REDUCING EMOTIONAL DISTRESS IN MOTHERS OF CHILDREN RECENTLY

DIAGNOSED WITH CANCER

O.J. Sahler, MD

Professor of Pediatrics, Psychiatry, Medical Humanities, & Oncology

Golisano Children’s Hospital

University of Rochester Medical Center

Rochester, NY USA

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DEVELOPMENT, IMPLEMENTATION,

AND DISSEMINATION

OF THE BRIGHT IDEAS

PROBLEM-SOLVING SKILLS TRAINING PROGRAM

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From Science to Clinical Practice:

THE PRESENTER HAS NO

CONFLICT OF INTEREST TO DISCLOSE

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1. Mothers of children newly diagnosed with cancer often haveincreased anxiety and depression

2. We have completed 3 RCTs proving the efficacy of the Bright IDEAS paradigm of problem-solving skills training in > 820 mothers

3. Adding skills building to a social support intervention continues to have positive effects 3 months after the intervention ends

4. Dissemination strategy: (a) train-the-trainer workshops to build capacity for using

Bright IDEAS at child cancer centers throughout the US(b) an on-line version of Bright IDEAS for 24/7 availability

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Key Points

1986 - 2014

Supported by the WT Grant Foundation and

NCI/NIH Grants R25 CA65520, RO1 CA098954, and RO1 CA159013

Background

In the mid-1980’s, it was controversial if child cancer in the family was a traumatic or a growth experience for siblings

We developed a 7-site survey study

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Conceptual Model: Childhood Cancer: Sibling Adaptation

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Sibling Study

Interviewed parents of 279 siblings

• 270 respondents = mothers

• 9 respondents = fathers*

• We have focused on mothers in studies published to date

* Typical distribution of parental participation in open studies

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RESULTS OF THE SIBLING STUDY

Sibling Adaptation

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Mother’s Well-Being Using NHANES Comparison Data

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Resource Utilization:Mothers seeking help for themselves past year

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Hypothesis

• Mothers of siblings who were less well adapted would be isolated and have access to few resources

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Resource Utilization:Mothers seeking help for themselves past year

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Why?

Hypotheses:

1. Mothers could not define the problem well enough to access appropriate resources

2. Mothers could not implement advice they received

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OUR SOLUTION

Problem-Solving Skills Training

• Based on Problem-Solving Therapy, which is effective in treating clinical depression, anxiety

• Skills training is a psychological intervention that teaches management of life stresses to a non-clinical population

Problem-Solving Program Goals

• Learn new ways to: - solve problems- resolve conflicts - make effective decisions

• Control the controllable

• Feel better during an extremely difficult time

• Understand the thinking-feeling connection

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The Bright IDEAS Model

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The Model

“Bright” = OPTIMISM

Adopting a positive attitude toward

solving problems

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Step 1: Identify the Problem

• What is the problem?

• Where is this a problem?

• When does the problem occur?

• Who does the problem involve?

• Why does the problem occur?

• How do you feel when the problem occurs?

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Step 2: Define Options

• Define possible solutions

• Brainstorm without judgment

• Be creative

• S- t- r- e- t- c- h yourself

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Step 3: Evaluate Your Options

For each proposed solution, rate:

• Likelihood of achieving

• Time-effort commitment

• Short- and long-term cost/benefits

• Potential barriers

Rank your solutions

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Step 4: Act

• Decide on first choice

• Create a specific detailed action plan

• Envision the plan mentally & write it out

• Then, do it!

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Step 5: See If It Worked

• Assess if result was satisfactory

• If not satisfied, analyze why

• Modify the plan or try Plan B

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Currently, Bright IDEAS Is Provided Face-to-Face

Manualized training program

8 1-hour individual training sessions

Participant identifies problems to solve

Practice

Homework

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Conceptual Model

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Crisis Intervention Primary

Outcome

Secondary

Outcome

Diagnosis of

CancerPSST

Negative

Affectivity

(POMS/BDI/IES)

Problem-

Solving

Skills

(SPSI)

Non-Specific Effect

Specific

Effect

PSST Study Methods

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Sahler OJZ, et al. Problem-solving skills training for mothers of children with newly diagnosed cancer: A randomized trial. J Dev Behav Pediatr 2002; 23:77-86. PMID: 11943969

Sahler OJ, et al. Using problem-solving skills training to reduce negative affectivity in mothers of children with newly diagnosed cancer: Report of a multi-site randomized trial . JCCP, 2005;73:272283.

Askins MA, et al. Report from a multi-institutional randomized clinical trial examining computer-assisted problem-solving skills training for English- and Spanish-speaking mothers of children with newly diagnosed cancer. JPP, 2009; 34(5):551-563.

Sahler OJ, et al. Specificity of problem-solving skills training in mothers of children newly diagnosed with cancer: Results of a multi-site randomized clinical trial. J Clin Oncol; 2013; 31(10):1329- 35. Epub 2013 Jan 28.

