Measuring neurobehavioral side effects of corticosteroids in pediatric acute lymphoblastic leukemia: A scoping review

Corticosteroids are essential to curative acute lymphoblastic leukemia (ALL) treatment, yet have significant neuropsychiatric side effects that decrease quality of life for patients and families. We conducted a scoping review, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, to describe the existing measurement tools used to evaluate neurobehavioral side effects of corticosteroids in pediatric ALL. From various databases and registers, 4047 studies were identified. Twenty-four articles met inclusion criteria. Clinical assessment was most used to evaluate these symptoms. Twelve validated measures were identified. Existing data about neuropsychiatric side effects of corticosteroids in pediatric ALL are extremely heterogeneous, creating challenges for standardized assessment and management.

Validation of the Psychosocial Assessment Tool Sibling Module Follow-Up Version

OBJECTIVE

Psychosocial screening is recommended to connect siblings of youth with cancer to psychosocial services, but the lack of validated sibling-specific screening tools is a barrier to routine screening. The current study aimed to validate and establish a clinical cutoff for the recently developed Psychosocial Assessment Tool (PAT) Sibling Module follow-up version to address this barrier.

METHODS

Parents (N = 246) completed the PAT Sibling Module follow-up version for all siblings within their families ages 0-17 years (N = 458) at three time points between 6- and 24-month post-cancer diagnosis. For one target sibling within each family aged 8-17 years, parents also completed the Strengths and Difficulties Questionnaire, and the target sibling completed the Child PTSD Symptom Scale. Cross-sectional and longitudinal analyses examined internal consistency and convergent and predictive validity. Receiver operator characteristic analyses were used to establish a maximally sensitive and specific clinical cutoff.

RESULTS

Internal consistency was acceptable for all age versions (Kuder-Richardson 20s ≥ 0.79), except for the ages 0-2 version, which had low internal consistency at 18 months post-diagnosis (Kuder-Richardson 20 = 0.57). Convergent (r values >0.7, p values <.001) and predictive (r values >0.6, p values <.001) validity were strong at each time point. An optimal clinical cutoff of 0.32 was identified (range: 0.00-1.00).

CONCLUSIONS

The PAT Sibling Module follow-up version is a reliable and valid screener for sibling psychosocial risk following cancer diagnosis. Validation of a sibling-specific screener and establishment of a clinical cutoff are necessary first steps to addressing siblings' unmet psychosocial needs and improving trajectories of sibling functioning.

Adaptation and Psychometric Evaluation of the Parenting Concerns Questionnaire-Advanced Disease

PURPOSE

When patients with advanced cancer have minor children (age < 18), their health-related quality of life is closely linked to their concerns about the impact of progressive illness and death on their children. The Parenting Concerns Questionnaire (PCQ), a validated measure for parents with cancer, does not capture the full range of concerns in advanced cancer. The aim of this was study was to adapt and establish psychometrics for the PCQ for advanced disease (PCQ-AD).

METHODS

After generating an initial item-bank, we conducted concept elicitation interviews with clinicians (n = 8) and cognitive interviews with patients (n = 23) for face validity. New items addressed concerns about impact of parental death, making every moment count, communication, and financial impact of cancer on children. We administered 21 candidate items to 151 parents with advanced cancer. We conducted confirmatory factor analysis (CFA), calculated internal consistency, and assessed convergent and known-groups validity.

RESULTS

We removed 8 redundant items due to residual covariation between items. CFA of the 13-item PCQ-AD demonstrated satisfactory fit (CFI = 0.971, TLI = 0.966, RMSEA = 0.081) and high internal consistency (Cronbach's alpha = 0.94, composite reliability = 0.95). The PCQ-AD demonstrated convergent validity and known-groups validity; patients with poor functional status reported higher scores than patients with better functional status (Cohen's d = 0.56, p = 0.002).

CONCLUSION

Adaptation of the PCQ yielded the addition of constructs important in advanced cancer. The PCQ-AD appears to be a reliable and valid measure of parenting concerns in advanced cancer, but future studies are needed to examine measure performance in diverse populations and responsiveness of the PCQ-AD to interventions.

Disparities in pediatric psychosocial oncology utilization

BACKGROUND

Integratedbehavioral health models have been proposed as care delivery approaches to mitigate mental health disparities in primary care settings. However, these models have not yet been widely adopted or evaluated in pediatric oncology medical homes.

METHODS

We conducted a retrospective cohort study of 394 children with newly diagnosed cancer at Dana-Farber/Boston Children's Cancer and Blood Disorders Center (DF/BCH) from April 2013 to January 2017. Baseline sociodemographic characteristics and psychiatry utilization outcomes at 12 months following diagnosis were abstracted from the medical record. The severity of household material hardship (HMH), a concrete poverty exposure, at diagnosis and race/ethnicity were characterized by parent report using the Psychosocial Assessment Tool 2.0 (PAT). Associations between sociodemographic characteristics and receipt of psychiatry consultation were assessed with multivariable logistic regression models.

