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The Effectiveness of Psychosocial Interventions for Psychological Outcomes in Pediatric Oncology: A Systematic Review

Open ArchivePublished:September 26, 2017DOI:https://doi.org/10.1016/j.jpainsymman.2017.09.022

      Abstract

      Context

      This review summarizes the current randomized controlled trials literature on psychological and physical outcomes of psychosocial interventions in pediatric oncology.

      Objectives

      The objective of this study was to evaluate the effectiveness and impact of psychosocial interventions in children with cancer.

      Methods

      A search of the literature resulted in a total of 12 randomized clinical trials and these have evaluated psychosocial interventions in children younger than 18 years with current and previous diagnoses of cancer. Outcome measures were both psychological (e.g., symptoms of anxiety, depression, quality of life, and self-esteem) and physical (e.g., cancer symptoms, treatment adherence, and pain). Interventions identified included cognitive behavioral therapy (CBT; n = 4), joint CBT and physical exercise therapy (n = 1), family therapy (n = 2), therapeutic music video (n = 2), self-coping strategies (n = 1), a wish fulfillment intervention (n = 1), and joint family therapy and CBT (n = 1).

      Results

      Nine studies reported statistically significant improvements on psychological outcomes. These findings suggest that psychosocial interventions are effective at reducing anxiety and depressive symptoms as well as improving quality of life. Additionally, six studies found psychosocial interventions to have a positive impact on physical symptoms and well-being, including a reduction in procedural pain and symptom distress.

      Conclusion

      These findings suggest that mental health needs in pediatric oncology patients can and should be addressed, potentially which will lead to better mental and physical health outcomes.

      Key Words

      Introduction

      In the U.K., around 4000 children and young people are diagnosed with cancer yearly.
      About childhood cancer.
      Also, due to recent advances in medical care and treatment, more children are now surviving with cancer.
      • Lie Fong S.
      • van den Heuvel-Eibrink M.M.
      • Eijkemans M.J.
      • Schipper I.
      • Hukkelhoven C.W.
      • Laven J.S.
      Pregnancy outcome in female childhood cancer survivors.
      These survival rates, in addition to advances in diagnoses, result in an increased number of children living with the physical and psychological consequences of the disease and treatment. The psychological impact is diverse, ranging from worries about the future to concerns over “looking ill” and viewing oneself as different from one's peers.
      • McDougal S.
      Children with cancer: Effects and educational implications.
      At least one-quarter of patients develop significant mental health disorders such as major depressive disorder, anxiety disorders, and/or post-traumatic stress disorders
      • Kazak A.
      • Alderfer M.
      • Streisand R.
      • et al.
      Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial.
      • Seitz D.C.
      • Besier T.
      • Debatin K.M.
      • et al.
      Posttraumatic stress, depression and anxiety among adult long-term survivors of cancer in adolescence.
      with half of all patients experiencing significant symptoms of depression,
      • Li W.H.C.
      • Lopez V.
      • Chung J.O.K.
      • et al.
      The impact of cancer on the physical, psychological and social well-being of childhood cancer survivors.
      although rates of disorders vary by study.
      • Phipps S.
      • Klosky J.
      • Long A.
      • et al.
      Posttraumatic stress and psychological growth in children with cancer: has the traumatic impact of cancer been overestimated?.
      The psychological impact of cancer has broader implications for quality of life (QoL), school attendance, and the development of relationships and communication skills.
      • af Sandeberg M.
      • Jonansson E.
      • Bjork O.
      • Wettergren L.
      Health-related quality of life relates to school attendance in children on treatment for cancer.
      • Moody E.J.
      Internet use and its relationship to loneliness.
      It can also negatively affect symptom management and treatment adherence.
      • Malbasa T.
      • Kodish E.
      • Santacroce S.J.
      Adolescent adherence to oral therapy for leukaemia: a focus group study.
      In recognition of these consequences, the European Society for Paediatric Oncology developed the “Standards of Care for Children with Cancer”
      SIOPE
      European standards of care for children with cancer.
      which outlines recommendations of care including specific psychological and psychosocial support. The recommendations state that every child with cancer should be offered psychological support through all stages of the illness. Moreover, there should be long-term monitoring of QoL and efforts to reintegrate the child into society and education. The U.K.'s National Institute for Health and Care Excellence
      NICE
      Improving outcomes in children and young people with cancer.
      also highlighted the social, educational, and emotional needs for children with cancer in their “Improving Outcomes for Children with Cancer” guidance. The guidance states that the psychological needs of children and their families are idiosyncratic and change throughout the different stages of the patient pathway. Services should thus offer psychometric assessment to patients throughout their treatment and into adult life to ensure optimal psychological health.
      Given the high occurrence of psychological difficulties in pediatric cancer patients, it is important to know whether the interventions offered are effective. The last review of research in childhood cancer was over a decade ago, was narrative rather than systematic, and suggested that the most effective interventions are those that are tailored to specific outcomes for the child; for example, understanding procedural pain and late effects of cancer.
      • Kazak A.E.
      Evidence-based interventions for survivors of childhood cancer and their families.
      A meta-analysis conducted around the same time reported that psychological interventions in pediatric oncology have significant effect sizes for improving adjustment and decreasing distress in parents but show limited efficacy for child patients.
      • Pai A.L.H.
      • Drotar D.
      • Zebracki K.
      • et al.
      A meta-analysis of the effects of psychological interventions in pediatric oncology on outcomes of psychological distress and adjustment.
      The authors argued that the relatively small effect may be explained by weakened effectiveness of the treatment due to a mixture of modalities within interventions; neither review examined specific psychosocial outcomes such as depression and QoL.
      The aforementioned concerns have been addressed in part by recent reviews, which have evaluated psychosocial interventions for adolescents and young adults with cancer.
      • Seitz D.C.M.
      • Besier T.
      • Goldbeck L.
      Psychosocial interventions for adolescent cancer patients: a systematic review of the literature.
      • Richter D.
      • Koehler M.
      • Friedrich M.
      • et al.
      Psychosocial interventions for adolescents and young adult cancer patients: a systematic review and meta-analysis.
      • Walker E.
      • Martins A.
      • Aldiss S.
      • et al.
      Psychosocial interventions for adolescents and young adults diagnosed with cancer during adolescence: a critical review.
      Two reviews found that psychosocial interventions for young adults showed a potential benefit.
      • Seitz D.C.M.
      • Besier T.
      • Goldbeck L.
      Psychosocial interventions for adolescent cancer patients: a systematic review of the literature.
      • Walker E.
      • Martins A.
      • Aldiss S.
      • et al.
      Psychosocial interventions for adolescents and young adults diagnosed with cancer during adolescence: a critical review.
      In contrast, a meta-analysis of seven studies found small to nonsignificant effects.
      • Richter D.
      • Koehler M.
      • Friedrich M.
      • et al.
      Psychosocial interventions for adolescents and young adult cancer patients: a systematic review and meta-analysis.
      These reviews specifically focused on adolescents and young adults rather than children based on the assumption that the effects of cancer are dependent on the developmental stage.
      • Seitz D.C.M.
      • Besier T.
      • Goldbeck L.
      Psychosocial interventions for adolescent cancer patients: a systematic review of the literature.
      This assumption is drawn from the view that adolescents with cancer are under added stressors from the developmental transition from childhood to adulthood with increased vulnerability to emotional stress. Moreover, these reviews included a range of quantitative and mixed methods designs, with no requirement for control groups. These factors make it difficult to make clear conclusions about the effectiveness of such interventions for children younger than 18 years.
      Given the limitations of the previous literature, a systematic review of randomized controlled trials (RCTs) of psychological and psychosocial interventions for childhood cancer patients and survivors under the age of 18 years is warranted. The present study therefore aimed to conduct a systematic review to identify and compare the effect of psychosocial interventions on psychological outcomes for childhood cancer. Specifically, it addressed the following research questions:
      • How effective are psychological and psychosocial interventions for children with cancer on specific psychological outcomes?
      • Do psychosocial interventions have an effect on childhood cancer patients’ physical health?

