Psychological Problems in Children with Cancer in the Initial Period of Treatment

Maria Gerali, PhD; Marina Servitzoglou, MD, PhD; Dimitra Paikopoulou, PhD; Helen Theodosopoulou, PhD; Michael Madianos, MD, PhD; Helen Vasilatou-Kosmidis, MD, PhD

Disclosures

Cancer Nurs. 2011;34(4):269-276. 

In This Article

Results

Total Rutter Score

According to parents' responses, the patients' mean scores started from 9.70 (SD, 4.62) (T1), increased to 9.80 (SD, 3.92) (T2), and then reduced to 9.08 (SD, 3.90) (T3), whereas the relevant score for control subjects was 5.20 (SD, 2.07) at T3. According to the teachers' responses, the mean score was 9.42 (SD, 3.12) for patients and 7.48 (SD, 2.91) for participants in the control group (Table 2). The comparison of mean total Rutter scores in children with cancer at the 3 different time points, according to the parents' responses, showed a statistically significant difference (P < .001, Friedman test), thus implying the development of psychological problems during the 6-month treatment. Indeed, the comparison of the total Rutter scores for the children with cancer and participants in the control group at T3 revealed a striking difference, according to both the parents' (P < .00001, Mann-Whitney) and teachers' (P < .001) responses.

The comparison of the total Rutter scores for patients at the end of intensive treatment (T3), according to the parents' and teachers' responses, revealed no difference (P = .19).

Rutter Subscores

To investigate the kind of psychological problems during treatment of childhood cancer, we calculated the Rutter subscores for neurosis, hyperactivity, and behavior problems for the participants in the patients' group (Table 3).

The mean neurosis score for participant children with cancer, based on their parents' responses, was reduced from 3.17 (SD, 1.09) (T1), to 3.15 (SD, 0.94) (T2), and down to 3.01 (SD, 0.79) at the end of the study (T3). The relevant score, according to teachers' responses, was 3.62 (SD, 0.98). For participants in the control group, the mean neurosis score was 2.16 (SD, 1.06), on the basis of parents' responses, and 2.07 (SD, 1.07), according to teachers' responses. The application of Mann-Whitney test, for the comparison of scores between the pediatric participants and participants in the control groups at T3, revealed a statistically significant difference, according to both parents' and teachers' responses (P < .00001 and P < .001, respectively).

The initial (T1) mean Rutter hyperactivity score for pediatric participants, according to their parents' responses, was 2.38 (SD, 1.53) and became 2.37 (SD, 1.42) at T2 and 2.14 (SD, 1.41) at the end of the study (T3). The mean hyperactivity score for pediatric participants, according to teachers' responses, was 1.83 (SD, 1.20). For participants in the control group, the mean hyperactivity score was 1.10 (SD, 0.80), according to their parents' responses, and 1.53 (SD, 0.87), according to their teachers' responses. The comparison of scores of pediatric participants in the patients and control groups at T3 revealed a highly significant difference (P < .00001), according to parents' responses, but there was no difference, according to teachers' responses (P = .15), suggesting that teachers did not notice any hyperactivity symptoms in children with cancer, at the end of their treatment.

The mean behavioral problems score for patients, according to the parents' responses, was 0.83 (SD, 0.98) at T1, increased to 0.86 (SD, 0.87) at T2, and further increased to 0.94 (SD, 1.92) at the end of the study (T3). The relevant score at T3, according to the teachers' responses, was 0.61 (SD, 0.78). For participants in the control group, the mean behavioral disorder score was 0.60 (SD, 0.64), according to the parents' responses, and 1.33 (SD, 1.30), according to the teachers' responses. The mean behavioral problem scores for participants in the pediatric and control groups, according to parents' responses, when checked with Mann-Whitney test, were comparable (P = .69), implying that at the completion of intensive treatment, parents do not report such problems in their children with cancer. The comparison of pediatric participants' hyperactivity scores, according to parents' and teachers' responses, showed a statistically significant difference (P < .006), suggesting that teachers reported observing hyperactivity in these children at a much lower rate than did parents.

Rutter Scores According to Cancer Subtype and Age at Treatment

To study the impact of the cancer subtype in the development of psychological problems in pediatric participants, we divided them into the following 3 diagnostic groups, according to treatment intensity: (a) leukemia, (b) sarcoma and lymphoma, and (c) other types of cancer. Initially (T1), the cancer subgroup did not seem to play any role in the development of psychological problems, as the total Rutter score was comparable in all subgroups of pediatric patients (P = .48), even though children with leukemia had a tendency for higher score (Table 4). However, over the following 6 months, participants with leukemia improve their total Rutter score (from 10.38 [SD, 5.17] at T1 to 8.87 [SD, 3.99] at T3), whereas the other 2 groups' scores did not alter substantially. More specifically, for participants with lymphoma and sarcoma, the score changed from 9.14 (SD, 3.80) (T1) to 9.56 (SD, 3.81) (T3) and for the rest from 9.11 (SD, 4.31) (T1) to 8.97 (SD, 3.89) (T3).

The comparison of the alterations in total Rutter score for the 3 groups of pediatric participants, with Kruskal-Wallis statistical test, showed a statistically significant difference for participants with leukemia (P = .009), which decreased their score during treatment, according to the parents' responses, as opposed to the other participants' subgroups who kept their scores relatively stable. A statistically significant negative correlation was identified between this change in total Rutter score and pediatric participants' age (P = .013), suggesting a tendency for higher score reduction in younger children with cancer. These results are not independent, because the majority of younger children had a diagnosis of and treated for leukemia.

We used multivariate regression to evaluate the potential effect of age, sex, and subtype of cancer upon the total Rutter score. The analysis showed that younger pediatric participants present with higher scores during the initial phase of treatment (T1). According to the initial parents' responses (T1), only age had a marginal impact on the total score (R 2 = 0.040), implying that, with increasing age, the likelihood of development of psychological problems was diminishing. There was no significant correlation between age and the total Rutter score (R 2 = 0.052), at the following time points, T2 and T3. No significant correlation was found between age and the total score, according to the teachers' responses (R 2 = 0.068). No statistically significant correlation was identified between the total Rutter score with sex (R 2 = 0.34) or with subtype of cancer (R 2 = 0.22), according to the parents' responses at all the time points.

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