In the present study, we have investigated whether children with cancer develop psychological problems during the challenging intensive treatment period. The study progressed in 3 different phases: (a) 1 month after diagnosis, (b) 3 months after diagnosis, and (c) 6 months after diagnosis, at the end of intensive treatment. Our results suggest that children with cancer might develop psychological problems during their treatment, as indicated by both parents' and teachers' responses in Rutter instrument. These problems persist during the entire intensive period of treatment. The kinds of psychological problems, according to their parents' responses, are especially neurosis and hyperactivity, but not behavioral difficulties. The teachers reported higher neurosis scores for the children with cancer, but not hyperactivity and behavioral problems. Regarding subtype of cancer, children with leukemia had higher scores in the beginning of treatment but in the following 6 months showed significant improvement in their psychological condition, contrary to the other 2 subgroups of children. Similarly, younger children with cancer had higher scores in the end of the first month of treatment but showed the biggest improvement in the course of therapy.
The numerous stressful factors, starting from diagnosis and initial hospital admission to the administration of chemotherapy with subsequent toxicity, including body changes, challenge the psychological adaptation of children with cancer. Similar studies in other countries have also showed that cancer has a negative impact on children's psychological functioning.[15–17,23–25] Even in studies on quality of life of children with cancer, serious problems are described in psychosocial and emotional functioning, characteristically more prominent in children with newly diagnosed cancer compared with survivors.[26,27]
However, the development of neurosis, which in Rutter instrument defines the symptoms of distress, anxiety, and fear, is enhanced by subjective factors. The stress of treatment could cause a range of chronic problems, from phobia and anxiety for minor medical procedures, such as blood taking, to panic attack under difficult conditions. This view is further supported by studies focused on stress in children during the treatment for cancer.[1,15] On the contrary, other studies suggest that even though the nursing and medical staff perceive more patient distress, the self-reported anxiety in children with cancer is low.[10,11,28]
Parents in this study recognized the presence of psychological problems in their sick children and, specifically, neurosis and hyperactivity, but not behavioral difficulties. Observation of hyperactivity has been previously reported in children with cancer, as a reaction to their treatment.[29–31] Although children with no cancer are involved in normal developmental activities, children with cancer fight for their own life, spend long periods in the hospital, and present with neurotic symptoms, increased anxiety, and even hyperactivity.
The teachers in this study, compared with the parents, reported higher neurosis scores for the pediatric participants, but yet lower scores for hyperactivity and behavioral problems. A possible explanation could be that school lessons are made at the child's bedside, because children with cancer are frequently hospitalized. The sick children stay long in a hospital ward, often depressed and nervous. Hospital teachers meet them under these unpleasant conditions, and their responses to Rutter instrument might reflect their own anxiety and feelings of helplessness.
On the contrary, for the children with no cancer in the control group in this study, school is a meeting place with their peers, where they can enjoy, play, and receive social support. For children with cancer, school is another task they may be unable to fulfill. The school lessons in the pediatric oncology ward make them even more desperate and depressed, increasing their psychological burden.
Regarding the impact of subtype of cancer in the presence of psychological disorders and their severity in children on therapy, no statistically significant difference was found in the end of the first month of treatment, even though children with leukemia had a relatively higher total Rutter score. Leukemia treatment includes, except for intravenous and intrathecal chemotherapy, repeated painful procedures. Even if these are thoroughly explained to the child and the family and often performed under sedation, they increase children's stress, fear, and concern. The administration of steroids, critical drug for leukemia therapy, is deteriorating their quality of life, especially at emotional and behavioral level.[33,34] Interestingly, in the course of our study (from T1 to T3), children with leukemia showed significant improvement in their psychological condition, contrary to the other 2 subgroups of children with cancer. This finding is supported by the results of other previous studies.
The correlation of the total Rutter score with age for pediatric participants with cancer, according to parents' responses, showed a statistically significant difference. From T1 to T3, a reducing trend was identified in the total scores of younger children with cancer. The correlation of younger age and leukemia with total Rutter score is not irrelevant, because leukemia is the most frequent malignancy in this specific age group. These results could reflect the diversity in protocols, according to cancer subtype. The cancer treatments for the other subtypes of childhood cancer are not that complicated or painful initially. However, as they gradually become more intense with surgical procedures and/or radiotherapy including chemotherapy, the children's psychological distress may increase together with the adverse effects of treatment.
