Changes in siblings after the death of a child from cancer

Child bereavement-what matters to the families. Part 1: Immediate and short-term communication and care

The death of a child is a complex and hugely significant time for a family and community. Sophisticated but sensitive management by clinicians can have both short-term and long-term impacts on how families process the death. There is a paucity of guidance for optimal child bereavement care. A description of the child death review process including key legalities is provided here, and other essential aspects such as memory making, cultural aspects and sibling involvement are explored. Useful agencies and resources are also detailed. We, as both clinicians and bereaved parents, can uniquely provide an overview of the logistics of managing such a challenging event and highlight important subtleties in communication. We attempt, using our own experiences, to provide a framework and best inform future practice.

Healthy siblings' perspectives about paediatric palliative care: A qualitative systematic review and meta-synthesis

BACKGROUND

Siblings of children requiring palliative care are often forgotten and overlooked, as the focus tends to be on the ill child and their parents. Limited knowledge of non-bereaved siblings' perspectives makes it challenging to provide appropriate support for them. A review of existing literature is thus needed to better understand the experiences of these siblings and to identify research gaps that may require further examination.

AIM

To consolidate the available qualitative evidence on the perspectives of non-bereaved healthy siblings regarding paediatric palliative care.

DESIGN

A qualitative systematic review using a meta-synthesis approach was conducted.

DATA SOURCES

Six electronic databases (PubMed, CINAHL, PsycINFO, Embase, Scopus and ProQuest Dissertations and Theses Global) were searched from each database's inception date until October 2022. The search included qualitative and mixed-method studies that reported the perceptions and associations of siblings of patients receiving paediatric palliative care. Data were synthesised using thematic analysis.

RESULTS

Eleven studies were included. The overarching theme of the review would be 'A walking shadow: Living in the darkness shaped by the dying sibling', and three key themes and nine subthemes were identified from the included articles: (1) Changing family dynamics; (2) Impact on school and socialisation and (3) Psychological impact and coping.

CONCLUSION

Siblings demonstrated negative psychological impacts and were affected by changing family structure and relationships. However, socialisation with society, and varied coping skills such as cognitive coping and using distraction techniques, were significant for siblings to go through this journey and even led to some positive outcomes for them.

Associations between parental depression, communication, and self-worth of siblings bereaved by cancer

A child's death from cancer may increase the risk for poor self-worth in bereaved siblings. Furthermore, bereaved parents may experience depressive symptoms and communicate differently with their surviving children. However, limited research has examined family factors associated with self-worth in bereaved siblings. Thus, we examined: (a) differences in parental depressive symptoms, parent-child communication, and sibling self-worth between bereaved and nonbereaved families and (b) indirect effects of parental depressive symptoms and communication quality on the association between bereavement and sibling self-worth. Bereaved parents and siblings were recruited 3-12 months after a child's death from cancer. Bereaved (n = 72) and nonbereaved families of classmates (n = 58) completed home-based questionnaires upon enrollment (T1), and 48 bereaved and 45 nonbereaved families completed 1-year follow-up (T2). Relative to controls at T1 and T2, bereaved mothers, but not fathers, reported more depressive symptoms. Bereaved siblings reported poorer maternal and similar paternal communication, and similar levels of self-worth compared to controls. Both cross-sectional and longitudinal serial mediation models for mothers were significant. Bereaved mothers were at greater risk for depressive symptoms, which adversely affected sibling self-worth over time through disrupted mother-child communication. The father sample was limited, but the cross-sectional model was nonsignificant. Mothers and fathers may grieve differently and may require different therapeutic approaches. Family-centered interventions should target bereaved mothers' emotional adjustment and communication to enhance sibling self-worth. Additionally, clinicians should bolster other sources of support for bereaved siblings to promote adaptive outcomes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Changes in Relationships in Bereaved Families: Perspectives of Mothers Who Lost a Child to Cancer

The loss of a child greatly affects the dynamics of interpersonal relationships in bereaved families. This study explored the relationships in bereaved Korean families from the perspectives of mothers after the death of a child due to cancer. We conducted in-depth interviews with 15 bereaved mothers of a deceased child with childhood cancer. Thematic analysis identified 12 subthemes related to bereaved mothers' struggles in grief within three significant themes based on family relationships: (a) relationship with husband; (b) relationship with surviving child or children; and (c) relationships with extended family members. Findings highlight bereaved mothers' need to build supportive family relationships while acknowledging bereaved family members' different grieving styles and their own challenges in grieving the loss of a child.

The bereavement experiences of children following sibling death: An integrative review

PROBLEM

Sibling bereavement is one of the most distressing adverse life events during childhood but has received less attention in research than other forms of childhood bereavement. This integrative review identifies potential risk and protective factors for maladaptive coping following sibling bereavement and the influence of these factors on adjustment to loss.

ELIGIBILITY CRITERIA

Articles were limited to peer-reviewed studies, published in English in 2000 and beyond. Target population was bereaved siblings 0-18 years, and outcomes examined grief experiences by child self-report or parent-proxy report.

SAMPLE

The Whittemore and Knafl integrative framework was applied. Multidimensional Grief Theory guided the review with twenty-five studies synthesized across its domains: Separation Distress, Existential/Identity Crisis, and Circumstance-Related Distress.

RESULTS

Adjustment following sibling death is a complex process associated with a host of risk and protective factors that contribute to the bereavement process for this population. Age, sex, circumstance-related factors, continuing bonds, parental distress, and limited social support were critical influencing factors.

CONCLUSION

Definitive predictor variables were not identified but a combination of variables that influence the adjustment of bereaved siblings are discussed.

IMPLICATIONS

Future research is needed to explore the risk and protective factors of maladaptive coping to inform intervention development to promote individual and family adjustment following sibling death.

