T here are approximately 12,000children diagnosed with can-cer every year in the U.S. Thediagnosis of cancer is a trau- matic experience for both the family and the child.

306 PEDIATRIC NURSING/November-December 2010/Vol. 36/No. 6

T here are approximately 12,000children diagnosed with can-cer every year in the U.S. Thediagnosis of cancer is a trau- matic experience for both the family and the child. The psychological sequelae of childhood cancer in par- ents and children has been well docu- mented and includes post-traumatic stress symptoms, depression, and anxiety (Kazak, 2005). Childhood cancer involves the whole family: the diagnosed child, the parents, and the siblings. Findings from research have indicated parental stress has a nega- tive impact on the child’s social, emo- tional, and behavioral adjustment to the diagnosis and treatment of cancer, as well as the parents’ participation and compliance with their child’s complex health care needs (Melnyk et al., 2004; Streisand, Braniecki, Tercyak, & Kazak, 2001). Therefore, using psychological interventions to decrease parental stress, depression, and anxiety is important to enhance outcomes in children with cancer.

The diagnosis of cancer causes a great of deal of disruption in the fam- ily, which can be manifested as parental role confusion as well as parental distress about the child’s future. In addition, parents of chil- dren newly diagnosed with cancer must cope with their own reaction to their child’s diagnosis, as well as their child’s reaction (Patterson, Holm, & Gurney, 2004). Parents may have feel- ings of anger, guilt, fear, and grief. The parents’ ability to cope with these

Search for the Evidence The databases Medline, CINAHL,

Cochrane, and Psych Info were searched to identify psychosocial interventions for parents of children with cancer. The keywords used from the PICO question in the search process were parents, childhood cancer, and interventions. The search was lim- ited to the English language. This search yielded a total of 12 articles describing interventions for parents of children diagnosed with cancer. Four articles were obtained from CINAHL, one article from Cochrane, four articles from Psych Info, and three articles from Medline.

Presentation and Critical Appraisal of the Evidence

A total of 11 intervention studies and one meta-analysis for interven- tions for parents of children with can- cer were found, with one article specifically focused on psychological interventions for parents with chil- dren undergoing bone marrow trans- plant (see Table 1). Seven studies were randomized controlled trials, two were quasi-experiments, two were pre-experiments, and one was a meta- analysis of psychological interven- tions for children with cancer and

feelings has an impact on their men- tal health outcomes.

Numerous studies have demon- strated children diagnosed with cancer often have long-term quality-of-life issues, as well as feelings of stress that continue after the conclusion of treat- ment. Children, like their parents, may experience feelings of fear, anger, guilt, and grief, which can be manifested in behavioral problems and long-term adjustment issues. The child’s adjust- ment to his or her diagnosis and treat- ment is strongly correlated to the par- ents’ adjustment to the diagnosis and treatment (Ljungman et al., 2003).

The PICO Question The purpose of this evidence

review was to determine the impact of psychosocial interventions on parent mental health/coping outcomes. A PICO (P = Patient population; I = Intervention of interest; C = Com – parative intervention; O = Outcome) question was developed to facilitate the literature search (Melnyk & Fineout-Overholt, 2005). The PICO question was, “In parents of children newly diagnosed with cancer (P), how do psychosocial interventions (I) ver- sus no psychosocial interventions (C) affect parent mental health/coping outcomes (O)?”

There are approximately 12,000 children diagnosed with cancer every year in the U.S. The diagnosis of childhood cancer has an impact on the entire family. Parents of children newly diagnosed with cancer often exhibit symptoms of stress, depression, and anxiety. In addition, children diagnosed with cancer often exhibit behavioral changes during and after treatment. Although numerous stud- ies have demonstrated the adverse impact of the cancer diagnosis on the par- ents and children, few studies have been conducted on interventions designed to facilitate parental coping and mental health outcomes. The purpose of this evi- dence review was to determine the impact of psychosocial interventions on the mental health/coping outcomes of parents of children diagnosed with cancer. A synthesis of the current literature from the search demonstrates an urgent need for larger, theory-based, randomized controlled trials with attention control groups for parents of children newly diagnosed with cancer to improve their chil- dren’s coping/mental health outcomes as well as their own.

Gloanna Peek, MSN, CPNP, RN, is a Doctoral Student, Arizona State University College of Nursing & Healthcare Innovation, Phoenix, AZ.

Bernadette Mazurek Melnyk, PhD, RN, CPNP/NPP, FNAP, FAAN, is Dean and Distinguished Foundation Professor in Nursing, Arizona State University College of Nursing and Health Care Innovation, Phoenix, AZ, and a member of Pediatric Nursing’s Editorial Board.

