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Theme 1: adolescents’ emotions and behaviors
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 . When children were told that their parent was not going to die generally, they felt relieved .
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 . Adolescent female’s fears were associated with physical/sexual development  and  adolescent females reported significantly less frequent sexual intercourse and lower sexual satisfaction. Nelson et al.  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 . Fear of recurrence and loss of the parent may be expressed through somatic symptoms . However, according to Davey et al. , adolescents tried to maintain positive thoughts or attitudes, talked about the cancer, and relied on faith to alleviate fear and sadness.
Heiney et al.  reported that adolescents showed significantly higher state and trait anxiety compared to an age-normed sample. Lewis and Darby  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.  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 . According to Welch et al. , 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 .
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.’ (, p. 299). According to Lewis and Darby  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 . 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 . Watson  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’  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,  and  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
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 . 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 . They appreciated health care providers giving them information and providing them with local sources of support in a way that they understood . In addition to written information, they would have also valued the health care providers recommending a website on parental cancer . 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 . Huizinga et al.  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 . 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. , 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 .
Theme 3: adolescents’ changes in roles
Theme 4: adolescents’ ways of coping
Adolescents used problem-focused coping as they asked questions, read about the illness, and assumed responsibility for household chores or sibling care . 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) .
According to Compas et al. , 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 . 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 .
Some wished that their parent would die because they wanted their life to return to normal, and felt guilty for the thought . They appreciated health care professionals informing them that feelings such as anger and guilt were normal .
Few intervention studies have focused on adolescents who have a parent with cancer [30,31,34]. The psychoeducational group intervention ‘Kids Can Cope’  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.  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 , 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.  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 . The eight studies that included only the adolescent, defined as a person between the ages of 10–20 years .
Reflection Exercise #10
Online Continuing Education QUESTION 17
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