Children With Cancer; Effects and Educational Implications

Sarah McDougal

Indiana University

December 11, 1997

Introduction

Before the age of 19, one in every 330 children in the United States will develop some form of cancer. Cancer is the number one cause of death due to disease in children aged one through adolescence (National Children's Cancer Foundation, 1997). In 1997, approximately 8800 new cases will be diagnosed, and approximately 1700 children will die (American Cancer Society, 1997).

However, cancer is no longer equated with death, as it was in the past (Glazer, 1991). As new medical treatments and technologies are developed, more and more children each year are survivors of cancer; over 60% of children with cancer survive the disease (Bleyer, 1990). These children are able to continue normal lives during and after treatment. Thus, research relating to the effects of cancer and cancer treatment and how they affect the child's ability to carry on a normal life has become increasingly more important. More specifically, research regarding the educational implications of the child's illness has become vital to those who aid in the transition process from medical center to classroom. Children with cancer may experience medical and physical effects, psychological effects, and cognitive and neuropsychological effects, all of which may impact a child's experience upon reentry into the classroom.

The present paper examines the effects of various types of childhood cancer and their treatments, as well as the educational issues that may result from the illness and its treatments. It also examines the roles of the family, the teacher, peers, and the school psychologist in the hospital-to-school transition; each plays an important part in helping the child to adjust successfully to the school environment.

Types of Cancer and Their Treatments

Leukemia

Leukemia is the most common pediatric malignancy; it accounts for 39% of all childhood cancers (National Children's Cancer Foundation, 1997). Leukemia is cancer of the bone marrow, characterized by an abundance of abnormal white blood cells. Children with leukemia tend to show symptoms such as anemia, bleeding, fever, an increased susceptibility to infection, easy bleeding and bruising, enlarged lymph nodes, liver, and spleen, and bone pain.

There are two types of leukemia: acute lymphoblastic leukemia (ALL) and acute nonlymphoblastic leukemia (ANLL). Both involve a proliferation of abnormal blood cells in the bone marrow, which prevents it from producing normal blood cells. ALL is the most common type of leukemia, and occurs in the lymphoblasts, which is a type of white blood cells. Four out of every 100,000 children in the United States have ALL, with peak occurrence from ages three to six. ANLL, in contrast, is less common, occurring in one out of every 100,000 children in the United States; its incidence increases throughout adolescence. It targets the white blood cells in the marrow that are not lymphoblasts, and produces symptoms similar to the symptoms of ALL (Granowetter, 1994).

Treatment for leukemia consists of different procedures, one of which is bone marrow transplantation (BMT). During this treatment, high doses of chemotherapy and sometimes radiation are administered to the patient to kill the existing bone marrow and its functioning. Then, the patient receives the infusion of the replacement bone marrow. After this transfusion, the bone marrow does not function normally, putting the patient at risk for infection, so the patient is required to stay in protective isolation until normal bone marrow function begins, which can take two to four weeks (Phipps, 1994). The patient is at-risk for serious complications or death due to the lack of bone marrow functioning for an extended period of time, the high-intensity therapy, or donor rejection or mismatch (Granowetter, 1994).

An additional risk for patients with ALL is that the cancer is prone to entering the central nervous system (CNS), which requires further treatment for the patient. This treatment may include additional chemotherapy or cranial radiation therapy (CRT). However, CRT is becoming decreasingly common due to its linkage with significant neuropsychological problems post-treatment (Brown & Madan-Swain, 1993; Mulhern, 1994). This issue will be addressed later in the present paper. Treatment procedures for ALL result in a cure for 50-70% of patients (Niemayer, Hitchcock-Bryan, & Sallan, 1985), while treatment procedures for ANLL result in survival rates of 35% when chemotherapy is the only treatment (Gaynon, 1992) and 50-70% when BMT is employed (Granowetter, 1994).

Brain Tumors

Brain tumors are the second-leading cause of childhood cancer, accounting for 15% of all childhood malignancies. Brain tumors occur mainly in children between the ages of five and 10 (National Children's Cancer Foundation, 1997). Symptoms depend on the location of the tumor, but may include headache, vision problems, vomiting, balance and coordination problems, and cognitive and/or neurological deficits.

Most often, treatment of brain tumors requires surgical removal of the tumor, which includes laser surgery and microsurgery. Some tumors, however, may not be completely removed, due to their precarious location (for example, the brain stem); these tumors, in addition to recurring tumors, may require chemotherapy and CRT (Granowetter, 1994). For treatment of brain cancer, the 5-year survival rate can range from 15-20% for a more serious tumor to 70% for a less serious tumor (Duffner, Cohen, & Freeman, 1985).

Lymphomas

Lymphomas account for ten percent of all childhood cancers (National Children's Cancer Foundation, 1997). Lymphoma is cancer of the lymph nodes of which there are two types: non-Hodgkin's lymphoma (NHL) and Hodgkin's lymphoma.

NHL is most common in preadolescents and adolescents. Its most common symptoms "include enlarged lymph nodes, difficulty breathing because of enlarged lymph nodes in the chest, an abdominal tumor from enlarged lymph nodes, fevers, weight loss, and lethargy" (Granowetter, 1994, p. 25). This cancer tends to metastasize to other areas rapidly, most commonly to the bones, CNS, and the bone marrow. Due to the link between the lymph node system and the immune system, Horowitz and Pizzo (1990) predict that the incidence of NHL may increase as the number of children with the AIDS virus increases.

