Introduction
Breast cancer (BC) is the most common type of cancer
in women. In 2018, approximately 266,120 new BC
cases and 40,920 BC deaths were expected to occur in women, and female BC represents 15.3% of all new
cancer cases in the United States.[,] In addition, the
proportion of women who were diagnosed with BC before
the age of 40 years has increased, corresponding
to 6.6% of the total number of cases diagnosed with BC.[] An increase in the number of individuals diagnosed
with cancer and the prolongation of patient survival
in parallel with improvements in diagnostic and
treatment modalities lead to more active participation
of family members of patients with cancer in the care
process and/or getting greater responsibility for the
care of patients.[-] Having a life-threatening illness
may lead to the development of emotional problems
in parents or decrease their coping skills by increasing
stress that may decrease attention to their children.[-] It is reported that both maternal depression and
impaired parenting skills had negative effects on family
and child functioning in families affected by cancer.
Limited communication and scarcity of sharing in the
family also negatively affect functionality.[-]
A BC diagnosis not only affects the patient but also
causes a crisis in the family system, causing changes in
family dynamics, roles, rules, and routines. A particular
challenge for BC-diagnosed mothers <40 years is
that their children are younger and more dependent on
the mother.[,-] Previous studies have reported
higher rates of psychological distress, such as anxiety
and depression, in patients with cancer with <18-yearold
children and in their spouses.[]
Encountering with parental cancer is very traumatizing
for children, and many psychiatric disturbances,
such as anxiety; depression; social withdrawal; emotional
and behavioral problems; somatic complaints;
and sad, angry, and aggressive behaviors, can be seen
in children during this period depending on their age
and gender.[-] In addition, silencing, trying to
get away from cancer, controlling the movements of
the sick parent, and increased number of complaints
with siblings and friends are seen in school-age children.[] Parents" despair, depression, and situations
in which the prognosis of the disease worsens are
much more difficult for young people and school-age
children.[] However, there are mixed results in previous
studies that compare children and adolescents
who have a parent with cancer and control groups or
national norms.[,,] Latency-age children were
shown to have emotional and behavioral similarities
with other children.[,] However, some previous
studies showed that adolescent-age children of patients
with cancer had more emotional problems than other
adolescents.[,,] Other previous studies reported
that these children and adolescents had functionality
similar to or better than other children.[,,]
It has been reported that children and adolescents
of parents with cancer have psychological problems as
well as alterations in their roles in the family, increased responsibilities, a decrease in social activities, and a
loss of childhood as peer groups are needed for social
development.[,,]
Despite many studies have investigated the psychosocial
aspects of cancer on patients with BC and
their primary caregivers, data obtained for children
and adolescents <18 years are not sufficient and have
mixed results.[,-] Especially in Turkey, there
is a need for studies evaluating school-age children
and adolescents. The aim of the present study was to
determine the emotional and behavioral problems
among school-age children of mothers with BC and
the difficulties they experienced during the mothers"
illness.
Methods
This was a cross-sectional case-control study. Children
of patients with BC with an Eastern Cooperative
Oncology Group performance status of 0-2, who had
a child aged 6-17 years, and who applied to receive
adjuvant radiotherapy from Kahramanmaras Sutcu
Imam University, Medical Faculty Hospital, Radiation
Oncology Department were included. A total of
80 individuals (40 in the study group and 40 in the
control group) were included in the study. For the
study, patients with BC who were being treated in the
radiation oncology department were called by phone,
information about the study was provided, and questionnaire
forms were given to the families who accepted
to participate in the study to be filled out by
the patient, the healthy parent, or their children at the
childhood or adolescent age. Children with a known
intellectual disability; autism spectrum disorder; substance
abuse; psychosis and bipolar affective disorder;
any neurological, genetic, metabolic, or endocrine
disease; parents who are illiterate; and subjects who
filled out questionnaire forms incompletely were excluded
from the study. The study group filled out a
sociodemographic data form that was prepared by the
researchers and evaluated demographic data, mother"s
disease, and psychosocial problems that can be seen
in children, and their parents filled out the Strengths
and Difficulties Questionnaire (SDQ), Parent Form to
determine the emotional and behavioral problems in
children. The control group consisted of 40 age- and
gender-matched healthy children who did not have
any chronic, neurological, genetic, metabolic, endocrine,
and psychiatric diseases or substance abuse
and who had healthy parents. The control group was
informed about the study and asked to fill in the scales used for the study. However, in the sociodemographic
data form that was given to the control group,
there were only questions with regard to demographic
information, and there were no questions about the
parents" sickness. The study was approved by the
scientific research ethics committee of Sutcu Imam
University, Medical Faculty, Kahramanmaras, Turkey.
Written consent was obtained from all subjects who
participated in the study.