      Method

      A systematic review was carried out in accordance with the Cochrane guidelines for Systematic Reviews on Interventions.
      Cochrane Collaboration
      Supporting guidance for authors undertaking reviews with the Cochrane consumers and communication review group.

      Inclusion Criteria

      Study Type

      Only RCTs were included in this review since they are the gold standard for evidence-based clinical research.
      • Togerson C.J.
      • Togerson D.J.
      Randomised trials in education: an introductory handbook.

      Participants

      The study samples consisted of children with a mean age of 18 years old. Cancer services in the U.K. are commonly provided in two tiers: children (zero–13 years old) and teenage and young adults (13–24 years old).
      NHS Commissioning Board
      Cancer: Chemotherapy (children, teenagers and young adults).
      It was therefore considered acceptable for identified studies to include participants above 18 years old. However, unlike previous reviews, studies were only included if the mean age of participants was less than 18 years. Participants must have had a current or previous diagnosis of cancer of any type. “Survivors of cancer” were also included to increase our study pool.
      • Kazak A.E.
      Evidence-based interventions for survivors of childhood cancer and their families.
      This decision was made based on previous intervention reviews in this area where only a few studies were identified when limiting the cancer diagnosis.
      • Kazak A.E.
      Evidence-based interventions for survivors of childhood cancer and their families.
      Interventions that included parents and siblings were also included provided that the primary therapeutic target was the child.

      Interventions

      Only studies using psychological or psychosocial interventions for children with cancer were included in this review. For the purpose of this study, we define a psychological intervention as a non-pharmacological intervention that is intended to alleviate psychological distress and improve functioning.
      • Pai A.L.H.
      • Drotar D.
      • Zebracki K.
      • et al.
      A meta-analysis of the effects of psychological interventions in pediatric oncology on outcomes of psychological distress and adjustment.
      • Seitz D.C.M.
      • Besier T.
      • Goldbeck L.
      Psychosocial interventions for adolescent cancer patients: a systematic review of the literature.
      Psychosocial interventions were those involving social, behavioral, cognitive and/or psychoeducational approaches. Both interventions carried out individually or in groups were included.

      Comparators

      Studies included in this review were required to have an active (e.g., alternative intervention) or passive (e.g., waiting list or treatment as usual) control condition.

      Outcomes

      The primary outcome for this review is the psychological effects; therefore, studies were included if they reported any psychological outcomes, such as depression, anxiety, and post-traumatic stress symptomology, defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)
      American Psychiatric Association
      Diagnostic and statistical manual of mental disorders.
      or 5th Edition (DSM-V).
      American Psychiatric Association
      Diagnostic and statistical manual of mental disorders.
      Studies reporting participant QoL, self-esteem, perceived social support, or perceived emotional resistance were also included. Where available, secondary outcomes such as improvement in health symptomology and pain, educational benefits, and adherence to medication were also included. All response modalities, for example, self-report, parent reports, and clinician reports, were included.

      Exclusion Criteria

      Interventions were excluded if the mean age of participants was greater than 18 years old. Trials solely investigating sibling and parent outcomes were excluded. Additionally, interventions aimed at reducing procedural pain were excluded, as were studies with pharmacological-based interventions. There is already a wide body of research surrounding the use of drugs for children with cancer and including pharmacological studies would remove from the focus on psychological treatments, as these are two very separate areas of clinical research. Therefore, studies including drug treatment, for example, a study comparing a psychological intervention to a pharmacological drug on anxiety outcomes, were excluded. Only studies printed in English were included.

      Search Strategy

      A literature search was conducted in April 2015 and updated in August 2016 using PubMed, PsycINFO, and the Comprehensive Index to Nursing and Allied Health Literature (CINAHL). Figure 1 shows the combination of search terms used; there were no restrictions on publication dates. The medical subject heading (MeSH) terms and key words used in the search included the terms: “cancer AND intervention AND randomized control trial” and (“cancer”[MeSH Terms] OR “leukaemia”[All Fields] OR “oncology”[All Fields]) OR “lymphoma”[All Fields] OR “brain tumour”[All Fields] OR “Hodgkin disease”[All Fields] OR “medical oncology”[All Fields] OR “neoplasms”[All Fields]) AND (“intervention”[All Fields] OR “psychotherapy”[All Fields] OR “group therapy”[All Fields] OR “psychosocial”[All Fields] OR “support group”[All Fields] OR “psychological”[All Fields] OR “self-help techniques”[All Fields] OR “skills training”[All Fields]). A snowball method was also used, and the reference lists of all relevant studies and reviews were inspected for additional RCTs.
      Figure thumbnail gr1
      Fig. 1Search terms used to identify psychosocial intervention RCTs for children and adolescents. Records identified through database searching (n = 1660). RCTs = randomized controlled trials.

      Study Selection

      Studies were selected using the inclusion and exclusion criteria, carried out independently by three authors (A.C., A.M., and M.T.S.). First, titles of the articles identified using the search terms were screened; articles which were clearly irrelevant to this review were excluded. Thereafter, abstracts of the remaining articles were considered, and those not meeting the inclusion/exclusion criteria were excluded. Of the remaining articles, the full texts were accessed and further analyzed before ending up with the final selection.

      Data Collection and Analysis

      Data Extraction

      Data extracted from the studies included participant demographics (e.g., age, gender, and the type of cancer), methodology (e.g., type and length of intervention and follow-up), and results (e.g., psychological and health outcomes, and adherence rates).

      Methodological Quality Assessment

      Study quality was independently assessed by two authors (A.C. and A.M.) using the Cochrane Collaboration's tool for assessing risk of bias.
      Cochrane Collaboration
      The Cochrane collaboration's tool for accessing risk of bias.
      This tool was chosen for its suitability in assessing RCTs. Studies were rated as “low,” “unclear,” or “high” risk of bias using predefined criteria on a range of areas: blinding, attrition, participant allocation, reporting, performance, and other sources of biases.