RESULTS

Among 394 children, 29% received a psychiatric consultation within 12 months postdiagnosis. Of these, 88% received a new psychiatric diagnosis, 76% received a psychopharmacologic recommendation, and 62% received a new behavioral intervention recommendation. In multivariable logistic regression adjusting for age, cancer diagnosis, and PAT total score, there was no statistically significant association between HMH severity or household income and psychiatry utilization. Children who identified as racial/ethnic minorities were significantly less likely to receive a psychiatry consultation (OR = 0.48, 95% CI = 0.27-0.84).

CONCLUSIONS

In a pediatric oncology medical home with an integrated behavioral health model, socioeconomic status was not associated with disparate psychiatry utilization. However, there remained a profound racial/ethnic disparity in psychiatry utilization, highlighting the need for additional research and care delivery intervention.

Risk factors for steroid-induced affective disorder in children with leukemia

Corticosteroids are essential to treating childhood acute lymphoblastic leukemia (ALL), and can cause significant neuropsychiatric side effects. This retrospective chart review is a preliminary exploration of characteristics associated with psychiatry consultation and steroid-induced affective disorder (SIAD) during ALL treatment. Of 125 ALL patients (ages 1-10 years), 56 (44.8%) received psychiatry consultation. Thirty-nine (31.2%) of the total cohort were diagnosed with SIAD. SIAD was significantly associated with family psychiatric history, but not with steroid exposure, CNS radiation, sociodemographic factors, developmental delay, Trisomy 21, or prior psychiatric history. Gathering family psychiatric history may help identify children at increased risk of SIAD.

Screening and Assessment in Pediatric Psycho-Oncology

This chapter provides an overview of current and recommended practices regarding systematic screening and assessment of psychosocial needs in pediatric oncology. The chapter reviews published recommendations from the Psychosocial Standards of Care Project for Childhood Cancer and provides information about validated instruments for brief screening of children and their families. It also describes guidelines for using follow-up symptom-based measures and in-person clinical assessment. It includes a summary of what is known about the current implementation of screening nationally, and possible steps to enhance implementation. There is also special consideration of screening and assessment of unique medical populations within pediatric oncology, children with developmental concerns, and families from different cultures. Future directions include using implementation science to develop models for routine screening and demonstrating the impact of screening on psychosocial outcomes for patients and families and on the system of pediatric oncology care.

Parental awareness of sibling adjustment: Perspectives of parents and siblings of children with cancer

Childhood cancer is a significant psychosocial stressor, and sibling adjustment ranges from resilience to clinically significant psychopathology. Siblings and parents often describe siblings' psychosocial functioning differently, which may reflect parental unawareness of siblings' adjustment to cancer and increase the risk for negative sibling outcomes. The present study characterizes siblings' and parents' perceptions of parents' awareness of siblings' psychosocial functioning and describes how family functioning influences parental awareness. Parents (N = 13) and siblings (N = 17, ages 8-17) from 13 families completed in-depth qualitative interviews regarding siblings' psychosocial adjustment to cancer. Interviews were coded for dimensions of family functioning based on the McMaster Model and analyzed using applied thematic analysis. Families were stratified based on higher or lower levels of parental awareness (i.e., knowledge of the presence, severity, or content of siblings' cancer-related feelings). Themes related to communication, affective involvement, roles, problem-solving, and affective responsiveness influenced parental awareness. Parental awareness was hindered by siblings' reluctance to communicate their feelings to parents due to the messages they received about cancer (e.g., be positive/helpful), siblings' hesitancy to rely on parents for emotional support, and parents not consistently asking about siblings' emotions. Additionally, parents' cancer-related stress and family disruptions reduced parental focus on siblings and decreased parents' tolerance of siblings' negative emotions. Higher parental awareness was facilitated by closer relationships prediagnosis, consistent communication, and affective problem-solving in response to cancer-related changes. Findings provide a more comprehensive understanding of the family processes underlying parental awareness and inform best practices for sibling assessment and support. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Development of a Psychosocial Risk Screener for Siblings of Children With Cancer: Incorporating the Perspectives of Parents

Objective

Although many siblings experience distress after a child's cancer diagnosis, their psychosocial functioning is seldom assessed in clinical oncology settings. One barrier to systematic sibling screening is the lack of a validated, sibling-specific screening instrument. Thus, this study developed sibling-specific screening modules in English and Spanish for the Psychosocial Assessment Tool (PAT), a well-validated screener of family psychosocial risk.

Methods

A purposive sample of English- and Spanish-speaking parents of children with cancer (N = 29) completed cognitive interviews to provide in-depth feedback on the development of the new PAT sibling modules. Interviews were transcribed verbatim, cleaned, and analyzed using applied thematic analysis. Items were updated iteratively according to participants' feedback. Data collection continued until saturation was reached (i.e., all items were clear and valid).