Measurements
Sociodemographic Data Form
The sociodemographic data form was prepared by the
researchers and included questions about age, gender,
educational status, age of parents, role change within
the family during the disease process, responsibilities,
difficulties they experience, fear of getting ill, knowledge
about the mother"s disease, reaction to the disease,
and thoughts about the seriousness of the disease.
SDQ, Parent Form
The SDQ was developed by Robert Goodman in 1997.
The purpose of the SDQ is to investigate mental problems
in children and young people. The SDQ includes
25 questions that investigate behavioral characteristics,
some of which are positive and some are negative.
These questions are subdivided into five subscales:
"conduct problems," "attention deficit and hyperactivity,"
"emotional problems," "peer problems," and
"prosocial behaviors." Each title is assessed within itself,
and the sum of the first four subscales gives the
total difficulty score. Although both the SDQ and the
Child Behavior Checklist (CBCL) were developed for
similar purposes, they have significant differences. The
most important difference is their length. The second
important difference is that because it has appropriate
items that question the diagnostic criteria of the Diagnostic
and Statistical Manual of Mental Disorders,
4th Edition, especially for attention deficit and hyperactivity
disorder, the SDQ can scan the problems in
this area more meaningfully. Another difference is
that in contrast to the CBCL, some items of the SDQ
aim to question the positive areas and therefore allow
the assessment of the strengths of the child and the
adolescent. Evaluations with CBCL showed high-reliability
values for both scales that were also correlated
with each other. Turkish translation and validity and
reliability study were performed by Guvenir et al.[]
Results
The mean age of the cases in the study group was
13.37±2.94 years, and the mean age of the healthy
controls was 12.52±2.57 years. There were no significant
differences between the two groups with regard
to mean age, age range, mean parental age, and gender
(p>0.05) (Table 1). There was a statistically significant
difference between the two groups with regard to
emotional and behavioral problems (p<0.05). Conduct
problems, attention deficit and hyperactivity, and total
difficulty scores were significantly higher in children
of mothers with BC (p≤0.001, p=0.001, and p=0.002,
respectively). Scores for emotional problems, peer relationship
problems, and prosocial behaviors were similar
in both groups (p>0.05) (Table 2). With regard to
gender, emotional problems, peer problems, and total
difficulty scores were significantly higher in girls of
patients with BC than in boys (p=0.024, p=0.022, and
p=0.030, respectively) (Table 3). Prosocial behavior
score was lower, and emotional, conduct, and peer relationship
problems; attention deficit and hyperactivity;
and total difficulty scores were higher in 12-17-yearold
adolescents than in 6-11-year-old children although
the differences were not statistically significant
(p>0.05) (Table 4). Children whose mothers were diagnosed
in the last year (n=26, 65%) had higher scores
in emotional problems, conduct problems, attention
deficit and hyperactivity, and total difficulty and lower
scores in peer problems and prosocial behaviors than
children whose mothers were diagnosed 1-5 years
ago although the difference was not statistically significant
(p>0.05). Most children of mothers with BC
experienced role changes in the family, they mostly undertook
mother and caregiver roles, they had one or
more responsibilities, and they had fears of becoming
ill. Some variables, such as difficulties, responsibilities,
and intrafamily role changes, according to gender and
age range are given in Tables 3 and 4. According to the
Spearman correlation analysis, there were statistically
significant positive correlations between age of the
case and total difficulty score (r=0.401, p=0.010) and
between maternal age and attention deficit and hyperactivity
score in children of patients with BC (r=0.357,
p=0.024).
Table 1: Demographic and clinical data of children and adolescents of mothers with breast cancer (study group) and
control groups
Table 2: SDQ subscale scores of the study and control groups
Table 3: SDQ subscale scores of the study group according to gender
Table 4: SDQ subscale scores of the study group according to age range
Discussion
The present study evaluated emotional and behavioral
problems, related factors, and life problems experienced
by school-age children of mothers with BC and
demonstrated that conduct problems, attention deficit
and hyperactivity, and total difficulty scores were higher in school-age children and adolescents of mothers
with BC than in children of healthy control parents;
therefore, these children experienced more emotional
and behavioral problems.
Our study supports previous studies that reported
emotional and behavioral problems and psychiatric
problems in children of mothers with BC.[,,,,] Many psychological problems, such as externalizing
behaviors (aggressiveness and defiance), and emotional problems (sadness, emotional lability, internalizing
problems, and somatic complaints) can be seen
in these children.[,,-] A study in 2018 that
reviewed the literature with regard to the psychological,
social, and behavioral effects of parental cancer on
10-24-year-old children reported that most of these
children were significantly affected by parental cancer.[] In contrast to these studies, a study showed
that patients followed for 1 year with a diagnosis of BC had better function than a group not affected by
cancer.[] In another study, 6-12-year-old children
of mothers with non-metastatic BC had lower selfesteem than children of mothers with benign BC but
had better mean behavioral adjustment than those of
the non-cancer group.[] Moreover, a study evaluated 6-17-year-old children of patients with BC using
the CBCL and reported no difference in internalizing
and externalizing subscale scores or total score. However,
self-reports by girls yielded higher t-scores than
questionnaires filled out by the parents. A significant
minority of school-age children of mothers with earlystage
BC had emotional and behavioral problems.[]
In our study, it was determined that girls had statistically
significantly more problems in emotional,
peer relationship, and total difficulty areas than boys.
