The presence of psychological and emotional morbidities is an important indicator of well-being in children with cancer. Psychiatric disorders such as anxiety, depression, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, behavioral and adjustment disorders are common in children and adolescents with cancer^1-3. Moreover, childhood and adolescent cancer survivors showed increased risks of six major psychiatric disorders including autism spectrum disorder, attention-deficit/hyperactivity disorder, schizophrenia, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, and post-traumatic stress disorder⁴.

The quality of the interparental relationship is recognized as an important influence on child and adolescent psychopathology. Recent research has highlighted that children are affected by attributes of interparental conflict, specifically how parents express and manage conflicts in their relationship, across a continuum of expressed severity and negativity-ranging from silence to violence⁵. Herein, we discuss risk factors for anxiety/depression in children and adolescents with cancer and interparental conflict. Our aim is to draw attention to the fact that interparental conflict may be a risk factor for anxiety/depression in children with cancer. To the best of our knowledge, no study has been published about this subject in the literature.

Prevalence rates of anxiety and depression among children and adolescents with cancer was found to be 13.9% and 20.4% in a meta-analysis, respectively¹. Although depression and anxiety are common in pediatric cancer patients, data on the course and risk factors of these disorders are limited in the literature. Yardeni et al.² reported that higher baseline levels of depression and anxiety, female gender, older age, and having brain tumors have been reported as risk factors for anxiety and/or depressive disorders in Jewish children and adolescents with cancer. Case examination of depressed adolescent patients with cancer living in Cape Town suggests that illness and treatment factors may not be primary risk factors for the development of psychological morbidity. External stressors such as poor family support and past sexual abuse, when compounded by illness and treatment factors, may be more relevant³.

Katz et al.⁶ reported that there was a higher than expected proportion of children with clinically relevant internalizing symptoms around the time of diagnosis of cancer in urban areas of the Northwest and Southeast United States. The children were well adjusted and their symptoms declined over time. However, caregivers were less well-adjusted, with a high proportion reporting clinically relevant symptoms over time for depression and anxiety⁶. In another study, caregivers from nine pediatric oncology centers in United States of America consistently overestimated anxiety and depressive symptoms and underestimated mobility relative to the children with cancer themselves⁷.

To prevent negative outcomes for parents and potential negative downstream effects on their children with cancer and other family members, there is a need to understand both which caregivers are at highest risk and how to prevent continued psychological distress during and after treatment⁶. Prevention programs such as cognitive-behavioral and interpersonal psychotherapy traditions appear to have greatest impact where children and adolescents are identified based on risk factors for developing an anxiety disorder and depression^8,9.

Extensive literature has shown that interparental conflicts and violence have detrimental effects on children’s adjustment in childhood and adolescence¹⁰. Ran et al.¹¹ reported a significant positive association between interparental conflict and youth anxiety. More specifically, youth anxiety was more strongly associated with parents’ use of overt conflict style than with their use of cooperative conflict style¹¹. Interparental conflict was positively related to depressive symptoms in children, which was partially and serially mediated by parent-child communication and self-esteem in that order¹². Zhang et al.¹³ reported that interparental conflict in 7th grade adolescents significantly predicted depression in 8th grade, but adolescent depression in 7th grade was not a significant predictor of interparental conflict in 8th grade.

In conclusion, based on the literature data we think that interparental conflict, overlooked by many health professionals, may be as a risk factor for anxiety/depression in children and adolescents with cancer; however, comprehensive, randomized, controlled studies should be performed on this subject.

Correspondence
Hüseyin Çaksen
https://orcid.org/0000-0002-8992-4386
huseyincaksen@hotmail.com

REFERENCES

1. Al-Saadi LS, Chan MF, Al-Azri M. Prevalence of anxiety, depression, and post-traumatic stress disorder among children and adolescents with cancer: a systematic review and meta-analysis. J Pediatr Hematol Oncol Nurs 2022; 39 (2): 114-131. https://doi.org/10.1177/27527530211056001
2. Yardeni M, Abebe Campino G, Hasson-Ohayon I, et al. Trajectories and risk factors for anxiety and depression in children and adolescents with cancer: A 1-year follow-up. Cancer Med 2021; 10 (16): 5653-5660. https://doi.org/10.1002/cam4.4100
3. Berard RM, Boermeester F. Psychiatric symptomatology in adolescents with cancer. Pediatr Hematol Oncol 1998; 15 (3): 211-221. https://doi.org/10.3109/08880019809028787
4. Hsu TW, Liang CS, Tsai SJ, et al. Risk of major psychiatric disorders among children and adolescents surviving malignancies: a nationwide longitudinal study. J Clin Oncol 2023; 41 (11): 2054-2066. https://doi.org/10.1200/JCO.22.01189
5. Harold GT, Sellers R. Annual research review: Interparental conflict and youth psychopathology: an evidence reviews and practice focused update. J Child Psychol Psychiatry 2018; 59 (4): 374-402. https://doi.org/10.1111/jcpp.12893
6. Katz LF, Fladeboe K, King K, et al. Trajectories of child and caregiver psychological adjustment in families of children with cancer. Health Psychol 2018; 37 (8): 725-735. https://doi.org/10.1037/hea0000619
7. Mack JW, McFatrich M, Withycombe JS, et al. Agreement between child self-report and caregiver-proxy report for symptoms and functioning of children undergoing cancer treatment. JAMA Pediatr 2020; 174 (11): e202861. https://doi.org/10.1001/jamapediatrics.2020.2861
8. Lawrence PJ, Rooke SM, Creswell C. Review: Prevention of anxiety among at-risk children and adolescents – a systematic review and meta-analysis. Child Adolesc Ment Health 2017; 22 (3): 118-130. https://doi.org/10.1111/camh.12226
9. Gladstone TR, Beardslee WR. The prevention of depression in children and adolescents: a review. Can J Psychiatry 2009; 54 (4): 212-221. https://doi.org/10.1177/070674370905400402
10. Nicolaus C, Kress V, Kopp M, Garthus-Niegel S. The impact of parental relationship satisfaction on infant development: results from the population-based cohort study DREAM. Front Psychol 2021; 12: 667577. https://doi.org/10.3389/fpsyg.2021.667577
11. Ran G, Niu X, Zhang Q, et al. The association between interparental conflict and youth anxiety: a three-level meta-analysis. J Youth Adolesc 2021; 50 (4): 599-612. https://doi.org/10.1007/s10964-020-01388-7
12. Ying L, Zhou H, Yu S, et al. Parent-child communication and self-esteem mediate the relationship between interparental conflict and children’s depressive symptoms. Child Care Health Dev 2018; 44 (6): 908-915. https://doi.org/10.1111/cch.12610
13. Zhang Z, Wang Y, Zhao J. Longitudinal relationships between interparental conflict and adolescent depression: moderating effects of school connectedness. Child Psychiatry Hum Dev 2023; 54 (5): 1489-1498. https://doi.org/10.1007/s10578-022-01355-2