Results

Two sibling modules were developed to assess siblings' psychosocial risk at diagnosis (preexisting risk factors) and several months thereafter (reactions to cancer). Most prior PAT items were retained; however, parents recommended changes to improve screening format (separately assessing each sibling within the family and expanding response options to include "sometimes"), developmental sensitivity (developing or revising items for ages 0-2, 3-4, 5-9, and 10+ years), and content (adding items related to sibling-specific social support, global assessments of sibling risk, emotional/behavioral reactions to cancer, and social ecological factors such as family and school).

Conclusions

Psychosocial screening requires sibling-specific screening items that correspond to preexisting risk (at diagnosis) and reactions to cancer (several months after diagnosis). Validated, sibling-specific screeners will facilitate identification of siblings with elevated psychosocial risk.

What do surviving children wish for from a dying parent? A qualitative exploration

Legacy may play an important role in how children integrate the loss of a parent. Sixteen adults (19-40 years old, 69% women) who experienced the death of a parent from an illness before age 12 were interviewed, exploring legacies from their deceased parent. Transcribed interviews were iteratively analyzed by three independent coders. Extracted themes described their experiences and wish for remembrances and specific communication left for them, information about the parent's values and feelings about them, and personal possessions. This study provides novel data about legacies that bereaved children wish for in adulthood.

Parental psychological distress and cancer stage: a comparison of adults with metastatic and non-metastatic cancer

PURPOSE

Parents with cancer have unique and often under-recognized psychological distress about the impact of their illness on their children. Relatively little is known about how parenting concerns may differ among patients by cancer stage.

METHODS

This is a secondary data analysis of 203 adults with cancer who had children < 18 years old from two geographically distinct areas. We used an analysis of covariance to estimate the mean differences in PCQ, depression symptom severity and anxiety symptom severity (Hospital Anxiety and Depression Scale, HADS) scores between participants with metastatic and non-metastatic disease, and Pearson's correlation coefficients to assess associations between HADS and PCQ scores by cancer stage.

RESULTS

Seventy-two percent of participants (n = 146) had metastatic solid tumor cancer. In adjusted analyses, mean PCQ scores did not significantly differ between parents with metastatic and non-metastatic disease (2.0 vs. 2.2, p = 0.06). Differences in mean PCQ scores were driven by a single question concerning the impact of death on children (2.3 vs. 2.9, p = 0.004). Mean HADS scores did not significantly differ between groups, although PCQ scores explained a greater amount of variance in HADS scores for the metastatic group as compared to the non-metastatic group.

CONCLUSIONS

With the exception of concerns about death, intensity of parenting concerns, as measured by the PCQ, was similar between parents with metastatic and non-metastatic cancer. However, parenting concerns may be more strongly linked to overall psychological distress in patients with metastatic disease. Further research is needed to clarify how parenting concerns uniquely relate to advanced stage illness.

The multidisciplinary pediatric psycho-oncology workforce: A national report on supervision for staff and training opportunities

OBJECTIVE

This paper presents data on licensure/certification status, supervision of multidisciplinary pediatric psychosocial staff, and training opportunities in pediatric cancer programs in the United States, data that are critical to provide care aligned with the Standards of Psychosocial Care in Pediatric Cancer (Psychosocial Standards).

METHODS

An online survey of psychosocial care consistent with the Psychosocial Standards was completed from a national sample of pediatric cancer programs (144/200). Licensure/certification status, availability and format of supervision for multidisciplinary staff (social workers, psychologists, psychiatrists, child life specialists/recreational therapists), and types and number of psychosocial trainees were reported.

RESULTS

Nearly all pediatric psychosocial providers were licensed/certified. Peer consultation was the most frequently endorsed form of staff supervision although a sizeable group of centers reported no systematic ongoing supervision. Trainees in social work and child life were most common although the size of trainee cohorts is generally small. Psychosocial trainees are more prevalent in sites with pediatric hematology/oncology medical fellowship programs and in larger programs.

CONCLUSIONS

A properly trained and supported psychosocial workforce is essential to providing evidence-based care consistent with the Psychosocial Standards. Psychosocial providers are appropriately licensed. However, supervision opportunities are variable and may be inadequate for the intensity of the work. It is important to address the limited opportunities for trainees in pediatric cancer programs, which may influence the pipeline for ongoing and future work in this area.

The Effectiveness of a Hospital-Based School Liaison Program: A Comparative Study of Parental Perception of School Supports for Children With Pediatric Cancer and Neurofibromatosis Type 1

Childhood survivors of central nervous system (CNS) cancers (defined as cancers whose diagnosis or treatment affect the CNS) are at increased risk for educational related difficulties, as are children affected by neurofibromatosis type 1. This study evaluated the effectiveness of and satisfaction with a model of psychoeducation, consultation, and advocacy provided by a School Liaison Program (SLP) for families and schools of children with CNS-involved cancers compared with a control group of parents of children with a diagnosis of neurofibromatosis type 1 who did not receive school-based services. Results indicated significant between-group differences in parents’ belief that their child is meeting academic potential, with parents who received SLP services reporting greater satisfaction with their child’s progress, better understanding of their child’s learning needs, and an increased ability to access school supports. The strong, positive impact associated with the consultation, psychoeducation, and parental advocacy training provided by the SLP suggests that a similar model of care would potentially benefit other groups of children whose neurocognitive functioning is compromised by chronic medical conditions.

