Kazak AE, Alderfer MA, Streisand R, Simms S, Rourke MT, Barakat LP, Gallagher P, Cnaan A. (2004, Sep). Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial. Journal of Family Psychology, 183 , 493-504.
Designed to help adolescent cancer survivors and their families enhance their skills for coping with cancer, this one-day manualized intervention delivered in four group sessions combines cognitive-behavioral and family therapy approaches to reduce posttraumatic stress symptoms (e.g., intrusive memories, avoidance, hypervigilance). The study showed decreases in hyperarousal, intrusive thoughts, and state anxiety.
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The diagnosis and treatment of childhood cancer represents unquestionably a distressing period in the lives of pediatric patients. The experience is never forgotten and has lasting psychological implications for both the children who survive the cancer and their families. A cancer diagnosis represents a life threat, which is central to the concept of traumatic stress. In addition to the disease itself, the multiple invasive procedures required in the treatment of childhood cancer and complications from these procedures can pose lethal threats and may evoke feelings of helplessness and intense fear. Other potentially traumatic events often occur in the course of treatment, including deaths of other children known to the patient and family, admission to the intensive care unit, surgeries, and the threat of relapse or secondary cancers. Although rates of posttraumatic stress disorder (PTSD) for survivors and parents are modest, subclinical posttraumatic stress symptoms (PTSS) are common--particularly in the parents of survivors.
The Surviving Cancer Competently Intervention Program (SCCIP) is an intensive, one-day manualized intervention that combines cognitive-behavioral and family therapy approaches to reduce posttraumatic stress symptoms (e.g., intrusive memories, avoidance, hypervigilance) related to the cancer experience in adolescent cancer survivors and their families. SCCIP targets anxiety, beliefs about cancer and its treatment, social support, and family communication as areas of expected change. Fundamental to SCCIP is an appreciation of the long-term psychological effects of the cancer experience on the survivor as well as the entire family unit.
The intervention consists of four sequential sessions conducted with a group of six to eight families:
- Session 1: How Cancer Has Affected Me and My Family
- Session 2: Coping Skills
- Session 3: Getting On With Life: Cancer, Adolescents, and Families
- Session 4: Pulling It All Together: Family Health and Our Future
Sessions 1 and 2 take place in the morning and are conducted separately with adolescent survivors, mothers, fathers, and siblings in four different rooms. These sessions emphasize the use of cognitive-behavioral strategies to reduce distress and teach coping skills through age-appropriate role-play activities. Sessions 3 and 4 are conducted in the afternoon with all families in one room. Session 3 includes a series of four interfamily group conversations among mothers, fathers, survivors, and siblings that are observed and then discussed by the whole group. In Session 4, families are asked to identify what they have learned about the impact of cancer on individual family members and to consider how they will apply what they have learned as a family at home.
Training: Twelve hours of basic training and 8 hours of advanced training are required prior to serving as a SCCIP interventionist. The basic training consists of six 2-hour didactic and experiential training modules, delivered using a formalized training syllabus and corresponding PowerPoint slide sets, plus supplemental reading. Advanced training involves role-play and supervised practice delivering the intervention to assure treatment fidelity. The developer will work with implementers on a case-by-case basis to determine procedures for the advanced and ongoing training. Ongoing training and supervision can be provided by the developer via telephone or videophone.
Program Implementation: The implementation of SCCIP requires three trained interventionists (four if siblings are included). It is important that the lead interventionist be an experienced mental health professional familiar with cognitive behavioral and family therapy approaches and the sequelae associated with childhood cancer survival. All interventionists should be comfortable with working with groups and have basic knowledge of cognitive behavioral therapy.
SCCIP is delivered on 1 weekend day. The duration of each intervention component is as follows:
- Introductions - 20 minutes
- Session 1 - 60 minutes
- Session 2 - 90 minutes
- Session 3 - 90 minutes
- Session 4 - 60 minutes
SCCIP targets childhood cancer survivors and their immediate families (parents and siblings). Survivors are between the ages of 11 and 18 and have completed cancer treatment within the past 10 years with no subsequent relapse or second cancers. In complex family structures, discussion may be required to determine which family members should attend treatment. In all cases, the participation of the adolescent survivor is required.