The Lived Experience of Siblings of Children With Cancer Who Attended a Peer Support Camp in the United States

Childhood cancer has a profound and negative impact on siblings, yet there are limited studies exploring lived experiences from their perspective. This qualitative study examined the perceptions and experiences of siblings of children with cancer who attended a peer support camp. Semi-structured interviews were conducted three to six weeks after the weeklong peer support camp with a stratified random sample of 10 siblings (six non-bereaved and four bereaved) ages 8 to 16 years. The qualitative data were analyzed using conventional content analysis and an inductive data-driven approach. Four themes emerged: social connection (subthemes: support/feeling of belonging, mentorship, and expressing feelings), personal growth, identity, and freedom to have fun and relax. These findings add to the scant body of research by providing enhanced understanding of the siblings' experiences and new insights into their perceptions of meaning and outcomes associated with participation in a peer support camp. These findings have implications for peer support camp programs and the well-being of siblings of children with cancer.

Impact of resilience and social support on long-term grief in cancer-bereaved siblings: an exploratory study

Background

Bereavement research has mainly explored potential risk factors associated with adverse outcomes, and the role of protective factors has received less attention. More knowledge is needed about factors related to unresolved grief in bereaved siblings. This study aimed to assess grief adjustment and possible gender differences among bereaved young adults 2–10 years after losing a brother or sister to cancer. We also sought to explore how resilience and social support influenced their grief.

Methods

A total of 99 young adults (18–26 years) who had lost a brother or sister to cancer between the years 2009 and 2014 were invited to participate in this Norwegian nationwide study. The study-specific questionnaire was completed by 36 participants (36.4%). Social support during the sibling's illness, after the death, and during the past year, in addition to grief and resilience, were measured.

Results

Overall, the prevalence of unresolved grief was 47.2% among bereaved siblings, whereas 52.8% had worked through their grief. The level of having worked through grief and resilience was similar between male and female siblings. Bereaved siblings with higher Personal Competence reported lower unresolved grief.

Conclusion

Approximately half of the young adults experience unresolved grief 2–10 years after losing a sibling to cancer. The findings also highlight the need for long-term support for bereaved siblings to help improve their resilience and better have worked through their grief.

Impact of End-of-Life Circumstances on the Adjustment of Bereaved Siblings of Children Who Died from Cancer

The aim of this study was to examine the impact of end-of-life (EoL) circumstances on grief and internalizing symptoms among bereaved siblings. Bereaved families (N = 88) were recruited from three sites 3-12 months (M = 11.57, SD = 3.48) after their child's death from cancer. One sibling per family aged 8-17 years (M = 12.41, SD = 2.64) was randomly selected to participate. Families completed measures of siblings' grief and internalizing symptoms, as well as a structured interview about circumstances surrounding the death. Mother and sibling reports of EoL circumstances were generally concordant, except there was a discrepancy between mothers and children about whether or not children expected their sibling's death (t(75) = 1.52, p = .018). Mother reports of sibling internalizing symptoms were above the normative mean (t(83) = 4.44, p ≤ .001 (M = 56.01 ± 12.48), with 39% (n = 33) in the borderline/clinical range. Sibling opportunity to say goodbye was associated with greater grief-related growth (t(79) = - 1.95, p = .05). Presence at the death and wishing they had done something differently were both associated with greater grief (t(80) = - 2.08, p = .04 and t(80) = - 2.24, p = .028, respectively) and grief-related growth (t(80) = - 2.01, p = .048 and t(80) = - 2.31, p = .024, respectively). However, findings were primarily unique to sibling report, with few mother-reported effects. The adjustment of bereaved siblings may be affected by certain modifiable circumstances surrounding the death of their brother or sister. A proportion of bereaved siblings had elevated internalizing symptoms irrespective of circumstances at EoL. Further work is needed to understand predictors of adjustment among bereaved siblings to provide better support and optimize their outcomes.

Long-Term Follow-Up of Legacy Services Offered by Children's Hospitals in the United States

Background: Our 2012 survey of providers described legacy services offered at children's hospitals nationwide. Since then, the science related to legacy interventions has advanced, resulting in increased recognition of the importance of legacy services. Yet, legacy interventions offered by children's hospitals have not been recently described.

Objective: To describe current legacy services offered by children's hospitals in the United States and compare with our previous results.

Design: Descriptive cross-sectional design.

Setting/Subjects: Participants included providers (N = 54) from teaching children's hospitals in the United States.

Measurements: Electronic REDCap survey.

Results: Similar to our prior research, 100% of respondents reported that their hospital offers legacy activities with 98% providing such services as a standard of care. Notable increased numbers of children are participating in legacy interventions compared with the previous study, now with 40% (compared with 9.5% previously) of participants reporting >50 children per year. Patients being offered legacy activities include neonatal intensive care unit (NICU) patients, those with life-threatening traumatic injuries, those on life support for extended periods of time, and those referred to hospice. Although not statistically significant, the percentage of hospitals offering legacy-making to children with cancer, neurodegenerative diseases, and life-threatening illnesses is slightly increased from the prior time point.

Conclusions: Children across developmental stages and illness contexts and their families can benefit from both the memories generated through the process of legacy services and the subsequent tangible products. Providers should continue to offer legacy opportunities to seriously ill children and their families across a wide array of settings and illness contexts.

