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Table of Contents Purpose of This PDQ Summary
Overview
Psychological Adjustment
Families
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Changes to This Summary (08/01/2008)
Questions or Comments About This Summary
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Purpose of This PDQ Summary
This PDQ cancer information summary provides comprehensive, peer-reviewed information for health professionals on supportive care issues related to treatment in children and adolescents. This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board.
Information about the following is included in this summary:
- Psychological adjustment to treatment.
The following information will be added to the summary as it is completed:
- Physical adjustment to treatment.
- Physical and cognitive development.
- Long-term survivorship.
This summary is intended as a resource to inform and assist clinicians and other health professionals who care for cancer patients during and after cancer treatment. It does not provide formal guidelines or recommendations for making health care decisions. Information in this summary should not be used as a basis for reimbursement determinations.
This summary will soon be available in a patient version, which is written in less technical language, and is available in Spanish.
Back to Top Overview
Between 1980 and 2005, treatment of childhood cancer resulted in a significant increase in long-term survivorship, with overall survival approximating 79% and some children with certain diseases approaching or exceeding 90% long-term survival.[1] With these improved outcomes, the focus of research and expectations of patients, parents, and health care providers has increasingly emphasized reducing the burden of cancer and its treatment for these children during treatment, after the completion of treatment, and as adult survivors.
Cancer treatment for children differs in many ways from treatment for adults. Some of the principal differences include the following:
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Intensity. In general, treatment of childhood cancer is more intense. Because the dose-limiting toxicities of most chemotherapy and radiation treatments are generally reached at higher doses, more-intensive chemotherapy and radiation therapy are feasible for children than would be possible for adults.
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Toxicity. Some of the toxicities of treatment have a much more significant and lasting effect on children than on adults because of the active development of nearly all organ systems during childhood and adolescence.
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Supportive Care. Developmental differences extend to the types of supportive care that children may receive. Medications that represent standards of care for adult cancer supportive care may be contraindicated for children because of adverse toxicities that are associated with specific periods of childhood development.
Fundamental to these differences is the clear recognition that children are not small adults and that even the term children is not all-encompassing. Treatment and supportive care require different approaches across the spectrum from newborn through young adult age groups, and the outcomes of both cancer survivorship (control of disease) and quality of survivorship (impact of toxicities) differ with the age of a child at the time of treatment.
Equally important is the recognition that treatment of childhood cancer inevitably occurs in the context of a family. Frequently, the impact of an adult’s cancer treatment focuses on one or two key adults in the cancer patient’s life. In childhood cancer, the effects are often felt by more individuals, including one or both parents, one or more siblings who are themselves children or adolescents, grandparents, aunts and uncles, teachers, friends, and other individuals who may be directly involved in the care or life experience of the child. Furthermore, because children are not considered legally competent exclusively on the basis of age, most decisions about cancer treatment are made by proxy. Instead of children making decisions about their own care, their parents or guardians make these decisions for them. The large number of people involved, legal issues related to decision making about minors by others, and ethical concerns about informed consent and assent involving children add extra layers to the complexity of treatment for children.
In this pediatric supportive care summary, issues specifically related to children and adolescents will be reviewed. Evidence and recommendations may differ significantly from information provided about supportive care for adults.
Topics addressed include the following:
- Psychological adjustment and treatment of psychological adjustment problems.
The following information will be added to the summary as it is completed:
- Pain and distress, particularly related to painful procedures.
- Acute toxicity issues.
- Neurodevelopment and learning.
- Growth and physical development.
- Impact of cancer treatment on families and family members.
- Long-term survivorship.
References
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American Cancer Society.: Cancer Facts and Figures 2005. Atlanta, Ga: American Cancer Society, 2005. Also available online. Last accessed July 31, 2008.