      Results

      The initial search identified 1660 independent articles of which 12 studies met the inclusion/exclusion criteria (see Fig. 2 for study selection process). Table 1 shows the data extracted from the studies, including methodology and participant demographics.
      Figure thumbnail gr2
      Fig. 2Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (2009) flow diagram of literature search. RCT = randomized controlled trial.
      Table 1Summary of Key Characteristics of Studies Included in This Review
      StudyIntervention DetailsParticipantsControl(s)CountryFollow-upMain Outcome Measures
      Butler et al.
      • Butler R.W.
      • Copeland D.R.
      • Fairclough D.L.
      • et al.
      A multicenter randomized clinical trial of a cognitive remediation program for childhood survivors of pediatric malignancy.
      A cognitive remediation program that combined brain injury rehabilitation, educational psychology, and child clinical psychology including CBT components.

      Delivered in hospital.

      Four-month duration; 20 two-hour sessions per week.
      Cancer survivors; N = 163; 38% female; 6–17 years; mean age = 11Waitlist controlUSA6 monthsCulture-Free Self-Esteem Inventory
      • Battle J.
      Culture-free self-esteem inventories: Examiner's manual.
      Huang et al.
      • Huang J.
      • Dillon L.
      • Terrones L.
      • et al.
      Fit4Life: a weight loss intervention for children who have survived childhood leukemia.
      Tailored weight management incorporating phone- and web-based counseling with behavioral determinants.

      Home-based.

      Four-month duration; weekly counseling calls, weekly Internet material, and SMS twice a day.
      Cancer survivors; N = 38; 60.5% female; 8–18 years; mean age = 13Active control (received materials and small amount of contact)USA4 monthsChildren's Depression Inventory
      • Kovacs M.
      The Children's Depression Inventory: A self-rated depression scale for school-age youngsters.
      Kato et al.
      • Kato P.
      • Cole S.
      • Bradlyn A.
      • Pollock B.
      A video game improves behavioral outcomes in adolescents and young adults with cancer: a randomized trial.
      Computer-based intervention that required participants to engage in positive self-care behaviors, use relaxation techniques to reduce stress, and eat to gain energy.

      Home based.

      Three-month duration.
      Current cancer patients; N = 271; 32.3% female; 13–29 years; mean age = 18Active control (played alternative nonmedical game)USA, Canada, and Australia3 monthsSelf-Efficacy Scale

      Paediatric Quality of Life Scale
      • Varni J.W.
      • Seid M.
      • Kurtin P.S.
      PedsQL™ 4.0: Reliability and validity of the pediatric quality of life Inventory™ version 4.0 generic Core scales in healthy and patient populations.


      Perceived Stress Scale
      Varni et al.
      • Varni J.
      • Katz E.
      • Colegrove R.
      • Dolgin M.
      The impact of social skills training on the adjustment of children with newly diagnosed cancer.
      Cognitive problem solving, CBT strategies for anxiety, assertiveness training, and coping with adverse social effects.

      Delivered in hospital.

      Three 60-minute sessions followed by two booster sessions at three and six months.
      Current cancer patients; N = 64; 5–13 yrs; mean age = 8Treatment as usualUSA6 and 9 monthsState-Trait Anxiety Inventory for Children
      • Spielberger C.D.
      Manual for the State-Trait Anxiety Inventory for Children.


      Child Behaviour Checklist
      • Achenbach T.M.
      Manual for the child behavior checklist and revised child behavior profile.


      Children's Depression Inventory
      • Kovacs M.
      The Children's Depression Inventory: A self-rated depression scale for school-age youngsters.
      Kazak et al.
      • Kazak A.
      • Alderfer M.
      • Streisand R.
      • et al.
      Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial.
      A four-session one-day manualized program of cognitive behavioral family therapy. Participants are seen both separately and with their families. CBT techniques are used to reduce stress, encourage cohesion, and understand the importance of cognitions. Family therapy principles were used to facilitate implementation of CBT techniques within the family environment.

      Delivered in hospital.

      One-day treatment.
      Cancer survivors; N = 150; 51% female; 11–19 years; mean age = 14Waitlist controlUSANone (pre-post only)Impact of Events Scale Revised
      • Weiss D.S.
      The impact of event scale: revised.


      Post-Traumatic Stress Disorder Reaction Index
      • Pynoos R.S.
      • Frederick C.
      • Nader K.
      • et al.
      Life threat and posttraumatic stress in school-age children.


      State-Trait Anxiety Inventory
      • Spielberger C.D.
      Manual for the State-Trait Anxiety Inventory for Children.


      Revised Children's Manifest Anxiety Scale
      • Reynolds C.R.
      • Richmond B.O.
      Revised children's manifest anxiety scale.
      Van Dijk-Lokkart et al.
      • Dijk-Lokkart E.M.
      • Braam K.I.
      • Dulmen-den Broeder E.
      • et al.
      Effects of a combined physical and psychosocial intervention program for childhood cancer patients on quality of life and psychosocial functioning: results of the QLIM randomized clinical trial.
      CBT with physical exercise training. CBT included thoughts, feelings and behavior, self-esteem, coping with difficult situations, relaxation, relationships, and managing the future. Physical exercise training combined cardiorespiratory and muscle strength training.

      Delivered in hospital

      12-week duration; 45-minute physical training twice a week, 60-minute CBT session every two weeks.
      Current cancer patients; N = 68; 47% female; Eight–18 years; mean age = 13Treatment as usualThe Netherlands4 and 6 months after baselinePaediatric Quality of Life Scale
      • Varni J.W.
      • Seid M.
      • Kurtin P.S.
      PedsQL™ 4.0: Reliability and validity of the pediatric quality of life Inventory™ version 4.0 generic Core scales in healthy and patient populations.


      Child Behaviour Checklist -Dutch version
      • Koot H.M.
      • Van Den Oord E.J.
      • Verhulst F.C.
      • Boomsma D.I.
      Behavioral and emotional problems in young preschoolers: Cross-cultural testing of the validity of the Child Behavior Checklist/2-3.


      Children's Depression Inventory
      • Kovacs M.
      The Children's Depression Inventory: A self-rated depression scale for school-age youngsters.


      Self-Perception Profile–Dutch version
      • Veerman J.W.
      • ten Brink L.T.
      • Straathof M.A.
      • Treffers P.D.
      Measuring children's self-concept with a Dutch version of the Self-Perception Profile for Children: Factorial validity and invariance across a nonclinic and a clinic group.
      Lyon et al.
      • Lyon M.
      • Jacobs S.
      • Briggs L.
      • et al.
      A longitudinal, randomized, controlled trial of advance care planning for teens with cancer: anxiety, depression, quality of Life, advance directives, spirituality.
      Family therapy delivered as part of palliative care to provide support to individuals and their families in decision-making and coping with cancer.

      Delivered in hospital.

      Three-week duration; one session per week.
      Current cancer patients (end-of-life care)N = 30;40% female;14–20 years;Mean age = 16Treatment as usualUSA3 monthsBeck Depression Inventory II
      • Beck A.T.
      • Steer R.A.
      • Brown G.K.
      Manual for the Beck Depression Inventory-II.