Coping Interventions for Parents of Children Newly Diagnosed with Cancer:

An Evidence Review with Implications for Clinical Practice and Future Research

Gloanna Peek, Bernadette Mazurek Melnyk

 

 

PEDIATRIC NURSING/November-December 2010/Vol. 36/No. 6 307

Author(s), Title of Study and Year of Publication

Purpose, Sample, and Setting Design

Outcomes with Measures and Time

Administered Findings Strengths and

Limitations

Othman, Blunden, Mohamad, Hussin, & Osman (2009)

Malaysia

Piloting a Psycho- Education Program for Parents of Pediatric Cancer Patients in Malaysia

Purpose: To evaluate a psycho- education program for parents of children with cancer in Malaysia.

Sample: Seventy-nine parents with children with cancer. All parents were married, Malay, and Muslim. No average age was documented.

Setting: Government hospital in Malaysia

Quasi experimental.

Experimental intervention: Standard care plus four 50-minute information sessions on childhood cancer and coping strategies.

Control intervention: Standard care.

Parents completed five self-assessment scales (Knowledge Assessment Scale, State-Trait Anxiety Inventory Scale [STAI], Strain Questionnaires [SQ], Strength and Difficulties Questionnaire [SDQ], and Parents’ Activities with Children [PA]). The scales were mailed to the families four to eight months after intervention.

Parents in the experimental intervention group reported increased knowledge and decreased anxiety.

The authors reported the effect size for the intervention was small.

Strengths: • 100% of the parents

completed the questionnaires.

Limitations: • Lack of true attention

control group to control for the time and attention spent with the parents in the experimental group.

• Study location of Malaysia may limit applicability to parents in the U,S.

• Convenient sample, no long-term follow up.

Stehl et al. (2009)

Conducting a Randomized Clinical Trial of an Psychological Intervention for Parents/Caregivers of Children with Cancer Shortly after Diagnosis

Purpose: To evaluate the feasibility of a brief psychological intervention for parents of children newly diagnosed with cancer.

Sample: A total of 82 families of children from birth to 17 years newly diagnosed with cancer. Families had to be composed of two parents/caregivers to participate.

Setting: University hospital in the U.S.

Randomized controlled trial.

Experimental Intervention: A three-session intervention program (SCCIP-ND) for parents/caregivers of children newly diagnosed with cancer. Timing for interventions included initial intervention started 24 hours to six days after diagnosis, and all three sessions completed within the first month of diagnosis. Interventions were provided by four psychology fellows and a PhD nurse.

Control Intervention: Standard psychosocial care.

Parents completed the Acute Stress Disorder Scale (ASDS), the Impact of Event Scale- Revised (IES-R), and the STAI. The ASDS was completed prior to intervention and one month after intervention. The IES-R was administered after the intervention. The STAI was administered prior to intervention, and a shortened version was administered one month after the intervention.

There were no reported significant differences in scores on the ASDS, IES-R, and the STAI for parents in the intervention group and the control group.

The authors reported the effect size for the intervention was small.

Strengths: • Theoretical framework

– Cognitive-Behavioral Theory and Family Therapy.

• Follow-up RCT of previous intervention study with larger sample size.

• Use of valid and reliable instruments.

Limitations: • Narrow inclusion

criteria (requirement for 2 parents or caregivers).

• Final retention rate of 23% for the intervention, which threatens the internal validity of the study.

• Use of psychology fellows and a PhD nurse may limit use of the intervention in institutions where these professionals are lacking.

Duncan et al. (2007)

Israel

The Effects of Guided Written Disclosure on Psychological Symptoms among Parents of Children with Cancer

Purpose: To evaluate the efficacy of three, 15-minute guided writing sessions.

Sample: Eight parents of children diagnosed with cancer within two months prior to study entry.

Setting: University hospital in Israel.

One group pre- and post-test pre- experimental design.

Parents completed the revised Post- Traumatic Diagnostic Scale (PTDS) at baseline and one month after guided writing intervention.

Guided writing intervention showed a decrease in parental posttraumatic stress symptoms but no change in parental depression. The effect size for PTSS was 0.84 (large), and there was no effect for depression.

Strengths: • Easily replicated. • 100% completion of

questionnaire.

Limitations: • Small sample size. • Location in Israel,

which may limit applicability to parents in the U.S.

• No attention control group, which threatens the internal validity of the study.

• No long-term follow up.

