Transcript Cognitive Risk Factors in Pediatric Cancer

Pediatric
Psycho-Oncology
Resident Education
Lecture Series
Cognitive & Behavioral
Aspects of Pediatric Cancer
 1960-1970’s: Survival
 improved chemotherapy, CNS prophylaxis
 1980’s: Survival, Cognitive Functioning
 improved chemotherapy, modified CNS treatment
 1990’s-present: Survival, Cognitive
Functioning, Quality of Life
 improved assessment, focus on academic &
psychosocial functioning over time, focus on
development of interventions
Cognitive Risk Factors in
Pediatric Cancer
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Brain tumor
CNS disease
Cranial irradiation (dose effect)
Child’s age (young children at greater risk)
Time since end of treatment
Intrathecal chemotherapy
 systemic chemo to lesser degree
 Frequent school absences
Common Cognitive
Impairments/Late Effects
 Decline in intellectual functioning
 age & dose related
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Memory problems (short-term)
Attention/concentration difficulties
Slower processing speed
Visual-spatial/motor problems
Arithmetic & other learning problems
Problems in executive functioning
(working memory, behavioral inhibition,
self-monitoring, self-regulation, organization &
planning, cognitive flexibility/shifting)
Current Cognitive
Interventions
 Serial assessment of cognitive functioning
 School consultation, education, and services
 504 plan for accommodations/modifications
 special education services/IEP (OHI, CD, LD)
 Tutoring to learn compensatory strategies
 Cognitive remediation?? (Butler & Copeland, 2002)
 Medication, e.g. methylphenidate, for
attention/concentration & executive functioning
difficulties??? (Butler & Mulhern, 2005)
Cognitive Functioning in
Pediatric Blood & Marrow
Transplant (BMT)
 Are pediatric BMT patients at greater risk
of developing cognitive problems due
to….
 Myeloblative chemotherapy?
 Total body irradiation?
 Treatment history?
Cognitive Functioning in
Pediatric BMT: Longitudinal
Studies
 No significant IQ changes at 1 & 2 years
 Phipps et al., 2000; Simms et al., 2002
 Correlates:
 pre-BMT functioning,
 age at BMT,
 diagnosis,
 TBI dose,
 length of time since BMT,
 Rx regimen,
 gender
MCW Transplant Study
Kupst et al. (2002)
 No significant changes in IQ over two years
 IQ scores were within normal limits
 No significant changes in Reading or Math
Achievement
 Predictors of Cognitive Outcome: SES, Pre-BMT
IQ, Prior Academic Problems
 Not significantly related: age, previous
treatment, GVHD status, TBI
 Cognitive Development (<3 yrs): no pattern
 5+ yr follow-up study funded by HSK
Psychosocial Functioning in
Childhood Cancer
 Longitudinal research indicates that most
children & families are resilient to cancer
diagnosis & treatment.
 Coping is a process
 Wide variety of coping strategies
(no single best way)
 However, 20-30% develop clinically significant
adjustment problems (i.e., anxiety, depression)
that may require intervention.
Coping and Adaptation in
Pediatric Cancer
 Disease Factors
 Personal Factors
 Age (mixed results)
 Rx intensity
 Cognitive & academic functioning
 Severity of late effects &
(brain tumors)
functional impairment in
 Prior psychosocial functioning
survivors
 Personality/temperament
 Visibility of disease or Rx
effect
 Family/Environmental
 Duration of disease/time
 Family resources/SES
since Dx
 Support system
 Degree of CNS involvement
 Family variables: adaptability,
communication, cohesiveness,
 Parental, parent-child & sibling
coping
 Concurrent stressors
Natural Reactions to Cancer
Journey
 Diagnosis-Early Treatment:
 shocked, overwhelmed, info overload, emotional
distress, why me?, blaming of self or others,
questions/worries about death, isolation, missing school
& friends, coping with changes in daily life, finances,
job, & caregiving roles, difficulty asking others for help,
some experience anticipatory anxiety/procedural
distress.
