|A meta-analysis of the effects of psychological interventions in pediatric oncology on outcomes of psychological distress and adjustment
|Pai A L, Drotar D, Zebracki K, Moore M, Youngstrom E
The authors concluded that psychological investigations show promise in improving parent adjustment and decreasing parent distress. However, effects for child distress and adjustment are minimal. This was generally a well-conducted review and the conclusions are likely to be reliable.
To evaluate the impact of psychological interventions on psychological distress and adjustment in parents and children in paediatric oncology.
MEDLINE, CINAHL, PsycINFO, Digital Dissertations and the Cochrane Database of Systematic Reviews were searched from 1967 to 2005 for articles published in English; the search terms were reported. Four relevant journals were handsearched and citations in identified studies and review articles were checked .
Studies of psychological interventions in paediatric oncology were eligible for inclusion. Treatments that were exclusively medication, bibliotherapy, art therapy or music therapy were excluded. The interventions evaluated in the included studies were educational, behavioural/cognitive-behavioural, social-skills training, relaxation, written disclosure and social support. The number of sessions delivered ranged from 1 to 8 and the duration of a session ranged from 20 to 120 minutes. Both group and individual interventions were evaluated in the included studies. Studies of children aged 18 years or younger with a diagnosis of cancer and/or studies of families with children diagnosed with cancer were eligible for inclusion. The majority of studies included were of children with a range of cancer diagnoses, sites of malignancy and treatment regimens. One study was exclusively of children with brain tumours, while another targeted families of children undergoing bone marrow or stem cell transplantation. The included studies targeted patients across the cancer course: from newly diagnosed, in treatment and survivor phases. The included studies were of younger children, adolescents and younger adults. Where reported, the majority of participants were Caucasian (range: 45 to 95%) and participants from low social economic status (SES) groups were well represented (range: 22 to 62% in the lowest SES category). Studies of parent or child distress, or adjustment which reported sufficient data to calculate a raw effect size statistic, were eligible for inclusion. The included studies used a wide range of standardised tools to measure outcomes, and outcomes were categorised as self-reported child distress, self-reported child adjustment, self-reported parent distress, self-reported parent adjustment, parent-reported child distress and parent-reported child adjustment. The included studies had a mean follow-up period of 4.35 months (range: 5 weeks to 9 months).
The authors did not state how the studies were selected for the review, or how many reviewers performed the selection.
Assessment of study quality
A modified version of the Jadad scale was used to assess validity. Each study scored up to a maximum of 5 points for randomisation, description of randomisation, numbers and reasons for drop-outs, use of a control group and monitoring of treatment fidelity. Aspects of study quality were also discussed in the text. The authors did not state how the validity assessment was performed, or how many reviewers performed the assessment.
Mean control group or baseline scores and mean treatment group or post-intervention scores were extracted. Effect sizes (Cohen's d) were calculated for each study using either between groups or pre-test post-test comparisons. Where subscale scores were reported, only total scale scores were extracted. Where studies included more than one measure for the outcome studies, mean effect sizes were calculated across multiple measures of the same construct. Authors were contacted for further data where necessary.
Two reviewers independently extracted the data. Inter-rater reliability was calculated using the κ coefficient.
Methods of synthesis
The data were combined using a weighted least-squares approach and a random-effects model. Heterogeneity was assessed using the Q statistic. Further information on study characteristics and differences between the studies was evident from the table.
Results of the review
Twelve studies (n=1,158) were included in the review: 9 randomised controlled trials (RCTs), 2 quasi-experimental designs and a within-subjects design (n=13). There was insufficient information to determine the number of participants in the RCT and quasi-experimental groups.
Nine studies scored 3 or higher on the Jadad scale for quality. Five studies used a treatment fidelity check, but only two used an attention control group.
Psychological interventions had a small but significant positive impact on parent adjustment (5 studies; weighted mean effect size 0.23, 95% confidence interval, CI: 0.07, 0.40, p<0.05) and parent distress (7 studies; weighted mean effect size 0.35, 95% CI: 0.20, 0.49, p<0.05). There was no evidence of statistical heterogeneity. Psychological interventions did not significantly impact on self-reported or parent-reported measures of child adjustment and distress in between-group studies. There was no evidence of statistical heterogeneity for any of these outcomes except parent-reported child adjustment (QT = 5.66, p=0.02).
The within-group study reported significant medium effects of psychological interventions on self-reported child distress (effect size 0.64) and self-reported child adjustment (effect size 0.56), and significant small effects of psychological interventions on parent-reported child distress (effect size 0.22) and parent-reported child adjustment (effect size 0.32). No p-values were reported for this study.
Psychological interventions in paediatric oncology show promise in decreasing stress and improving adjustment of parents of children with cancer. However, they have minimal impact on child distress and adjustment.
The review addressed a question that was clearly defined. Several relevant sources were searched and attempts were made to identify unpublished material. The search was restricted to articles in English, therefore language bias might have been introduced and relevant data missed. Appropriate methods were used to minimise bias and error at the data extraction and analysis stages. However, it is unclear whether similar steps were taken in the study selection and validity assessment processes, therefore error and bias cannot be ruled out. An appropriate validity assessment was carried out and the results were reported, though not in detail. The quality of the included studies was generally good. Given the considerable clinical heterogeneity between the studies, the review might have benefited from a narrative synthesis. Furthermore, the combination of randomised, quasi-experimental and within-subjects research designs limits the conclusions that can be drawn from the meta analysis. This was generally a well-conducted review and the results are likely to be reliable.
Implications of the review for practice and research
Practice: The authors did not state any implications for practice.
Research: The authors stated that further research with attention control groups, long-term follow-up periods and the reporting of effect sizes is required.
National Institutes of Health Ruth L Kirchstein National Research Service Award; Lance Armstrong Foundation Center for Survivors of Pediatric Cancer at Rainbow Babies and Children's Hospital.
Pai A L, Drotar D, Zebracki K, Moore M, Youngstrom E. A meta-analysis of the effects of psychological interventions in pediatric oncology on outcomes of psychological distress and adjustment. Journal of Pediatric Psychology 2006; 31(9): 978-988
Subject indexing assigned by NLM
Adolescent; Child; Depressive Disorder, Major /epidemiology /etiology /therapy; Female; Humans; Male; Neoplasms /epidemiology /psychology; Psychotherapy /methods; Social Adjustment; Treatment Outcome
Database entry date
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.