Effectiveness of Complementary Supportive Interventions on Mental Health Issues in Pediatric Oncology Patients. A Systematic Review of Randomized Controlled Trials ()
1. Introduction
Suffering from cancer can provoke extensive and excessively emotional, physical and social strains, especially for the very vulnerable demographic population of pediatric oncology. Although great progress has been made in cancer survival, this disease remains the leading cause of death in children and its treatments have short-term and long-term consequences for the well-being of children. This accomplishment, along with the several medical breakthroughs in diagnoses, led to many pediatric patients suffering from either psychological consequences or issues of the pathological condition, in addition to the treatment side-effects or complications. “The psychological impact is varying, extending from increased anxiety eventuality, up to concerns over haggard and tired appearance and viewing oneself as distinct from his peers” according to McDougal (1997). Approximately 25% of patients experience severe mental health problems such as critical anxiety disorders, depression and/or PTSD, with over 50% of patients developing severe warning signs of depression (Seitz et al., 2010; Li et al., 2013).
The main scope of this paper was to delineate if various auxiliary and supportive interventions are effective enough on the main psychological issues and whether they can be considered as a main coping intervention in pediatric oncology. The secondary goal was to detect which types of these therapies are most effective in reducing distress, anxiety and depression in children and adolescents patients with cancer. Numerous random clinical experiments were administered with the use of amalgamating supportive therapies for adults and children, to reduce their anxiety or distress. The majority of papers canvass the pervasiveness of auxiliary therapies practice (Bishop et al., 2010; Post-White, 2006), but not the efficiency of a specific type of interventions for the treatment or relief of the main psychological symptoms (such as distress, anxiety, depression). Although several papers addressed the problem of anxiety or pain in the course of painful methods that have been conducted to combat pediatric cancer (Kleiber & Harper, 1999; Landier & Tse, 2010; Richardson, Smith, McCall, & Pilkington, 2006), no recent review has evaluated supportive interventions putting to action, explicitly regarding the anxiety, distress and depression symptoms restricted in pediatric oncology patients. Therefore, this review focused specifically on the effectiveness of various types of auxiliary interventions comparing the results of those on the main psychological issues (distress, anxiety, and depression) in pediatric oncology patients, regardless of the cancer treatment phase.
2. Methods
The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher et al, 2010).
2.1. Selection Criteria
The standards for including or excluding a study were set according to the PICOS components. With regards to Population, studies had to be conducted solely on children or adolescents, from 1 up to 19 years old. Participants were incorporated, at any point during the course of their treatment, from cancer diagnosis to ongoing therapy, to long-term follow-up after treatment, or death. The participants recruited must have received a medical diagnosis or positive diagnostic testing of cancer, of any type. Regarding Intervention, only studies using interventions to reduce symptoms including distress, anxiety or depression for children diagnosed with cancer were taken into consideration in this systematic review paper. Interventions included should have involved a psychological intervention of either music therapy, video gaming and technological nature, or of hypnosis and other relaxation techniques. As far as Outcome a study should have to examine at least one of the desirable outcomes (distress, anxiety, depression) to be included. All types of anxiety whether it was procedural, state, or treatment-related were included in the outcomes of the review in order to examine the full aspect of the anxiety at every stage of the cancer treatment the patient experiences. Young patients may experience anxiety about medical treatments or methods, hospital admission, clinic appointments, or recrudescence, so full aspect examination of the disorder was required. Various types of distress that were manifested either as somatic or psychological were incorporated in the paper, with a range of tools for measuring it. For depression, mainly the common Childhood Depression Inventory (CDI) and Beck Depression Inventory tools have been used for evaluating the studies included. Lastly, with regards to Studies, RCTs with a matched control group were sought. Identified research protocols that did not present satisfactory data were also excluded. Additionally, studies had to be published solely in the English language by journals with a peer-review process.
2.2. Search Strategy
An orderly literature inspection was performed within Pub Med, Web of Science & SCOPUS databases without date constraint. Search filter for English language only was applied and no other filter prior or after the search. The keywords used in each database are stated below in the following combination. (Childhood cancer OR Paediatric Oncology OR paediatric cancer OR pediatric oncology)AND (child*OR adolescent* OR teen*OR paediatric)AND (mental health issues)AND (anxiety OR depression OR Distress OR stress)AND (supportive therapy OR palliative care OR music*OR video game OR game*OR virtual). Terms were searched for in each title and abstract, and in the keywords of each study, and were adapted accordingly to each electronic database. The researchers separately searched introduction sections and reference lists of papers that were to be included for supplementary studies consistent with to the question of the review.