Eligibility Criteria

- Mothers of children with newly diagnosed cancer 2-16 weeks after diagnosis

- English, Spanish, Hebrew Language (2005 only)

Procedures

- Recruitment Time 1 Assessment Randomization PSST

Training Intervention (8 1-hr sessions)

- Time 2 Assessment (immediately post PSST or 3 mos. post T1)

- Time 3 Assessment (3 mos. post T2)

Assessments

- SPSI-R; POMS, BDI-II, IES-R

Sequence of PSST Studies

• Randomization Groups by Study

- 1995: Efficacy --- PSST vs. Usual Psychosocial Care (n = 92)

- 2005: PSST vs. Usual Psychosocial Care (n = 430)

- 2010: PSST vs. Reflective Listening (n = 301)

- 2013: f 2 f vs. Online (n = 620; to date >125 enrolled)

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2005 Study (n = 430)

Mothers gaining more benefit

• Single

• Young

• Introverted

• Spanish immigrant

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Differential Impact of PSST: English- vs. Spanish-Speaking Mothers

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Relationships among Cultural Factors & Baseline Measures

Lower acculturation correlated with:• Poorer problem solving

Higher immigrant stress correlated with:

• Depressive symptoms

• Traumatic stress symptoms

Sherman-Bien, et al. “A cross-cultural perspective of mothers of children with newly diagnosed cancer: Results of multi-institutional randomized trials of maternal problem-solving skills training”. International Society of Pediatric Oncology (SIOP), Boston, Massachusetts, October 21, 2010.

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Conclusions about PSST and Spanish-speaking Mothers

• Cultural factors predict both psychosocial functioning and problem-solving skills at baseline

• Interventions for specific cultural groups need to incorporate culturally sensitive approaches relevant to mothers’ unique experiences

PSST can be effective for any cultural group

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Take Away Point:

Problem-Solving Skills Training is generic and culturally neutral

but…

the specific problems and solutions individuals focus on are culturally determined

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Overall Study Conclusions

• PSST effectively teaches problem-solving skills to mothers of children with cancer

• PSST reduces maternal depression and increases sense of competence

•Differences between PSST and control groupsdiminish over time as control mothers improveconfidence/competence

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Trajectory of Negative Affectivity

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Next Step

• Replicate with time and attention control to measure the role of non-specific (social) support

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Conceptual Model

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Crisis Intervention Primary

Outcome

Secondary

Outcome

Diagnosis of

CancerPSST

Negative

Affectivity

(POMS/BDI/IES)

Problem-

Solving

Skills

(SPSI)

Non-Specific Effect

Specific

Effect

Time and Attention Control Condition (TACC)

Non-Directive Support (Reflective Listening)8 1-hour sessions

ManualizedProcess and Content

1. Reflection2. Focus on Feelings3. Empathetic4. Accept affective experiences5. Supportive statements

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Hypothesis

Mothers receiving PSST would have:

Problem-solving skills

Negative affectivity

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2010 Study (n = 301)Results: PSST vs. TACC

1. No differences in subjects’ ratings --- both interventions seen as potentially useful

2. Problem-solving skills were significantly improved in PSST mothers

3. Both groups showed significant improvement in affectivity at T2 (immediately post intervention)

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But…

3 months after the intervention

Mothers in the PSST Group continued to improve at a significantly greater rate than mothers in the TACC Group

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PSST LESS DISTRESS OVER TIME

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If you give a man a fish,

you feed him for a day

If you teach a man to fish,

you feed him for a lifetime

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In 2010, data from Bright IDEAS RCTs

were independently analyzed:

Research Integrity 4.4/5.0

Dissemination Capability 5.0/5.0

Intervention Impact 2.0/5.0

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was designated

a Research-Tested Intervention Program (RTIP) by NCI

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Our impact score of 2.0 reflects

the very low incidence (~12,000) of new child cancer diagnoses/yr

Our dissemination capability score of 5.0 reflects

comprehensive product development

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In reality:

Bright IDEAS is a generic approach to problem solving that can be used

• by anyone• at any time• under any circumstance• for any problem

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The Challenge:

…Disseminate!

…Disseminate!

…Disseminate!

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The Problem:

The intervention is labor intensive and requires trained personnel

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The Solutions:#1: Build capacity: Train 200 psychologists, nurses, and social workers to increase the number of skilled providers

#2: Increase accessibility: Put Bright IDEAS online (PC and App)

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The Question:

Will ePSST be as effective as f2f PSST?

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OR…

If you give a man a rod and reel

and an instruction book,

will he learn to fish as well by himself

as he would if you were

standing next to him coaching him?

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Thank you to my many colleagues

• Martha A. Askins, PhD UT/MD Anderson Cancer Center

• Oscar A. Barbarin, PhD University of Michigan

• Robert W. Butler, PhD Oregon Health Sciences Center

• Donna R. Copeland, PhD UT/MD Anderson Cancer Center

• Katie A. Devine, PhD Rutgers University

• Michael J. Dolgin, PhD Ariel University (Israel)

• Diane L. Fairclough, DrPH University of Colorado Denver

• Ernest R. Katz, PhD Children’s Hospital, Los Angeles

• Raymond K. Mulhern, PhD St. Jude Children’s Research Hospital

• Robert B. Noll, PhD Children’s Hospital of Pittsburgh

• Sean Phipps, PhD St. Jude Children’s Research Hospital

• Klaus J. Roghmann, PhD University of Rochester

• Janice R. Sargent, PhD University of Utah

• Sandra Sherman-Bien, PhD Miller Children’s Hospital

• James W. Varni, PhD University of California San Diego

• Lonnie K. Zeltzer, MD University of California Los Angeles

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