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Section 17
Coping with Parental Cancer

Question 17 | Test | Table of Contents

Theme 1: adolescents’ emotions and behaviors
Research on adolescents who have a parent with cancer encompasses the adolescents’ emotions and behaviors. Internalizing behaviors are behaviors that are ‘directed inward to the individual that affect his or her mental, cognitive, or emotional functioning, such as depression or anxiety.’ ([2], p. 299). Fear is the anticipation of ‘the possibility that something dreaded or unwanted may occur. Fear may be regarded as a predisposition to perceive a specific set of conditions as a threat and to react with anxiety when exposed to these conditions.’ ([49], p. 354). Anxiety is a state of uneasiness and distress about future uncertainties, apprehension, and worry. ‘It is clear that the object or situation is not feared, per se, but rather the possible consequences of exposure to such an object.’ ([49], p. 354).

A salient point in the literature is that adolescents feared that their parent would die [6,7,16,26] and the piece of information that adolescents sought, regardless of their age, was knowing whether or not their parent was going to survive [29]. When children were told that their parent was not going to die generally, they felt relieved [26].

Female adolescents of individuals with cancer felt increased vulnerability to cancer related to genetic risk [6,20,23,29,45] and could identify symptoms of breast cancer [20]. Adolescent female’s fears were associated with physical/sexual development [23] and [20] adolescent females reported significantly less frequent sexual intercourse and lower sexual satisfaction. Nelson et al. [36] reported that males felt anxious about their parent’s illness but felt unable to discuss their fears with either parent. Evidence suggests that adolescents conceal their thoughts, fears, and feelings in an attempt to protect the parent and not cause tension in the relationship [45]. Fear of recurrence and loss of the parent may be expressed through somatic symptoms [23]. However, according to Davey et al. [45], adolescents tried to maintain positive thoughts or attitudes, talked about the cancer, and relied on faith to alleviate fear and sadness.

Heiney et al. [39] reported that adolescents showed significantly higher state and trait anxiety compared to an age-normed sample. Lewis and Darby [27] noted that when both parents’ relationships with the adolescent were poor, adolescents showed significantly lower self-esteem and increased anxiety. Adolescent females whose mothers had cancer were significantly distressed [18,35,37,42,47,48]. According to Watson et al. [32] maternal depression combined with poorly defined family roles increased the likelihood of internalizing problems, especially in females. Increased family responsibilities and the use of ruminative coping were also examined as possible mechanisms leading to increased distress in females with ill mothers [37]. According to Welch et al. [18], adolescents’ self-reported symptoms of anxiety/ depression did not vary according to type of parental cancer. Thus, adolescents whose mothers had breast cancer were no more likely to experience higher levels of anxiety/depression than adolescents whose mothers had other types of cancer [18].

Externalizing behaviors are behaviors that are ‘directed to other people or, more generally, to the social context, i.e. aggression, arson, or disruptive behavior in the school or home.’ ([2], p. 299). According to Lewis and Darby [27] adolescents tended to show increased behavioral problems when both parents had depressed mood; maternal depressed mood was the main source of influence.

Males reported that parental illness had affected their schoolwork and amount of leisure time for sports and activities with friends [36]. Family functioning was significantly related to emotional and behavioral problems; extremely high adaptation and extremely low family cohesion were related to the prevalence of emotional and behavioral problems in children [44]. Watson [32] reported that adolescent’s externalizing problems were predicted when the adolescent reported worse family communication, family affective responsiveness, family affective involvement, family behavioral control, and family general functioning. An increase in the adolescent’s externalizing problems was also associated with lower family cohesion.

Lewis’ [4] correlational analyses between the mother’s illness-related demands and the adolescent’s functioning revealed that the greater the number of family-related illness demands the mother experienced, the greater the number of behavioral problems reported by the adolescent. Interestingly, [50] and [18] noted that parents do not perceive their children as being distressed, either in terms of internalizing (anxiety/depression) or externalizing (aggression) emotional or behavioral problems.

Theme 2: adolescents’ perceptions and knowledge of parental cancer
To perceive is ‘to take notice of; observe’ and knowledge is ‘the sum or range of what has been perceived, discovered or learned.’ ([51], p. 920).

Adolescents were in turmoil during the diagnosis and treatment of their parent’s cancer however, once the immediate threat was over, they did not see the situation as a continued threat to themselves, their families or their parent [16]. Adolescents stated that when they were given information, the timing of the information in relation to their mother’s cancer was important. They required understandable, detailed, information soon after diagnosis and reported the importance of receiving information as the illness progressed such as the potential side effects of treatment, alternative therapies, the seriousness of the illness, and the medical ‘facts’ about the disease [29]. They appreciated health care providers giving them information and providing them with local sources of support in a way that they understood [46]. In addition to written information, they would have also valued the health care providers recommending a website on parental cancer [33]. Adolescents wanted to be informed about treatments by attending appointments, reading books and looking things up in the dictionary or on the Internet [26,45]. They had a desire to know more about their parent’s illness so that they could contribute to the family in a positive way and be supportive of other family members [46]. Huizinga et al. [44] reported that whether or not the child was well informed was a factor that was perceived as having an impact on the child’s coping.

Unfortunately, mothers with breast cancer and other family members do not always know what the child is experiencing because of the breast cancer [52]. Adolescents reported that within and outside of the family, their information and support needs were poorly met [29,53]. In a study by Issel et al. [19], 15% of adolescents ages 13–20 years said that the family did nothing to help them. Adolescents mentioned that people from the community (churches and neighbors) were helpful to their family but did not offer them personal support [29].