Measuring Medication Adherence in Pediatric Cancer: An Approach to Validation

Objective

This study described the prospective relationship between pharmacological and behavioral measures of 6-mercaptopurine (6MP) medication adherence in a multisite cohort of pediatric patients diagnosed with cancer ( N  = 139).

Methods

Pharmacological measures (i.e., metabolite concentrations) assessed 6MP intake. Behavioral measures (e.g., electronic monitoring) described adherence patterns over time.

Results

Three metabolite profiles were identified across 15 months: one group demonstrated low levels of both metabolites (40.8%) consistent with nonadherence and/or suboptimal therapy; two other groups demonstrated metabolite clusters indicative of adequate adherence (59.2%). Those patients whose metabolite profile demonstrated low levels of both metabolites had consistently lower behavioral adherence rates.

Conclusions

To our knowledge, this was the first study to prospectively validate a pharmacological measure of medication adherence with a behavioral adherence measure in a relatively large sample of pediatric patients with cancer. Using multiple methods of adherence measurement could inform clinical care and target patients in need of intervention.

Preparing youth with cancer for amputation: A systematic review

Children and adolescents who require limb amputation as part of cancer treatment face many physical and emotional challenges. Preparatory interventions may serve to facilitate positive coping and improve long-term adjustment during pediatric cancer treatment, including decreasing anxiety and postoperative distress. This review aimed to examine and identify the type and degree of psychosocial preparation provided to the child with cancer and family prior to amputation. Electronic databases including Embase, PubMed, and PsycINFO were searched for relevant research articles. Five studies were identified that satisfied inclusion criteria and revealed common themes for preparatory interventions, but results were limited by a lack of empirical approaches and revealed little consensus on pre-operative support prior to amputation. These findings demonstrate that there is a lack of studies to date that have adequately addressed psychosocial preparation prior to amputation for pediatric oncology patients. Future research on preparatory interventions is needed using prospective and quantitative research to establish evidence-based recommendations for interventions to support this vulnerable population.

Risk factors and treatment for steroid-related mood and behavior symptoms in preschool children with leukemia: A case series

Treatment of pediatric acute lymphoblastic leukemia (ALL) relies on systemic corticosteroids for remission; however, they can cause significant mood and behavior changes that interfere with quality of life and may increase risk for injury. This case series reports on preschool children with preexisting developmental and psychiatric risk factors who presented with behavioral side effects that required intervention. Identification of these vulnerable children may provide opportunities for early intervention, anticipatory guidance, and effective treatment to minimize behavioral side effects and improve quality of life and safety during ALL treatment.

The perceived influence of childhood cancer on the parents' relationship

OBJECTIVE

When a child is diagnosed with cancer, parents are faced with many practical and emotional challenges that can significantly affect their relationship. This study explores how having a child with cancer affects the quality of the parents' relationship, categorizes time points and events during the child's treatment when the relationship becomes most stressed and/or strengthened, identifies factors that help couples remain emotionally engaged throughout their child's cancer treatment, and assesses parental interest in a counseling intervention.

METHODS

This is a cross-sectional, multicenter study conducted via a semistructured self-administered questionnaire that included the Revised Dyadic Adjustment Scale.

RESULTS

One hundred ninety-two parents of children diagnosed between the ages of 1 and 21 participated. Forty percent felt their relationship moved in a negative direction. Diagnosis and relapse of disease were cited as the most individually stressful time points in the disease trajectory, with hospitalizations and relapse being most stressful on the relationship. Participants felt most emotionally connected at diagnosis and least emotionally connected at the start and end of treatment. The majority of couples indicated interest in counseling to address ways to support their relationship. Soon after diagnosis and during treatment was reported as the preferred time to offer these interventions.

CONCLUSION

This study identified specific events and parent behaviors that strain the couples' relationship during the childhood cancer trajectory. This information can inform the development of a couple's intervention. Prospective research is needed to better understand how childhood cancer affects caregivers' partnerships through survivorship and beyond.

Psychometric properties of the Parenting Concerns Questionnaire in cancer survivors with minor and young adult children

OBJECTIVE

Although cancer patients with minor children have become more of a focus of psycho-oncological research, little is known about specific parenting concerns. Instruments to assess the concerns and worries of parents with cancer are rare. The Parenting Concerns Questionnaire (PCQ) addresses this issue. We analyzed parenting concerns in cancer survivors and evaluated the German version of the PCQ.