Back to Top Psychological Adjustment
Treatment of childhood cancer is a highly stressful experience, challenging and disruptive to children and their family members. It is therefore assumed that children undergoing cancer treatment are at significantly higher risk for depression, anxiety, and other indicators of psychological distress. However, the empirical evidence to support this assumption is weak. Overall, studies suggest that children treated for cancer and children who are long-term survivors of cancer experience few significant psychological adjustment problems.[1-3]
There is evidence that children experience distress during the cancer treatment process. Distress appears to be most significant early in therapy, typically when frequent hospitalizations are necessary, with a pattern of less distress occurring over time.[4,5] One group of 39 families of children newly diagnosed with leukemia was compared with a group of 49 families of healthy children. While parents and the children treated for cancer reported higher levels of distress immediately following diagnosis, these levels of distress decreased over 4 years of follow-up, and there were no significant differences in psychological distress compared with the healthy comparison cohort.[4] Similar findings have been reported across cultures.[6]
The validity of obtaining accurate reports of psychologic distress in this population has been questioned. One investigation of whether psychological defensiveness might mask the reporting of depression and other symptoms of psychological distress studied 107 children treated for cancer and 422 healthy controls who completed a series of measures of depression and anxiety.[7] Children treated for cancer reported significantly fewer depressive symptoms than did healthy children, and defensive style was not related to report of depression. Another study of 205 children and 321 parents of children with either cancer, asthma, or no significant health problem also found no significant levels of depression in children treated for cancer. However, parents of children with cancer attributed more cheerful characteristics to their children than did the parents of children in the other groups.[8]
Studies have reported no differences from controls on measures of self-esteem,[9,10] hopefulness,[9] depression, anxiety, or loneliness.[10] One group of investigators [10] found that teachers perceived children with cancer as more social and less aggressive, and peers rated them as less aggressive and having greater social acceptance than other peers. It may make a difference who is reporting: parents of children report more limitations in their children than the children themselves report,[11] although children do report lower satisfaction with athletic competence than do their peers.[10]
Diagnosis and type of treatment appear to make a difference in adjustment in specific subgroups of children with cancer.[12] Children treated for solid tumors not involving the central nervous system (CNS) appear to have minimal psychological distress, and this is maintained after treatment. Children treated for acute lymphoblastic leukemia (ALL) or lymphoma report poorer emotional functioning, cognitive skills, autonomy, and family interaction than do children treated for non-CNS solid tumors.[13] For children whose disease or treatment directly involves the CNS, the risk of developing social and emotional problems appears much greater. Children with brain tumors are seen by their peers as being sick, fatigued, absent from school, and socially isolated and are less likely to be endorsed as friends by their peers.[14] Similarly, children receiving hematopoietic stem cell transplantation (HSCT) are likely to experience declines in both social competence and self-concept over time.[15]
Family Factors
Family factors appear to play a large role in child adjustment, with family cohesion and expressiveness associated with better outcomes and family conflict associated with poorer outcomes, particularly for children experiencing more-intensive treatment.[15] Younger (pre-school) children are more likely to experience higher levels of externalizing behavior problems (e.g., aggression, impulsivity, or disruptive behavior) during treatment than do adolescents, but overall health-related quality of life (HRQL) reported by parents is better for younger children than for adolescents.[16] Age may also serve as a mediator in the approach to coping and perceived level of control experienced by children being treated for cancer. While one group of researchers found that children with cancer reported significantly more use of avoidant coping strategies than did healthy children, regardless of age,[17] another group found that the relationship between perceived control and problem-focused or emotion-focused coping (problem-focused coping related to higher appraisals of control) was mediated by age.[18] A limited number of studies has been conducted in this area, and there are likely a number of additional mediators of adjustment-coping relationships that have not yet been examined.