Theme 3: adolescents’ changes in roles
Roles are characteristic and expected social behaviors of individuals. The results of Wellisch et al. [21] study showed that adolescents were prone to change roles with the ill parent. The majority of children remembered having to take on extra domestic chores and responsibilities for sibling care during diagnosis and treatment [16,36,45]. According to Spira and Kenemore [23], females feared that changing roles would alter the existing mother/daughter relationship. They wanted to maintain the relationship with their mothers that they had before the illness. Adolescents were impacted by changes in family patterns and were involved in helping at home [19,26,38].

Theme 4: adolescents’ ways of coping
Lazarus ([54], p. 237) defines coping as ‘ongoing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person.’ Problem-focused coping is ‘the management or alteration of the person–environment relationship that is the source of stress’ and emotion-focused coping is the ‘regulation of stressful emotions’ ([55], p. 223).

Adolescents used problem-focused coping as they asked questions, read about the illness, and assumed responsibility for household chores or sibling care [36]. They also reported using emotion-focused coping by refusing to think or talk about the illness [19,36] and dual-focused coping (both problem- and emotion-focused in intent) [38].

According to Compas et al. [38], emotion-focused coping is related to greater avoidance and to higher symptoms of anxiety/depression in the adolescent. Adolescents stressed the importance of family, friends and the school system in providing a sense of normality about their life, which helped them cope [19,29,44,45]. Humor was used as a way of coping [23,45]; friends were described as being supportive when they tried to be close, asked about their parent, and offered hugs and jokes [29]. Adolescents discussed the importance of having time to be a normal teenager. Teens valued information about the normal feelings of the adolescent whose parent has cancer. For example, wanting to spend time with friends and away from the day-to-day management of their parent’s illness. They emphasized the importance of continuing to meet their own needs such as moving away from home and working for the summer [46].

Some wished that their parent would die because they wanted their life to return to normal, and felt guilty for the thought [23]. They appreciated health care professionals informing them that feelings such as anger and guilt were normal [29].

Few intervention studies have focused on adolescents who have a parent with cancer [30,31,34]. The psychoeducational group intervention ‘Kids Can Cope’ [34] assisted school-age children and adolescents (ages 5–18 years) in learning about cancer and its treatments. The intervention provided them with the opportunity to share concerns in a safe environment and increase their coping strategies. Lewis et al. [31] stated ‘research reveals that both mothers and children have elevated distress attributed to the cancer, struggle with how to talk about and deal with the impact of the cancer, and both fear that the mother will die.’ The Enhancing Connections Program [31], was developed for school-age children and adolescents (ages 8–12 years) to reduce cancer-related distress and morbidity. Results revealed significant improvements in mother’s depressed mood, anxiety and self-confidence to assist her child. There were also significant decreases in the child’s behavioral problems, the child’s cancer-related worries, and the child’s anxiety/depressed mood. Davey et al. [30] conducted focus groups with adolescents whose mothers had breast cancer to elicit their opinion about how future intervention programs should be developed. Adolescents suggested that intervention programs: include adolescent groups of males and females within 4 months of the cancerdiagnosis; teach coping skills sensitive to males and females of different ethnic and racial backgrounds; and be followed by family therapy groups that promote shared family understanding and open communication between parents and adolescents.

Several of the studies on children who have a parent with cancer examined school-age children and adolescents [39,40,42,44,48] or adolescents and young adults [47]. The eight studies that included only the adolescent, defined as a person between the ages of 10–20 years [2].
- Grabiak, Beth, Bender, Catherine & Kathryn Puskar; The impact of parental cancer on the adolescent: an analysis of the literature; Psycho-Oncology; Feb 2007; Vol. 16; Issue 2.

Personal Reflection Exercise #10
The preceding section contained information about the impact of parental cancer on the adolescent.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Coping Strategy Among the Women
with Metastatic Breast Cancer
Attending A Palliative Care Unit
of A Tertiary Care Hospital of Bangladesh

Islam N, Bhuiyan AKMMR, Alam A, Chowdhury MK, Biswas J, Banik PC, et al. (2023) Coping strategy among the women with metastatic breast cancer attending a palliative care unit of a tertiary care hospital of Bangladesh. PLoS ONE 18(1): e0278620.

Peer-Reviewed Journal Article References:
Egberts, M. R., Verkaik, D., Spuij, M., Mooren, T. T. M., van Baar, A. L., & Boelen, P. A. (2021). Child adjustment to parental cancer: A latent profile analysis. Health Psychology.

Katz, L. F., Fladeboe, K., Lavi, I., King, K., Kawamura, J., Friedman, D., Compas, B., Breiger, D., Lengua, L., Gurtovenko, K., & Stettler, N. (2018). Trajectories of marital, parent-child, and sibling conflict during pediatric cancer treatment. Health Psychology, 37(8), 736–745.

Martire, L. M., & Helgeson, V. S. (2017). Close relationships and the management of chronic illness: Associations and interventions. American Psychologist, 72(6), 601–612.

Merluzzi, T. V., Philip, E. J., Heitzmann Ruhf, C. A., Liu, H., Yang, M., & Conley, C. C. (2018). Self-efficacy for coping with cancer: Revision of the Cancer Behavior Inventory (Version 3.0). Psychological Assessment, 30(4), 486–499.

QUESTION 17
What type of coping is related to greater avoidance and to higher symptoms of anxiety/depression in the adolescent? To select and enter your answer go to Test.

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