METHODS

A total of 1416 cancer survivors with minor and young adult children (≤21 years) were recruited in a register-based study. Descriptive analyses as well as reliability and validity analyses were conducted. We performed a confirmatory factorial analysis of the factor structure proposed by the authors of the original version on the PCQ.

RESULTS

Seventy-three percent of the cancer survivors were women, average age was 47.5 years (SD 5.9). Mean time since diagnosis was 44 months (SD 23.4). Between 18 and 31% of survivors reported that they were concerned about their children. The PCQ proved to be a reliable and valid instrument showing medium correlations with standardized measures in expected directions and discriminating between survivors with and without use of psychosocial support services. The factor structure was supported by the confirmatory factorial analysis.

CONCLUSIONS

Assessing parenting concerns gives an additional insight into the situation of parents with cancer. In our sample of cancer survivors, we identified one out of three survivors being concerned regarding the impact of their illness on their children. The PCQ can be considered as a valid and reliable instrument with regard to identifying concerned parents with cancer. Copyright © 2015 John Wiley & Sons, Ltd.

Standards of Psychosocial Care for Parents of Children With Cancer

Parents and caregivers of children with cancer are both resilient and deeply affected by the child's cancer. A systematic review of published research since 1995 identified 138 studies of moderate quality indicating that parent distress increases around diagnosis, then returns to normal levels. Post-traumatic symptoms are common. Distress may be impairing for vulnerable parents and may impact a child's coping and adjustment. Moderate quality evidence and expert consensus informed a strong recommendation for parents and caregivers to receive early and ongoing assessment of their mental health needs with access to appropriate interventions facilitated to optimize parent, child, and family well being.

Psychosocial Interventions and Therapeutic Support as a Standard of Care in Pediatric Oncology

Research indicates that a subset of youths with childhood cancer and their parents will experience significant psychological distress throughout the course of their illness. Importantly, the existing literature indicates that psychosocial support is beneficial in decreasing symptoms of distress in these families. The aim of the current review is to determine the extent of the evidence to support a standard of psychosocial care for children and their families throughout the cancer trajectory; thus, we examined the research related to psychosocial outcomes in youth with cancer and their parents.

Parenting concerns, quality of life, and psychological distress in patients with advanced cancer

OBJECTIVE

Parents with life-limiting illness anticipate the loss of their parental role and the long-term consequences of their illness on their children. The purpose of this study was to examine relationships between parenting concerns, quality of life (QOL), and symptoms of depression and anxiety in parents with advanced cancer who have dependent children.

METHODS

Sixty-three parents diagnosed with a Stage IV solid malignancy completed the Hospital Anxiety Depression Scale (HADS), Parenting Concerns Questionnaire (PCQ), and Functional Assessment of Cancer Therapy-General (FACT-G). The Medical Outcomes Study Social Support Survey (social support) and Eastern Cooperative Oncology Group (ECOG) performance status were assessed as potential covariates. We performed descriptive statistics and multivariable linear regression models for depression, anxiety, and QOL measures.

RESULTS

Mean PCQ score was 2.3 (SD 0.9), reflecting mild to moderate parenting concerns. Average depression and anxiety scores were 6.0 (SD 4.2) and 8.2 (SD 3.9), respectively. PCQ scores were associated with depressive symptoms (r = 0.46, p < 0.001), anxiety symptoms (r = 0.52, p < 0.0001), and QOL scores (r = -0.60, p < 0.001). The relationship of PCQ scores to anxiety symptoms (B = 1.5 p = 0.016) and QOL (B = -5.7, p = 0.02) remained significant after controlling for ECOG status, social support, and treatment status.

CONCLUSIONS

Parenting concerns are associated with anxiety and depressive symptoms and worse QOL in parents diagnosed with advanced cancer. Further studies that evaluate how parental status affects coping and psychological distress in advanced cancer are needed.Copyright © 2015 John Wiley & Sons, Ltd.

Parenting changes in adults with cancer

BACKGROUND

Children whose parents have cancer are at risk for psychosocial difficulties; however, the mechanisms are not well understood. This cross-sectional study sought support for a model connecting parental cancer to child distress through its impact on parenting self-efficacy beliefs and parenting behaviors by examining relations among parental illness, quality of life/parent functioning, parenting efficacy beliefs, and concerns about children's emotional distress.

METHODS

One hundred ninety-four adult oncology outpatients with children who were 18 years old or younger completed questionnaires assessing their health-related quality of life (Functional Assessment of Cancer Therapy-General), depression and anxiety symptoms (Hospital Anxiety and Depression Scale), overall distress (Distress Thermometer), and parenting efficacy beliefs and parenting concerns (Parenting Concerns Questionnaire).

RESULTS

Parenting efficacy scores for parents and coparents declined significantly after diagnosis. This decline correlated with more visits to a medical clinic, treatment with intravenous chemotherapy in the past month, poorer health-related quality of life, and more depression and distress. Parents experiencing the most concern about the impact of mood, physical limitations, and changes in routines on their children experienced the biggest declines in their own sense of efficacy as parents and in their belief in their coparent's efficacy. Finally, declines in parenting efficacy beliefs correlated with parental concerns about children's emotional distress about aspects of the parent's illness.