Effectiveness of Theraplay in Internalizing and Externalizing Problems in Bereaved Siblings of Children with Cancer

Background: Sibling relationships are very significant relationships, and their termination due to death will have profound long-term effects on the life of the surviving children. Objectives: The purpose of the current study was to determine the effectiveness of theraplay on internalizing and externalizing problems in bereaved siblings. Methods: This study was carried out using a single-subject multiple baseline design with follow-up. The statistical population included siblings and mothers of children aged 6 - 10 years who were on treatment at Mahak Pediatric Cancer Hospital and died one or two years ago. From this population, four mother-child pairs were selected as the study sample by convenience sampling. Each mother-child pair participated in 15 theraplay sessions once a week (45-min sessions). The assessments were carried out using the Child Behavior Checklist (CBCL) at baseline and in the intervention sessions and follow-up. Visual analysis of graphic displays of level, Reliable Change Index (RCI), and clinical significance were used to analyze the data. Data analysis and drawing the graphs were performed in Microsoft Excel 2016. Results: The results of the visual and quantitative data analysis showed a significant reduction in the four participants' internalizing problems during therapy. The reduction in the scores of this subscale in participants 1, 2, and 3 continued into the follow-up period and was noticeable. The results also showed that theraplay reduced the externalizing problems of most participants. A large proportion of these results persisted into the follow-up period. Conclusions: Theraplay appears to effectively reduce the internalizing and externalizing problems of bereaved siblings.

Parent and child perceptions of the child's health at 2, 4, 6, and 13 months after sibling intensive care or emergency department death

BACKGROUND

Approximately 50,000 US infants and children die annually, leaving surviving children and families with long-lasting effects. In most studies, children's health is rated by parents, but not the children.

PURPOSE

To compare the surviving children's self-rated health with parents' ratings at 2, 4, 6, and 13 months after sibling neonatal intensive care unit/pediatric intensive care unit/emergency department death death and identify the related factors.

METHODS

Children and their parents rated the child's health "now," "now compared with others your age," and "now versus before" the sibling's death.

SAMPLE

One hundred thirty-two children (58% girls, 72% school-aged, and 50% Black non-Hispanic), 70 mothers, and 26 fathers from 71 bereaved families.

CONCLUSIONS

Children self-rated their health: "now" as lower than their mothers at 4, 6, and 13 months and their fathers at 2, 4, and 13 months; "now compared with others your age" as lower than their mothers at each time point and fathers at 4, 6, and 13 months; and "now versus before" their sibling's death as higher than their mothers at 4, 6, and 13 months and fathers at 6 months. Ratings did not differ by age, gender, or race/ethnicity. At 6 months, children self-rated their health "now" as higher than their fathers in families with one to two surviving children but lower than their fathers in families with three to eight surviving children.

IMPLICATIONS FOR PRACTICE

Parents often perceive their children as healthier than children perceive themselves after sibling death, especially in larger families. Talking with children separately can identify the children at risk for emotional and physical illnesses earlier, providing more timely and appropriate interventions and referrals.

The Influence of Parent Distress and Parenting on Bereaved Siblings' Externalizing Problems

OBJECTIVES

Bereaved siblings experience more externalizing problems compared to non-bereaved peers and norms; however, the mechanisms explaining this phenomenon have not been empirically examined. This study tested the serial indirect effects of sibling bereavement on adolescents' externalizing problems through parent distress (i.e., internalizing symptoms) and parenting (i.e., parenting behaviors, parent-adolescent communication).

METHODS

During home visits, 72 bereaved adolescents (ages 10-18) whose brother/sister died from cancer and 60 comparison peers reported about their externalizing problems and their mothers' and fathers' parenting behaviors (warmth, behavioral control, psychological control) and parent-adolescent communication (open communication, problematic communication). Mothers and fathers reported their own internalizing symptoms.

RESULTS

Bereaved siblings reported more externalizing problems (p =.048) and bereaved mothers reported more internalizing symptoms relative to the comparison group (p =.015). Serial multiple mediation models indicated that elevated externalizing problems were partially explained by both bereaved mothers' internalizing symptoms and parenting and communication (less warmth [CI: 0.04, 0.86], more psychological control [CI: 0.03, 0.66], and more problematic mother-adolescent communication [CI: 0.03, 0.79]), with a significant indirect effect also emerging for open mother-adolescent communication [CI: 0.05, 1.59]. Bereaved fathers did not significantly differ in internalizing symptoms from comparison fathers (p =.453), and no significant indirect effects emerged for fathers.

CONCLUSIONS

Elevated externalizing problems in bereaved siblings may result from mothers' distress and the impact on their parenting and communication. Targeting adjustment and parenting in bereaved mothers following a child's death may reduce externalizing problems in bereaved siblings. Research to evaluate family-centered interventions is needed.

Bereavement Accommodations in the Classroom: Experiences and Opinions of School Staff

BACKGROUND

Bereaved children often struggle in the school environment and school personnel often feel inadequately prepared to support them. This pilot study explored the experiences and opinions of school staff regarding approaches to addressing the needs of bereaved students in the classroom.

METHODS

Teachers/school personnel (N = 29) completed written open-ended questions about their experiences with bereaved students and opinions regarding a bereavement-focused accommodation (ie, 504) plan. Responses were summarized using qualitative content analysis.

RESULTS

Most participants (93%) reported interacting with bereaved students and: (1) providing emotional support; (2) making classroom accommodations; (3) collaborating with the family/community; and (4) referring the student for counseling. Many (72%) expressed interest in a templated bereavement plan (21% did not respond; 7% said no) with education/resources for school personnel and suggested accommodations for students.

CONCLUSIONS

Teachers encountering grieving students would welcome a templated bereavement plan to help meet students' needs. Such a plan would allow staff to become more knowledgeable about grief and provide guidance for developing specific strategies to accommodate grieving students both emotionally and academically.

Changes in Siblings Over Time After the Death of a Brother or Sister From Cancer

BACKGROUND

Limited research has examined the impact of a child's death from cancer on siblings. Even less is known about how these siblings change over time.

OBJECTIVE

This study compared changes in siblings 1 (T1) and 2 (T2) years after the death of a brother or sister from cancer based on bereaved parent and sibling interviews.

METHODS

Participants across 3 institutions represented 27 families and included bereaved mothers (n = 21), fathers (n = 15), and siblings (n = 26) ranging from 8 to 17 years old. Participants completed semistructured interviews. Content analysis identified emerging themes and included frequency counts of participant responses. McNemar tests examined differences in the frequency of responses between T1 and T2 data.