Childhood Cancer Survivor Study
The Childhood Cancer Survivor Study (CCSS) is a large, ongoing, multicenter study of more than 10,000 long-term survivors of childhood cancer and a comparison sibling control population. Using extensive survey methodology that links reports of current functioning to diagnosis, types of treatment, and other health factors associated with cancer and its treatment, the CCSS has selectively looked at long-term adjustment in large samples of young adults treated for similar childhood cancers. In one CCSS report, 2,778 survivors of solid tumors diagnosed in childhood and 2,925 siblings were surveyed using a standardized long-term follow-up questionnaire. Symptoms associated with depression, somatization, and anxiety were reported, along with demographic, health, and medical information. Few, if any, symptoms of psychological distress were reported by the cancer survivors, although survivors of solid-tumor cancers reported higher levels of global distress than did their siblings. There were no differences on these measures from population norms. For both cancer survivors and their siblings, female gender, lower education and income attainment, perceived poor health status, and reports of current health problems were all associated with higher levels of psychological distress symptoms.[19]
Positive findings also have been reported by the CCSS for young adults who are survivors of leukemias and lymphomas. Follow-up questionnaires about psychological adjustment were administered to 5,736 young adult survivors of leukemia, non-Hodgkin lymphoma, and Hodgkin disease and to 2,565 adult siblings. Survivors reported higher levels of depressive symptoms and somatic distress than did siblings, but scores for neither group fell within the clinically significant range for the general population. Sociodemographic factors such as gender and socioeconomic status were associated with reports of depressive symptoms, regardless of treatment status. The only disease-related factor associated with psychological distress was intensive chemotherapy, which was associated with an increase in somatic complaints.[2] Similar outcomes were reported for survivors of brain cancers. Brain tumor survivors reported higher levels of depressive symptomatology than did siblings, but the rates for both groups were similar to rates for the general population.[3]
Depression and Suicide
Young adult survivors of childhood cancer may have an elevated risk for suicidality. A report from Eastern Europe compared the responses of 228 long-term survivors of childhood cancer with those of 127 controls to the Center for Epidemiologic Studies Depression Scale (CES-D) and the Suicidal Ideation and Behaviour Questionnaire. The rates of depressive symptoms reported by the childhood cancer survivors were three times the rates reported by the controls, with 13% indicating some level of suicidal ideation.[20] Similarly, 226 adult survivors of childhood cancer seen in a survivor clinic completed the Short Form-36 (SF-36), the Beck Depression Inventory (BDI), and suicide items from the Symptom Checklist-90-Revised (SCL-90-R) and the Beck Scale for Suicide Ideation (BSS). The measures assessed whether the survivors had ever attempted suicide or whether they had experienced significant suicidal ideation within the past week; 29 participants (12.83%) reported suicidality. Suicidality was associated with younger age at diagnosis, longer time since diagnosis, cranial radiation therapy, a diagnosis of leukemia, pain, and concerns about physical appearance. Current physical condition, including pain, was associated with suicidality.[21] These studies represent relatively small samples with small comparison groups and may reflect a reporting bias represented in individuals who actively attend follow-up clinics. Nonetheless, while these results are inconsistent with other findings related to psychological distress, they do suggest the need for ongoing monitoring and surveillance of adults who are survivors of childhood cancer.
Post-traumatic Stress Disorder and Post-traumatic Stress Symptoms
The cancer treatment experience may be considered a significant traumatic event, given the nature of diagnosis, the number of invasive and painful procedures, and the often long hospitalizations that children and their families must experience. On the basis of this exposure model, a number of studies have examined whether children treated for cancer are at a significantly higher risk for the development of symptoms of post-traumatic stress disorder (PTSD). The results of these studies have been mixed.[22] One study reported that children and adolescents who were undergoing treatment reported some symptoms of post-traumatic stress; however, for most children these symptoms did not meet the criteria for a diagnosis of PTSD, and the symptoms diminished over time.[23]
Other studies suggest that survivors of childhood cancer have an increased risk for post-traumatic stress symptoms and PTSD after treatment is finished. In a study of 78 young adults aged 18 to 41 years who had been treated for childhood cancer, 20.5% met the criteria for a diagnosis of PTSD at some time since the end of their treatment. Clinically significant events of intrusive symptoms (9%) and avoidant symptoms (16.7%) were reported in the sample, and the symptoms were associated with elevated reports of anxiety and other measures of psychologic distress.[24] Survivors who report higher levels of uncertainty about their disease and future appear to be more likely to have elevated reports of post-traumatic stress symptoms.[25,26] A study of 182 adolescent and young adult cancer survivors who were more than 5 years from diagnosis and more than 2 years from completion of cancer treatment also found that 16% met the criteria for PTSD. A relationship between PTSD and higher levels of other psychological problems was also reported.[27] When survivors meet the criteria for PTSD, they are more likely to experience depression and negative affect, lower satisfaction with life, and poorer reported health-related quality of life (HRQL), as well as difficulty performing developmental tasks.[28]
References
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Eiser C, Hill JJ, Vance YH: Examining the psychological consequences of surviving childhood cancer: systematic review as a research method in pediatric psychology. J Pediatr Psychol 25 (6): 449-60, 2000.