      Beck Anxiety Inventory
      • Beck A.T.
      • Steer R.A.
      Beck Anxiety Inventory Manual.


      Paediatric Quality of Life Scale with Cancer-Specific Module
      • Varni J.W.
      • Seid M.
      • Kurtin P.S.
      PedsQL™ 4.0: Reliability and validity of the pediatric quality of life Inventory™ version 4.0 generic Core scales in healthy and patient populations.
      Yu et al.
      • Yu L.
      • Mo L.
      • Tang Y.
      • et al.
      Effects of nursing intervention models on social adaption capability development in preschool children with malignant tumours: a randomized control trial.
      A nursing intervention incorporating psychological, physical, and social aspects of cancer. Participants were seen with their families in groups used to share ideas, strategies, and behavioral techniques.

      Delivered in hospital.

      12-week duration.
      Current cancer patients; N = 240; 39% female; 3–7 yearsTreatment as usualChinaNone (pre-post only)Infant Junior Middle School Students Social Adaption Scale
      • Zhang Z.X.
      • Zuo Q.H.
      The standardisation of the infant junior middle school students questionnaires.
      Hinds et al.
      • Hinds P.
      • Quargnenti A.
      • Bush A.
      • et al.
      An evaluation of the impact of a self-care coping intervention on psychological and clinical outcomes in adolescents with newly diagnosed cancer.
      A three-component self-help intervention (1) information on self-care provided by nurse researchers or social workers; (2) 25-minute video of four young people describing and demonstrating coping strategies they found helpful; and (3) rehearsing the strategies the participant thought would be most helpful.

      Delivered in hospital.

      Single session.
      Current cancer patients; N = 78; 59% female; 12–21 years; mean age = 16Active control (spent equal time with researcher discussing the topic of their choice)USA3 and 6 monthsHopefulness Scale for Adolescents
      • Hinds P.
      Adolescent hopefulness in health and illness.


      Locus of Control Scale
      • Nowicki S.
      • Strickland B.R.
      A locus of control scale for children.


      Hopelessness Scale
      • Kazdin A.E.
      • Rodgers A.
      • Colbus D.
      The hopelessness scale for children: psychometric characteristics and concurrent validity.


      Rosenberg Self-Esteem Scale
      • Rosenberg M.
      Society and the adolescent self-image.


      Symptom Distress Scale (SDS)
      • McCorkle R.
      • Young K.
      Development of a symptom distress scale.
      Burns et al.
      • Burns D.
      • Robb S.
      • Haase J.
      Exploring the feasibility of a therapeutic music video intervention in adolescents and young adults during stem-cell transplantation.
      Therapeutic music video intervention grounded in motivational and developmental coping theory to promote positive health outcomes, improve coping, and manage distress. Participants produce a music video including music selection, lyric writing, discussions with researcher/family/friends, photo and artwork selection, video design, and digitally recording songs.

      Delivered in hospital.

      Three-week duration; two sessions per week.
      Current cancer patients; N = 12; 40% female; 13–24 years; mean age = 17Active control (low-dose audio book)USA100 daysCoping Scale Revised
      • Jalowiec A.N.E.
      • Murphy S.P.
      • Powers M.J.
      Psychometric assessment of the Jalowiec coping scale.


      Rosenberg Self-Esteem Scale
      • Rosenberg M.
      Society and the adolescent self-image.


      Herth Hope Index
      • Herth K.
      Abbreviated instrument to measure hope: development and psychometric evaluation.


      Child Health Questionnaire: Bodily Pain Scale
      • Landgraf J.
      • Abetz L.
      • Ware J.
      Child Health Questionnaire (CHQ) Manual: A User's Manual.
      Robb et al.
      • Robb S.L.
      • Burns D.S.
      • Stergena K.A.
      • et al.
      Randomized clinical trial of therapeutic music video intervention for resilience outcomes in adolescents/young adults undergoing hematopoietic stem cell transplant.
      Therapeutic music video intervention grounded in motivational and developmental coping theory to promote positive health outcomes, improve coping, and manage distress. Participants produce a music video including music selection, lyric writing, discussions with researcher/family/friends, photo and artwork selection, video design, and digitally recording songs.

      Delivered in hospital.

      Three-week duration; two sessions per week.
      Current cancer patients; N = 113; 43% female; 11–24 years; mean age = 17Active control (low-dose audio book)USA100 daysCoping Scale Revised
      • Jalowiec A.N.E.
      • Murphy S.P.
      • Powers M.J.
      Psychometric assessment of the Jalowiec coping scale.


      Perceived Social Support
      • Procidano M.E.
      • Heller K.
      Measures of perceived social support from friends and from family: three validation studies.


      Herth Hope Index
      • Herth K.
      Abbreviated instrument to measure hope: development and psychometric evaluation.


      Symptom Distress Scale (SDC)
      • McCorkle R.
      • Young K.
      Development of a symptom distress scale.
      Shohani et al.
      • Shoshani A.
      • Mifano K.
      • Czamanski-Cohen J.
      The effects of the make a wish intervention on psychiatric symptoms and health-related quality of life of children with cancer: a randomised controlled trial.
      Make a wish intervention. Aims to fulfill the child's greatest wish based on the assumption that evoking joy and hope will give children more strength to cope with their illness.

      Home based

      Wishes were fulfilled after five–six months
      Current cancer patients; N = 66; 41% female; Five–12 years; mean age = 11Waitlist controlIsrael5 weeksBrief Symptom Inventory
      • Derogatis L.R.
      • Spencer P.M.
      Brief symptom inventory: BSI.


      Paediatric Quality of Life Scale
      • Varni J.W.
      • Seid M.
      • Kurtin P.S.
      PedsQL™ 4.0: Reliability and validity of the pediatric quality of life Inventory™ version 4.0 generic Core scales in healthy and patient populations.


      Positive and Negative Schedule for Children
      • Ebesutani C.
      • Regan J.
      • Smith A.
      • et al.
      The 10-item positive and negative affect schedule for children, child and parent shortened versions: application of Item Response Theory for more efficient assessment.
      of children's emotional mood

      Life Orientation Test Revised
      • Bamford C.
      • Lagattuta K.H.
      Looking on the bright side: children's knowledge about the benefits of positive versus negative thinking.