The younger age in our studies may have provided a protective role for the development of psychological problems in pediatric participants with cancer. Yet, the impact of age has been controversial and can be either a risk or a protective factor for the psychological functioning of children with cancer. Some studies suggest that younger children can adapt more effectively to the stress of disease and treatment, probably because the impact in their social life may be less intense. Older children and especially teenagers with cancer are deeply affected by frequent hospital visits and treatment-related symptoms in association with body changes, resulting in lower self-esteem and disappointment. Toddlers do not easily realize their body alterations. They do not thoroughly understand the risks of disease and the complications of treatment, and, more importantly, they do not perceive completely the meaning of death. In addition, older children have the necessary cognitive abilities to interpret the health information provided, creating a greater pool of external stressors.[8,38] On the contrary, older age has been considered by others as positive prognostic factor for the psychological adjustment for children with cancer. Specifically, their higher cognitive ability can be associated with better control over life. Older children and adolescents have developed a larger variety of coping strategies to face challenges and have the maturity to deal with their disease anxiety.
Our study had some limitations, such as the completion of questionnaire by only 1 parent, typically the mother. It would be desirable to have it completed by both parents, but most of the time, this was impossible for practical reasons. Even though this fact may limit the generalizability of the findings, it is usually common practice in relevant studies in pediatric oncology. Another limitation was the use of only parent or teacher reports. Parent report and child report are known to differ, especially at psychosocial level.[40,41] In our study, we have decided not to use self-reports as the age of the large proportion of our sample was very young. Also, the age and sex distribution in the control group versus the children with cancer was unequal. In statistical analysis, power analysis calculation was not reported. Finally, the Rutter instrument has not been previously used with pediatric oncology patients.
It is important that studies on psychological functioning of children with malignant disorders have clinical implications for the multidisciplinary team. The medical and nursing staff involved in the care of children with cancer should be aware of all the possible psychological problems, which can develop and persist in children even after cure. Doctors and nurses with appropriate interventions could reduce the negative impact of cancer diagnosis and treatment and help the family get through the stressful situation as smoothly as possible. Psychological counseling may help the children deal with the possible effects of treatment and improve their quality of life. The reduction of adverse effects of chemotherapy, in general, and certain drugs that can affect the psychological condition such as steroids, in particular, should be the subject of future studies.
Despite the progress in treatment and supportive care, cancer may compromise children's psychological functioning not only during therapy but also in the long term. Despite the use of central lines and supportive therapy, such as antiemetics and analgesia, which reduce children's unpleasant experiences, still much needs to be done to improve the quality of life of children with cancer. Understanding the psychological problems of children with cancer may be helpful in developing appropriate intervention strategies. Indeed, it might be quite challenging for the children with cancer to maintain their psychological health despite the stressful disease and treatment, in the period of their development and maturation. As a result, prompt and effective interventions are absolutely critical for their normal psychosocial adaptation. Additional information about the children who are more vulnerable to psychological problems during treatment can be used for offering enhanced support for these specific groups. For example, priority could be given to children receiving more aggressive chemotherapy so that their physical, psychological, and emotional problems stay in lower possible levels.
Our study confirms the need for repeated careful evaluation of emotional and psychological health in children undergoing cancer treatment. Psychosocial interventions may have to be specifically tailored according to the child's diagnosis, age, and different stage of treatment. More longitudinal studies using parent, teacher, and, when possible, child's self-reports are necessary to identify the factors that impede transition to optimal children's psychological health. We need to find ways to reduce the stress of diagnosis and treatment and improve the standard of care offered by the multidisciplinary team. The family needs the support of the medical and nursing staff to cope with the challenges of the disease and eventually return to their previous life, with the minimal anxiety and fear for the future.
Cancer Nurs. 2011;34(4):269-276. © 2011 Lippincott Williams & Wilkins
Cite this: Psychological Problems in Children with Cancer in the Initial Period of Treatment - Medscape - Jul 01, 2011.