Table 1. Comparison Table of Psychosocial Interventions for Parents of Children with Cancer

(Table 1 continued on next page).

 

 

308 PEDIATRIC NURSING/November-December 2010/Vol. 36/No. 6

Author(s), Title of Study and Year of Publication

Purpose, Sample, and Setting Design

Outcomes with Measures and Time

Administered Findings Strengths and

Limitations

Svavarsdottir & Sigurdardottier (2006)

Iceland

Developing a Family- Level Intervention for Families of Children with Cancer

Purpose: To evaluate the feasibility and efficacy of a family- level intervention for parents of children from birth to 18 years of age newly diagnosed with cancer.

Sample: Ten families (19 parents) of children newly diagnosed with cancer. The average age of the mothers was 37.5 years, and the average age of the fathers was 39.4 years.

Setting: University hospital in Iceland.

One group pre- and post-test pre- experimental design.

Parents were given access to an educational and informational Web site focusing on practical issues regarding their child’s cancer, including treatments, management of side effect, and future concerns, as well as Internet-based support and one to two in-person support interviews.

Parents completed self- assessment scales (Cancer Factor Index [CFI], Coping Health Inventory for Parents [CHIP], Family Hardiness Index [FHI], General Well-Being Schedule [GWB], and the Family Adaptation Scale [FAS]). The self-assessment scales where completed at baseline, six months, and 12 months after the intervention.

Parents self-reported improvement in well- being measures, coping behaviors, and family hardiness at both the six and 12 months after the intervention.

The effect size for this study was small for coping, family hardiness, and well-being.

Strengths: • Theoretical framework

– Calgary Family Intervention Model to guide the study.

• Long-term follow up (12 months after intervention).

• 1% subject attrition.

Limitations: • Lack of control group,

which weakens internal validity of the study.

• Small sample size. • Difficult to reproduce

based on constantly changing Web-based intervention.

• Study location was Iceland, which may limit applicability to parents in the U.S.

Pai, Drotar, Zebracki, Moore, & Youngstom (2006)

A Meta-Analysis of the Effects of Psychological Interventions in Pediatric Oncology on Outcomes of Psychological Distress

Purpose: To evaluate the efficacy of psychological interventions in decreasing psychological distress in pediatric oncology.

Sample: A total of 28 studies were reviewed for interventions of pediatric oncology. Twelve studies met the criteria for inclusion, which included children 18 years of age or younger and/or their families. Published in English.

Meta-analysis of preventive interventions designed to reduce the level of negative psychological sequelae of pediatric cancer in parents and children.

The meta-analysis reviewed 12 pediatric oncology intervention studies. Five studies included parental interventions, but only three studies assessed parent outcomes with psychosocial interventions. Five parental interventions included teaching problem-solving skills, engaging in written disclosure, and teaching cognitive behavioral techniques. The delivery format varied based on the intervention.

Meta-analysis reported decreased parental distress in intervention groups.

The authors reported the effect size as small.

Strengths: • Meta analysis of

intervention studies.

Limitations: • Small number of

psychological interventions to review.

• Diversity of intervention approaches, making it difficult to analyze effects across studies and draw conclusions regarding the most potent intervention for parents of children diagnosed with cancer.

Kazak et al. (2005)

Feasibility and Preliminary Outcomes from a Pilot Study of a Brief Psychological Intervention for Families of Children Newly Diagnosed with Cancer

Kazak et al. (2005) (continued on next page)

Purpose: To evaluate the feasibility and outcomes of a pilot study that tested the effects of a new, three- session intervention program for caregivers of children with cancer.

Sample: Nineteen families (38 caregivers) with children from birth to 17 years of age who were newly diagnosed with pediatric malignancy. Nineteen mothers, 18 fathers, and one grandmother participated. The average age of the primary caregiver was 37, and the average age of the partner was 42.

Two-group randomized controlled trial.

Experimental intervention: Three, 45-minute sessions of SCCIP-ND, which incorporates a CD- ROM, and three discussion intervention sessions to focus on the cancer journey. The intervention started within 24 hours after the caregiver received diagnosis of the child’s cancer and was administered by two psychology fellows and one psychology graduate student who had received specialized training to provide the intervention.

Four scales were completed by caregivers: ASDS – completed after the first intervention, IES-R – completed after the second intervention, STAI – completed after the first and second intervention, and the Program Evaluation Form – completed after the third intervention.

One form was completed by oncology social workers and child life specialists to track contact provided to the family to verify usual psychosocial care for the control group.

Caregivers in the intervention group self-reported a decrease in anxiety and post- traumatic stress symptoms.