CONCLUSIONS

This study highlights the importance of identifying and addressing parenting concerns to alleviate patient distress, and it may help to guide future intervention efforts.

Suicide ideation and associated mortality in adult survivors of childhood cancer

BACKGROUND

Adult survivors of childhood cancer are at risk for suicide ideation, although longitudinal patterns and rates of recurrent suicide ideation are unknown. This study investigated the prevalence of late report (ie, after initial assessment) and recurrent suicide ideation in adult survivors of childhood cancer, identified predictors of suicide ideation, and examined associations among suicide ideation and mortality.

METHODS

Participants included 9128 adult survivors of childhood cancer and 3082 sibling controls enrolled in the Childhood Cancer Survivor Study who completed a survey question assessing suicide ideation on one or more occasions between 1994 and 2010. Suicide ideation was assessed using the Brief Symptom Inventory-18 instrument. Mortality data was ascertained from the National Death Index.

RESULTS

Survivors were more likely to report late (odds ratio [OR] =1.9, 95% confidence interval [CI] =1.5-2.5) and recurrent suicide ideation (OR=2.6, 95% CI=1.8-3.8) compared to siblings. Poor physical health status was associated with increased risk of suicide ideation in survivors (late report: OR=1.9, 95% CI=1.3-2.7; recurrent: OR=1.9, 95% CI=1.2-2.9). Suicide ideation was associated with increased risk for all-cause mortality (hazard ratio=1.3, 95% CI=1.03-1.6) and death by external causes (hazard ratio=2.4, 95% CI=1.4-4.1).

CONCLUSIONS

Adult survivors of childhood cancer are at risk for late-report and recurrent suicide ideation, which is associated with increased risk of mortality. Routine screening for psychological distress in adult survivors appears warranted, especially for survivors who develop chronic physical health conditions.

Measuring psychosocial distress and parenting concerns among adults with cancer: the Parenting Concerns Questionnaire

BACKGROUND

A 2-phase, mixed methods study was conducted to develop a Parenting Concerns Questionnaire (PCQ) for adults with cancer. Limited information about this area of psychosocial distress highlights the need for a measurement tool that can identify adult oncology patients with heightened parenting concerns who could benefit from additional intervention.

METHODS

Telephone focus groups were conducted with 16 oncology patients who had children 18 years old and younger. Group interview transcripts were analyzed to generate qualitative themes and candidate items for the PCQ. A 38-item version of the questionnaire was completed by 173 oncology outpatients who had children 18 years old and under. Participants also completed the Distress Thermometer, HADS (Hospital Anxiety and Depression Scale), and FACT-G (Functional Assessment of Cancer Therapy-General). Exploratory factor analyses revealed the emergence of 3 subscales of 5 items each, yielding a 15-item questionnaire. Associations between total PCQ scores, standardized measures of distress, depression, anxiety, quality of life, and demographic and illness characteristics were examined.

RESULTS

The 15-item PCQ demonstrates good internal consistency (Cronbach's α = .83). PCQ scores were significantly associated (P < .01) with standardized measures of psychosocial distress (Distress Thermometer, HADS, and FACT-G) in the expected directions. Higher PCQ scores were associated with female sex, single parenthood, metastatic or recurrent cancer, subjective understanding of incurable disease, comorbid chronic health condition, and current mental health treatment.

CONCLUSIONS

The PCQ proved a reliable and valid measure of parenting distress among cancer patients, and thus merits further study.

Depression and post-traumatic stress disorder among Haitian immigrant students: implications for access to mental health services and educational programming

BACKGROUND

Previous studies of Haitian immigrant and refugee youth have emphasized "externalizing" behaviors, such as substance use, high risk sexual behavior, and delinquency, with very little information available on "internalizing" symptoms, such as depression and anxiety. Analyzing stressors and "internalizing" symptoms offers a more balanced picture of the type of social and mental health services that may be needed for this population. The present study aims to: 1) estimate the prevalence of depression and post-traumatic stress disorder (PTSD) among Haitian immigrant students; and 2) examine factors associated with depression and PTSD to identify potential areas of intervention that may enhance psychosocial health outcomes among immigrant youth from Haiti in the U.S.

METHODS

A stratified random sample of Haitian immigrant students enrolled in Boston public high schools was selected for participation; 84% agreed to be interviewed with a standardized questionnaire. Diagnosis of depression and PTSD was ascertained using the best estimate diagnosis method.

RESULTS

The prevalence estimates of depression and PTSD were 14.0% and 11.6%; 7.9% suffered from comorbid PTSD and depression. Multivariate logistic regression demonstrated factors most strongly associated with depression (history of father's death, self-report of schoolwork not going well, not spending time with friends) and PTSD (concern for physical safety, having many arguments with parents, history of physical abuse, and lack of safety of neighborhood).