RESULTS

Participants reported similar types of changes in bereaved siblings at both time points, including changes in sibling relationships, life perspectives, their personal lives, and school performance. A new theme of "openness" emerged at T2. Frequencies of responses differed according to mother, father, or sibling informant. Overall, participants less frequently reported changes at T2 versus T1. Compared with findings in the first year, participants reported greater sibling maturity at follow-up.

CONCLUSION

Overall changes in bereaved siblings continued over 2 years with less frequency over time, with the exception of increases in maturity and openness.

IMPLICATIONS FOR PRACTICE

Providers can educate parents regarding the impact of death of a brother or sister over time. Nurses can foster open communication in surviving grieving siblings and parents as potential protective factors in families going through their grief.

"It has been fun. Super-duper fantastic": Findings from a Danish respite programme to support young carers

Awareness of young carers' experiences and needs is low on governmental and societal levels in Denmark. This article presents findings from the first evaluation of a Danish respite programme, the Buddy Programme, which aims to provide support to young carers aged 5-15 years who experience serious, chronic or mental health problems and/or death of a parent or sibling. Over a four-six month period, volunteer students from University College Copenhagen offer young carers the opportunity of respite through participating in ordinary activities such as play and sports. In 2017-2018, based on a child-centred approach, we conducted a qualitative study with interviews focusing on how the Buddy programme affected the children. The interviews took place at programme start, halfway through, and after completion with 22 children and 21 parents, as well as single interviews with 20 Buddies assigned to families after completion. Three main themes were identified: (1) the Buddy programme as an activity, (2) how the Buddy Programme affected the children and (3) ending the Buddy programme and wanting to continue the friendship. Our findings emphasise the importance of fun and cosy activities that provide children with respite from the serious concerns that otherwise fill the lives of young carers. Being with a Buddy created a free space, allowing children to play undisturbed and to temporarily keep concerns and a guilty conscience at a distance. By offering friendship, Buddies provided opportunities for young carers to feel special, be seen, acknowledged and taken seriously as a child with valid and specific needs and interests. Our findings may help increase awareness of the needs and interests of young carers on governmental and societal levels.

Long-Term Mental Health Outcomes in Mothers and Siblings of Children With Cancer: A Population-Based, Matched Cohort Study

PURPOSE

Although a diagnosis of childhood cancer can have a profound effect on the entire family unit, its impact on the long-term mental health of family members is not well characterized.

METHODS

A provincial childhood cancer registry in Ontario, Canada, was linked to birth records to identify separate population-based cohorts of mothers and siblings of children diagnosed with cancer between 1998 and 2014. The mother and sibling cohorts were matched to corresponding population controls and linked to health services data. The rate of mental health-related outpatient visits (family physician, psychiatrist) and the incidence of severe psychiatric events (psychiatric emergency department visit, psychiatric hospitalization, suicide) were compared between mothers and siblings and their controls. Possible predictors of mental health outcomes were examined, including demographics, characteristics of the cancer-affected child, and cancer treatment.

RESULTS

We identified 4,773 mothers and 7,897 siblings of children diagnosed with cancer during the study period. Compared with controls, both groups experienced elevated rates of outpatient visits (mothers: rate ratio [RR], 1.4; P < .0001; siblings: RR, 1.1; P < .0001). The risk of severe psychiatric events was not increased in either cohort. Mother and sibling demographic factors associated with increased risk of adverse mental health included younger maternal age at cancer diagnosis, low socioeconomic status, and rural residence among mothers and older sibling age among siblings. Treatment-related variables pertaining to the cancer-affected child were not associated with mental health outcomes. Mental health outcomes clustered within families.

CONCLUSION

Both mothers and siblings experience elevated and prolonged need for mental health-related health care as compared with the general population. Demographic risk factors predict subpopulations at highest risk. Increased psychosocial support for family members during and after cancer therapy is warranted.

Black, White, and Hispanic Children's Health and Function 2-13 Months After Sibling Intensive Care Unit Death

OBJECTIVE

To describe children's anxiety, depression, behaviors, and school performance at 2-13 months after sibling neonatal/pediatric intensive care unit (NICU/PICU) or emergency department (ED) death and compare these outcomes by child age, sex, race/ethnicity, whether the child saw their sibling in the NICU/PICU/ED, and attended the sibling's funeral.

STUDY DESIGN

Children in 71 families were recruited for this longitudinal study from 4 children's hospitals and 14 other Florida hospitals. Children rated anxiety (Spence Children's Anxiety Scale) and depression (Children's Depression Inventory); parents rated child behaviors (Child Behavior Checklist) and reported school performance (detentions, suspensions, requested parent-teacher meetings) at 2, 4, 6, and 13 months post-sibling death. Analyses included repeated measures-ANOVA, t-tests, and 1-way ANOVA.

RESULTS

In total, 132 children and 96 parents participated. More children were female (58%), black (50%), and school-age (72%). Of the children, 43% had elevated anxiety and 6% had elevated depression over 13 months post-sibling death. Child-rated anxiety was higher for girls and black vs white children. Child-rated anxiety and depression were lower if they saw their sibling in the NICU/PICU/ED before and/or after the death, and/or attended the funeral. Teens were more withdrawn than school-age children at all time points. Children who did not see their deceased sibling in the NICU/PICU/ED after death had more requests for parent-teacher conferences.

CONCLUSIONS

Children's anxiety was more common than depression, especially in girls and black children. Children who saw their siblings in the NICU/PICU/ED before/after death and/or attended funeral services had lower anxiety and depression over the first 13 months after sibling death.

Adaption strategies used by siblings to childhood cancer patients

OBJECTIVE

Siblings of childhood cancer patients experience social challenges. The results presented in this article are part of a larger qualitative study aiming to generate empirical knowledge about social consequences of childhood cancer from the family's perspective.

