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Children with cancer: Are we healing the body & missing the mind?
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Received: ,
This article was originally published by Wolters Kluwer - Medknow and was migrated to Scientific Scholar after the change of Publisher.
A large proportion of the global paediatric cancer burden is from low- and middle-income countries (LMICs)1. Over the past three decades, the five-year outcome of paediatric cancer has improved significantly2. The focus of treatment is mostly targeted at controlling the primary disease. However, there is evidence from around the world that going through the journey of cancer treatment is associated with significant psychological morbidity and emotional distress in children diagnosed with cancer3. This narrative highlights some of the common psychological problems and potential ways to address them (Figure).
- Common psychological difficulties faced by children with cancer and ways to help them. Image was generated exclusively for this article (image created using Procreate R online software).
Common mental health issues during cancer treatment
Many children adapt quickly to the hospital environment and procedures that they must undergo. However, some children with cancer may be distressed at the time of diagnosis, and others during treatment, or following treatment completion4. Common psychosocial issues that affect children with cancer may be slightly different for different age groups. This narrative talks about integrating psychological care for children with cancer as part of the usual standard of care in LMICs.
Communicating with children with cancer
Children process information related to their health conditions according to their developmental level. More often than not, they remain as silent partners or are excluded from the discussions about their treatment. We have previously published data from India highlighting that children and adolescents with cancer are often aware of their diagnosis and have different information needs than those of their caregivers5. Young children aged less than 12 yr may be more interested in knowing the ‘here and now’ of the treatment. Older adolescents (12-18 yr) may want to have more detailed information about the impact of the disease on their lives in the longer term5. All staff involved in the treatment of children with cancer should be attuned emotionally to discuss difficult topics with children and at a pace that they are comfortable with. This may require a change in work culture in paediatric oncology units in LMICs, moving on from an authoritarian to a more participatory model of care with young people at the centre of care.
Procedural anxieties
During cancer diagnosis, most children undergo several invasive investigations. This can be distressing not only for children but also for their parents3. Children may be scared of hospital settings and health professionals4. The hospital wards and outpatient clinics should have a child-friendly design that provides a healing environment to the sick child. Reassuring staff in a positive environment will lay the foundation for psychologically matured care. A recent systematic review on the management of procedural anxiety in children reported the positive role of hypnosis in reducing anxiety and pain in this group of children6.
Depression
Adolescents and young adults (AYAs) undergoing cancer treatment are at a higher risk of developing depression, more so when there is a high symptom burden of their disease or the cancer treatment poses significant disruptions in their daily routine7. Young people with depression may present with irritability and anger as opposed to low mood. At times, the moodiness of the young person may be perceived as being ‘rebellious’. It is crucial to engage this group of AYAs in psychiatric treatment after appropriate referral to existing children’s mental health services.
Body image problems
The experience of cancer may impact the self-identity of most individuals. Body image related issues are common among adolescents with cancer8. Young people with osteosarcoma undergoing amputation commonly go through a period of grief associated with losing a limb. There may be times when the child is clinically depressed. Paediatric surgeons and clinical psychologists should liaise at the time of the surgery and continue to provide appropriate mental healthcare beyond the immediate period of surgery. Identifying and treating clinical depression is important for all children with cancer.
Dying children and grief in parents
Recent research from the USA has shown that mothers of children who died due to cancer often have decisional regret, especially if their child had significant physical suffering at the end-of-life9. The above authors suggested that preparing the parents beforehand about potential symptoms reduced future guilt and regret. Irrespective of the context, losing a child is incredibly stressful for parents and oncology clinicians. Whenever possible, children and families going through end-of-life care should have access to psychosocially attuned care. The family and siblings may take several decades to get over the loss. Formal grief therapy may be indicated in situations of pathological and disabling grief.
Burnout in paediatric oncology professionals
Paediatric oncology can be a satisfying yet stressful profession. A recent review10 on compassion fatigue in paediatric haematology/oncology staff commented on the high rates of staff burnout.
Research trends in paediatric oncology
There is a worrying trend of a lesser percentage of children diagnosed with cancer participating in clinical trials over the years, and experts have called for multidisciplinary, multinational collaborations11. A recent situation analysis published by the Indian Council of Medical Research highlighted that the majority of children’s cancer facilities are clustered around big cities12. In a country like India, there needs to be more coordinated efforts of multi-site research studies that investigate novel service models, evaluate and integrate psychosocial care alongside oncology care for children with cancer and address rehabilitation efforts beyond recovery from the disease.
Coping beyond treatment completion
Childhood cancer survivors may have residual cognitive and psychosocial difficulties well into adulthood13. These issues may lead to problems in peer relationships and poorer quality of life. This requires children to be evaluated early on for psychiatric morbidities during follow up visits to the hospital. Screening for psychological morbidity could be a way forward.
Training in paediatric psycho-oncology
In a country like India, which has a paucity of mental health resources for children in general, it would be easier to adopt a tiered approach towards identifying and managing mental health comorbidities in children with cancer. We had earlier proposed a model for this4 that suggested all paediatric oncology staff be trained in primary psychosocial skills that would be useful for the majority of children undergoing treatment for cancer. Specialists in children’s mental health should be involved when problems are of acute onset and disabling or when the diagnosis is complex requiring multimodal treatment.
Financial support and sponsorship
None.
Conflicts of interest
None.
Acknowledgment:
The author acknowledge Ms Rajendrani Mukherjee for creating the illustration used in this article.
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