      Herth Hope Index
      • Herth K.
      Abbreviated instrument to measure hope: development and psychometric evaluation.
      Table 2Summary of Key Findings Extracted From Studies Included in the Current Review
      StudyPsychological outcomes consideredMain study findings for psychological outcomesMain study findings for physical health outcomesOther study findings
      Cognitive behavioral therapy
      Butler et al.
      • Butler R.W.
      • Copeland D.R.
      • Fairclough D.L.
      • et al.
      A multicenter randomized clinical trial of a cognitive remediation program for childhood survivors of pediatric malignancy.
      Self-esteemNo significant differences between before and after treatment for both groups for self-esteemNone reported
      • Significant improvements in academic achievement for experimental group
      • No significant differences in neurocognitive functioning
      Huang et al.
      • Huang J.
      • Dillon L.
      • Terrones L.
      • et al.
      Fit4Life: a weight loss intervention for children who have survived childhood leukemia.
      Depressive symptoms, social integration, self-esteem and “nothingness”Participants in intervention reported significant lower depressive symptoms than control
      • Other measures showed no difference
      Greater weight loss in experimental group (nonsignificant)A tailored approach to treatment is more effective than generic treatment
      Kato et al.
      • Kato P.
      • Cole S.
      • Bradlyn A.
      • Pollock B.
      A video game improves behavioral outcomes in adolescents and young adults with cancer: a randomized trial.
      Quality of life, control, stress, and self-efficacy
      • No significant difference between preintervention and postintervention quality of life (slight improvement for experimental group)
      • No significant difference between pretreatment and post-treatment of self-perceived stress
      • Significant improvements in self-efficacy for experimental group after intervention
      • Significant improvements for medication health-related adherence
      • Significant improvements in cancer-related knowledge
      • The interactive game-based intervention represented a novel approach for optimizing adherence and cancer-related knowledge
      • Absolute lack of adverse effects of the intervention
      Varni et al.
      • Varni J.
      • Katz E.
      • Colegrove R.
      • Dolgin M.
      The impact of social skills training on the adjustment of children with newly diagnosed cancer.
      Depressive symptoms, self-esteem, anxiety, behavioral difficulties, and social supportSignificant improvement of anxiety in experimental group
      • Reduction in anxiety scores continued across time points for experimental group
      Significant improvements of self-esteem in experimental group

      No significant reduction for depressive symptoms
      • Lower means in experimental group
      None reportedParent reports indicated significantly lower behavioral difficulties in experimental group at the six- and nine-month follow-up
      Cognitive behavioral family therapy
      Kazak et al.
      • Kazak A.
      • Alderfer M.
      • Streisand R.
      • et al.
      Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial.
      Post-traumatic stress symptoms (PTSS), anxiety, and arousalGreater reduction in PTSS for experimental group with a significant treatment effect
      • No group difference for reported anxiety between conditions
      Arousal decreased in both conditions
      • Experimental group arousal reduction from 4.0 to 0.0
      None reportedFamily members assessed
      • Fathers reported greatest treatment effects
      • No significant treatment effects for mothers
      • Siblings reported no significant differences between groups
      Higher dropout rates in the intervention condition
      Cognitive behavioral therapy and physical exercise training
      Van Dijk-Lokkart et al.
      • Dijk-Lokkart E.M.
      • Braam K.I.
      • Dulmen-den Broeder E.
      • et al.
      Effects of a combined physical and psychosocial intervention program for childhood cancer patients on quality of life and psychosocial functioning: results of the QLIM randomized clinical trial.
      Quality of life, behavioral problems, depressive symptoms, and self-perception
      • No significant differences were found in self-report measures between groups after intervention.
      • Significant improvement in the perception of procedural anxiety was found in parent reports of children in intervention group compared to controls
      Significant improvements in levels on pain and hurt subscale based on parental reports
      Family therapy
      Lyon et al.
      • Lyon M.
      • Jacobs S.
      • Briggs L.
      • et al.
      A longitudinal, randomized, controlled trial of advance care planning for teens with cancer: anxiety, depression, quality of Life, advance directives, spirituality.
      Quality of life, depression, and anxiety
      • Anxiety scores dropped significantly in both groups
      • Significant reduction in depressive symptoms reported in experimental group
      • No significant difference of quality of life between groups
      • Family reported significant improved quality of life in experimental group, whereas participants did not report this
      No differences of reported symptoms between baseline and postintervention.
      • Intervention has high feasibility for African-American families
      • Higher reported spirituality in experimental group (both before and after intervention)
      Yu et al.
      • Yu L.
      • Mo L.
      • Tang Y.
      • et al.
      Effects of nursing intervention models on social adaption capability development in preschool children with malignant tumours: a randomized control trial.
      Social adaptation capability and quality of lifeSignificant difference of social adaptation between groups
      • 33% presented with excellent levels compared with 2.5% of control group
      None reportedSocial adaptation is related to improved quality of life for participants
      Self-help coping
      Hinds et al.
      • Hinds P.
      • Quargnenti A.
      • Bush A.
      • et al.
      An evaluation of the impact of a self-care coping intervention on psychological and clinical outcomes in adolescents with newly diagnosed cancer.
      Hopefulness, helplessness, self-esteem, and self-efficacyNo statistical difference between experimental and control group.
      • Hopefulness increased significantly between T3 and T4 in experimental group
      • Hopelessness highest after diagnosis and initial treatment
      Symptom distress reduction in both conditionsFeedback from experimental group was generally good
      • Suggestions of a shortened intervention
      Therapeutic music video
      Burns et al.
      • Burns D.
      • Robb S.
      • Haase J.
      Exploring the feasibility of a therapeutic music video intervention in adolescents and young adults during stem-cell transplantation.
      Quality of life, anxiety, and moodReported quality of life increased in both groups, with the experimental group improved greatlyA larger overall reduction of reported pain in experimental conditionA feasible intervention (low withdrawal rate with 100% completion)
      Robb et al.
      • Robb S.L.
      • Burns D.S.
      • Stergena K.A.
      • et al.
      Randomized clinical trial of therapeutic music video intervention for resilience outcomes in adolescents/young adults undergoing hematopoietic stem cell transplant.
      Social integration and courageous copingSignificant difference between groups for reported courageous coping and social integrationLower levels of illness-related distress (nonsignificant)
      • Increased use of positive coping strategies for experimental group
      • A difference (nonsignificant) between groups for spirituality
      Wish fulfilling
      Shoshani et al.
      • Shoshani A.
      • Mifano K.
      • Czamanski-Cohen J.
      The effects of the make a wish intervention on psychiatric symptoms and health-related quality of life of children with cancer: a randomised controlled trial.
      Psychiatric symptoms, HR-QoL, positive and negative emotions, sense of hope, optimism, and pessimism
      • Significant decrease in psychiatric symptoms, anxiety, and depression in experimental group
      • Significant increase in sense of hope and positive emotions in experimental group
      Significant increase in physical health in experimental group
      QoL = quality of life; HR-QoL = health related quality of life.
      Studies are organized by the mode of intervention employed in each study.
      A total of 1393 participants took part in the studies. All studies included childhood cancer patients with a mean age of less than 18 years. Nine studies included participants currently diagnosed with cancer; three studies reported interventions with cancer survivors.
      Participants in the studies received different forms of interventions. The interventions used fall under seven subheadings: cognitive behavioral therapy (CBT) based (n = 4), therapeutic music video therapy (n = 2), self-coping strategies (n = 1), family therapy (n = 2), joint family therapy and CBT (n = 1), joint CBT and physical exercise therapy (n = 1), and a wish-fulfilling intervention (n = 1). Control groups included standard treatment as usual (n = 4), waitlist (n = 3), and an alternative low-dose intervention (n = 5) such as speaking to a researcher about a mundane topic for the same amount of time as intervention.

