis and is supported in the high physical and emotional symptom burden reported by our patients, with heightened involvement initiated at 16 weeks. Prompt palliative care involvement, mitigating anxiety associated with clinic visits and procedures, management of brain tumor specific symptoms, advanced care planning, anticipatory grief and bereavement services, and care coordination may maximize HRQOL for patients and ensure positive long-term outcomes for parents of children with DIPG.

Pediatric Cancer Patients' Treatment-Related Distress and Longer-Term Anxiety: An Individual Differences Perspective

OBJECTIVE

Although distress during treatment procedures and longer-term treatment-related anxiety are among the most common cancer-related stressors for children and their families, they are not invariant. This study examined whether individual differences in temperament and personality play a role in how children respond to treatment procedures. Attention control, a facet of the effortful control dimension of temperament, and the personality attribute ego-resilience were hypothesized to predict lower levels of distress during procedures. Moreover, ego-resilience and distress during procedures were hypothesized to account for indirect associations between attention control and longer-term treatment-related anxiety. Child gender was examined as a potential moderator of these relationships.

METHOD

Participants were 147 children undergoing treatment for pediatric cancer and their parents. At baseline, parents reported on children's effortful control and ego-resilience. Multiple raters assessed children's distress during multiple cancer-related procedures. Treatment-related anxiety was measured 3 and 9 months after the last assessed treatment procedure.

RESULTS

Attention control was linked to ego-resilience and lower levels of distress, and these variables, in turn, accounted for indirect associations between attention control and treatment-related anxiety. Associations involving ego-resilience were stronger for boys than girls.

CONCLUSION

Attention control plays an important role in children's immediate and longer-term responses to cancer-related medical procedures. Medical staff should consider individual differences in child temperament and personality when considering the nature and extent of support to provide to pediatric cancer patients and their families.

Self-distancing Buffers High Trait Anxious Pediatric Cancer Caregivers against Short- and Longer-term Distress

Pediatric cancer caregivers are typically present at their child's frequent, invasive treatments, and such treatments elicit substantial distress. Yet, variability exists in how even the most anxious caregivers cope. Here we examined one potential source of this variability: caregivers' tendencies to self-distance when reflecting on their feelings surrounding their child's treatments. We measured caregivers' self-distancing and trait anxiety at baseline, anticipatory anxiety during their child's treatment procedures, and psychological distress and avoidance three months later. Self-distancing buffered high (but not low) trait anxious caregivers against short- and long-term distress without promoting avoidance. These findings held when controlling for other buffers, highlighting the unique benefits of self-distancing. These results identify a coping process that buffers vulnerable caregivers against a chronic life stressor while also demonstrating the ecological validly of laboratory research on self-distancing. Future research is needed to explicate causality and the cognitive and physiological processes that mediate these results.

Profiles of Dispositional Expectancies and Affectivity Predict Later Psychosocial Functioning in Children and Adolescents With Cancer

OBJECTIVE

Examined how individual differences in disposition among pediatric cancer patients predict their later psychosocial functioning.

METHODS

Patients aged 8-17 years (N = 223) reported on their disposition at baseline. One and three years later, self-reports and parent reports of patient psychosocial functioning were obtained. Latent profile analysis was used to identify subgroups that differed on baseline disposition and to compare them on later outcomes.

ESULTS

Three groups were identified: The "Positive" group (59%) had high optimism and positive affectivity and low pessimism and negative affectivity; the "Moderate" group (39%) had a similar profile, with less exaggerated scores; a small, "Negative" group (2%) had the opposite profile (low optimism/positive affectivity; high pessimism/negative affectivity). These groups differed in psychosocial functioning at follow-up, generally in expected directions.

CONCLUSIONS

Most patients have a disposition that may be protective. A small minority at high risk for maladjustment is distinguished by their disposition.

The Effect of Perceived Parental Rearing Behaviors on Health-Related Quality of Life in Adolescents with Leukemia

As the prognosis of childhood leukemia has dramatically improved, clinical interest has been growing in health-related quality of life in adolescents with leukemia. An important factor in adolescent quality of life is their perception of parental rearing behavior. The aim of this study was to explore how perceived parental rearing behaviors related to the quality of life of adolescents with leukemia. A descriptive, exploratory study was conducted among 106 adolescents with leukemia using the Recalled Parental Rearing Behavior and the Minneapolis-Manchester Quality of Life scales. Data were examined using descriptive, correlation, and path analyses. The coefficients of total effect of paternal and maternal emotional warmth on the quality of life of adolescents were 0.36 and 0.45, respectively. We found that paternal rejection/punishment behavior was significantly correlated with maternal rejection/punishment behavior (P < .00); paternal and maternal control/overprotection behavior were also significantly correlated with each other (P < .00). We found that perceived parental warmth has a moderate effect on the quality of life of adolescents, that quality of life was related to both paternal and maternal rearing behaviors, and that the mother's and father's rearing behaviors were correlated with each other. To improve the quality of life of adolescents with leukemia, the patient's care plan should aim to enhance positive parental rearing behaviors in both parents.

Temperament and social behavior in pediatric brain tumor survivors and comparison peers

OBJECTIVE

To examine the role of temperament (i.e., surgency/positive affect, negative affect, and effortful control) in the social behavior of pediatric brain tumor survivors and comparison classmates.

METHODS

Parent-, peer-, and self-report data were collected for 75 children after treatment for a brain tumor, and 67 comparison classmates. Tests of mediation and moderated mediation were run to examine whether effortful control accounted for group differences in social behavior and whether this indirect effect was moderated by surgency/positive or negative affectivity.

RESULTS

Peers described survivors as lower in Leadership-popularity and higher in Sensitivity-isolation and victimization than comparison classmates. Parent and self-report of surgency/positive affect revealed survivors were lower on this dimension. Survivors were rated by parents as demonstrating less effortful control. Effortful control did not consistently account for group differences in social behavior. There was limited evidence of moderated mediation.

CONCLUSIONS

Research on the implications of potential changes in temperament following treatment is warranted.