The role of psychotherapy

in paediatric oncology
By
Dr. Zainab Ali Hassan
Psychiatric Senior
Arabic Board Degree Achiever
Iraq/Basra medical college
• The psychological impact of cancer has broader implications for
quality of life , school attendance, and the development of
relationships and communication skills. It can also negatively affect
symptom management and treatment adherence.

• 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 Standards for Psychosocial Care for Children with Cancer and Their
Families (UK national health) provides the first evidence-based clinical
standards for addressing the psychosocial care of paediatric cancer patients
and their families. These standards recommend that:
1. Youth with cancer and their families should receive routine and systematic
assessment of their psychosocial needs during treatment and survivorship
2. High risk patients should be routinely monitored for neuropsychological
deficits
3. Youth and family should have access to psychosocial interventions,
including psychological interventions for invasive medical procedures, and
psychiatry as needed
4. When necessary, youth and families should receive developmentally
appropriate end of life care, including bereavement support.
• The services offered by the mental health providers may include:
1. Diagnostic evaluation and assessments of children and family
members
2. Development and implementation of psychotherapeutic individual
and family treatments
3. Neuropsychological testing, and
4. School-based consultation regarding school re-entry
 CBT
• Common modalities of psychological therapy are behavioural management
and CBT.
• For very young children, behavioural strategies are often the most feasible.
• However, for adolescents and school aged children, adapted models of CBT
may be used. Some commonly used techniques are:
1. Keeping thought diaries
2. Teaching progressive muscle relaxation
3. Deep breathing
4. Guided imagery
5. Behavioural activation, and
6. Positive self-talk.
• Research into interventions for social deficits is limited but one promising
study found improvements in self-reported social skills in brain tumour
survivors following social skills training, role play, and training in conflict
resolution

• The benefits of child psychotherapy

The task of the child psychotherapist - who plays no role in the medical care of
the patient - is to try to reflect with the patient (and/or parent) on their
experience, their capacity for adaptation to the reality of their illness, treatment
and prognosis, and to enable the expression of fear, anger, anxiety and sadness.
 PLAY THERAPY TO SUPPORT
• To CHILDREN IN HOSPITAL Play therapy is an ideal opportunity where suffering
children usually act out characters, share experiences, and discuss the fears of being
patients.
• In the group room, there is a small table in the middle and an intimate circle of
chairs.
• The group therapist is part of the circle.
• Playing with someone else, within a therapeutic relationship, in the hospital,
becomes an occasion of encouragement to stage dramatic intimate stories related to
pain and suffering, in a transition area, between reality and imagination.
• At the same time, patients can find explanations to their questions and alternative
imaginative endings regarding their illnesses, thanks to the interaction with other
people; thus, it is possible to change the perspective of pain, in order to evaluate the
events and add new elements of hope.
• Chronic diseases, in fact, reduce the ability to create and to invent, because
the disease and the medical therapies usually introduce a series of lifestyle
changes, which impose limitations on the children’s talents.
• The negative emotions linked to painful experiences confirm the idea of being
completely under the power of the events, without any chance of controlling
them ;
• these therefore reduce the children’s trust and hope for being in charge of their
lives.
• When the chronic disease is potentially mortal (for example, cancer), the
feelings are complicated by psychic impotence and sorrow.
• Play therapy, in these particular contexts, becomes an important occasion to
communicate and to reobtain some normality in their life .
 The supportive therapy

• Either group or individual support therapy.

• namely, the confidential link between the patients and their therapist, the
atmosphere of free-floating discussion, and the climate of easy
permissiveness, all enhance the creation of a good matrix, as a secure base,
where children can try new ways of facing the events .
• The creation of mutual storytelling, within the group-setting, encourages
greater autonomy, different perspectives of the events that the patients are
living, and a sense of hope, so that the children feel more able to adopt
different strategies to deal with their illness.
• Empowering the ego defences.
 Family supportive therapy
• Planning a Family Session
• Once there is a referral to the paediatric psycho-oncology team, it is useful to plan a family
session.
• If there are siblings who are in school, a session should be arranged on a weekend or after
school hours.
• The main message that needs to be communicated to the family is that family, the
professionals and the young person are all on the same side, trying to deal with the cancer.
• Making such a symbolic divide between the “cancer” and “everyone else,” often helps the
professionals and the family bond as a team.
• The team should encourage the family to continue being a close-knit unit, especially when
the sick child is at home.
• The family needs to be empowered while myths and irrational fears should be dispelled.
• “Cope, Adapt, Survive”
• Making Time for Siblings.
 Procedural anxiety
• Procedural anxiety can develop when a newly diagnosed child with cancer
has to undergo invasive procedures that are deeply unpleasant (e.g., blood
tests, bone marrow biopsy) and must endure frequent admissions to hospital.
• For a premorbidly anxious child this may lead to extreme fear of hospitals
and medical staff.
• Anticipating painful procedures, children may panic when they travel towards
the hospital.
• It is not uncommon for some children to cry inconsolably or freeze during the
procedures.
• In between procedures they may remain anxious and often talk about the
experience of undergoing tests.
 TREATMENT REFUSAL