[PUBMED Abstract]
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Zebrack BJ, Zeltzer LK, Whitton J, et al.: Psychological outcomes in long-term survivors of childhood leukemia, Hodgkin's disease, and non-Hodgkin's lymphoma: a report from the Childhood Cancer Survivor Study. Pediatrics 110 (1 Pt 1): 42-52, 2002.
[PUBMED Abstract]
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Zebrack BJ, Gurney JG, Oeffinger K, et al.: Psychological outcomes in long-term survivors of childhood brain cancer: a report from the childhood cancer survivor study. J Clin Oncol 22 (6): 999-1006, 2004.
[PUBMED Abstract]
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Sawyer M, Antoniou G, Toogood I, et al.: Childhood cancer: a 4-year prospective study of the psychological adjustment of children and parents. J Pediatr Hematol Oncol 22 (3): 214-20, 2000 May-Jun.
[PUBMED Abstract]
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Varni JW, Katz E: Stress, social support and negative affectivity in children with newly diagnosed cancer: a prospective transactional analysis. Psychooncology 6 (4): 267-78, 1997.
[PUBMED Abstract]
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Chao CC, Chen SH, Wang CY, et al.: Psychosocial adjustment among pediatric cancer patients and their parents. Psychiatry Clin Neurosci 57 (1): 75-81, 2003.
[PUBMED Abstract]
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Phipps S, Srivastava DK: Approaches to the measurement of depressive symptomatology in children with cancer: attempting to circumvent the effects of defensiveness. J Dev Behav Pediatr 20 (3): 150-6, 1999.
[PUBMED Abstract]
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Grootenhuis MA, Last BF, van der Wel M, et al.: Parents' attribution of positive characteristics to their children with cancer. Psychol Health 13: 67-81, 1998.
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Ritchie MA: Self-esteem and hopefulness in adolescents with cancer. J Pediatr Nurs 16 (1): 35-42, 2001.
[PUBMED Abstract]
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Noll RB, Gartstein MA, Vannatta K, et al.: Social, emotional, and behavioral functioning of children with cancer. Pediatrics 103 (1): 71-8, 1999.
[PUBMED Abstract]
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Levi RB, Drotar D: Health-related quality of life in childhood cancer: discrepancy in parent-child reports. Int J Cancer Suppl 12: 58-64, 1999.
[PUBMED Abstract]
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Armstrong FD, Toledano SR, Miloslavich K, et al.: The Miami pediatric quality of life questionnaire: parent scale. Int J Cancer Suppl 12: 11-7, 1999.
[PUBMED Abstract]
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Calaminus G, Weinspach S, Teske C, et al.: Quality of life in children and adolescents with cancer. First results of an evaluation of 49 patients with the PEDQOL questionnaire. Klin Padiatr 212 (4): 211-5, 2000 Jul-Aug.
[PUBMED Abstract]
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Vannatta K, Gartstein MA, Short A, et al.: A controlled study of peer relationships of children surviving brain tumors: teacher, peer, and self ratings. J Pediatr Psychol 23 (5): 279-87, 1998.
[PUBMED Abstract]
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Phipps S, Mulhern RK: Family cohesion and expressiveness promote resilience to the stress of pediatric bone marrow transplant: a preliminary report. J Dev Behav Pediatr 16 (4): 257-63, 1995.
[PUBMED Abstract]
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Barrera M, Wayland LA, D’Agostino NM, et al.: Developmental differences in psychological adjustment and health-related quality of life in pediatric cancer patients. Child Health Care 32 (3): 215-32, 2003.
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Phipps S, Fairclough D, Mulhern RK: Avoidant coping in children with cancer. J Pediatr Psychol 20 (2): 217-32, 1995.
[PUBMED Abstract]
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Sorgen KE, Manne SL: Coping in children with cancer: examining the goodness-of-fit hypothesis. Child Health Care 31 (3): 191-207, 2002.
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Zebrack BJ, Zevon MA, Turk N, et al.: Psychological distress in long-term survivors of solid tumors diagnosed in childhood: a report from the childhood cancer survivor study. Pediatr Blood Cancer 49 (1): 47-51, 2007.
[PUBMED Abstract]
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Svetičič J, Jereb B, Bucik V, et al.: Suicidal behaviour in long-term survivors of childhood cancer. [Abstract] Psychiatr Danub 18 (Suppl 1): 39-40, 2006.
