الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
In childhood, mental health means reaching developmental, emotional milestones, and learning healthy social skills and how to cope when there are problems. A cancer diagnosis is distressing at any age, but especially so when the patient is a child. The term “childhood cancer” is most commonly used to entitle cancers that arise in children before the age of 15 years.
Each year more than 215,000 children are diagnosed with the disease in the world. Of this total, 80% of children with cancer live in the developing countries, thus collectively childhood cancers represent an important global public health problem.According to Children’s Cancer Hospital, 8,500 children are expected to be diagnosed with cancer in Egypt every year.
More than 80 % of children with cancer survive the disease every year. The period of the disease and its treatment is physically and emotionally stressful not only for the children but also for their families, who have to adjust to hospital environment with physical and psychosocial challenges.
Psychosocial effects can be expressed as increased levels of depression, anxiety, and concerns about mortality. Comorbidity of cancer and depression magnifies the symptom burden and mortality, as one disease complicates the management of the other.
In Egypt, diagnosis and treatment of childhood cancer are the main focus not only for the medical staff but also for the family, with little or no attention to the emotional problems (i.e. depression and anxiety) that are considered as an inseparable part of the disease and its treatment. Nowadays, researches are conducted to bridge the missing gap concerning childhood cancer and emotional problems.
The aim of the present study was to estimate the prevalence of emotional problems (depression and anxiety) and to identify some determinants of the emotional problems (depression and anxiety) among children with cancer.
To fulfill this aim, a cross-sectional study design was carried out at the outpatient pediatric oncology clinic of the Clinical Oncology department in Alexandria Main University Hospital, which is a referral hospital serving Alexandria and the nearby governorates (i.e. Biehera and Matrouh). The target population included children diagnosed with cancer aged 8-15 years old and treated for up to 2 years period.
Based on a prevalence rate of depression in pediatric oncology of 35%,the minimal required sample size was 178 children using 7% accepted degree of precision, 95% confidence limits and power 80. The sample size was calculated using Epi-Info computer package version 7. The total sample size in the present study was 180 children.
The sample was chosen consequently from the outpatient pediatric oncology clinic in Alexandria Main University Hospital. The researcher visited the clinic 3 days per week until the required sample size was completed.
For the execution of this work, the children were subjected to the following technique and tools to collect data from the sampled children:
I. A pre-designed structured interviewing questionnaire was used to collect the following data from the children with cancer with the help of their parents:
1.Socio-demographic data:
a) Personal data: age, sex, residence, level of education, birth order, work, hobbies, age at puberty, smoking.
b)Socio-economic data: parent’s education and occupation, family size, number of rooms in the house, family income.
These data were used to calculate the socioeconomic score. The socioeconomic score was categorized with some modification after Fahmy et al.:
•Very low socioeconomic score (<16)
•Low socioeconomic score (16-<21)
•Moderate socioeconomic score (21-<26)
•High socioeconomic score (26-31)
2.Scholastic history including:
•Type of school
•School attendance/month
•Causes of absenteeism
•Scholastic achievement
•History and causes of failure at school
3.Relation between the child and his parents, siblings, peers and teachers.
4.Types and appropriateness of parental punishment.
5.Clinical profile of the child: type of cancer, age of onset of cancer, who discovered the cancer, type of treatment, and number of hospital admissions during the past year.
6.Medical history of chronic illness of the child (e.g. cardiac diseases, diabetes mellitus) and congenital anomalies.
7.Psychiatric history including previous diagnosis of psychiatric disorder/sin the children.
8. Exposure of the child to mental stressors during the past 6 months, its type and effects.
9. Family history of previously diagnosed psychiatric disorder (e.g. depression, anxiety) or chronic medical condition (e.g. cancer, cardiac diseases, diabetes mellitus)
II. The Arabic version of the Children’s Depression Inventory (CDI):
CDI was used to assess depression among the selected children. It consists of 27 questions which describe the emotions and thoughts of the children in the previous 2 weeks prior to test. The CDI cutoff score is 25 i.e. <25 non-depressed, 25 or more is depressed.
III. The Arabic version of the Children’s Manifest Anxiety (CMA):
CMA was used to assess symptoms of anxiety among children. It consists of 53 statements and measures six aspects of anxiety (i.e. somatic, physiological, motor, emotional, mental, and social features). The CMA cutoff score is:
•<18………. Mild anxiety
•19-28 ……. Moderate anxiety
•≥29 …… …Severe anxiety
The results of the present study revealed the following:
•The present study was carried out among 180 children diagnosed with cancer attending the outpatient pediatric oncology clinic of the Clinical Oncology department in Alexandria Main University Hospital. Males were more represented than females (55.6% and 44.4% respectively).
•The age of the children enrolled in the study, ranged from 8-15 years with a mean age of 11.37±2.77 years.
•As regards children education, it was found that the majority of the studied sample were educated, 66.3% attending primary school and 33.7% attending preparatory school. Only 6% of the studied sample never attended school (9 females and 2 males).
•Most of the studied sample (62.2%) was belonging to very low socio-economic level.
•Most of the studied sample (71.7%) was accompanied by their mothers during the interview.
