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Addressing psychosocial concerns

Addressing psychosocial concerns



Why might a child be referred to a psychosocial/mental health professional?


  • To support families - families may experience intense distress or conflicts as a result of the stress that treatment places on them, or it may highlight pre-existing communication problems.
  • Persistent and intense distress that interferes with the patient’s quality of life or ability to access medical care. This may be exhibited in withdrawal, throwing tantrums, difficulty eating and/or sleeping, or refusing to comply with recommended treatment.
  • Distress or pain related to treatments or procedures- in conjunction with the treating team’s hospital based professionals e.g. procedural pain clinician, play therapist etc.
  • Disease-related pain.
  • School refusal- when a patient refuses to attend school after being medically cleared and is physically capable of going to school.
  • Poor adherence to treatment and medical recommendations.
  • Patient’s safety - concerns about the patient’s safety because of statements or behaviours.
  • Mental Health Diagnosis- a patient has a known or suspected past history of mental health issues such as ADHD, anxiety or depression that may interfere or impact treatment and functioning.
  • Developmental disorder- a patient who has a known or suspected past history of a developmental or communication disorder such as Down Syndrome or Autism that interferes with their quality of life or ability to access medical care.

If a child/adolescent or young adult with cancer arrived for an appointment, how would you modify your assessment procedure?


A psychosocial assessment provides information about an individual’s current functioning, presenting problems, developmental history and assessment of risk. It is advised that a psychosocial assessment would incorporate a biopsychosocial framework, emphasising the impact of the biological state of the individual i.e. cancer on their psychological and social functioning.

Although it is important to carry out a thorough psychosocial assessment, it is equally important to honour the individual’s ‘cancer story’- when we think about a patient and/or family navigating in the traditional medical model, a mental health clinician may be the first person that a patient or family member has encountered that has the primary goal of listening rather than focusing on task completion.

The primary goal of a psychosocial assessment attempts to gather information regarding a young cancer patient and/or their family’s adaptation to the disease. This adaptation is an ongoing process of adjustment.

As a general rule, markers of successful psychological adaptation to cancer include:
1. Continued active involvement in daily life
2. Ability to minimise disruptions to life roles
3. Skill at regulating emotional distress.

These markers are influenced by cancer specific and other factors.

Cancer specific factors include:
  • Cancer type, site, stage and prognosis
  • Clinical course of cancer and treatment
  • Treatment with long term survival and cure
  • Cancer as a chronic illness with possible long-term disabilities.

Other factors include:
  • Disability
  • Functional impairments caused by cancer treatments, side effects and or the disease itself i.e. fatigue, anorexia, self image and pain
  • Neuropsychological deficits i.e. concentration / attention, speed of information processing, working memory and organisation.

Patient specific factors:
  • Past History i.e. previous mental health issues, family history, previous experience in medical/hospital environments
  • Demographics i.e. socio-economic factors
  • Developmental stage: As noted previously, an individual’s developmental stage must be taken into account when conducting a psychosocial assessment - being mindful of regression as an impact of hospitalisation. In addition, it is important to assess a parent or caregiver’s knowledge of their child’s developmental stage and how that may affect how they provide information, and address developmental needs
  • Coping styles i.e. assessment of age appropriate coping strategies. For example, is a young person who attends Day Oncology with their iPod permanently attached to their ears avoiding or is this a developmentally appropriate coping strategy?
  • Social support i.e. assessment of both quantity (how many) versus quality of support, what type - practical assistance, emotional support etc.

Social factors:
  • Culture: every individual has their own set of preconceived ideas about cancer, however a patient’s and/or family’s ethnic or cultural background can have a societal wide impact on how they respond to a cancer diagnosis and consequent cancer treatment.

Information about cultural competence is available on the below websites:

Remember, the main question to ask when making a clinical judgement in the assessment of a young cancer patient’s mental health:‘Is this behaviour completely out of character?’

Reference:
  • Nicholas, D.R. & Veach, T.A. (2000). The Psychosocial Assessment of the Adult Cancer Patient. Professional Psychology: Research and Practice, 31(2), 206-215.

Conceptualising Somatic Symptoms in an Assessment


A clinician must be wary of the assessment of somatic symptoms such as appetite and fatigue, as to do so without consideration can result in ‘false positives’ in a mental health diagnosis. A child or young person with a cancer diagnosis may experience significant changes in sleep, appetite, energy, weight and appearance as a result of their illness and/or treatment.

Comprehensive assessment of these somatic symptoms is not likely to be done solely by the psychologist, rather, the mental health professionals’ role is to determine to what extent any of these somatic symptoms may be influenced by co-morbid mental health disorders or due to increased distress. Therefore the best course of action when formulating, is to talk to the child/adolescent’s treating team in order to seek clarification on these issues.

Case study
Billie presents as a withdrawn and tired young person. He/she has recently lost a substantial amount of weight and reports little to no appetite. In addition, Billie reports a negative change in their self image. He/She reports that they haven’t seen their friends recently and although they report enjoying school have not been attending.

As we can see from the above case study, a number of ‘red flags’ of concern are evident for Billie:
  • Loss of Appetite & Weight Loss
  • Fatigue
  • Withdrawal from previously enjoyed activities.

These ‘red flags’ would appear to fit all the hallmarks for further exploration for a mental health diagnosis in a young person. However when a cancer diagnosis is factored in to the profile, the ‘concerns’ raised seem appropriate within the profile of the illness. For instance:
  • withdrawal from previously enjoyed activities/friends may be due to being unable to participate in a regular sports team due to fatigue
  • lack of appetite and weight loss may be a consequence of chemo treatment.

Of course, the effects of these symptoms may cause a high degree of ongoing distress for a patient and therefore require a mental health intervention; on the other hand, they may result in a period of short term distress that resolves naturally as a process of adjustment.

Assessing Post Traumatic Symptoms in Paediatric Oncology


As noted previously, the majority of patients and families who are impacted by a cancer diagnosis will adjust well over time. However there is a subset of individuals who will continue to experience distressing symptoms. A clinician should be mindful of assessing for symptoms for both a child and their parent/caregiver that may indicate post trauma symptoms. For more information please click here.
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