Family therapy reduces stress symptoms in adolescent survivors of childhood cancer

Family therapy and other psychological treatments may help reduce symptoms of post-traumatic stress among teenaged survivors of childhood cancer–as well as among their parents.

In studying a group of 150 families, researchers at The Children’s Hospital of Philadelphia found that participants had significantly fewer symptoms of post-traumatic stress after a one-day treatment program, compared to a control group who did not receive the treatment. Each family included an adolescent who had completed cancer treatment an average of five years previously.

The study, in the September 2004 issue of the Journal of Family Psychology, is the first reported large randomized clinical trial of treatment related to family adjustment to a serious pediatric illness. Half of the group, randomly chosen, received the treatment, which combined cognitive-behavioral therapy with family therapy. The other half of the group received the treatment after the study was completed.

“Because cancer is a life-threatening experience, it represents a traumatic stress that may leave aftereffects such as those found in survivors of war and natural disasters,” says Anne E. Kazak, Ph.D., director of Psychology at The Children’s Hospital of Philadelphia, and senior author of the study. Posttraumatic stress symptoms (PTSS) include intrusive, unwanted thoughts; avoidance of stress-inducing settings and situations; and heightened arousal, such as nausea or increased heart rate triggered by reminders of the original experience.

Researchers found the strongest effects of the treatment in the adolescent survivors, who had decreased arousal symptoms, and among the survivors’ fathers, who had fewer intrusive thoughts. “Fathers are often underrepresented in pediatric research samples, because so many studies occur in outpatient settings where mothers accompany their children,” remarked Dr. Kazak. Dr. Kazak’s previous studies found that fathers of childhood cancer survivors have PTSS at levels nearly as high as mothers. “Many of the fathers in this study said they had feared that expressing their upsetting memories would be detrimental to other family members,” Dr. Kazak added. “They found that sharing those reactions with their family was a powerful experience, and helped to reduce their sense of being isolated with those feelings.”

Surprisingly, mothers of survivors did not show a significant effect from the treatment. One complicating factor, said Dr. Kazak, is that families with higher PTSS levels were more likely to drop out of the study. A statistical analysis of their findings suggested that the treatment would have had stronger effects if the families with higher distress levels had completed the study. “Delving into distressing memories is difficult,” Dr. Kazak added. “Many families had reservations about opening this can of worms. However, families who did participate in the treatment benefited from it.” She added that future treatments might occur away from a hospital setting, because people with PTSS may avoid locations such as hospitals that are associated with the cancer experience.

For the treatment, the researchers used the Surviving Cancer Competently Intervention Program (SCCIP), established by Dr. Kazak and her team at Children’s Hospital. The four-session, one-day program uses a family group treatment model. Employing cognitive-behavioral principles, therapists encouraged group participants to identify bothersome memories about the child’s cancer and to express personal beliefs about the adverse experiences.

Therapists then taught the participants coping skills by encouraging them to reframe their thoughts to focus on controllable and positive consequences. “We might urge a survivor to say, for example, ’Cancer is still unfair, but what can I do about it now?”’ said Dr. Kazak,

In family discussion groups, the researchers offered take-home messages to assist family members in supporting each other through stressful episodes stemming from their shared experiences. “We help family members figure out how to talk about cancer as a family, and how to recognize when a family member is upset from the stress,” said Dr. Kazak. “For instance, parents may not always be aware how siblings of the cancer survivor may be affected.”

The study’s findings, that brief psychological interventions are effective in relieving traumatic stress symptoms in family members, may have a broader relevance beyond childhood cancer. “This approach may be applicable to other situations in treating the aftereffects of trauma associated with medical diagnosis and treatment,” said Dr. Kazak. “For instance, we have studied stress symptoms following automobile injuries. Accidental injuries, burns, and chronic conditions such as asthma or sickle cell disease may also involve painful or frightening treatments that engender traumatic stress.”

Co-authors with Dr. Kazak were Melissa A. Alderfer, Ph.D.; Randy Streisand, Ph.D.; Steven Simms, Ph.D.; Mary T. Rourke, Ph.D.; Paul Gallagher, M.A.; and Avital Cnaan, Ph.D.; of The Children’s Hospital of Philadelphia; and Lamia P. Barakat, Ph.D., of Drexel University. Drs. Kazak, Alderfer and Cnaan also are faculty members of the University of Pennsylvania. Funding support for the study came from the National Cancer Institute and the Abramson Cancer Center of the University of Pennsylvania.