The intervention is suitable for implementation in hospital-based and outpatient oncology clinics. It also may be carried out in other community-based health facility centers.
The SCCIP program includes the following materials:
- The Surviving Cancer Competently Intervention Program (SCCIP) Manual
- SCCIP Training Manual
- SCCIP Training Module
- Three sets of cards (31 per set) from the Impact of Traumatic Stressors Interview Schedule (ITSIS), one set for each group (adolescent survivors, siblings, and parents)
For information on cost, please contact the developer.
About the Study
A randomized clinical study investigated the effects of the Surviving Cancer Competently Intervention Program on posttraumatic stress symptoms in teenaged cancer survivors and their siblings and parents. One hundred and fifty families were randomly assigned to either the SCCIP intervention or a wait-list control condition. The survivors were 51% female, 85% White, 9% African American, 5% Hispanic, and 1% Asian; ranged in age from 10.8 to 19.3 years; and had completed cancer treatment 1.1 to 12.2 years prior to study enrollment. Age ranges of family members were 26.9 to 59.4 years for mothers, 21.3 to 58.4 years for fathers, and 10.4 to 20.6 years for siblings. Survivors' cancers included leukemias (25%), solid tumors (22%), lymphoma (21%), bone tumors (8%), and other (24%). Survivors were between 2.8 months and 16.4 years of age at the time of initial diagnosis.
Four self-report interview scales were used to measure changes in PTSS and state anxiety:
- Impact of Events Scale - Revised (IES-R), a 22-item measurement tool that generates subscales on intrusive thoughts, avoidance, and hyperarousal symptom frequency in the prior week
- Post-Traumatic Stress Disorder Reaction Index (PTSD-RI), a 20-item interview that reflects diagnostic criteria for PTSD
- State-Trait Anxiety Inventory (STAI), a 40-item tool that measures the level of current and dispositional anxiety in adults
- Revised Children's Manifest Anxiety Scale (RCMAS), a 37-item instrument that measures the state anxiety in children and adolescents
The instruments were administered to SCCIP-assigned families at baseline (4 to 6 months before the intervention) and posttreatment (within 11 months after baseline). Wait-list control families had their second assessment within 10 months after the baseline assessment. SCCIP intervention participants did not differ from wait-list control participants at baseline in any demographic characteristics, PTSS, or state anxiety symptoms.
- Adolescent survivors assigned to the intervention reported less hyperarousal at followup than adolescent survivors assigned to the wait-list control condition (p=.01; see Figure 1). Hyperarousal is a specific PTSS cluster that reflects a high level of arousal/anxiety characterized by difficulty falling/staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and a heightened startle response.
- Fathers assigned to the intervention reported fewer intrusive thoughts at followup than fathers assigned to the wait-list control condition (p<.01; see Figure 2).
- Fathers assigned to the intervention reported less hyperarousal at followup than fathers assigned to the wait-list control condition (p=.05; see Figure 3).
- Fathers assigned to the intervention reported less state anxiety at followup than fathers assigned to the wait-list control condition (p=.05; see Figure 4).
- Neither mothers nor siblings assigned to the intervention had pre/post changes in PTSS or state anxiety symptoms that differed significantly from pre/post changes among mothers and siblings assigned to the wait-list control condition.
Kazak, A.E., Simms, S., Barakat, L., Hobbie, W., Foley, B., Golomb, B., & Best, M. (1999). Surviving Cancer Competently Intervention Program (SCCIP): A cognitive-behavioral and family therapy intervention for adolescent survivors of childhood cancer and their families. Fam Process, 38, 176-191.
Alderfer, M.A., Cnaan, A., Annunziato, R.A., & Kazak, A.E. (2005). Patterns of posttraumatic stress symptoms in parents of childhood cancer survivors. J Fam Psychol, 19(3), 430-440.
Steinberg, A.M., Brymer, M.J., Decker, K.B., & Pynoos, R.S. (2004). The University of California at Los Angeles post-traumatic stress disorder reaction index. Curr.Psychiatry Rep., 6, 96-100.
Sundin, E.C., & Horowitz, M.J. (2002). Impact of event scale: Psychometric properties. British Journal of Psychiatry, 180, 205-209.