      Risk of Bias

      The Cochrane Risk of Bias tool concluded that all studies had some risk of bias. The risk of bias detected was generally low across most parts of the studies, but all studies had a high risk of bias or an unclear conclusion for at least one criterion. Where a conclusion to the risk of bias could not be made, a classification of “unclear” was given. No study achieved low risk of bias across all domains.
      All but one study
      • Yu L.
      • Mo L.
      • Tang Y.
      • et al.
      Effects of nursing intervention models on social adaption capability development in preschool children with malignant tumours: a randomized control trial.
      achieved a low risk of reporting bias. This study claimed to be reporting QoL data but did not present this in the Results section of the article. Attrition bias was low for all studies, but one study
      • Kazak A.
      • Alderfer M.
      • Streisand R.
      • et al.
      Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial.
      reported higher dropout rates in the intervention group compared to control group. An “other form of bias” was found in the same study
      • Kazak A.
      • Alderfer M.
      • Streisand R.
      • et al.
      Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial.
      ; participants received a monetary incentive which may have reduced attrition. Performance bias was high for most studies, as expected, since it may be difficult and sometimes impossible to blind a participant who is receiving a psychological intervention or not.
      It is noted that this tool does not account for sample size. Where some studies may appear to have a low risk of bias, a very small sample may have been used which could have led to an underestimation of risk. In addition, the tool may be rigid when applied to intervention studies, for example, the blinding criteria may be too high. High or low risks of bias therefore need to be interpreted with caution.

      Interventions

      Table 1 summarizes the key characteristics of the studies included in this review and Table 2 presents the main findings from the studies.

      Cognitive Behavioral Therapy

      Four studies investigated cognitive- and behavioral-based interventions for pediatric cancer patients. These studies can be divided into participants with a current or previous cancer diagnosis.

      Survivors of cancer

      Butler et al.
      • Butler R.W.
      • Copeland D.R.
      • Fairclough D.L.
      • et al.
      A multicenter randomized clinical trial of a cognitive remediation program for childhood survivors of pediatric malignancy.
      assessed the effects of a cognitive remediation program on cognitive functioning and academic achievement in cancer survivors aged 6–17 years who had attentional problems. Secondary measures included patient-reported self-esteem, as measured with the Culture-Free Self-Esteem Inventory,
      • Battle J.
      Culture-free self-esteem inventories: Examiner's manual.
      a self-reported measure of self-image that assesses overall independent reliance and perception of academic adjustment. It addresses self-image over the course of the developmental span. Parent/teacher ratings of attention were also reported as secondary measures. Results indicate that self-esteem did not significantly differ before and after treatment in both groups. Significant improvements for the experimental group were reported for academic achievement, and parent reports suggested improved attention.
      Huang et al.
      • Huang J.
      • Dillon L.
      • Terrones L.
      • et al.
      Fit4Life: a weight loss intervention for children who have survived childhood leukemia.
      incorporated social cognitive theory
      • Bandura A.
      Social Learning through Imitation.
      within a tailored weight-management intervention for clinically overweight cancer survivors (aged 8–18 years). Participants in the experimental group reported significant reductions in negative mood compared to controls, and older participants showed significant improvements in weight management and physical activity.

      Current Diagnosis

      Kato et al.
      • Kato P.
      • Cole S.
      • Bradlyn A.
      • Pollock B.
      A video game improves behavioral outcomes in adolescents and young adults with cancer: a randomized trial.
      used a video game intervention to improve cancer treatment adherence in 13- to 29-year old cancer patients (with 87% of participants being under the age of 18 years at the time of the intervention and follow-up). Results showed significant improvement in self-efficacy, treatment adherence, and cancer-related knowledge in the experimental group. Although there was an improvement in QoL, this did not reach significance.
      Varni et al.
      • Varni J.
      • Katz E.
      • Colegrove R.
      • Dolgin M.
      The impact of social skills training on the adjustment of children with newly diagnosed cancer.
      used social skills training in addition to usual school reintegration for children with a current diagnosis of cancer aged 5–13 years. The participants were given specific homework tasks after each session similar to CBT, and when they met again for follow-ups, material from the intervention was again shared and feedback was taken. Booster sessions were used to practice the skills learned. Significant improvements in state anxiety (at six-month follow-up) and behavior (at six- and nine-month follow-up) were reported by participants in the experimental group compared to treatment as usual controls. Fewer depressive symptoms were found for the experimental group, but this result was not statistically significant.

      CBT in Conjunction with Physical Exercise Training

      One study
      • Dijk-Lokkart E.M.
      • Braam K.I.
      • Dulmen-den Broeder E.
      • et al.
      Effects of a combined physical and psychosocial intervention program for childhood cancer patients on quality of life and psychosocial functioning: results of the QLIM randomized clinical trial.
      evaluated the effects of a combined physical exercise and psychosocial intervention on QoL, behavioral problems, and self-perception on a small sample (n = 68) of cancer patients (aged 8–18 years) in the Netherlands using both self-report and parental report measures. In contrast to initial hypotheses, the authors found no significant differences between the intervention group and the treatment as usual control group when analyzing self-report measures. Analyses of parental reports, on the other hand, showed significant improvements in the perceived level of procedural anxiety. This discrepant finding may reflect the difference between the observed (external) level of physical exercise, and the actual (internal) feeling of pain, as measured with the patient-reported pain and hurt subscale of the QoL questionnaire.
      • Varni J.W.
      • Seid M.
      • Kurtin P.S.
      PedsQL™ 4.0: Reliability and validity of the pediatric quality of life Inventory™ version 4.0 generic Core scales in healthy and patient populations.
      For example, children participating in the intervention may be more willing to do exercise and perform normal activities, despite still feeling the same level of pain. Parents, however, may interpret this increase in exercise and activity as their child experiencing less pain, thus reporting greater improvement for their children on the pain and hurt scale.

      Family Therapy

      Two studies considered the effects of a family therapy approach to improving psychological outcomes for children with cancer. The Family-Centered Advance Care Planning for Teens with Cancer intervention was investigated in a three-month follow-up RCT for adolescents aged 14–20 years old with a current cancer diagnosis facing end-of-life treatment.
      • Lyon M.
      • Jacobs S.
      • Briggs L.
      • et al.
      A longitudinal, randomized, controlled trial of advance care planning for teens with cancer: anxiety, depression, quality of Life, advance directives, spirituality.
      Depression scores were significantly lower in the experimental group compared to controls after the intervention, whereas anxiety scores dropped significantly in both groups. There were no significant differences in QoL scores; however, both groups showed improved ratings. For physical symptom outcomes, measured by the Pediatric Quality of Life Cancer-Specific Module,
      • Varni J.W.
      • Seid M.
      • Kurtin P.S.
      PedsQL™ 4.0: Reliability and validity of the pediatric quality of life Inventory™ version 4.0 generic Core scales in healthy and patient populations.
      there were no differences reported before and after intervention.
      The second of the family therapy–centered interventions
      • Yu L.
      • Mo L.
      • Tang Y.
      • et al.
      Effects of nursing intervention models on social adaption capability development in preschool children with malignant tumours: a randomized control trial.
      compared two nursing intervention models of the socialization abilities of preschool children on adaptation and QoL in young children, aged three to seven years old, with a current cancer diagnosis. A significant difference for social adaptation capability between groups was identified. Furthermore, all results from the subcategories of the assessment including self-help, socialization, and self-direction were significantly higher for the experimental group compared to the controls. Although the study's objectives specified an investigation on the reported QoL of participants, it failed to report such results.

