Date of Award

January 2013

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Nina S. Kadan-Lottick

Subject Area(s)

Medicine, Oncology

Abstract

Over 90% of children with standard risk-acute lymphoblastic leukemia (SR-ALL) will survive, but there are limited data concerning their psychological adjustment during treatment. We prospectively assessed symptoms of anxiety, depression and behavioral disturbances in children with SR-ALL during the first 12 months of therapy and identified factors associated with psychological distress. We conducted a cohort study of 159 children 2-9.99 years old with SR-ALL enrolled and treated on Children's Oncology Group study AALL0331 at 31 selected sites. The primary caregiver completed the Behavior Assessment System for Children-Second Edition, the Family Assessment Device-General Functioning, and the Coping Health Inventory for Parents at about 1, 6 and 12 months after starting treatment. The mean scores for anxiety, depression, aggression and hyperactivity in the child were within the average range at all timepoints. However, compared to a normative population, a higher percentage of children scored in the at-risk/clinical range for depression throughout the first year: one month (21.7% vs. 15%, p=0.022), six months (28.6% vs. 15%, p<0.001), and twelve months (21.1% vs. 15%, p=0.032). For anxiety, a greater percentage scored in the at-risk/clinical range at one month (25.2% vs. 15%, p=0.001), but then reverted to expected levels at six and twelve months after diagnosis. Children with elevated anxiety symptoms at one month were more likely to have elevated symptoms at six (OR=7.70, p<0.001) and twelve months (OR=7.11, p=0.002) after diagnosis. Similarly, those with elevated depression symptoms at one month were more likely to have elevated symptoms at six (OR=3.51, p=0.015) and twelve months (OR=3.31, p=0.023) after diagnosis. In multivariate longitudinal analysis with repeated measures at the three timepoints, unhealthy family functioning was associated with anxiety (OR=2.24, p=0.033) and depression (OR=2.40, p=0.008). Hispanic ethnicity was also associated with anxiety (OR=3.35, p=0.009). Worse physical functioning (p=0.049), unmarried parents (p=0.017), and less reliance on the coping strategy of maintaining social support (p=0.004) were associated with depression. Based upon parental assessments, anxiety is a significant problem in young children with ALL one month after starting therapy, though it resolves within the first year. Depression remains a significant problem for at least one year, highlighting the need for psychosocial screening and the availability of mental health staff. We found that we could identify children at one month after diagnosis who were substantially more likely to have poor emotional functioning throughout the first year of therapy. Children of Hispanic ethnicity or from families reporting unhealthy family functioning may be particularly vulnerable.

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