METHODS

Data were collected through interviews, observational studies, and questionnaires. The study included 68 childhood cancer patients, 39 siblings, and 39 parents from a total of 78 families. Grounded theory informed the data analysis.

RESULTS

Major life changes caused by childhood cancer entail an emotional hierarchy regarding the accommodation of each family member's need for help. This study identified a dynamic three-variable, four-adaption model for adaption strategies among siblings towards their parents, based on the sibling's perspective: (1) receives help without asking; (2) receives help after asking; (3) receives no help despite asking; and (4) receives no help and does not ask. Three variables are elaborative to understand the dynamic in adaption strategies: the patient's prognosis, the course of the disease, and the current situation of the diagnosed child. Even though the adaptions are reported by siblings, both patients and parents are aware of and concerned about the siblings' challenges.

CONCLUSIONS

These results have implications for practice and have the potential to improve social and health care professionals' awareness and ability to offer support and information needed by the families and the siblings. The knowledge presented in this article should be considered basic health care information in line with other information such as treatment protocols.

The Phenomenon of Bereaved Parenting: An Integrative Review of Literature

Bereaved parenting, a role that entails parenting surviving children after experiencing the death of a child, is a unique but understudied phenomenon within bereavement research. Not much is known about the impact of a child's death on this crucial familial role. An integrative review of literature of 20 studies across psychology, nursing, communications, social work, and family sciences was undertaken to determine the current state of science regarding bereaved parenting. Results revealed three influential contexts: the general context of parental grief and bereavement, described as traumatic and life-changing experiences; the personal context of the resulting parental changes and coping strategies; and the relational context of the subsequent parenting of surviving children, an experience characterized by periodic conflict between personal and children's needs, emotional fluctuations, challenges with levels of protectiveness and control, and a heightened sense of responsibility within the parental role. Discussion of results and implications for research are presented.

An integrative review of sibling responses to childhood cancer

TOPIC

Siblings of children with cancer experience extraordinary responses and changes to their lives over the course of their family's cancer journey.

PURPOSE

The purpose of this paper is to conduct an integrative literature review to synthesize and analyze relevant findings related to the siblings' experiences of childhood cancer.

SOURCES USED

CINAHL, PubMed, Embase, MEDLINE, and PsycINFO were searched using the key terms: "sibling*" AND "pediatric*" AND "cancer" AND "experienc*" OR "experience*." Inclusion criteria for this review were research studies focused on sibling responses to having a brother or sister with cancer, published in English between January 1, 2012 and December 31, 2017.

CONCLUSIONS

Siblings of children with cancer experience many changes to their emotions, relationships, family and home life, school life, and extracurricular activities. They have specific needs and desires including the need for information. Whereas they undergo many changes during the cancer journey, siblings often demonstrate resilience and personal growth and find ways to problem-solve and cope.

Grief and growth in bereaved siblings: Interactions between different sources of social support

The objective was to characterize the relation between different sources of school-based social support (friends, peers, and teachers) and bereaved siblings' grief and grief-related growth and to examine whether nonparental sources of social support buffer the effects of low parent support on bereaved siblings. Families (N = 85) were recruited from cancer registries at 3 pediatric institutions 3-12 months after a child's death. Bereaved siblings were 8-18 years old (M = 12.39, SD = 2.65) and majority female (58%) and White (74%). During home visits, siblings reported their perceptions of social support from parental and nonparental sources using the Social Support Scale for Children, as well as grief and grief-related growth using the Hogan Sibling Inventory of Bereavement. Parent, friend, and teacher support were positively correlated with grief-related growth, whereas parent and peer support were negatively correlated with grief for adolescents. Teacher and friend support significantly moderated the association between parent support and grief such that teacher and friend support accentuated the positive effects of parent support. Friend and peer support moderated associations between parent support and grief/growth for adolescents but not children. School-based social support, namely from friends, peers, and teachers, appears to facilitate the adjustment of bereaved siblings. Findings suggest that bereaved siblings may benefit from enhanced support from teachers and friends regardless of age, with middle/high school students particularly benefitting from increased support from close friends and peers. (PsycINFO Database Record

Psychosocial outcomes in cancer-bereaved children and adolescents: A systematic review

OBJECTIVE

Due to the unique importance of parental and sibling relationships and concurrently existing developmental challenges, the loss of a parent or sibling due to cancer is a highly stressful event for children and adolescents. This is the first systematic review that integrates findings on psychosocial outcomes after parental or sibling cancer bereavement.

METHODS

A systematic search of Web of Science, PubMed, PsycINFO, and PubPsych was conducted, last in December 2017. Quantitative studies on psychosocial outcomes of children and adolescents who lost a parent or sibling due to cancer were included.

RESULTS

Twenty-four studies (N = 10 parental and N = 14 sibling bereavement), based on 13 projects, were included. Ten projects had cross-sectional designs. Only 2 projects used large, population-based samples and nonbereaved comparison groups. Outcomes were partially measured by single-item questions. Bereaved children and adolescents showed similar levels of depression and anxiety compared with nonbereaved or norms. Severe behavioral problems were found rarely. However, in 2 large, population-based studies, about half of the bereaved individuals reported unresolved grief. Bereaved adolescents had a higher risk for self-injury compared with the general population in one large, population-based study. Communication with health-care professionals, family, and other people; social support; distress during illness; age; gender; and time because loss were associated with psychosocial bereavement outcomes.

CONCLUSIONS

Results indicate a high level of adjustment in cancer-bereaved children and adolescents. A modifiable risk factor for adverse psychosocial consequences is poor communication. Prospective designs, representative samples, and validated instruments, eg, for prolonged grief, are suggested for future research.

