Many children do not understand what is happening in the midst of a cancer diagnosis and treatment. Large numbers experience psychosocial dysfunction such as anger, fear, depression, sleep disturbances, unjustifiable guilt, or panic. A cancer diagnosis and treatment also impact siblings, parents, and the family as a whole. This article will review a number of psychosocial issues facing the pediatrician's patient with cancer and discusses practice strategies for their identification and treatment.
Scope of the problem
Unfortunately, psychosocial care for children with cancer and their families is not systematically provided across or within pediatric cancer programs, and few programs use empirically supported assessments or treatments.1 As a result, an effort has been made to develop standards for the assessment and treatment of the psychosocial needs of children with cancer.2
For the pediatrician attempting to better understand the impact of psychosocial issues, it is useful to think about several different domains that impact children with cancer:3
Additionally, development plays a significant role as to how the pediatric patient may experience psychosocial dysfunction. Patients may experience issues in only some of the domains and may have issues in different domains over time.
In the emotional/behavioral spectrum, the infant/toddler may experience dysfunction related to self-soothing while the preschool-aged child may develop temper tantrums and procedural resistance when control is threatened or with frequent changing routines because of their illness. School-aged children may experience significant aversion to medicine, diets, or another domain compared with siblings as a result of feeling unfairness or a disruption of normalcy. Adolescents may display risk taking and nonadherence behaviors as well as behaviors for the benefit of social/peer values with less concern about the immediate family.4
In the cognitive domain, normal development of sensory and motor curiosity in the infant/toddler may be disrupted by pain and treatment discomfort. As they develop imagination and magical thinking, preschoolers can develop complex fears and fantasies linked to both their treatment and treatment environment. School-aged children begin to develop concrete thinking about the length and number of treatments and begin to develop an understanding of death. The adolescent can understand both abstract and theoretical constructs about death as well as critical thinking, planning, and agency related to their treatment.4
In the psychosocial domain, difficulties with feeding and comfort can lead to caregiver mistrust and attachment issues in infancy. Preschoolers are at risk of losing the sense of personal control related to their environment and tasks such as eating and toileting that may result in fear, anxiety, doubt, and frustration. School disruption can lead to an inability to participate in activities valued by the family, resulting in a sense of inferiority and guilt. Adolescents are at risk of frustration and confusion if they are unable to find acceptance in peer groups and subsequent feelings of loneliness and isolation.4
Parents and families are also at risk for psychosocial dysfunction. Families with an existing prediagnosis dysfunction and those with poor psychosocial support networks appear to be at greatest risk.5 Parents may experience issues with marital satisfaction as well as individual problems with anxiety, stress, and depression. This can be made worse by ineffective social support and a lack of awareness from family or friends that words and actions can negatively impact the family, even when trying to help. Similarly, families also experience a sense of overinvolvement with some and feeling of abandonment from certain people in their life.6
Finally, siblings of children with cancer are an at-risk group and experience both different and similar feelings of psychosocial dysfunction such as:7,8
· A “forgotten” child
· Diminished sense of self-importance in a family
Despite the guidelines outlining the need for and best practices for psychosocial care among children with cancer (Table 1), unmet needs remain.9