CONCLUSIONS

A significant level of depression and PTSD was observed. Stressors subsequent to immigration, such as living in an unsafe neighborhood and concern for physical safety, were associated with an increased risk of PTSD and should be considered when developing programs to assist this population. Reducing exposure to these stressors and enhancing access to social support and appropriate school-based and mental health services may improve educational attainment and psychosocial health outcomes among Haitian immigrant youth.

Management of psychosocial distress by oncologists

OBJECTIVE

Little is known about the nature of psychosocial care delivered by oncologists. The goal of this study was to survey oncologists about their management of psychosocial distress, referencing the National Comprehensive Cancer Network guidelines.

METHODS

A random sample of 1,000 oncologists were sent an e-mail requesting their participation in an online survey; nonrespondents were sent the survey through postal mail. Regression analyses were conducted to identify independent predictors of care.

RESULTS

Forty-six percent (448 of 965) of oncologists responded. Practice locations included: community (63%), cancer center (25%), and hospital (7%). Respondents estimated that over one-third of their patients (mean+/-SD=38%+/-22%) experience psychosocial distress warranting intervention, although only 225 of 447 (50%) indicated having mental health services affiliated with their practice. Nearly half (212 of 447, 47%) reported only initiating a referral for psychosocial services, and 214 of 447 (48%) reported both making a referral and starting psychiatric medications, mainly selective serotonin reuptake inhibitors and benzodiazepines.

CONCLUSIONS

Most oncologists delivered some level of psychosocial care, although only half had affiliated mental health services.

Management of psychosocial distress by oncologists

OBJECTIVE

Little is known about the nature of psychosocial care delivered by oncologists. The goal of this study was to survey oncologists about their management of psychosocial distress, referencing the National Comprehensive Cancer Network guidelines.

METHODS

A random sample of 1,000 oncologists were sent an e-mail requesting their participation in an online survey; nonrespondents were sent the survey through postal mail. Regression analyses were conducted to identify independent predictors of care.

RESULTS

Forty-six percent (448 of 965) of oncologists responded. Practice locations included: community (63%), cancer center (25%), and hospital (7%). Respondents estimated that over one-third of their patients (mean+/-SD=38%+/-22%) experience psychosocial distress warranting intervention, although only 225 of 447 (50%) indicated having mental health services affiliated with their practice. Nearly half (212 of 447, 47%) reported only initiating a referral for psychosocial services, and 214 of 447 (48%) reported both making a referral and starting psychiatric medications, mainly selective serotonin reuptake inhibitors and benzodiazepines.

CONCLUSIONS

Most oncologists delivered some level of psychosocial care, although only half had affiliated mental health services.

Mental health, treatment preferences, advance care planning, location, and quality of death in advanced cancer patients with dependent children

BACKGROUND

Clinicians observe that advanced cancer patients with dependent children agonize over the impact their death will have on their children. The objective of this study was to determine empirically whether advanced cancer patients with and without dependent children differ in treatment preferences, mental health, and end-of-life (EOL) outcomes.

METHODS

Coping with Cancer is a National Cancer Institute/National Institute of Mental Health-funded, multi-institutional, prospective cohort study of 668 patients with advanced cancer. Patients with and without dependent children were compared on rates of psychiatric disorders, advance care planning (ACP), EOL care, quality of their last week of life, and location of death.

RESULTS

In adjusted analyses, patients with advanced cancer who had dependent children were more likely to meet panic disorder criteria (adjusted odds ratio [AOR], 5.41; 95% confidence interval [95% CI], 2.13-13.69), more likely to be worried (mean difference in standard deviations [delta], 0.09; P=.006), and more likely to prefer aggressive treatment over palliative care (AOR, 1.77; 95% CI, 1.07-2.93). Patients with dependent children were less likely to engage in ACP (eg, do not resuscitate orders: AOR, 0.44; 95% CI, 0.26-0.75) and had a worse quality of life in the last week of life (delta, 0.15; P=.007). Among spousal caregivers, those with dependent children were more likely to meet criteria for major depressive disorder (AOR, 4.53; 95% CI, 1.47-14) and generalized anxiety disorder (AOR, 3.95; 95% CI, 1.29-12.16).

CONCLUSIONS

Patients with dependent children were more anxious, were less likely to engage in ACP, and were more likely to have a worse quality of life in their last week of life. Advanced cancer patients and spousal caregivers with dependent children represent a particularly distressed group that warrants further clinical attention, research, and support.

Complicated grief and its correlates in patients with bipolar disorder

BACKGROUND

While the recent loss of a loved one has been identified as a risk factor for suicide in patients with bipolar disorder, and complicated grief (CG) has been associated with elevated rates of suicidality compared with loss without CG, little is known about the frequency or impact of CG in bipolar disorder. We investigated the frequency and implications of loss of loved ones in an ongoing study of bipolar disorder.

