Most Children With Cancer Are Well-adjusted, Psychologist Reports

"We see them as a flourishing population that has adapted to the stress of having cancer and undergoing treatment," said Sean Phipps, Ph.D., a member of the St. Jude Division of Behavioral Medicine. "They become quite resilient to the long-and short-term emotional and physical effects of their disease and the treatments."

The unexpected finding that children with cancer are emotionally resilient is important because of the dramatic improvement in survival rates of pediatric cancers. "There has been a shift in research toward the concerns of long-term survivors of pediatric cancers," Phipps said. "The ability of these children to cope with the after-effects of cancer is the major issue now. What we are learning from this population might help us learn how to improve the quality of life of children who are not doing so well."

Phipps is the author of an article on adaptive styles in children with cancer that appears in the advanced online issue of "Journal of Pediatric Psychology." The article, based on research done by his group and other research teams around the country, was presented at the conference "Psychosocial and Neurocognitive Consequences of Childhood Cancer: A Symposium in Tribute to Raymond K. Mulhern," held at St. Jude in September 2006, in honor of the late Raymond K. Mulhern, Ph.D., a pioneer in psychological research in pediatric oncology at the hospital. The symposium's presentations will also appear in a special December issue of the journal.

The low level of depression among children with cancer does not reflect a state of "illusory mental health," Phipps said. That is, these children are not simply clinging to an illusion of mental health by denying distress. Rather, many of them simply have a reduced awareness of emotional distress, and they think of themselves as being well-adjusted and content, a response called a "repressive adaptive style."

Children who have a repressive adaptive style have a personality characterized by a positive self-image and avoidance of threat, Phipps said. Such children tend to think of themselves as well-adjusted, self-controlled and content. Only a small percentage of these children experience emotional difficulties that become serious enough to be called pathologic, he said.

"The finding that children with cancer are flourishing comes largely from self-report studies in which children discussed their own responses to stresses in their lives," Phipps said. "This is good news that many researchers in the field have been reluctant to embrace. There is a tendency instead to question whether this conclusion is mistaken; whether we've missed something in our studies or have not done the right studies. But the finding has held up over time, and we have not yet found a self-report test that documents in children a high level of difficulty adjusting to their disease."

One possible clue to the successful adaptation to cancer and its treatment might be the good care, nurturing and love these children receive, Phipps noted. In addition, they are not confronted with tests in school, bullies or other common stresses their peers face. "A repressive adaptive style appears to provide a pathway to resilience or a route to successful adjustment for these children," he said. "However, it might be only one of several mechanisms that allow them to flourish."

The low levels of depression found in children with cancer using self-reporting and other traditional psychological testing led some researchers to believe different tests were needed to study this population, such as tests of posttraumatic stress disorder. Posttraumatic stress disorder is a disorder based on anxiety that follows a terrifying event or ordeal that either harmed or threatened to harm the person.

The diagnosis of posttraumatic stress disorder depends on the patient having certain symptoms from several different categories, such as experiencing flashbacks and nightmares; feeling detached; avoiding people or things linked to the trauma; losing interest in activities; and having difficulty sleeping.

But investigators found that most children with cancer did not have the full range of symptoms to indicate the disorder. Instead, they had a few of the symptoms that can occur, but not enough of them to qualify for the full diagnosis. This led other investigators to abandon these test and instead look for posttraumatic stress symptoms, even if those symptoms are too few to permit a diagnosis of posttraumatic stress disorder.

"Even with this strategy, researchers found that children with cancer appear to have lower levels of stress than do individuals who experienced a natural disaster, serious injury, the death of a parent or another type of major stress," Phipps said.

A team led by Phipps examined self-reported somatic symptoms of 120 children with cancer who had finished medical treatment at least six months previously. Somatic symptoms are physical problems such as loss of weight, trouble sleeping and loss of energy. The researchers found no differences between children with cancer and healthy controls in self-reported somatic symptoms. In fact, cancer patients reported slightly lower symptom levels.

Phipps and his colleagues are also studying several other factors from the growing field of "positive psychology," such as optimism, benefit-finding, post-traumatic growth and the concept that people facing adversity might actually benefit and become stronger from it in many ways.

"Research psychologists have historically focused on searching for problems that need fixing, rather than on a person's strengths," Phipps said. "However, our findings suggest that gaining a better understanding of how children are able to remain so well adjusted in the face of difficult life challenges may provide a more fruitful approach to our research."

This work was supported in part by the National Institutes of Health and ALSAC.