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Recklitis CJ, Lockwood RA, Rothwell MA, et al.: Suicidal ideation and attempts in adult survivors of childhood cancer. J Clin Oncol 24 (24): 3852-7, 2006.
[PUBMED Abstract]
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Bruce M: A systematic and conceptual review of posttraumatic stress in childhood cancer survivors and their parents. Clin Psychol Rev 26 (3): 233-56, 2006.
[PUBMED Abstract]
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Phipps S, Long A, Hudson M, et al.: Symptoms of post-traumatic stress in children with cancer and their parents: effects of informant and time from diagnosis. Pediatr Blood Cancer 45 (7): 952-9, 2005.
[PUBMED Abstract]
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Hobbie WL, Stuber M, Meeske K, et al.: Symptoms of posttraumatic stress in young adult survivors of childhood cancer. J Clin Oncol 18 (24): 4060-6, 2000.
[PUBMED Abstract]
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Lee YL: The relationships between uncertainty and posttraumatic stress in survivors of childhood cancer. J Nurs Res 14 (2): 133-42, 2006.
[PUBMED Abstract]
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Santacroce SJ, Lee YL: Uncertainty, posttraumatic stress, and health behavior in young adult childhood cancer survivors. Nurs Res 55 (4): 259-66, 2006 Jul-Aug.
[PUBMED Abstract]
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Rourke MT, Hobbie WL, Schwartz L, et al.: Posttraumatic stress disorder (PTSD) in young adult survivors of childhood cancer. Pediatr Blood Cancer 49 (2): 177-82, 2007.
[PUBMED Abstract]
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Schwartz L, Drotar D: Posttraumatic stress and related impairment in survivors of childhood cancer in early adulthood compared to healthy peers. J Pediatr Psychol 31 (4): 356-66, 2006.
[PUBMED Abstract]
Back to Top Families
A commonly repeated idea in the cancer community is that cancer is a family disease; this concept is clearly supported by parents and siblings of children who are being treated for cancer. However, the effects of having a child or sibling with cancer are not uniform, either for all family members or at all points in the treatment process, and the literature reflects the variability of each family member’s experience.
Parents
The diagnosis of childhood cancer represents the start of a period of substantial distress for parents, who report shock, emotional pain, difficulty coping with the necessary procedures performed on their child, rumination, and high levels of information seeking accompanied by a sense of lack of control.[1-3] One study found that all but one participant in a sample of 119 mothers and 52 fathers of children undergoing cancer treatment reported traumatic stress symptoms such as intrusive thoughts, physiologic arousal, and avoidance.[4] When parents of children undergoing treatment (n = 175) were compared with parents of children who had completed treatment (n = 238), symptoms of traumatic stress (intrusion, arousal) were reported more frequently by the parents during the acute phase of treatment than by the parents after treatment, though some parents reported these symptoms after treatment. Some demographic factors may play a role in the degree to which parents experienced significant stress that impairs function. Mothers were more likely to report higher levels of stress than were fathers, and parents with fewer years of formal education and lower socioeconomic status were more likely to experience traumatic stress at any time.[5]
Patterns of parental stress in families of children treated for cancer differ from those in families of children treated for other diseases. In one large study of 675 parents of children who were treated for cancer or diabetes or who were healthy, parents of children with cancer reported significantly higher levels of distress—as indicated in the specific areas of anxiety, physical and psychological distress, depression, and loneliness—than did parents of children with diabetes. Distress levels of parents of patients with cancer matched those in parents of patients with diabetes in measures of uncertainty, loss of control, self-esteem, disease-related fear, and sleep disturbances. Distress levels for parents of children with cancer decreased in intensity with longer time since diagnosis.[6]
At the same time that they are dealing with increased distress, parents of children with cancer report wanting to remain strong and optimistic for their children.[7] One study found no differences in multiple measures of family distress and psychological functioning between families of children with cancer and families with healthy children.[8] Several factors appear to be predictive of long-term parental adjustment. Parents who are employed; who have social support from family, friends, and health care team members; who experience lower levels of parenting stress; who view their children’s quality of life positively; and who have positive expectations for treatment outcome are more likely to experience better short- and long-term adjustment.[9-11] Alternatively, low parental expectations for positive outcomes, feelings of helplessness, uncertainty, anxiety, low levels of social support, negative interactions with health care team members, and negative assessment of the child’s quality of life have been associated with poorer parental adjustment.[12,13] Race [14] and parent gender [15] may affect the intensity of the effect of these factors on parental functioning. In rare circumstances, the stress of coping with pain, adverse side effects, lack of control or understanding of information or outcomes, and conflicts with health care professionals may lead parents to drop out of cancer treatment for their children.[16]