      Cognitive Behavioral Family Therapy Intervention

      Kazak et al.
      • Kazak A.
      • Alderfer M.
      • Streisand R.
      • et al.
      Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial.
      looked primarily at the treatment for post-traumatic stress symptoms (PTSS) in adolescents aged 11–19 years old who had survived cancer and their immediate families.
      • Kazak A.
      • Alderfer M.
      • Streisand R.
      • et al.
      Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial.
      Given the potential association of anxiety with PTSS, anxiety was examined as a secondary outcome. For PTSS outcomes, the experimental group reported a greater reduction in symptoms relative to the waitlist control group. Participants in the experimental group reported a greater reduction in arousal compared to the controls. For reported anxiety measures, no differences between groups were detected.

      Self-help Coping

      One study
      • Hinds P.
      • Quargnenti A.
      • Bush A.
      • et al.
      An evaluation of the impact of a self-care coping intervention on psychological and clinical outcomes in adolescents with newly diagnosed cancer.
      evaluated an intervention integrating self-help coping strategies for dealing with the demands of a new cancer diagnosis in adolescents aged 12–21 years. The three-part educational intervention incorporated self-care coping, behavioral coping strategies, and rehearsal techniques to encourage coping with the demands of the diagnosis. No significant differences were found between groups on any measure. However, hopefulness significantly increased at postintervention for the experimental group.

      Therapeutic Music Video

      Two studies used a therapeutic music video intervention targeting protective factors for psychological difficulties. This intervention uses music to provide predictability through choices, autonomy support, and relationship building in a therapeutic relationship for children and young people. An initial feasibility study reported improvements in QoL and improved mood following the intervention.
      • Burns D.
      • Robb S.
      • Haase J.
      Exploring the feasibility of a therapeutic music video intervention in adolescents and young adults during stem-cell transplantation.
      A subsequent full-scale trial of the intervention in a large sample size of 11–24 year-olds with a current cancer diagnosis found significant increases in courageous coping and social integration compared to controls.
      • Robb S.L.
      • Burns D.S.
      • Stergena K.A.
      • et al.
      Randomized clinical trial of therapeutic music video intervention for resilience outcomes in adolescents/young adults undergoing hematopoietic stem cell transplant.
      For illness-related distress, the experimental group's mean was lower than the control group's but not significantly so, as measured by the Symptom Distress Scale,
      • McCorkle R.
      • Young K.
      Development of a symptom distress scale.
      a 10-item Likert scale intended to measure an individual's perceived degree of discomfort from specific symptoms.

      Make a Wish Intervention

      Shoshani et al.
      • Shoshani A.
      • Mifano K.
      • Czamanski-Cohen J.
      The effects of the make a wish intervention on psychiatric symptoms and health-related quality of life of children with cancer: a randomised controlled trial.
      evaluated the efficacy of a wish-fulfilling intervention service in 66 children aged 5–12 years old in Israel. Children were interviewed about a wish that they wanted to come true, which was subsequently fulfilled after five to six months. Measures of psychiatric symptoms, QoL, sense of hope, and positive and negative effects were collected at baseline and five weeks after fulfillment of the wish. Results showed significant decreases in anxiety and depression in the intervention group compared to a waitlist control group. In addition, the intervention group reported significantly increased sense of hope, physical health (subscale of QoL), and positive emotions.

