Depression is characterized by a set of symptoms such as sadness, irritability, loss of interest, fatigue, feelings of ineptitude and guilt, insomnia, suicidal thoughts, loss of appetite, weight loss, and difficulty concentrating, etc. When a patient is diagnosed with any form of cancer, it may suffer depression among other behavioral disorders. Therefore, this research was conducted in order to know the depressive symptoms that cancer patients present at the Children´s Hospital (Spanish: Hospital del Niño DIF) and strategies used by parents to notice these changes in their children. The Zung Depression Scale was used as the measuring instrument to determine children's depressive symptoms and a parent questionnaire to know the strategies used to observe these emotional changes. A total of 24 patients diagnosed with cancer were included. It was found that 6 children had mild depression and 18 children with a normal range of depression. The main coping strategies of parents were distraction, reinforcement, detachment, avoidance, social support and activities. We observed a relatively low prevalence of mild depression in these patients and the strategies used were very heterogeneous.
Keywords: Childhood Depression, Coping Strategies, Cancer.
It is a fact that boys and girls can present depression. Statistics reveal that between 3% and 5 % of child population has developed any degree of depression, reflected in a set of symptoms and because of its quantity, intensity and length, affects the normal development of children.1 Currently, we find children who suffer under covered mental disorders, some of them are the ones called child symptoms of depression with different degrees of severity.2 In a research about the identification of symptoms used to predict the success of an anti-depressive treatment, the 6 symptoms that met the requirements were the following: sadness, unexcused asthenia (without an organic cause or being attributed to normal tiredness) irritability, indecision, low self-esteem and feelings of incapacity and failure.3 The causes of depression in children may be varied, as for example, loss of a beloved one, a parent divorce, a diagnosis of a serious or an incurable disease such as cancer, among others.1-5
The incidence of cancer in infants younger than 15 years is around 7,800 new cases yearly, looking at a sustained increase of 0.7% each year. In Mexico, the incidence of cancer in patients younger than 15 years is around 122 cases/million/year.6 In a pediatric patient with diagnosis of cancer, an emotional change is developed, mainly when it is heard about the disease and the constant hospital consultations due to the fact that this situation impedes him to continue with his previous lifestyle. These changes provoke to the patient fear of being abandoned by his guardian, anxiety, depression, insomnia, detachment; however, this not only affects patients, also family and friends around them, such as parents and siblings. In this way, parents are in a state of shock when they receive the oncology diagnosis presenting fear, insecurity, feelings of guilt, anger, fury, excess of protection, denial of the diagnosis, fear of a death and even problems in the relationship with the couple.4, 7, 8 These behavioral changes provoke that parents react in a distinct way, facing the problematic situation to obtain control of emotions and not allowing impulses to rule themselves. It is distinguished as coping mechanisms, isolation, denial, motor activity, search of help, reinforcement, difficulty concentrating and anticipatory duel.4, 7, 8 When parents hear the diagnosis of their children’s disease, they can experience anger, pain or denial; then, depressive traits appear and eventually the acceptance of diagnosis of cancer. Parents can feel guilty and powerless because of the incapacity to protect their children from cancer. The coping mechanisms used by the parents, those focused on the problem are emphasized; to illustrate, the search of information or try to organize themselves to perceive few of control in the situation.4, 7-9 Coping mechanisms commonly used are: isolation of affection, excessive interest of the medical techniques and denial, which is translated as a more optimistic estimation that provokes parents to wait for a favorable evolution. Thus, this research was developed in order to know the depressive symptoms that cancer patients present within the Children’s Hospital (Spanish: Hospital del Niño DIF) and the strategies used by parents to notice these changes in their children.
A non-experimental, transversal, prospective, descriptive study was carried out; it was made in the department of Psycho-oncology of the Children’s Hospital (Spanish: Hospital del Niño DIF). The protocol of the study was evaluated and accepted by the Research and Ethics Committees of the Children’s Hospital (Spanish: Comisiones de Investigación y de Ética del Hospital del Niño DIF). Moreover, the study was carried out in accordance with the Regulation of the General Health Law on Health Research and the Declaration of Helsinki (Spanish: Reglamento de la Ley General de Salud en Materia de Investigación para la Salud y la Declaración de Helsinki). The informed consent of the parents of the patients with cancer diagnosis was also obtained. This study involved patients from 6 to 16 years old diagnosed with cancer under medical treatment, including the patients with precedents of abandoning the treatment, relapsing the disease or in palliative treatment. The inventory of Depression of Zung (Bank of Basic Instruments to the Practice of Clinical Psychiatry in the University of Oviedo)10 was applied to know the depressive symptoms that these patients presented. According to this test, patients with results from 25 to 49 points are considered as normal or without depression, from 60 to 69 points are considered as patients with moderate depression, and from 70 to more points as severely depressed. A questionnaire previously validated was used to evaluate the strategies that parents used as a support when these emotional changes are presented in their patients. This method was applied before starting the round of chemotherapy in order to not affect as an external variable and modify the results. The results were analyzed using Excel and it was obtained key trends and dispersion measurements, frequencies and percentages.