Defining Provider-Prioritized Domains of Quality in Pediatric Home-Based Hospice and Palliative Care: A Study of the Ohio Pediatric Palliative Care and End-of-Life Network

BACKGROUND

In 2017, the Ohio Pediatric Palliative Care and End-of-Life Network (OPPEN) published nine domains of high-quality care for pediatric home-based hospice and palliative care (HBHPC). Eight domains established by the National Consensus Project (NCP) were validated for pediatric HBHPC, and a ninth domain of "Continuity and Coordination of Care" was added.

OBJECTIVE

The aim of this study was to establish definition criteria for each of these domains.

DESIGN AND SETTING

Using a modified Delphi technique, providers from the OPPEN were surveyed regarding definitions drawn from the NCP domain criteria. For the ninth domain, new definition criteria were generated de novo based on qualitative responses.

RESULTS

Definition criteria were established for the nine domains of quality in HBHPC previously identified. In the course of analysis, Bereavement Care was established as a 10th domain of quality, and definition criteria generated.

CONCLUSIONS

This is the first study to define domains of quality for pediatric HBHPC, and the second to leverage the infrastructure of a pediatric HPC statewide consortium toward this work. Future studies are needed to establish parent and patient-prioritized domains of quality in pediatric HBHPC, and to map indicators validated in pediatrics to these domains.

Siblings' voices: A prospective investigation of experiences with a dying child

Sibling relationships reflect a unique childhood bond, thus the impact on a sibling when a child is seriously ill or dying is profound. We conducted a prospective, longitudinal, qualitative study over 2 years using interpretive descriptive methodology to understand siblings' perspectives when a brother or sister was dying at home or in hospital. The insights from the 10 siblings revealed complex experiences, both personal and with the ill child, their families, and peers. These experiences were paradoxically sources of strain and of support, revealing the importance of validation and normalization in assisting siblings to successfully navigate the experience.

Parental experiences with a paediatric palliative care team: A qualitative study

BACKGROUND

Parents of children with a life-limiting disease have to rely on themselves at home while adequate paediatric palliative care is lacking. In several countries, paediatric palliative care teams are introduced to ensure continuity and quality of care and to support the child and the family. Yet, little is known about how parents experience such multidisciplinary teams.

AIM

To obtain insight into the support provided by a new paediatric palliative care team from the parents' perspective.

DESIGN

An interpretative qualitative interview study using thematic analysis was performed.

SETTING/PARTICIPANTS

A total of 47 single or repeated interviews were undertaken with 42 parents of 24 children supported by a multidisciplinary paediatric palliative care team located at a university children's hospital. The children suffered from malignant or non-malignant diseases.

RESULTS

In advance, parents had limited expectations of the paediatric palliative care team. Some had difficulty accepting the need for palliative care for their child. Once parents experienced what the team achieved for their child and family, they valued the team's involvement. Valuable elements were as follows: (1) process-related aspects such as continuity, coordination of care, and providing one reliable point of contact; (2) practical support; and (3) the team members' sensitive and reliable attitude. As a point of improvement, parents suggested more concrete clarification upfront of the content of the team's support.

CONCLUSION

Parents feel supported by the paediatric palliative care team. The three elements valued by parents probably form the structure that underlies quality of paediatric palliative care. New teams should cover these three valuable elements.

Parenting in Childhood Life-Threatening Illness: A Mixed-Methods Study

BACKGROUND

Parenting children with life-threatening illness (LTI) and their healthy siblings requires parents to consider their various needs.

OBJECTIVE AND METHODS

We conducted a concurrent, cross-sectional mixed-methods study to describe challenges parents face prioritizing tasks and goals for each child with qualitative data, compare parents' tasks and goals for children with LTI and healthy siblings with quantitative data, and describe parenting in terms of the process of prioritizing tasks and goals for all children in the family.

RESULTS

Participants included 31 parents of children with LTI who have healthy siblings and were admitted to a children's hospital. Qualitative interviews revealed how parents managed children's needs and their perceptions of the toll it takes. Quantitative data revealed that parents prioritized "making sure my child feels loved" highest for ill and healthy children. Other goals for healthy siblings focused on maintaining emotional connection and regularity within the family and for ill children focused on illness management. Mixed-methods analysis revealed that parents engaged in a process decision making and traded-off competing demands by considering needs which ultimately transformed the meaning of parenting.

DISCUSSION

Future research can further examine trade-offs and associated effects, how to support parent problem-solving and decision-making around trade-offs, and how to best offer social services alongside illness-directed care.

Approaching the third decade of paediatric palliative oncology investigation: historical progress and future directions

Paediatric palliative care (PPC) endeavours to alleviate the suffering and improve the quality of life of children with serious illnesses and their families. In the past two decades since WHO defined PPC and called for its inclusion in paediatric oncology care, rigorous investigation has provided important insights. For example, the first decade of research focused on end-of-life experiences of the child and the family, underscoring the high prevalence of symptom burden, the barriers to parent-provider concordance with regards to prognosis, as well as the need for bereavement supports. The second decade expanded PPC oncology investigation to include the entire cancer continuum and the voices of patients. Other studies identified the need for support of parents, siblings, and racial and ethnic minority groups. Promising interventions designed to improve outcomes were tested in randomised clinical trials. Future research will build on these findings and pose novel questions about how to continue to reduce the burdens of paediatric cancer.

Encontrar sentido para continuar viviendo el reto al perder un hijo por cáncer infantil: revisión integrativa

La experiencia de perder un hijo por cáncer representa para los padres una carga emocional de alto impacto individual, familiar y social que no finaliza con la muerte. Esta revisión integrativa tuvo como objetivo identificar aspectos clave en la experiencia de perder un hijo como consecuencia del cáncer infantil. Los resultados mostraron un patrón (búsqueda de sentido) que rodea seis momentos del proceso de duelo, que pueden ser elementos de intervención para acompañar el proceso de afrontamiento de los padres. Se concluye que este patrón es un fenómeno importante para el desarrollo del área de cuidado paliativo al final de la vida y posterior.