Most studies suggest that over time, maternal affective distress and perceived stress have been shown to decline, but the perceived burden of caring for a child with cancer remains stable, as do positive characteristics such as parental control, nurturance, and responsiveness.[14] This pattern may be related to the high levels of social support provided at the time of diagnosis, with a gradual decrease in the quantity of support but stable perceived quality of support across all phases of cancer treatment.[15] In general, parents are seen as resilient,[12] but parental loneliness and continued uncertainty may last far beyond the treatment phase if there are ongoing late effects of treatment for the child.[17] A few studies have found that a substantial number of parents (30%–36%) of long-term cancer survivors may experience intense long-term stress-related symptoms that fall below the threshold for a diagnosis of post-traumatic stress disorder (PTSD) but that are nevertheless a significant problem for these parents.[18,19] Symptoms were severe enough that in 20% of families, at least one parent met the criteria for a diagnosis of PTSD.[19]
Siblings
The challenges of dealing with the diagnosis and treatment of childhood cancer also has implications for the coping and adjustment of siblings. During treatment, siblings of children with cancer may report higher levels of anxiety and loneliness than do siblings of healthy children.[20] While approximately 50% of siblings report post-traumatic distress symptoms,[21] others report distress about family disruptions and separations, lack of attention associated with the focus of other family members on the ill child, negative interactions with family members, and fear of the sibling’s death. They also report becoming more compassionate and perceiving that their families are drawn closer together through the experience.[22] The risk to families increases with younger patient age,[22] longer duration of cancer treatment,[20] and whether the child with cancer dies.[23] For siblings of children who undergo allogeneic hematopoietic stem cell transplantation, the risk for anxiety and lower self-esteem is higher for siblings who serve as hematopoietic stem cell donors, while non-donors are at higher risk of developing school problems.[24] Social support programs such as sibling groups [25] or summer camp experiences [26] appear to result in reductions in reported anxiety and improved self-esteem in siblings of children treated for cancer.
References
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McGrath P: Treatment for childhood acute lymphoblastic leukaemia: the fathers' perspective. Aust Health Rev 24 (2): 135-42, 2001.
[PUBMED Abstract]
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Levi RB, Marsick R, Drotar D, et al.: Diagnosis, disclosure, and informed consent: learning from parents of children with cancer. J Pediatr Hematol Oncol 22 (1): 3-12, 2000 Jan-Feb.
[PUBMED Abstract]
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Goldbeck L: Parental coping with the diagnosis of childhood cancer: gender effects, dissimilarity within couples, and quality of life. Psychooncology 10 (4): 325-35, 2001 Jul-Aug.
[PUBMED Abstract]
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Kazak AE, Boeving CA, Alderfer MA, et al.: Posttraumatic stress symptoms during treatment in parents of children with cancer. J Clin Oncol 23 (30): 7405-10, 2005.
[PUBMED Abstract]
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Norberg AL, Lindblad F, Boman KK: Parental traumatic stress during and after paediatric cancer treatment. Acta Oncol 44 (4): 382-8, 2005.
[PUBMED Abstract]
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Boman KK, Viksten J, Kogner P, et al.: Serious illness in childhood: the different threats of cancer and diabetes from a parent perspective. J Pediatr 145 (3): 373-9, 2004.
[PUBMED Abstract]
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Young B, Dixon-Woods M, Windridge KC, et al.: Managing communication with young people who have a potentially life threatening chronic illness: qualitative study of patients and parents. BMJ 326 (7384): 305, 2003.
[PUBMED Abstract]
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Noll RB, Gartstein MA, Hawkins A, et al.: Comparing parental distress for families with children who have cancer and matched comparison families without children with cancer. Fam Syst Med 13 (1): 11-27, 1995.