• It is not unusual to receive urgent referrals from paediatric oncology teams when young people suddenly
refuse treatment . This is to be considered as an emergency. MX as follows :
1. Establish rapport with the child. This is facilitated if the psycho-oncology team is familiar with all the
children seeking treatment for cancer in the hospital, following a shared care model of service delivery
2. Discuss neutral, developmentally appropriate topics
3. Assess the child’s mental state to ascertain if the refusal is related to depression, anxiety, or other
problems. If that is the case, start treatment for the psychiatric condition
4. Conduct a risk assessment
5. Establish the context of treatment refusal. Evaluate if the young person has specific fears associated with
the treatment. A common reason is body image concerns associated with chemotherapy. Situational fear
or anxiety may require a few days to alleviate
6. Work with the paediatric oncology team to explain in a developmentally appropriate language the nature
of the treatment and its importance. Convey, without instilling undue fear, that without the treatment the
disease is likely to become worse
7. Spend time discussing the treatment and addressing the fears
 Depression
• Some children undergoing treatment for cancer may present with ( social
withdrawal, low mood, irritability, crying spells, and psycho-motor
retardation/ agitation) suggestive of subsyndromal depression.
• Some young people may experience depression following mutilating surgery,
which may affect their ability to participate in preferred activities or that
change their physical appearance.
• Depression may also emerge due to the loss of contact with peers or the
inability to go to school.
• In the absence of randomized controlled trials on depression in children with
cancer, clinicians rely on the existing evidence base.
• A combination of medication and psychological treatment is possibly the best
option as there is no evidence for one treatment over another.
 Agitation and Behavioural Difficulties
• Corticosteroids are vital in the treatment of acute lymphoblastic leukaemia,
which is the commonest malignancy in childhood.
• Children with leukaemia on corticosteroids can present with increased
restlessness and agitation.
• The effectiveness of this group of medications comes with a range of physical
and psychological side effects ranging from mild changes in mood and
cognition to overt psychotic symptoms .
• Psychological side effects usually emerge within days of onset of treatment.
• Like in adults, mood symptoms (e.g., irritability, emotional lability, pressured
speech) are the commonest, and are sometimes accompanied by psychotic
symptoms (delusions, hallucinations).
• Chronic treatment with corticosteroids may cause depressive symptoms, while
short-term therapy has a greater association with manic symptoms
• The Life of a 12-year-old
• “I want to… I want to walk “but I am scared, what if I fall? My
parents worry all the time. They usually hold my hands when I walk.
Well, I am not like the other kids and I’ll never again be like them”
muttered, a 12-yearold boy diagnosed with medulloblastoma.
Following surgery, he started having difficulties walking, often losing
his balance. He had resumed schooling recently. However, he skipped
school often, preferring to stay at home. He showed low mood, had
lost interest in activities that he enjoyed earlier, had dwindling self
confidence, and low self-esteem.
• The Mother who Wanted her Child to Eat Fruit
• An 8-year-old diagnosed with acute lymphocytic leukaemia was
admitted to the paediatric oncology ward. Nurses noticed that his
mouth was often full of food. The staff soon discovered that his
mother believed that eating pomegranate would “help to replenish the
red blood cells.” The child hated to eat pomegranate, kept the food in
his mouth, and avoided swallowing it. The clinicians were soon
worried that poor oral hygiene may make him vulnerable to infections.
Nursing instructions had not been accepted by the parent and a referral
was made to pediatric psychooncology.
THANK YOU FOR LISTENING