2.3. Data Extraction and Quality Evaluation
The data were collected independently by two researchers (C.Z. and M.M.). Data gathered from the studies included: 1) participant demographics (e.g. sex, age and participants’ number), 2) methodology (e.g., interventions’ and follow-up measurements’ type and length), and 3) results (e.g., psychological consequences on distress, anxiety and depression). Quality assessment of individual studies was conducted according to the Cochrane Collaboration’s tool for assessing risk of bias (Higgins et al., 2011) by two researchers (C.Z. and M.M.).
3. Results
3.1. Study Flow and Included Studies
Initial search yielded 468 papers. The reviewing investigators concluded in 17 randomized control trials. The complete screening process is illustrated in Figure 1. Table 1 presents the information gathered from the studies, making allowance for trial intervention, design and type of study, participants’ demographics, type of control group, outcomes measures, timeline of follow-up calculation and main judgements.
A total number of 572 pediatric oncology patients with mean age ranging between 5 to 19 years old participated in the studies. All papers consisted of patients with childhood cancer only and excluded cancer survivors. The individuals who participated in the studies received diverse forms of psychological intercessions. The intercession applied can be categorized to 3 subcategories of interventions: music therapy interventions (n = 5), relaxation and hypnosis interventions (n = 7), technology and video games interventions (n = 5). Results and main findings of the studies indicate that 14 out of 17 studies reviewed in this paper reported statistically significant improvements in at least one of the examined psychological outcomes. Studies were compared and analyzed across their own category and type of intervention.
The outcome and tools of measurement mentioned in the following table of studies and results are in regard to the desired psychological outcomes (distress, anxiety, and depression) that this review examines. There are also additional outcomes of psychological nature that several studies are reporting, but they are not mentioned in the following table as they are not in the reviewing interest of this paper.
3.2. Qualitative Evaluation of Studies
Figure 2 illustrates the results of the quality evaluation of the involved studies based on the Cochrane Collaboration’s tool for assessing risk of bias (Higgins et al., 2011). The synopsis of the “risk of bias using the Cochrane’s ROB 2 tool for every study” is entailed in this review, as shown in Table 2. The five risks of bias areas are individually evaluated, and then rated as a total for a comprehensive risk of bias for every study. From the table of risk of bias, the quality of evidence in every study is evident. Five out of the 17 trials evaluated to be of “Low Risk” thus indicating a higher quality of trials evidence, 7 evaluated to be of “Some
![]()
Figure 1. Flow chart and methodology of the selected studies of the review process.
![]()
![]()
![]()
Table 1. Studies characteristics & outcomes.
![]()
Figure 2. Quality evaluation of studies.
Concerns” and 5 of a “High Risk” of bias. In Figure 2, we can see a graphical representation of the distribution of the studies in every risk of bias area. In Table 2, all the studies are evaluated for every “risk of bias” area and presented in a table form.
3.3. Results of Supportive Interventions
As mentioned above, studies in this review are sorted by type of similarity of intervention. Although all trials involve supportive psychological interventions, further categorizations by type of intervention were required to clearly appraise the effectiveness of each trial on the main psychological outcomes, not only by any individual intervention, but by type of intervention as well. Thus, we can examine which type of trials are the most efficient.
3.4. Music Therapy Interventions
There are five studies involving music-related interventions examining the effectiveness of music therapy on the main psychological symptoms of distress and anxiety. From these five trials, four are reporting significant positive results, two on distress outcomes (Robb et al., 2017; Uggla et al., 2016) and two on anxiety outcomes (Nguyen et al., 2010; Uggla et al., 2018). There was a study that reported positive results on distress, but it was not considered statistically significant (Barry et al., 2010).