•The majority of the studied sample (94.1%) were at governmental schools, while only 5.9% were in private schools. Nearly one third (34.9%) of the children were absent for more than 7 days per month, this was because of treatment (53.6%), or medical condition (32.1%) or both (14.3%). Nearly half of the studied sample (49.7%) had good grades at the school.
•As for children relationships, good relationships with parents, siblings, teachers and colleagues were in the range of 40.2%-42.3%. However, 67.8% of the studied sample were punished from their parents and 82% of the punished children accepted the punishment.
•Regarding the cancer characteristics, age of onset of cancer in the studied sample ranged between 6-14.9 years, with a mean age of 9.3 ± 2.9 years. Leukemia was the most common type of cancer (31.1%) in the studied sample followed by brain and spinal cord tumors and lymphoma representing 20.6% and 16.7% respectively. Almost all children were treated by chemotherapy (97.2%).
•The majority of the studied sample didn’t experience any psychological problems before or chronic illness (93.9% and 92.8% respectively).
•Almost all (99.4%) of the families of the studied sample reported no psychological problems, while family history of cancer was present among 21.1% of the studied sample. Grandparents and uncles/aunts are most commonly affected by cancer representing 42.1% each. Breast cancer and gastrointestinal (GIT) tumors were the most common types in the families representing 21.1% each.
• The prevalence of depression among the studied sample was 63.9%, severe anxiety was 83.9%, and moderate anxiety was 16.1%, while there were no mild anxiety cases. Prevalence of comorbidity between depression and severe anxiety was 62.8% of the studied sample.
•Depression was observed more among the older age group 12-15 years of age (71.8%) and this result was statistically significant (p=0.037). On the other hand, severe anxiety was more observed among the younger age group 8- <12 years of age (89.5%) and also the result was statistically significant (p=0.031).
•Regarding sex difference, depression and severe anxiety were slightly more prevalent among males but with no statistically significant difference (p=0.510 and p=0.964 respectively).
•Severe anxiety was more in children from urban areas (91.3%) than those from rural areas (76.1%). The result was statistically significant (p=0.006).
•Concerning the socioeconomic level, 69.6% of the children with very low socioeconomic level compared to 20% of the children in the high socioeconomic group suffered from depression. This result was statistically significant (p=0.030).
•Depression and severe anxiety were more prevalent among children who didn’t have any hobbies with statistically significant difference (p=0.004 and p=0.007 respectively).
•A significantly higher proportion of children attending governmental schools compared with those attending private school had depression (p=0.043). Also, children having fair and poor grades (failed at school) significantly suffered from depression (p=0.046).
•Concerning children relationships, depression and severe anxiety were significantly more prevalent among children with bad relationship with their parents, siblings, teachers and their colleagues (p<0.001).
• Although depression was more prevalent among children who had brain and spinal cord tumors, but this was not statistically significant (p=0.181).
• There was no significant association between depression and different types of cancer treatment.
• According to binary logistic regression analysis of significant variables affecting depression, the possible variable proved to be significant were: having fair grades at school (OR=3.034) and not being punished by parents (OR=0.405).
• According to binary logistic regression analysis of significant variables affecting anxiety, the possible variable proved to be significant were: age 8-˂12 years old (OR=0.285), urban residence (OR=3.314) and not having hobbies (OR=11.248).
Based on the results of the present study, the following items are recommended:
I.Recommendations concerning health professionals:
•Adopt multidisciplinary team for treating children with cancer all through the management plan. This team should include a pediatrician, mental health specialist, oncologist, a nutritionist, and a specialized nurse.
•Early detection of emotional problems (depression and anxiety) among children suffering from cancer by using routine screening for depression and anxiety.
•Regular follow up for emotional problems of children with cancer after discharge from hospital or after cure.
•Specialized training courses for health professionals to understand children’s psychological status during hospitalization and help nurses to plan individualized psychological care for children.
II.Recommendations concerning children with cancer and their families:
•Awareness sessions for children and their families before starting treatment, about nature of the disease, treatment and its side effects, possible complications and prognosis.
•group therapy for children with cancer with cancer survivor children, to share emotional trauma and exchange experience of beating cancer.
•Encouraging parents of children with cancer to attend group therapy with each other and with parents of cancer survivor children, to share and exchange day to day problems of child care.
•Tailor health education programs directed to families (parents and siblings) about role of the family towards the child during his treatment journey, awareness about nature of cancer, effect of psychological well-being on treatment, and importance of family support.
•Educating parents different rearing styles and the proper types of punishment.
III.Recommendations concerning school:
•Enforcement of the role of the school doctor, which is periodic check-up for the students, screening and early detection of signs and symptoms, and referral to higher level of service.
•Teacher directed programs to detect and refer children with emotional problems.
•Health education programs forschool students to increase awareness about emotional problems.
• There is a need for intervention programs suggesting the optimal path for the reintegration of children with cancer into the education system and into the society of their peers, and also about the importance of school supportive environment for a child with cancer.
IV.Recommendations concerning community:
•Raise community awareness about psychological problems not only in healthy children but also in children with cancer.
•Enforcement and implementation of laws concerning child education and child labor especially in very low socioeconomic level.
•Raise community awareness concerning the importance of reading and physical activity for both sexes.