Feasibility of group intervention for bereaved siblings after pediatric cancer death

This study evaluated the feasibility (acceptability, recruitment, retention rates, treatment fidelity, and outcome measures) of implementing a manualized group intervention for bereaved siblings after pediatric cancer death. A convenience sample of 10 siblings participated. The intervention consisted of eight 2-hour sessions that focused on strategies for coping with grief, relationships, and emotional growth. Positive outcomes were obtained with respect to acceptability, recruitment, retention rates, and treatment fidelity. Preliminary outcomes were mixed. Parent pre- and post-intervention outcomes suggested improvements in siblings' overall emotional and social quality of life. Siblings' self-reports reflected no improvements. These data support the feasibility of conducting this intervention and suggest beneficial outcomes based on parental reports. Further research is recommended to evaluate the group intervention efficacy with a large sample using a randomized controlled trial to address the needs of bereaved siblings.

Facebook advertisements recruit parents of children with cancer for an online survey of web-based research preferences

BACKGROUND

Studies involving samples of children with life-threatening illnesses and their families face significant challenges, including inadequate sample sizes and limited diversity. Social media recruitment and Web-based research methods may help address such challenges yet have not been explored in pediatric cancer populations.

OBJECTIVE

This study examined the feasibility of using Facebook advertisements to recruit parent caregivers of children and teenagers with cancer. We also explored the feasibility of Web-based video recording in pediatric palliative care populations by surveying parents of children with cancer regarding (a) their preferences for research methods and (b) technological capabilities of their computers and phones.

METHODS

Facebook's paid advertising program was used to recruit parent caregivers of children currently living with cancer to complete an electronic survey about research preferences and technological capabilities.

RESULTS

The advertising campaign generated 3 897 981 impressions, which resulted in 1050 clicks at a total cost of $1129.88. Of 284 screened individuals, 106 were eligible. Forty-five caregivers of children with cancer completed the entire electronic survey. Parents preferred and had technological capabilities for Web-based and electronic research methods. Participant survey responses are reported.

CONCLUSION

Facebook was a useful, cost-effective method to recruit a diverse sample of parent caregivers of children with cancer. Web-based video recording and data collection may be feasible and desirable in samples of children with cancer and their families.

IMPLICATIONS FOR PRACTICE

Web-based methods (eg, Facebook, Skype) may enhance communication and access between nurses and pediatric oncology patients and their families.

Parent & Child Perceptions of Child Health after Sibling Death

BACKGROUND

Understanding children's health after a sibling's death and what factors may affect it is important for treatment and clinical care. This study compared children's and their parents' perceptions of children's health and identified relationships of children's age, gender, race/ethnicity, anxiety, and depression and sibling's cause of death to these perceptions at 2 and 4 months after sibling death.

METHODS

64 children and 48 parents rated the child's health "now" and "now vs before" the sibling's death in an ICU or ER or at home shortly after withdrawal of life-prolonging technology. Children completed the Child Depression Inventory and Spence Children's Anxiety Scale. Sibling cause of death was collected from hospital records.

RESULTS

At 2 and 4 months, 45% to 54% of mothers' and 53% to 84% of fathers' ratings of their child's health "now" were higher than their children's ratings. Child health ratings were lower for: children with greater depression; fathers whose children reported greater anxiety; mothers whose child died of a chronic condition. Children's ratings of their health "now vs before" their sibling's death did not differ significantly from mothers' or fathers' ratings at 2 or 4 months. Black fathers were more likely to rate the child's health better "now vs before" the death; there were no significant differences by child gender and cause of death in child's health "now vs before" the death.

CONCLUSIONS

Children's responses to a sibling's death may not be visually apparent or become known by asking parents. Parents often perceive their children as healthier than children perceive themselves at 2 and 4 months after sibling death, so talking with children separately is important. Children's perceptions of their health may be influenced by depression, fathers' perceptions by children's anxiety, and mother's perceptions by the cause of sibling death.

Bereavement after sibling death: a population-based longitudinal case-control study

The objective of this study was to examine mental disorders and treatment use among bereaved siblings in the general population. Siblings (N=7243) of all deceased children in the population of Manitoba, Canada who died between 1984 and 2009 were matched 1:3 to control siblings (N=21,729) who did not have a sibling die in the study period. Generalized estimating equations were used to compare the two sibling groups in the two years before and after the index child's death on physician-diagnosed mental disorders and treatment utilization, with adjustment for confounding factors including pre-existing mental illness. Analyses were stratified by age of the bereaved (<13 vs. 13+). Results revealed that, in the two years after the death of the child, bereaved siblings had significantly higher rates of mental disorders than control siblings, even after adjusting for pre-existing mental illness. When comparing the effect of a child's death on younger versus older siblings, the rise in depression rates from pre-death to post-death was significantly higher for siblings aged under 13 (p<0.0001), increasing more than 7-fold (adjusted relative rate, ARR=7.25, 95% CI: 3.65-14.43). Bereaved siblings aged 13+ had substantial morbidity in the two years after the death: 25% were diagnosed with a mental disorder (vs. 17% of controls), and they had higher rates of almost all mental disorder outcomes compared to controls, including twice the rate of suicide attempts (ARR=2.01, 95% CI: 1.29-3.12). Siblings in the bereaved cohort had higher rates of alcohol and drug use disorders already before the death of their sibling. In conclusion, the death of a child is associated with considerable mental disorder burden among surviving siblings. Pre-existing health problems and social disadvantage do not fully account for the increase in mental disorder rates.

Bereavement Follow-Up After the Death of a Child as a Standard of Care in Pediatric Oncology

After a child's death to cancer, families commonly want continued connection with the healthcare team that cared for their child, yet bereavement follow-up is often sporadic. A comprehensive literature search found that many bereaved parents experience poor psychological outcomes during bereavement and that parents want follow-up and benefit from continued connection with their child's healthcare providers. Evidence suggests that the standard of care should consist of at least one meaningful contact between the healthcare team and bereaved parents to identify those at risk for negative psychosocial sequelae and to provide resources for bereavement support.