On this research, 24 cancer patients participated. The average age of the total of the patients was around 10.0 ± 3.3 years, from which 15 (62.5%) patients were female and 9 (37.5%) were male. The average age of women was about 9.1 ± 3.1 and the average age of men was about 11.4 ± 3.1.
Once the test was applied in order to identify the degree of depression in patients, it was found that from the 24 patients, just 6 of them (25%) presented symptoms of a mild depression (scores equal or higher than 50) and 18 patients (75%) had a score in the normal range (scores lower than 50) it means that they did not present child depression. Of the 18 patients without depression, the average age of the 18 participants was about 10.2 ± 3.2, 10 (55.6%) were female patients about 9.0 ± 2.7 years and 8 (44.4%) were male patients about 11.8 ± 3.2 years. On the other hand, from the 6 patients with depression, the average age of the 6 participants was about 9.3 ± 3.8, 5 (83.3%) were female patients about 9.4 ± 4.2 years and 1 (16.7%) male patient who is 9 years old.
Regarding the evaluation of the coping strategies of the children's parents with cancer, 54 cases were obtained, divided into 6 types of predominant strategies used by parents when they notice emotional changes on their children, these are: 1. Distancing, 5% (3 cases); 2. Avoidance, 21% (10 cases); 5. Difficulty concentrating, 24% (12 cases); and 6. Reinforcement, 6% (4 cases). The styles of confrontation and self-control were not presented in any case. From the six cancer patients who presented symptoms compatible with a mild depression, the strategies that parents use frequently when these symptoms are presented are: activities (3 options), social support (3 options), avoidance (3 options), distraction (1 option), reinforcement (1 option) and distancing (1 option) as it is being illustrated in figure 3. In patients that did not present depression, the strategies observed in their parents were, social support with 13 options, distraction with 10 options, activities with 7 options, avoidance with 6 options, reinforcement with 3 options and finally distancing with 2 options.
In general, it is estimated that percentages of child depression detected in the general population could be around 8% and 10 % (Del Barrio V., 2000).11 In the case of children with cancer, it is found a prevalence from zero up to 31%.4, 5 In our case, it could be mentioned that the frequency of mild depression in cancer patients was relatively low. Some of the main causes of depression in people with cancer are: the risk factors related directly with the disease, such as, depression during diagnosis time, poor control of pain, progress in cancer stage, stress in life, increase of physical changes, a type of cancer as well as the treatment with specific chemotherapeutic agents. There are also risk factors that are not related directly with the disease: personal background of depression, loss of family support, family background of depression or suicide, background of alcoholism or drug abuse, previous psychological problems and psychotherapeutic treatment, among others.12 However, there are also many myths about cancer and how people face it. One of the main ones is that people with cancer are always depressed, it is considered that depression is normal in people who suffer cancer, or that treatments are useless due to the fact that each one of them will have a constant suffering and a painful death. It is thought that sadness and guilt are specific feelings of people with cancer. Certainly all the people will experiment these reactions in one or some stages of the disease, but it does not have be constant, thus it is important to be capable to make a distinction between normal degrees of sadness and depression disorders.12
The coping strategies that parents offer to the pediatric cancer patient vary according to the style of the family when confronting the cancer diagnosis, the social support that parents offer to their patients is the normal manner to look after their needs when presenting depressive symptoms; the strategy of distraction worked to improve the mood; however, other alternative that stood out in the results was avoidance, this means not to confront them when their mood is declined since, instead of helping them, it harms them regarding the perspective of their parents. Considering the above, the strategies of social support, avoidance and distraction are positive to manage the intervention of the adaptation of the diagnosis of cancer patients and to the cognitive restructuring about this to begin the mobilization of social resources necessary to the attachment of the treatment and the recovery. In order to support parents of oncologic patients, it has being resorted to use coping techniques as an alternative, with the purpose of decreasing depressive symptoms in their patients and reach a better adaptation in their treatments.
It could be observed a relatively low prevalence of mild depression on these patients and the strategies used were quite heterogeneous.
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Hospital del Niño DIF, Hidalgo. Pachuca, Hidalgo. México.