The effect size for the STAI was large (0.88).

There is no reported effect size for the ASDS and the IES-R, and no reported measures to calculate effect size

Strengths: • Randomization to

study group. • Intervention

commenced within 24 hours of diagnosis.

Limitations: • Small convenient

sample size. • Lack of specified

theoretical framework. • Lack of long-term

follow up. • No child measures. • No reported outcomes

for the IES-R and the ASDS.

(Table 1 continued on next page)

Table 1. (continued) Comparison Table of Psychosocial Interventions for Parents of Children with Cancer

Coping Interventions for Parents of Children Newly Diagnosed with Cancer: An Evidence Review with Implications for Clinical Practice and Future Research

 

 

PEDIATRIC NURSING/November-December 2010/Vol. 36/No. 6 309

Author(s), Title of Study and Year of Publication

Purpose, Sample, and Setting Design

Outcomes with Measures and Time

Administered Findings Strengths and

Limitations

Kazak et al. (2005) (continued)

Setting: A children’s hospital in the U.S.

Control intervention: Usual psychosocial care (social worker, written resources including information about diagnosis and treatment).

A scale was completed by the treating oncologist blinded to patient identity to classify treatment protocol (Intensity of Treatment Rating).

Sahler et al. (2005)

U.S. and Israel

Using Problem-Solving Skills Training to Reduce Negative Affectivity in Mothers of Children with Newly Diagnosed Cancer: Report of a Multi-Site Randomized Trial

Purpose: To evaluate the efficacy of problem-solving, training- skills interventions to decrease the emotional distress in mothers of children newly diagnosed with cancer. Replication study from earlier study, with inclusion of Spanish- speaking-only mother, English-speaking-only mother, and Hebrew- speaking-only mothers.

Sample: A total of 217 mothers of children diagnosed with cancer 2 to 16 weeks before study enrollment. Spanish- speaking-only mothers were recruited first to obtain 20% of total sample. The average age of mothers was 35 years. The majority of mothers (88%) were married, and 85% had a minimum of high school education. The primary language was English (66%), with Spanish (20%) and Hebrew (13%) following.

Setting: Seven children’s hospitals in the U.S. and one hospital in Israel.

Randomized controlled trial (replication study).

Experimental Intervention: Eight, one-hour individual sessions of specific problems identified by each mother provided by a mental health professional.

Control Intervention: Usual psychosocial care.

Mothers completed Neo- Five Factor Inventory (NEO-FFI) at baseline and The Social Problem- Solving Inventory – Cancer (SPSI-C), the Profile of Mood States (POMS), the Beck Depression Inventory-II (BDI-II), and the IES-R at baseline 10 to 12 weeks after the intervention and 6 months after the intervention.

Mothers in the intervention group reported decreased emotional distress and depression immediately following the intervention, which was maintained at the six- month follow up.

The effect size for the intervention was medium.

Strengths: • 10% attrition. • Randomization to

study group.

Limitations: • Lack of long-term

follow up. • No child outcomes

measures. • Fathers not included in

intervention. • Intervention delivered

by a mental health professional, which may not be feasible in some settings.

• Lack of an attention control group, which weakens the internal validity of the study.

Kazak et al. (2004)

Treatment of Posttraumatic Stress Symptoms in Adolescent Survivors of Childhood Cancer and Their Families: A Randomized Clinical Trial

Purpose: To determine the efficacy of a cognitive behavior- based intervention to reduce symptoms of post-traumatic stress in adolescent survivors of childhood cancer and their parents.

Sample: A total of 150 families with children 11 to 19 years of age who had completed treatment for childhood cancer 1 to 10 years prior to participation. The average age of mothers was 42 years and the fathers was 46 years.

Setting: University hospital in the U.S.

Randomized controlled trial (replication study).

Experimental Intervention: Interventions were conducted as a one-day manualized program that consisted of 4 topics: how cancer has affected me and my family, coping skills, getting on with life, and putting it all together. Mother, fathers, siblings, and adolescents attended individual sessions provided by therapists.

Control Intervention: Wait control list were invited to participate in intervention 8 to 10 months after baseline.

Parents and survivors completed the Post- traumatic Stress Disorder Reaction Index, Impact of Event Scale, and the STAI prior to intervention (T1) and three to five months later (T2).

Parents and survivors showed a greater decrease in post- traumatic stress between T1 and T2 than the control wait list group.

The effect size for the intervention in this study was small.

Strengths: • Child outcome

measures included. • Inclusion of fathers.

Limitations: • Lack of true control

group. • 38% attrition. • Intervention

implementation by therapist may limit intervention in institutions where therapists are not readily available.