Supporting Siblings as a Standard of Care in Pediatric Oncology

In this study, evidence is provided for supporting siblings as a standard of care in pediatric oncology. Using Medline, PsycInfo, and CINAHL, a systematic search of articles published over the past two decades about siblings of children with cancer was conducted. A total of 125 articles, which were primarily descriptive studies, were evaluated by the four investigators using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. There is moderate-quality evidence, as well as support from community stakeholders, to justify a strong recommendation that siblings of children with cancer should be provided with psychosocial services and that parents and professionals are advised about how to meet siblings' needs.

Psychological Well-Being and Family Environment of Siblings of Children with Life Threatening Illness

BACKGROUND

The psychological well-being of siblings of children with life threatening illness remains largely uncharted. Pediatric cancer research suggests that a supportive family environment may protect the psychological well-being of siblings.

OBJECTIVE

We hypothesized that (1) siblings of pediatric palliative care patients would show clinical/behavioral scores that were elevated but that rates of serious psychopathology would be comparable to the general population of children their age; and (2) higher family functioning scores would be associated with lower clinical scores and higher adaptive scores for these siblings.

METHODS

We conducted an observational study with families in which a patient receiving palliative care had one or more siblings between the ages of 6 and 11. Parents completed the Behavioral Assessment System for Children, Second Edition (BASC-2) to assess the siblings' psychological well-being and the Family Assessment Device (FAD) to assess the family environment.

RESULTS

Twenty-four parents reported data for 30 siblings. Only three siblings scored in the clinical range on a BASC-2 composite clinical scale, and 11 siblings scored in the at-risk range on one or more composite scales. Higher FAD scores predicted significantly higher externalization composite clinical scores (7.54, 95% CI: 1.12, 13.97, p < 0.05) and significantly higher behavioral composite scores (7.88, 95% CI: 1.55, 14.21, p < 0.05).

DISCUSSION

Siblings of pediatric palliative care patients are not experiencing lower psychological well-being than the general population. The prediction that a positive family environment would be associated with higher levels of psychological health was supported.

Long-term psychosocial outcomes among bereaved siblings of children with cancer

CONTEXT

The death of a child from cancer affects the entire family. Little is known about the long-term psychosocial outcomes of bereaved siblings.

OBJECTIVES

To describe 1) the prevalence of risky health behaviors, psychological distress, and social support among bereaved siblings and 2) potentially modifiable factors associated with poor outcomes.

METHODS

Bereaved siblings were eligible for this dual-center, cross-sectional, survey-based study if they were 16 years or older and their parents had enrolled in one of three prior studies about caring for children with cancer at the end of life. Linear regression models identified associations between personal perspectives before, during, and after the family's cancer experience and outcomes (health behaviors, psychological distress, and social support).

RESULTS

Fifty-eight siblings completed surveys (62% response rate). They were approximately 12 years bereaved, with a mean age of 26 years at the time of the survey (SD 7.8). Anxiety, depression, and illicit substance use increased during the year after their brother/sister's death but then returned to baseline. Siblings who reported dissatisfaction with communication, poor preparation for death, missed opportunities to say goodbye, and/or a perceived negative impact of the cancer experience on relationships tended to have higher distress and lower social support scores (P < 0.001-0.031). Almost all siblings reported that their loss still affected them; half stated that the experience impacted current educational and career goals.

CONCLUSION

How siblings experience the death of a child with cancer may impact their long-term psychosocial well-being. Sibling-directed communication and concurrent supportive care during the cancer experience and the year after the sibling death may mitigate poor long-term outcomes.

Impact of Social Support on Bereaved Siblings’ Anxiety

Purpose:To assess adolescent and young adult siblings’ perception of social support prior to and following the loss of their brother or sister to cancer, 2 to 9 years earlier, and their anxiety at follow-up. Method: In 2009, 174 (73%) bereaved siblings (12-25 years) participated in a nationwide, long-term follow-up study in Sweden using an anonymous study-specific questionnaire. The Hospital Anxiety and Depression Scale was used to measure self-assessed anxiety. Results: Siblings had a higher risk of anxiety if they perceived their need for social support was unsatisfied during their brother or sisters’ last month before death, relative risk (RR) = 3.6 (95% confidence interval [CI] = 1.8-7.3); time after death, RR = 2.9 (95% CI = 1.5-5.6); and at follow-up, RR = 3.8 (95% CI = 2.0-7.2). Furthermore, a higher risk for anxiety was shown for siblings if they did not perceive that their parents and neighbors cared for them after their brother or sisters’ death, RR = 2.7 (95% CI = 1.3-5.5), RR = 5.4 (95% CI = 1.3-21.9), respectively. Conclusion: Bereaved siblings had a greater probability to report self-assessed anxiety if they perceived that their need for social support was not satisfied prior to and following death. Information from both nurses and other health care professionals to families about the impact of social support may contribute to lessen the siblings’ risk of anxiety.

Using a psychosocial registry as a data source for nurses

Nurses at the bedside strive to base their practice on the best available information derived from evidence. However, issues related to patient care often arise for which evidence is either difficult to attain or not available. This can be particularly true for nurses who care for patients with diverse diagnoses because most studies focus on patients with a single cancer diagnosis. For example, evidence about quality of life (QOL) as perceived by the patient is a concern for clinicians but is of particular importance to nurses at the bedside. A great deal of study has been performed on the QOL of patients with cancer; however, most of these reports focus on narrow or limited samples, typically one specific cancer type. Having access to a registry that enrolls patients with diverse types of cancer and collects QOL data could be very useful to practicing bedside nurses.