Kids who get stem cell transplants are resilient, study shows. For some time now, doctors have widely assumed that children undergoing stem cell transplantation (SCT) are at risk for increased distress, adjustment difficulties and impaired health-related quality of life.
But a new study seems to disprove this. Published online Feb. 6 in the journal Pediatrics, the study showed that, six months after undergoing SCT, children were able to recover emotionally and bore no signs of depression or posttraumatic stress disorder.
The findings are from a randomized, multisite trial on 171 child patients who had undergone SCT at four pediatric SCT centers in the United States and Canada. The trial was conducted by Dr. Sean Phipps from the Department of Psychology of St. Jude Children’s Research Hospital in Memphis, Tennessee, and his colleagues.
Wanting to find out if children had better long-term adjustments after SCT when they were given additional therapies, or when their parents were also given therapy, the researchers grouped the children and their parents randomly into three sets:
• One group received child-targeted intervention that included humor therapy and massage therapy on top of to standard care
• The second group received child and parent intervention, with the child receiving humor and massage therapy and one of the parents receiving massage and relaxation/imagery therapy.
• The last group, which did not receive additional therapies on top of standard care, served as the control.
Six months or 24 weeks after SCT, the researchers measured symptoms of depression and posttraumatic stress, health-related quality of life, as well as the overall benefit received from the therapies.
What they found out was stunning and contradicted prior research: there was no statistical significance between the groups. Children in all groups “improved to normal or better than average levels of adjustment and HRQL” — meaning six months after stem cell transplant, the child patients were at least as happy as healthy children were.
Writing in the journal Pediatrics, the researchers say, “Such excellent adjustment has been reported previously in general pediatric oncology populations, but children undergoing SCT were thought to be a subgroup at higher risk of adjustment difficulties.”
“Given that the normative response to SCT is recovery after a brief disruption, it appears that a resilience model, rather than a posttraumatic stress model, is a better fit for conceptualizing child response to SCT,” the authors conclude.
But they say further study is needed. They concede, “The observed pattern of good adjustment and low distress during SCT is counterintuitive and contradictory to prior research, warranting further investigation about the factors that may contribute to these findings.”
The study, which was funded by the National Institutes of Health and the American Lebanese Syrian Associated Charities, had a few limitations, including a high rate of attrition and a wide age range of participants.
How they did the study
Of a sample of 163 patients at baseline, 25 patients had died, 11 withdrew from the study, eight were removed from the study for medical reasons including relapse or second transplant, and 22 missed the assessment at week 24. In the study’s end at week 24, only 97 children remained in the study.
As soon as the children were admitted for stem cell transplantation, the children and their parents were asked to complete questionnaires about the child’s physical health, health-related quality of life and emotional wellbeing. The patients and their parents were then randomly assigned to one of the three groups, stratified by age group, site, and type of transplantation.
The standard-care group received typical supportive care that involved aggressive drug treatment of symptoms and psychosocial support by a multidisciplinary team.
On top of standard care, children grouped into the “child-only intervention set” were given a 30-minute massage by a licensed massage therapist three times per week, for three weeks. Humor therapy was also given to children in this group, and a research assistant therapist was allowed to visit them regularly, once a week.
Children in the “child-and-parent intervention group” were given standard care, plus massage and humor therapy. In addition, their parents were also given the same massage treatment the child received, as well as a relaxation intervention with guided imagery. Researchers provided parents with a relaxation CD and were directed to use it every day. They also received weekly refresher sessions with the RA therapist.
Depression in the child patients was measured using the Children’s Depression Inventory (CDI). At admission, 5.3 percent of participants had CDI scores in the clinical range, which dropped to 4.7 percent at the end of the study. In normal children, 9.6 percent of children have scores in the clinical range.
On admission, the children showed signs of posttraumatic stress syndrome that were found to be greater than historic reports by healthy children. But by week 24, there were no longer significant differences between study participants and healthy children.
The children in all groups showed significantly reduced depression and posttraumatic stress syndrome by the end of the study, six months after admission—but there were no significant differences seen among groups.
In all three groups, children’s health—as measured by the subscales of the Children’s Health Questionnaire—improved. Again, no differences were found between intervention groups.
One interesting, unexplained and beneficial offshoot of the treatment, however, was that all child patients seemed to have better esteem, behavior and mental health after six months of therapy—better than healthy children who hadn’t undergone stem cell transplants, in fact.
When asked upon admission to fill out the Children’s Health Questionnaire, the children who underwent stem cell transplantation reported lower “physical functioning” scores and “general health” scores than healthy children—but their mental health, self-esteem and bodily pain scores were not any lower than healthy children.
After six months of therapy, they reported self-esteem, behavior, mental health and bodily pain scores that were significantly better than normal values for healthy children.
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