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Rourke MT, Stuber ML, Hobbie WL, et al.: Posttraumatic stress disorder: understanding the psychosocial impact of surviving childhood cancer into young adulthood. J Pediatr Oncol Nurs 16 (3): 126-35, 1999.
[PUBMED Abstract]
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Kazak AE, Barakat LP: Brief report: parenting stress and quality of life during treatment for childhood leukemia predicts child and parent adjustment after treatment ends. J Pediatr Psychol 22 (5): 749-58, 1997.
[PUBMED Abstract]
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Grootenhuis MA, Last BF: Predictors of parental emotional adjustment to childhood cancer. Psychooncology 6 (2): 115-28, 1997.
[PUBMED Abstract]
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Dockerty JD, Williams SM, McGee R, et al.: Impact of childhood cancer on the mental health of parents. Med Pediatr Oncol 35 (5): 475-83, 2000.
[PUBMED Abstract]
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Santacroce S: Uncertainty, anxiety, and symptoms of posttraumatic stress in parents of children recently diagnosed with cancer. J Pediatr Oncol Nurs 19 (3): 104-11, 2002 May-Jun.
[PUBMED Abstract]
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Steele RG, Long A, Reddy KA, et al.: Changes in maternal distress and child-rearing strategies across treatment for pediatric cancer. J Pediatr Psychol 28 (7): 447-52, 2003 Oct-Nov.
[PUBMED Abstract]
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Hoekstra-Weebers JE, Jaspers JP, Kamps WA, et al.: Psychological adaptation and social support of parents of pediatric cancer patients: a prospective longitudinal study. J Pediatr Psychol 26 (4): 225-35, 2001.
[PUBMED Abstract]
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Yeh CH, Lin CF, Tsai JL, et al.: Determinants of parental decisions on 'drop out' from cancer treatment for childhood cancer patients. J Adv Nurs 30 (1): 193-9, 1999.
[PUBMED Abstract]
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Van Dongen-Melman JE, Pruyn JF, De Groot A, et al.: Late psychosocial consequences for parents of children who survived cancer. J Pediatr Psychol 20 (5): 567-86, 1995.
[PUBMED Abstract]
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Brown RT, Madan-Swain A, Lambert R: Posttraumatic stress symptoms in adolescent survivors of childhood cancer and their mothers. J Trauma Stress 16 (4): 309-18, 2003.
[PUBMED Abstract]
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Kazak AE, Alderfer M, Rourke MT, et al.: Posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) in families of adolescent childhood cancer survivors. J Pediatr Psychol 29 (3): 211-9, 2004 Apr-May.
[PUBMED Abstract]
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Hamama R, Ronen T, Feigin R: Self-control, anxiety, and loneliness in siblings of children with cancer. Soc Work Health Care 31 (1): 63-83, 2000.
[PUBMED Abstract]
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Alderfer MA, Labay LE, Kazak AE: Brief report: does posttraumatic stress apply to siblings of childhood cancer survivors? J Pediatr Psychol 28 (4): 281-6, 2003.
[PUBMED Abstract]
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Sargent JR, Sahler OJ, Roghmann KJ, et al.: Sibling adaptation to childhood cancer collaborative study: siblings' perceptions of the cancer experience. J Pediatr Psychol 20 (2): 151-64, 1995.
[PUBMED Abstract]
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MacLeod KD, Whitsett SF, Mash EJ, et al.: Pediatric sibling donors of successful and unsuccessful hematopoietic stem cell transplants (HSCT): a qualitative study of their psychosocial experience. J Pediatr Psychol 28 (4): 223-30, 2003.
[PUBMED Abstract]
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Packman W: Psychosocial impact of pediatric BMT on siblings. Bone Marrow Transplant 24 (7): 701-6, 1999.
[PUBMED Abstract]
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Houtzager BA, Grootenhuis MA, Last BF: Supportive groups for siblings of pediatric oncology patients: impact on anxiety. Psychooncology 10 (4): 315-24, 2001 Jul-Aug.
[PUBMED Abstract]
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Murray JS: Self-concept of siblings of children with cancer. Issues Compr Pediatr Nurs 24 (2): 85-94, 2001 Apr-Jun.
[PUBMED Abstract]
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Back to Top Changes to This Summary (08/01/2008)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Editorial changes were made to this summary.
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Additional PDQ Summaries
Important:
This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).
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