METHOD

We conducted a survey of 120 patients with well-characterized DSM-IV bipolar disorder participating in Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), a large naturalistic study, in order to identify frequency of loss and to examine the presence of CG and its clinical correlates. Survey data were gathered from October 2003 to March 2004.

RESULTS

A lifetime history of a significant loss was reported by 86% (103/120) of participants; 24.3% (25/103) of those met criteria for CG, defined as a score > or = 25 on the Inventory of Complicated Grief (ICG), with a mean +/- SD ICG score of 33.7 +/- 6.9. The presence of CG was associated with elevated rates of panic disorder and alcohol abuse comorbidity, as well as other measures of panic symptoms and phobic avoidance. CG was also associated with a higher rate of lifetime suicide attempts, greater functional impairment, and poorer social support.

CONCLUSION

Our findings suggest the presence of a substantial burden of comorbid grief-related illness and impairment in patients with bipolar disorder. Further research is needed to understand the overlap of anxiety disorders and phobic avoidance in bipolar patients with complicated grief.

Impact of 3-tier formularies on drug treatment of attention-deficit/hyperactivity disorder in children

BACKGROUND

Expenditures for medications used to treat attention-deficit/hyperactivity disorder (ADHD) in children have increased rapidly. Many employers and health plans have adopted 3-tier formularies in an attempt to control costs for these and other drugs.

OBJECTIVE

To assess the effect of copayment increases associated with 3-tier formulary adoption on use and spending patterns for ADHD medications for children.

DESIGN AND SETTING

Observational study using quasi-experimental design to compare effects on ADHD medication use and spending for children enrolled as dependents in an employer-sponsored plan that made major changes to its pharmacy benefit design and a comparison group of children covered by the same insurer. The plan simultaneously moved from a 1-tier (same copayment required for all drugs) to a 3-tier formulary and implemented an across-the-board copayment increase. The plan later moved 3 drugs from tier 3 to tier 2.

PARTICIPANTS

An intervention group of 20 326 and a comparison group of 15 776 children aged 18 years and younger.

MAIN OUTCOME MEASURES

Monthly probability of using an ADHD medication; plan, enrollee, and total ADHD medication spending; and medication continuation.

RESULTS

A 3-tier formulary implementation resulted in a 17% decrease in the monthly probability of using medication (P<.001), a 20% decrease in expected total medication expenditures, and a substantial shifting of costs from the plan to families (P<.001). Intervention group children using medications in the pre-period were more likely to change to a medication in a different tier after 3-tier adoption, relative to the comparison group (P = .08). The subsequent tier changes resulted in increased plan spending (P<.001) and decreased patient spending (P = .003) for users but no differences in continuation.

CONCLUSIONS

The copayment increases associated with 3-tier formulary implementation by 1 employer resulted in lower total ADHD medication spending, sizeable increases in out-of-pocket expenditures for families of children with ADHD, and a significant decrease in the probability of using these medications.

The importance of parenting concerns among patients with cancer

Almost one quarter of all cancer patients in the United States is estimated to have children under 18-years-old living with them. However, there is limited research on how children's functioning is affected by parental cancer, and the impact of parenting concerns on treatment decisions. This paper will review the literature and hypothesize about why addressing the needs of the children has not been part of routine cancer care. In addition, we will make a case for the importance of including parenting issues in cancer care, and in assessments of treatment decision-making and quality of life. We also describe a clinical program that is attempting to address these issues, and offer practical recommendations for oncologists who want to help parents with cancer and their partners support their children through the challenges of cancer treatment.

Anorexia nervosa in a 7-year-old girl

We report on a 7-year-old girl with anorexia nervosa and consider factors contributing to this early emergency. Cognitive differences in younger children can alter their understanding of this illness, so we chronicled this girl's treatment because it diverged from practices used with older patients. Accordingly, effective interventions in very young anorexics might require modifications of treatments used in postpubertal populations.

Mother-infant feeding interaction in full-term small-for-gestational-age infants

Maternal and infant behavior during feeding was assessed in 30 mother-infant dyads: 15 small-for-gestational-age (SGA) infants (birth weights below the 10th percentile) and 15 appropriate-for-gestational-age (AGA) infants (birth weights between the 25th and 90th percentiles). The groups were balanced for gestational age, sex, neonatal risk factors, and maternal age, parity, socioeconomic status, and race. Behaviors indicative of infant feeding difficulties were coded for mother and infant. The SGA mothers had higher frequencies of these behaviors than did their AGA counterparts. Qualitative ratings of interactive behavior were recorded for mother and infant: SGA infants had ratings indicative of less optimal interactions than those of the AGA group. Infant caloric intake (calories per kilogram per feeding) was calculated by first dividing the change in infant weight in grams before feeding and immediately after feeding by the infant's weight before feeding and then converting it to calories. Although no difference in caloric intake was observed between the two groups, infant behaviors and ratings were associated with caloric intake. These data suggest the importance of including neonatal behavior during feeding in the risk assessment of potential growth failure in SGA infants.