3.5. Relaxation and Hypnosis Interventions.
There are seven studies involving relaxation and hypnosis-related interventions examining the effectiveness of these interventions on the main psychological symptoms of distress and anxiety. There are 4 trials involving hypnosis and self-hypnosis techniques, two examine massage techniques as their main intervention, and one experiment with an aromatherapy intervention. Of these seven trials, three reported statistically significant positive results, across all measured checkpoints, for both distress and anxiety outcomes (Liossi & Hatira, 1999; Liossi et al., 2003; Liossi et al., 2009), two reported statistically significant results for anxiety outcomes (Wall & Womack, 1989; Post-White et al., 2009) and one reported statistically significant results for distress (Wong et al., 2013). There is also one study with significant negative results for the intervention group (Ndao et al., 2012).
3.6. Technology/Video Games Interventions
There are five studies involving video gaming and robotics interventions examining the effectiveness of technologically advanced and innovative therapies on the main psychological symptoms of distress, anxiety and depression. Out of these five studies, three are using a video game intervention and two are an innovative robotic psychotherapy experiment. From these five studies, three are reporting significant positive results, two on anxiety and depression outcomes (Sajjad et al., 2014: Alemi et al., 2016) and one on distress outcomes, but not on anxiety, which was also examined (Gershon et al., 2004). One study reported positive results on distress but not statistically significant (Nilsson et al., 2009) and one shows non-significant negative results for its intervention on outcomes of distress (Jibb et al., 2018).
4. Discussion
Investigating the summary of evidence, it’s evident that from the systematic research of the literature a collectively considerable amount of research material has been gathered providing clear evidence for the efficacy of innovative supportive methods in dealing with distress, anxiety and depression in young patients suffering from cancer. All three examined types of interventions included many trials with significantly positive results and high-value effect sizes, thus proving the effectiveness of these therapies and validating their use and standardization in future clinical methodology and psychological treatment approach in pediatric oncology.
Twelve out of 17 trials achieved high quality of evidence across all bias areas, a fact that underlines and further promotes the significance of these outcomes.
Regarding the music therapy-related interventions, 3 out of 5 studies are reporting significantly positive results through all measured sessions of the trials, achieving an effect size up to 1.49. However, music interventions on the other hand presented the highest amount of “High Risk of Bias” with two studies indicating an overall rating of “high risk” and another study with “some concerns” concerning their quality of evidence.
In terms of the hypnosis and relaxation-related interventions, 5 out of 7 studies are reporting significantly positive results through all measured sessions and for all examined outcomes, achieving an effect size up to 1.0. On the quality of evidence hypnosis and relaxation related interventions, presented a high amount of “Some Concerns” rating with four of the studies indicating an overall rating of “some concerns” and another one with “High Risk” for their quality of evidence.
Regarding the video games and technology-related interventions, 2 out of 5 studies are reporting significantly positive results through all measured sessions and for all the examined outcomes, achieving an effect size up to 0.7, which, in many cases, is regarded as statistically significant. Technology-related interventions also are the only type that examines the depression outcome with 2 trials reporting significantly positive results. Video games and technology-related interventions also presented a significant amount of lower quality of evidence, with 2 out of 5 studies indicating an overall rating of “high risk” or “some concerns” for their quality of evidence.
Taking into account all the above, we can see that hypnosis and relaxation-related interventions are the most effective as they presented the highest amount of statistically significant results which continued to be significantly positive across all measured sessions. Video games and technology-related interventions presented an overall highest quality of evidence showing 3 out of 5 trials with a “low risk of bias” rating.
5. Limitations
While efforts were carried out to eliminate bias in the best possible way, there is a possibility that the concluding remarks of this paper had inherent limitations and weaknesses. To strengthen the impact of potential significant findings, only reviews applying randomization techniques were taken into consideration. This was the primary concern, as it posed great limitations to the papers produced abroad, prone to conducting open, non-randomized designs.
6. Conclusion
There is solid evidence that auxiliary and supportive interventions, which complement the overall palliative care, may support children receiving cancer remedy in general and especially in uncomfortable and aching procedures. This area of expertise is of essential and fundamental importance to children fighting cancer, as well as to their relatives. This paper proves that a variety of psychological & social interventions and measures are helpful and efficacious and can have a beneficial effect on their mental health and alleviate their psychological burden. Overall, the results demonstrate that children and adolescents’ mental health needs when facing cancer are addressable, while complementary supportive psychological interventions are essential in addressing the issue of their psychological wellbeing and fast rehabilitation, which is of paramount significance for ascertaining quality of life.