 Middle to Later Treatment:
 increased sense of control, Rx regimen becomes more
routine, process thoughts & feelings, grieve loss of
normal life/activities, sadness-anger re: limitations,
feelings of abandonment/reduced support, coping with
altered friendships
Natural Reactions to
Cancer Journey
 End of Treatment:
 ambivalent feelings, uncertainty about future,
transition back to school/work, focus on rebuilding
vs. returning to life, worries about relapse
 Survivorship Concerns
 physical & cognitive late effects, concerns of
relapse/secondary cancer, difficulty
identifying/connecting with peers, future health
concerns/choices
 Death/Dying
Impact of Pediatric Cancer:
Developmental Issues
Infancy-Preschool Yrs:
School-Aged:
 adjustment to Rx with limited
cognitive understanding
 loss of control
 fears of abandonment/separation
 developmental
regression/interruption
 behavioral reactions
 Rx regimen becomes “normal”
 Coping: problem-focused,
action-oriented, distraction
 isolated from peers
 missed school
 understands
seriousness
 awareness of physical
changes/feeling
different
 Coping: development
of emotion-focused
Impact of Pediatric Cancer:
Developmental Issues
Adolescents & Young Adults:
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disruptions in school & social activities
isolation
difficulty identifying with care-free friends
self-image problems
sense of invulnerability (compliance issues)
more intense emotional reactions, distress, existential
issues
 independence-dependence parent-child struggle
 Young Adults: may have to postpone college, work,
marriage, family
 Coping: use of social support, emotion-focused, cognitive
strategies, info-seeking
Family Adjustment Issues
Parents/Caregivers
Siblings
 impact often is more
intense & distressing
(post-traumatic stress Sx)
 fears & worries about
child’s acute & long-term
survival
 guilt feelings with limit
setting
 parental adjustment
strongly related to child
adjustment
 feel forgotten/passed
off
 jealous of patient’s
attention
 acting out/negativeattention seeking
 guilt feelings
 sadness & anger
 mild somatic
symptoms
Psychosocial
Functioning: BMT
 Regression, withdrawal & decrease in mood are natural
reactions to long-term isolation/hospitalization &
physical discomfort
 Longitudinal studies indicate PTSD Sx, lower selfcompetence & self-esteem, withdrawal during 1st yr
 BUT psychosocial adjustment & QOL tend to improve or
return to baseline by one yr post-BMT
 Correlates: pre-BMT child & family adjustment, time
since BMT, level of maternal distress, type of Rx (TBI)
(Barrera et al., 2000; Debban et al., 1998; Phipps & Mulhern, 1995;
Simms et al., 2002; Stuber & Nader, 1995; Vannata et al., 1998)
MCW BMT Study:
Kupst et al. (2002)
 No significant behavioral or social changes over
time
 Psychosocial functioning significantly correlated
with prior behavioral and social scores
 Behavioral scores not related to age, gender,
SES, diagnosis or type of treatment
 Social competence significantly correlated with
age (older, higher) at one year, but not at two
years
What is Pediatric Psychology?
 AKA: child health psychology, behavioral
medicine/pediatrics, medical psychology
 Refers to interdisciplinary field that
addresses the psychological well-being of
children, adolescents, and their families
with health and illness issues.
 Pediatric Psycho-Oncology address the
psychosocial needs of pediatric cancer
patients and their families.
What Do Hem/Onc/Transplant
Psychology Do?
 Provide consultation, evaluation, psychological
testing, and intervention to children,
adolescents, young adults, and families who
have been affected by cancer and other blood
disorders.
 Help pediatric patients and their families cope
with the stress of a cancer diagnosis and
treatment.
Reasons to Consult HOT
Psychology
• Adjustment difficulties
(emotional & behavioral
reactions)
• Anxiety, panic attack
symptoms
• Depression
• Behavioral disturbances
(oppositionality,
noncompliance)
• Premorbid mental health
issues impacting
psychological well-being
and medical care
 Crisis intervention
 Nonadherence to
medical regimen
 Anticipatory anxiety &
nausea/Procedural
distress
 Needle phobia
 Parent adjustment
 Sibling reactions
 Family conflict
 Survivorship issues post
treatment
Intervention Services
 Psychologists provide both inpatient and
outpatient services.
 Primary goals are to provide support, reduce
stress, improve coping, and facilitate
normalcy.
 These goals are met through
consultation/assessment, behavioral
interventions, therapy, psychological testing,
and school and community liaison.
Intervention Services, cont.
1 - CONSULTATION / ASSESSMENT
 Learn about the problem through
interviews with patient, family, and staff,
and/or through observation of patient.
 Make recommendations for treatment
and provide resources.
 May take from ½ hour to 2 hours.
Intervention Services, cont.
2 - BEHAVIORAL INTERVENTION
 Help patient with medical issues, such as
managing pain/stress, coping with
procedural distress, taking medications,
complying with treatment regiment.