Similar to our study, previous studies have shown that
internalizing disorders, such as depression and anxiety,
were more prevalent in girls, whereas hostility and
irritability were more prevalent in boys.[,] Many
studies have demonstrated that especially adolescent
girls had a high risk for internalizing problems if their
mother had a hereditary cancer disease, such as BC,
because they worried about the long-term effects of the
disease and about the hereditary risk of their becoming ill.[,] We also found that girls had more fear of
getting the illness than boys. Less frequent emotional
problems in males in our study may be due to less common
expression of emotions in males.
In our study, there was a significant relationship between
age and total difficulty score in children of mothers
with BC. As age increased, the total difficulty score of
children also increased. However, in our study, prosocial
behavior subscale score was lower, and emotional problems,
peer problems, attention deficit and hyperactivity,
and total difficulty scores were higher in 12-17-year-old
adolescents than in 6-11-year-old children although the
differences were not statistically significant. This may
be due to small sample size. Nevertheless, these results
show that every age group is affected by mother"s BC.
A study result demonstrated that primary school
and adolescent children had similar levels of emotional
and behavioral problems within 4 months after the
parent's cancer diagnosis to children of the norm group and children of parents diagnosed 1 to 5 years ago (retrospective
group).[] However, in some studies, it was
reported that a high percentage of children had higher
clinical scores for emotional problems during the first
months after their parents were diagnosed.[,] In
our study, children whose mothers were diagnosed in
the last year had higher scores in emotional problems,
conduct problems, attention deficit and hyperactivity,
and total difficulty and lower scores in peer problems
and prosocial behaviors than children whose mothers
were diagnosed 1-5 years ago although the difference
was not statistically significant. This may be related to
the small number of cases.
Previous studies demonstrated that alterations in
social roles occurred, and that new responsibilities,
such as assuming parental role, limitation of daily activities,
undertaking responsibilities of siblings, and
having to do housework, developed in caregiving family
members of patients with cancer. These new responsibilities
bring additional emotional and physical
burdens on children and cause psychological distress.
Children and adolescents of patients with BC had various
problems, such as changes in family responsibilities
and some life challenges.[,,] In our study,
lifestyle changes and responsibilities were more common
especially in the adolescent group. This may be
due to the expectation of parents and caregivers that
the adolescent should take more responsibility and
provide more support to the family as he/she gets older.
The primary limitation of the present study was its
cross-sectional design. Our study was conducted with a
small sample size. For this reason, it cannot be generalized
to children of all patients with BC. Another limitation
was that the psychiatric examination of the cases
was not performed, and they were not assessed by a semistructured
psychiatric interview, such as the Schedule for
Affective Disorders and Schizophrenia for School-Aged
Children, Present and Lifetime Version. Another limitation
was the use of measurement tools based on self-reports
of the families for the groups. It is also a limitation
that a scale that measures the self-esteem of adolescent
patients was not used. However, to the best of our knowledge,
this is the first study to identify emotional and behavioral
problems and difficulties in under 18-year-old
children of mothers with BC in Turkey that may form
the basis for future prospective, large-scale studies.
Conclusion
The results of the present study showed that the emotional
and behavioral problems of children and ado The results of the present study showed that the emotional
and behavioral problems of children and adolescents
of mothers with BC were higher than those
of healthy children with healthy parents, and that
maternal illness caused distress for children in many
areas of their lives. There was a positive relationship
between increasing age and total difficulty, and more
emotional and behavioral problems were observed
in girls. The results of this contemporary study may
increase the awareness of health care providers that
some children may have difficulties in adjusting to
their parents" illness. Health care providers can help
parents to support their children in the early stages
of cancer and to be particularly sensitive to children
at risk.
Acknowledgment: The authors wish to thank the patients
and families who participated in this study.
Peer-review: Externally peer-reviewed.
Conflict of Interest: None declared.
Ethics Committee Approval: The study was approved by
the scientific research Ethical Committee of Sütçü İmam
University, Medical Faculty, Kahramanmaraş.
Financial Support: None declared.
Authorship contributions: Concept - H.A., N.K., A.A.,
E.M.K.; Design - H.A., N.K., A.A., E.M.K.; Supervision
- H.A., N.K., A.A., E.M.K.; Materials - H.A., N.K., A.A.,
E.M.K.; Data collection &/or processing - H.A., N.K., A.A.,
E.M.K.; Analysis and/or interpretation - H.A., N.K.; Literature
search - H.A., N.K., A.A., E.M.K.; Writing - H.A., N.K.;
Critical review - H.A., N.K., A.A., E.M.K.
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