(Table 1 continued on next page)

Table 1. (continued) Comparison Table of Psychosocial Interventions for Parents of Children with Cancer

 

 

310 PEDIATRIC NURSING/November-December 2010/Vol. 36/No. 6

Author(s), Title of Study and Year of Publication

Purpose, Sample, and Setting Design

Outcomes with Measures and Time

Administered Findings Strengths and

Limitations

Sahler et al. (2002)

U.S. and Israel

Problem-Solving Skills for Mother of Children with Newly Diagnosed Cancer: A Randomized Trial

Purpose: To evaluate the efficacy of problem-solving training-skills interventions to decrease emotional distress in mothers of children newly diagnosed with cancer.

Sample: A total of 92 mothers of children diagnosed with cancer 2 to 16 weeks before study enrollment. The average age of the mothers was 34.7 years. The majority of mothers were married, and all had a minimum of high school education.

Setting: Five children’s hospital in the U.S. and one hospital in Israel

Randomized controlled trial(pilot study).

Experimental Intervention: Eight, one-hour individual sessions of specific problems identified by each mother provided by a mental health professional.

Control Intervention: Standard psychosocial care.

Mothers completed the SPSI-C and the POMS. All mothers completed the SPSI-C and the POMS prior to randomization to the intervention or control group. Mothers in the intervention group completed the SPSI-C and POMS immediately after the intervention and three months later, while the mothers in the control group completed the SPSI-C and the POMS at 10 to 12 weeks and at 22 to 24 weeks.

The SPSI-C was adapted from the Social Problem Solving Inventory for this study.

Mothers in the intervention group reported decreased emotional distress immediately following the intervention, with a diminishing effect in decreased emotional distress three months after the intervention.

The effect size for the intervention on problem- solving skills training was moderate (0.45 to 0.57) and for dysfunctional problem solving was small (0.24 to 0.31).

Strengths: • 100% completion of

questionnaires.

Limitations: • Lack of an attention

control group, which weakens the internal validity of the study.

• Fathers not included in intervention.

• Intervention delivered by a mental health professional, which may not be feasible in some settings

Streisand, Rodrigue, Houck, & Graham-Pole (2000)

Brief Report: Parents of Children Undergoing Bone Marrow Transplantation: Documenting Stress and Piloting a Psychological Intervention Program

Purpose: To document stress and evaluate efficacy of a psychological intervention in parents of children undergoing bone marrow transplant.

Sample: A total of 22 mothers of children aged 2 to 16 years undergoing a bone marrow transplant. Most mothers were married, Caucasian, and achieved a high school education.

Setting: Teaching hospital in the U.S.

Randomized controlled trial.

Experimental Intervention: A graduate psychology student provided one 90- minute intervention session focused on education, relaxation, and education. In addition, parents were provided handouts and a tape of relaxation techniques.

Control Intervention: Standard care.

All mothers completed the Daily Stress Inventory (DSI), the Parenting Stress Index (PSI), and a Semi- Structured Interview (SSINT).

The DSI was completed at six time points: baseline (two to four weeks prior to admission), seven days before transplant, the day of transplant, seven days after transplant, 14 days after transplant, and 21 days after transplant.

The PSI was conducted at baseline and 21 days after transplant. The SSINT developed for this study was conducted at baseline, seven days before transplant, 14 days after transplant, and 21 days after transplant.

Mothers in the intervention group reported less stress on the DSI and PSI both prior to and 21 days post-transplant.

On the SSINT, there was no significant difference between the control and intervention group.

The effect size for both the DSI and PSI was medium to large.

Strengths: • 100% completion of

questionnaires. • Random assignment to

groups.

Limitations: • Lack of long-term

follow up. • Small sample size. • No attention control

group intervention to control for the time and attention spent with the mothers in the experimental group.

• No child outcome measures.

Kazak et al. (1999) U.S. Surviving Cancer Competently Intervention Program (SCCIP): A Cognitive-Behavioral And Family Therapy Intervention for Adolescent Survivors of Childhood Cancer and Their Families Kazak et al. (1999) (continued on next page)

Purpose: To determine the effectiveness of a cognitive behavior-based intervention to reduce symptoms of post- traumatic stress in adolescent survivors of childhood cancer and their parents.

One group pre-and post- test pre-experimental design.

Parents completed four self-assessments (Post- Traumatic Stress Disorder Reaction Index, Impact of Event Scale, STAI, and Family Life Scale) prior to assessment and six months after the intervention.