      Discussion

      This review aimed to evaluate psychological and psychosocial interventions for childhood cancer patients and survivors aged 18 years and under, focusing primarily on specific psychological outcomes and secondarily on physical outcomes. A comprehensive search of existing literature confirms that research into psychological interventions for children with cancer is sparse and only 12 RCTs were found. Findings from the studies converge on reported improvements in both the experimental and control groups in terms of reduced anxiety and depressive symptoms and improved QoL.
      Of all the studies identified, two studies reported no improvements for the intervention group.
      • Butler R.W.
      • Copeland D.R.
      • Fairclough D.L.
      • et al.
      A multicenter randomized clinical trial of a cognitive remediation program for childhood survivors of pediatric malignancy.
      • Dijk-Lokkart E.M.
      • Braam K.I.
      • Dulmen-den Broeder E.
      • et al.
      Effects of a combined physical and psychosocial intervention program for childhood cancer patients on quality of life and psychosocial functioning: results of the QLIM randomized clinical trial.
      Butler et al.
      • Butler R.W.
      • Copeland D.R.
      • Fairclough D.L.
      • et al.
      A multicenter randomized clinical trial of a cognitive remediation program for childhood survivors of pediatric malignancy.
      aimed to evaluate the effectiveness of a cognitive remediation program for survivors of cancer. This study concluded that it would be naive to expect significant improvements in a short period, and at future follow-ups, they would expect to see improvements in neurocognitive abilities due to the rehearsal of skills learned from the CBT aspect of the intervention. However, other studies of a similar follow-up period analyzed in this review did report significant improvements from their intervention.
      • Varni J.
      • Katz E.
      • Colegrove R.
      • Dolgin M.
      The impact of social skills training on the adjustment of children with newly diagnosed cancer.
      • Hinds P.
      • Quargnenti A.
      • Bush A.
      • et al.
      An evaluation of the impact of a self-care coping intervention on psychological and clinical outcomes in adolescents with newly diagnosed cancer.
      A further study
      • Dijk-Lokkart E.M.
      • Braam K.I.
      • Dulmen-den Broeder E.
      • et al.
      Effects of a combined physical and psychosocial intervention program for childhood cancer patients on quality of life and psychosocial functioning: results of the QLIM randomized clinical trial.
      also reported no significant improvements for the intervention group for self-reported outcomes, although parental reports indicated improvements in perceived procedural anxiety. The lack of effects in this study may in part be explained by the relatively good psychosocial functioning reported in their sample (most participants scored within the normal range at baseline). In addition, the sample was specifically selected to include participants <12 months after treatment. Therefore, it is also possible that the natural recovery in the first year after the treatment may have overshadowed any intervention effects. Future studies comparing children within the clinical range of psychosocial functioning and studies including longer follow-up periods are needed to investigate this further. Moreover, future studies will benefit from including additional groups who receive only CBT or only exercise therapy to distinguish specific or combined intervention effects.
      For the studies that specifically included anxiety and depressive symptoms as outcome measures,
      • Kazak A.
      • Alderfer M.
      • Streisand R.
      • et al.
      Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial.
      • Huang J.
      • Dillon L.
      • Terrones L.
      • et al.
      Fit4Life: a weight loss intervention for children who have survived childhood leukemia.
      • Varni J.
      • Katz E.
      • Colegrove R.
      • Dolgin M.
      The impact of social skills training on the adjustment of children with newly diagnosed cancer.
      • Lyon M.
      • Jacobs S.
      • Briggs L.
      • et al.
      A longitudinal, randomized, controlled trial of advance care planning for teens with cancer: anxiety, depression, quality of Life, advance directives, spirituality.
      • Burns D.
      • Robb S.
      • Haase J.
      Exploring the feasibility of a therapeutic music video intervention in adolescents and young adults during stem-cell transplantation.
      CBT showed significant improvement in outcome. In CBT, there is an element of rehearsal of techniques and behavioral changes between sessions with therapists encouraging clients to complete “homework” tasks.
      NICE
      Common mental health disorders: Identification and pathways to care. Clinical guideline 123.
      Participants who are encouraged to rehearse what they have learned in intervention sessions have a higher likelihood of making concrete emotional and behavioral changes; this may suggest why follow-up results are positive. These results corroborate with findings of a systematic review on psychological interventions for mental health disorders in children with chronic disorders,
      • Bennett S.
      • Shafran R.
      • Coughtrey A.
      • et al.
      Psychological interventions for mental health disorders in children with chronic physical illness: a systematic review.
      which concluded that CBT has a positive effect in the treatment of anxiety and depression in these clinical populations. Chronic illnesses follow a similar treatment trajectory to cancer: long treatment times, periods of absences from education, and painful procedures. Therefore, this conclusion of intervention effects may be transferable. Although there are, of course, large differences between diagnoses of chronic illnesses and cancer, such as morbidity, side effects of treatment, and possible mortality, it is beneficial for clinical practice that CBT methodology is effective across diagnoses.
      It is notable that the one study incorporating family therapy and cognitive behavioral methodology
      • Kazak A.
      • Alderfer M.
      • Streisand R.
      • et al.
      Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial.
      produced high results overall. A significant reduction in symptoms of post-traumatic stress disorder and a complete reduction of arousal for the experimental group were reported. Findings indicate participants enjoyed the intervention which may be due to the incorporation of family members into the therapy sessions.
      Another study identified in this review utilized technology to deliver incorporated psychosocial support with physical activity and reported a significant reduction in negative mood in the intervention group compared to controls.
      • Huang J.
      • Dillon L.
      • Terrones L.
      • et al.
      Fit4Life: a weight loss intervention for children who have survived childhood leukemia.
      Support was delivered via text messages and phone calls, which is an inventive way of improving access to the intervention. Participants in the experimental group received daily contact which improved compliance and therapeutic alliance between the child and experimenter. The intervention was tailored for age, sex, and needs of participants which was deemed more helpful than a generic approach, in line with the suggested benefits of tailoring interventions previously reported in a review of interventions for childhood cancer survivors.
      • Kazak A.E.
      Evidence-based interventions for survivors of childhood cancer and their families.
      Overall, there was a paucity of RCTs for other treatment modalities, for example, solution-focused approaches, narrative therapy, or psychotherapy, despite these being used in clinical practice. Future research would benefit from exploring the effectiveness of these approaches and identifying which interventions work best for whom.
      As a secondary exploration, this review aimed to analyze the effect psychosocial interventions can have on children's physical symptoms and well-being. When analyzing these outcomes, eight studies reported physical outcomes for patients.
      • Kazak A.E.
      Evidence-based interventions for survivors of childhood cancer and their families.
      • Kato P.
      • Cole S.
      • Bradlyn A.
      • Pollock B.
      A video game improves behavioral outcomes in adolescents and young adults with cancer: a randomized trial.
      • Dijk-Lokkart E.M.
      • Braam K.I.
      • Dulmen-den Broeder E.
      • et al.
      Effects of a combined physical and psychosocial intervention program for childhood cancer patients on quality of life and psychosocial functioning: results of the QLIM randomized clinical trial.
      • Lyon M.
      • Jacobs S.
      • Briggs L.
      • et al.
      A longitudinal, randomized, controlled trial of advance care planning for teens with cancer: anxiety, depression, quality of Life, advance directives, spirituality.
      • Hinds P.
      • Quargnenti A.
      • Bush A.
      • et al.
      An evaluation of the impact of a self-care coping intervention on psychological and clinical outcomes in adolescents with newly diagnosed cancer.
      • Burns D.
      • Robb S.
      • Haase J.
      Exploring the feasibility of a therapeutic music video intervention in adolescents and young adults during stem-cell transplantation.
      • Robb S.L.
      • Burns D.S.
      • Stergena K.A.
      • et al.
      Randomized clinical trial of therapeutic music video intervention for resilience outcomes in adolescents/young adults undergoing hematopoietic stem cell transplant.
      • Shoshani A.
      • Mifano K.
      • Czamanski-Cohen J.
      The effects of the make a wish intervention on psychiatric symptoms and health-related quality of life of children with cancer: a randomised controlled trial.
      All these studies except one
      • Lyon M.
      • Jacobs S.
      • Briggs L.
      • et al.
      A longitudinal, randomized, controlled trial of advance care planning for teens with cancer: anxiety, depression, quality of Life, advance directives, spirituality.
      reported positive physical outcomes, including reduction in procedural pain and symptom distress. It should be noted though that participants in that study
      • Lyon M.
      • Jacobs S.
      • Briggs L.
      • et al.
      A longitudinal, randomized, controlled trial of advance care planning for teens with cancer: anxiety, depression, quality of Life, advance directives, spirituality.
      were facing end-of-life care and as such suffered from severe physical symptoms which would not improve over time. Aside from two studies,
      • Huang J.
      • Dillon L.
      • Terrones L.
      • et al.
      Fit4Life: a weight loss intervention for children who have survived childhood leukemia.
      • Dijk-Lokkart E.M.
      • Braam K.I.
      • Dulmen-den Broeder E.
      • et al.
      Effects of a combined physical and psychosocial intervention program for childhood cancer patients on quality of life and psychosocial functioning: results of the QLIM randomized clinical trial.
      none of the interventions were developed with the aim of improving physical health outcomes. These are promising results for real-life application of these interventions which demonstrate the close interplay between physical and mental health and the potential value of integrating services.
      This area of research is exceptionally important for the thousands of children suffering with cancer and their families. This review indicates that a range of psychosocial interventions are effective and can impact positively on both mental and physical health. The specificity of any particular intervention has yet to be established. Overall, the findings indicate that the mental health needs of children and adolescents with cancer can and should be addressed and that integration of mental and physical health has positive impacts in both domains.

      Disclosures and Acknowledgments

      This work was supported by an award from the Health Foundation (CRM 2159) and by the National Institute for Health Research Biomedical Research Centre at the Great Ormond Street Hospital for the Children NHS Foundation Trust and University College London. The funding sources had no role in the review design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. All research at the Great Ormond Street Hospital NHS Foundation Trust and UCL Great Ormond Street Institute of Child Health are made possible by the NIHR Great Ormond Street Hospital Biomedical Research Centre. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
      The authors declare no conflicts of interest.

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