 Interventions often consist of outlined plans
for behavioral modification. Support of the
medical team, family, and caregivers in
following these plans is very important for the
success of the patient.
Intervention Services, cont.
3 - THERAPY
 Help patients, family members, or
caregivers examine their thoughts,
feelings, and behaviors related to illness
and treatment and learn strategies to
cope more effectively. Provide support.
 Average length of therapy is 6 sessions,
but may vary depending on issues
discussed.
Intervention Services, cont.
4 - PSYCHOLOGICAL TESTING
 Determine patient’s level of cognitive,
academic, behavioral and emotional
functioning in order to evaluate the impact of
treatment, identify problems/strengths,
monitor changes, provide directions for
intervention, and provide information for
school services.
 Conduct psychological evaluations of all
pediatric bone marrow and stem cell
candidates and sibling donors.
Intervention Services, cont.
5 - SCHOOL AND COMMUNITY LIAISON
 Help the family and school work together
to ensure all patient’s academic support
needs are being met during and after
treatment.
 Educate school personnel on possible
limitations during treatment and/or
cognitive late effects of treatment.
How to Consult Psychology
 To initiate psychology services for a patient
in the HOT Unit, inpatient or outpatient:
 Create a formal consult using Sunrise.
There are several groups of psychologists serving this
hospital, so make sure you are consulting the HOT
psychologists.
 Alpha page Dr. Kristin Bingen to inform her of the
consult.
 The group of psychologists for HOT will then triage the
consult and notify you of our plan to proceed.
 To communicate additional concerns,
questions, or information to a psychologist
already working with a patient:
 Contact that psychologist directly. There is no need
to create another formal consult.
 For crisis intervention:
 During regular working hours, page Dr. Kristin
Bingen.
If she is not in, page either Dr. Mary Jo Kupst or Dr.
Suzanne Holm to find out who is covering.
 After hours, page psychiatry, as there is someone
there on-call at all times. Then follow-up with
psychology the next working day.
References/Resources
 Institute of Medicine (2003). Childhood cancer survivorship:
Improving care and quality of life. National Academies Press,
Washington, DC.
 Keene, N., et al. (2000) Childhood Cancer Survivors. Sepastopol
CA: O’Reilly Associates, Inc.
 Kupst MJ & Bingen, K. (2006) Stress and coping in the pediatric
cancer experience. In R. T. Brown (Ed.) Pediatric
hematology/oncology: A biopsychosocial approach. New York:
Oxford University Press.
 Patenaude, AF & Kupst MJ (Eds.) (2005) Special Issue on Surviving
Pediatric Cancer: Research Gains and Goals. Journal of Pediatric
Psychology, volume 30.
 Woznick, LA & Goodheart CD (2002). Living with childhood cancer: A
practical guide to help families cope. Washington DC: APA.
Current Psychology
Research Projects
 “Trajectories of Health and Adaptation after
Pediatric Stem Cell Transplant”,
American Cancer Society
 “Psychosocial Outcomes of Pediatric Brain
Tumors”, American Cancer Society
 “Cognitive and Psychosocial Functioning of
Long-term Survivors of Pediatric Hematopoietic
Stem Cell Transplant”
Hope Street Kids Foundation
 LTFU
 LAF
 MACC Fund
From ABP
Certifying Exam Content Outline
Chronic illness and handicapping conditions
 Understand the effect of a chronic illness on siblings
 Know that psychosocial factors are associated with but
do not cause chronic illness (e.g., asthma, seizures,
inflammatory bowel disease)
 Understand the importance of being supportive and
non-threatening while talking with parents whose
children have chronic diseases
 Know the factors involved in making appropriate ethical
decisions relating to children with chronic and
handicapping diseases
From ABP
Certifying Exam Content Outline, cont’d.
Death
 Understand that the developmental stage of a child will
have an impact on his/her response to a death in the
family
 Know the value of anticipatory guidance and the
provision of information and support for critical life
events
 Identify regressive behavior and somatic complaints as
signs of stress
 Know how to counsel a family and child regarding the
death of a loved one
 Know the stages of grief and the spectrum of reactions
for a child and a family when a loved one dies: shock,
anger, denial, disbelief, sadness
Credits
Mary Jo Kupst, PhD, Professor of Pediatrics
Kristin Bingen, PhD, Assistant Professor
Suzanne Holm, PhD, Psychology Fellow
Medical College of Wisconsin
Children’s Hospital of Wisconsin