Parents and adolescent survivors self-reported decreased symptoms of post-traumatic stress and anxiety.

Strengths: • Theoretical framework

– Cognitive-Behavioral Theory and Family Therapy.

• Study location U.S. • 100% completion of

questionnaires.

(Table 1 continued on next page)

Table 1. (continued) Comparison Table of Psychosocial Interventions for Parents of Children with Cancer

Coping Interventions for Parents of Children Newly Diagnosed with Cancer: An Evidence Review with Implications for Clinical Practice and Future Research

 

 

PEDIATRIC NURSING/November-December 2010/Vol. 36/No. 6 311

their parents. Five studies were con- ducted in university hospitals in the U.S. One study was conducted in Iceland, one study in Malaysia, one study in Israel, and one study in the Netherlands. Two studies were con- ducted as a joint study in five hospi- tals in the U.S. and one hospital in Israel.

Two studies included only mothers in the intervention (one pilot study and one replication study), eight stud- ies included fathers and mothers, and two studies included parents and ado- lescent survivors of cancer (one pilot study and one replication study). There were a variety of interventions, including a Web-designed interven- tion, a guided written disclosure, and a series of in-person support sessions that included all-day workshops. Interventions ranged from one instructional session to eight educa- tional sessions, with only one inter- vention specifically including booster interventions in the study’s design (Stehl et al., 2009). Timing of the interventions ranged from within the

the homogeneousness of the sample, which limits their external validity (the ability to generalize the findings from the sample to the greater popu- lation). Another limitation was only three studies included a theoretical framework, which limits interpreta- tion of the findings. In addition, interventions in many studies were delivered by mental health providers, which may be a limitation in many institutions where these providers are not readily available.

Another major limitation in the studies is that fidelity of interventions was not routinely assessed, and manipulation checks were not imple- mented to assure parents were pro- cessing the content of the interven- tions. In addition, mediating variables were not measured to explain the process through which the interven- tions worked to impact outcomes. Child outcomes were also not meas- ured in the studies to determine if a reduction in parent adverse outcomes had a positive effect on the children.

Although each intervention study

first month of diagnosis to one year after completion of treatment, with follow-up measurements ranging from 21 days to nine months.

Although the majority of interven- tions focused on parents of newly diagnosed children, there was no con- sensus on the definition of what con- stituted “newly diagnosed.” Five stud- ies did not define the term “newly diagnosed,” while six studies defined newly diagnosed as two months from diagnosis. All childhood cancer diag- noses (such as Hodgkin’s and leukemia) were included in the inter- vention, with the only exclusion crite- ria being terminal diagnosis and sec- ondary cancer diagnosis. Additionally, the age criteria for the children in the studies ranged from 0 to 17 years of age in two studies, less than 18 years of age in one study, 2 to 16 years of age in one study, 10 to 17 years of age in one study, 11 to 19 years of age in one study, and no mention of age in five studies.

Several studies reviewed were lim- ited by their small sample sizes and

Author(s), Title of Study and Year of Publication

Purpose, Sample, and Setting Design

Outcomes with Measures and Time

Administered Findings Strengths and

Limitations

Kazak et al. (1999) (continued)

Sample: A total of 19 families of adolescent survivors who had previously participated in studies.

Setting: University hospital in the U.S.

Intervention was developed by a multidisciplinary team consisting of psychologists, social workers, and a nurse practitioner. Interventions covered four topics: how cancer has affected me and my family, coping skills, getting on with life, and putting it all together. Mother, fathers, siblings, and adolescents attended individual sessions provided by therapists.

Limitations: • Lack of a control

group, which threatens the internal validity of the study.

• Small convenient sample size.

• Unable to determine effect size, based on results reported.

• Intervention implementation by therapist may limit inter-vention in institutions where therapist are not readily available.

Hoekstra-Weebers, Heuvel, Jaspers, Kamps, & Klip (1998)

The Netherlands

Brief Report: An Intervention Program for Parents of Pediatric Cancer Patients: A Randomized Controlled Trial

Purpose: To evaluate the efficacy of a psycho-educational program for parents of pediatric cancer patients.

Sample: A total of 120 parents of children newly diagnosed with cancer. The average age was 36.6 years, and the majority were married.

Setting: University hospital in the Netherlands.

Randomized controlled trial.

Experimental Intervention: Eight, 90-minute manual guided interventions at three-week intervals.

Control Intervention: Standard psychosocial care.

Parents completed the Goldberg General Health Questionnaire (GHQ) , The Symptom Check List (SCL), and the State-Trait Anxiety Inventory – State (STAI-S) within 14 days of enrollment (T1), immediately after completion of the intervention (T2), and six months after completion of the intervention (T3).

The study found although there was a decrease in parental distress over time, there was no significant decrease in distress between the intervention and the control group.

The authors reported the effect size for the intervention as medium.

Strengths: • Inclusion of both

mothers and fathers.

Limitations: • No child outcomes

included. • No long-term follow

up. • No attention control

group which limits the internal validity of the study.

• No theoretical framework

Table 1. (continued) Comparison Table of Psychosocial Interventions for Parents of Children with Cancer

 

 

312 PEDIATRIC NURSING/November-December 2010/Vol. 36/No. 6

had limitations, all documented a reduction in at least one negative out- come in parents of children with can- cer who had received a psychosocial intervention (see Table 2). In addi- tion, each study provides and sup- ports the development of future psy- chosocial interventions.

Implications for Clinical Practice and Future Research

Although there are currently no widely used psychosocial interven- tions for parents of children with can- cer, there is a body of evidence to guide clinicians who work with them. Clinicians currently have tools to assess parent stress, anxiety, depres- sive symptoms, and the need for psy- chosocial interventions. Findings from the majority of the studies reviewed indicated giving parents some type of psychological interven- tion improved their outcomes. These psychosocial interventions included allowing time for parents to express

parents of patients newly diagnosed with cancer should include full-scale, randomized clinical trials that meas- ure mediating variables so explana- tions of mechanisms through which the interventions work can be deter- mined. In addition, moderating vari- ables should be measured to deter- mine under what conditions inter- ventions work best (for example, par- ents in two parent families, parents with high stress levels). Further, there is a need to study the long-term out- comes associated with interventions beyond nine months to determine sustainability of intervention effects. In addition, future studies should also incorporate the measurement of child outcomes. Although the current evi- dence identifies vast differences in the timing of interventions from 24 hours after diagnosis until one year post- chemotherapy, future studies should focus on delivering interventions within the first two months of diag- nosis to allay adverse outcomes early

their feelings, as well as stress reduc- tion and coping strategies, which included recognizing and validating parents’ feelings of anxiety, depres- sion, and stress. Therefore, clinicians should routinely incorporate these strategies with parents of children newly diagnosed with cancer. This evidence review suggests clinicians should begin psychosocial interven- tions within 2 to 16 weeks after diag- nosis, with booster interventions to improve coping outcomes. Booster interventions included reviewing the impact of the diagnosis on the child’s behavior and parental role (Stehl et al., 2009). In addition, booster inter- ventions are useful in strengthening intervention effects and reinforcing expected outcomes. Childhood can- cer becomes a diagnosis that has an impact on the entire family; thus, interventions focused on facilitating parental coping will have a positive impact on the entire family.

Future intervention studies with

Table 2. Synthesis Table, Including Outcomes Comparison of Psychosocial Interventions for

Parents of Children with Cancer

Outcomes Measures

Author/Year

Significant Between-

Group Findings

Post- Traumatic

Stress Emotional Distress Anxiety

Personal Well-Being Coping

Family Hardiness Depression

Othman et al. (2009)

✓

Stehl et al. (2000)

✓ ✓

Duncan et al. (2007)

One group design

✓

Svavarsdottir et al. (2006)

One group design

✓ ✓ ✓

Kazak et al. (2005)

✓ ✓

Sahler et al. (2005) ✓

✓

Kazak et al. (2004)

✓

Sahler et al. (2002)

✓

Streisand et al. (2000)

✓

Kazak et al. (1999)

✓ ✓

Hoekstra- Weebers et al. (1998)

✓

Note: = No significant change; = improvement in symptoms with the intervention; = worsening of symptoms with the inter- vention; ✓ = outcome measure.

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and to provide a foundation for booster interventions.

It should be noted that none of the intervention studies addressed the change in parental role in childhood cancer. In addition, no interventions were designed to prepare parents for what to expect in their children’s responses to the diagnosis of child- hood cancer or how parents can help the child cope with the diagnosis.

Although not specifically designed for parents of patients newly diag- nosed with cancer, one well- researched program that enhances parental mental health/coping out- comes and does not require a mental health provider to deliver it is the Creating Opportunities for Parent Empowerment (COPE) program, a theory-based manualized interven- tion program shown to reduce short- and long-term stress, anxiety, and post-traumatic stress disorder symp- toms in parents of critically ill and hospitalized children (Melnyk, 1994; Melnyk et al., 2004; Melnyk, Alpert- Gillis, Hensel, Cable-Billing, & Rubenstein,1997). Based on self-regu- lation and control theories, the COPE program is an educational-behavioral skills-building program for parents that prepares them for what to expect in their child’s and their own adjust- ment to the hospitalization and criti- cal illness, and how to best help their children adapt to the stressful experi- ence. Findings from three full-scale, randomized controlled trials using COPE indicated parents who received COPE versus those who received attention-control programs reported significantly less parental stress, depression, anxiety, and fewer post- traumatic stress symptoms during and up to 12 months following hospi- talization (Melnyk et al., 1997, 2004). Additionally, children of parents who received the COPE program had fewer internalizing and externalizing behavior problems 12 months follow- ing hospitalization than children of parents who received an attention- control program. Therefore, it is plau- sible that COPE adapted for parents of children newly diagnosed with cancer could also produce similar positive outcomes.

Conclusion Based on this evidence review, few

published studies on interventions to decrease anxiety, depressive and post- traumatic stress symptoms, and im – prove coping/mental health out- comes in parents of children with cancer are available. The few pub-

Melnyk, B.M., Alpert-Gillis, L., Feinstein, N., Crean, H., Johnson, J., Fairbanks, E., …& Reichert, B. (2004). Creating oppor- tunities for parent empowerment: pro- gram effects on the mental health/cop- ing outcomes of critically ill young chil- dren and their mothers. Pediatrics, 113(6), 597-697.

Melnyk, B.M., Alpert-Gillis, L.J., Hensel, P.B., Cable-Billing, R.C., & Rubenstein, J. (1997). Helping mothers cope with a critically ill child: A pilot test of the COPE intervention. Research in Nursing and Health, 20, 3-14.

Melnyk, B.M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare. Philadelphia: Lippincott Williams & Wilkins.

Othman, A., Blunden, S., Mohamad, N., Hussin, Z., & Osman, Z. (2009). Piloting a psycho-education program for parents of pediatric cancer patients in Malaysia. Psycho-Oncology. Advance online pub- lication. doi: 10.1002/pon.1584.

Pai, A., Drotar, D., Zebracki, K., Moore, M., & Youngstom, E. (2006). A meta-analysis of the effects of psychological interven- tions in pediatric oncology on outcomes of psychological distress. Journal of Pediatric Psychology, 31(9), 978-988.

Patterson, J., Holm, K., & Gurney, J. (2004). The impact of childhood cancer on the family: A qualitative analysis of strains, resources and coping behaviors. Psychooncology, 13(6), 390-407.

Sahler, O., Fairclough, D., Varni, J., Mulhern, R., Noll, R., Dolgin, M., … & Copeland, D. (2005). Using problem-solving skills training to reduce negative affectivity in mothers of children with newly diag- nosed cancer: Report of a multi-site randomized trial. Journal of Consulting and Clinical Psychology, 73(2), 272- 283.

Sahler, O., Varni, J., Fairclough, D., Butler, R., Noll, R., Dolgin, M., … & Mulhern, R. (2002). Problem-solving skills for moth- er of children with newly diagnosed can- cer: A randomized trial. Developmental and Behavioral Pediatrics, 23(2), 77-86.

Stehl, M., Kazak, A., Alderfer, M., Rodriguez, A., Hwang, W., Pai, A., … & Reilly, A. (2009). Conducting a randomized clini- cal trial of a psychological intervention for parents/caregivers of children with cancer shortly after diagnosis. Journal of Pediatric Psychology, 34(8), 803-816.

Streisand, R., Braniecki, S., Tercyak, K., & Kazak, A. (2001). Childhood illness- related parenting stress: The pediatric inventory for parents. Journal of Pediatric of Psychology, 26(3), 314-321.

Streisand, R., Rodrigue, J., Houck, C., & Graham-Pole, J. (2000). Brief report: parents of children undergoing bone marrow transplantation: Documenting stress and piloting a psychological inter- vention program. Journal of Pediatric Psychology, 25(5), 331-337

Svavarsdottir, E., & Sigurdardottier, A. (2006). Developing a family-level inter- vention for families of children with can- cer. Oncology Nursing Forum, 33(5), 983-990.

lished studies on psychosocial inter- ventions for parents of children with cancer have been conducted with very small convenient samples, and most did not have attention-control groups, which weakens their internal validity (the ability to say the inter- vention caused a change in the out- comes, not other extraneous vari- ables). Findings from this evidence review support the urgent need for larger, theory-based, randomized con- trolled trials with attention-control groups for parents of children newly diagnosed with cancer to improve their children’s coping/mental health outcomes as well as their own.

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