Hodgkin's lymphoma "differs from NHL in that it usually demonstrates a slower onset and an orderly progression, involving contiguous lymph node areas" (Granowetter, 1994, p. 26). Its peak incidence occurs in late adolescence, early adulthood, and middle age.

Treatments for lymphomas may include chemotherapy, medication, radiation therapy, and possibly CRT (if the cancer has spread to the CNS). Treatment may be inpatient or outpatient, and although the survival rate depends on the type of lymphoma, the prognosis is excellent in general (Granowetter, 1994); the American Cancer Society (1997) reports that the five-year survival rate is 92% for patients with Hodgkin's lymphoma.

Wilms' Tumor

Wilms' Tumor, or cancer of the kidney, accounts for 6% of childhood cancers (National Children's Cancer Foundation, 1997). Its peak incidence is in children ages two to three. There may be no obvious symptoms, although the parent or child might notice a lump or swelling in the abdominal area.

Treatment usually consists of surgical removal of the tumor and chemotherapy. If the cancer has spread to the chest or other areas, the patient may receive radiation therapy. Treatment is normally done on an outpatient basis (Granowetter, 1994). Prognosis for Wilms' Tumor is excellent; the National Children's Cancer Foundation (1997) reports the five-year survival rate as 93%.

Neuroblastoma

Neuroblastomas account for seven percent of childhood cancers, occurring mainly in very young children. This cancer is characterized by tumors that start in the adrenal glands, chest and abdomen. These tumors are highly malignant, and spread quickly. Symptoms may include fever, bone pain, and abdominal swelling (American Cancer Society, 1997; Granowetter, 1994). If caught early, treatment may only consist of surgical removal of the tumor (National Children's Cancer Foundation, 1997). However, if the cancer has spread, the patient may require chemotherapy, radiation therapy, and/or bone marrow transplantation. The sooner the cancer is identified, the better the prognosis will be for the child, and the younger the child is, the better his/her outlook seems to be (Granowetter, 1994). The overall survival rate for neuroblastoma is 61% (American Cancer Society, 1997).

Bone Tumors

Six percent of childhood malignancies are bone tumors (National Children's Cancer Foundation, 1997). Two common types of bone cancer are osteosarcoma and Ewing's sarcoma. Osteosarcoma occurs mainly in children ages ten to 20. Its symptoms include a rapid growth spurt and swelling at the tumor site (American Cancer Society, 1997; Granowetter, 1994). Treatment for osteosarcoma is usually intensive and may interfere with normal functioning. It may include tumor removal, chemotherapy, and possibly amputation. Ewing's sarcoma consists of tumors that are found in the marrow spaces between the bones (National Children's Cancer Foundation, 1997). Like osteosarcoma, its peak incidence is from ages ten to 20. Ewing's sarcoma also requires intensive treatment; the patient may receive aggressive chemotherapy for approximately one year, then the tumors are surgically removed, and then the patient receives radiation therapy with continued chemotherapy (Granowetter, 1994). For all bone cancers, the five-year survival rate is estimated at 65% (American Cancer Society, 1997).

Retinoblastoma

Retinoblastoma is cancer of the eye. It is often present at birth, and 40% of the cases are hereditary. It occurs in one out of every 18,000 births, and is usually identified by age three. Symptoms include squinting and other vision problems. Retinoblastoma has various treatments; the most severe cases may require chemotherapy and/or radiation therapy. If treated early, a complete cure is possible (Granowetter, 1994).

Effects of Cancer and Its Treatment

Physical and Medical

There are numerous physical and medical conditions that may arise as a result of cancer and its various treatments. Chemotherapy, radiation therapy, BMT, and surgeries have different effects on each child; these effects depend on the methods employed and the aggressiveness of the treatment. Children who have undergone BMT and total body irradiation (TBI) often experience thyroid dysfunction, growth delay, problems with sexual maturation and fertility, and cataract development (Phipps, 1994). Meadows and Silber (1985) name several other long-term conditions that can occur as a result of cancer treatments, including scoliosis, dental and facial problems, cardiac abnormalities, pulmonary abnormalities, liver damage, urinary tract problems, and amputation. Mulhern, Wasserman, Friedman, and Fairclough (1989) add scars (due to surgical removal of tumors), immature development of organs, and hearing loss to this list. Kazak (1994) acknowledges that various short-term problems may result as well, including weight gain or weight loss and hair loss.

Psychological Effects Resulting from Appearance-Related Effects of Treatment

Undoubtedly, changes in physical appearance have psychological implications for youths that have undergone cancer treatment. In general, a poor body image is associated with self-rankings of academic, social, and psychological impairment, low self-esteem, and symptoms of depression (Hesse-Biber, Clayton-Matthews, & Downey, 1987; Noles, Cash, & Winstead, 1985; Silberstein, Striegel-Moore, Timko, & Rodin, 1988). A study by Varni, Katz, Colegrove, and Dolgin (1995) showed these associations to be true as well in children with cancer. In this study, 30 children ages 8-13 with varying types of cancer showed that a more positive perception of one's physical appearance was significantly correlated with fewer depressive symptoms, less social anxiety, and a higher self-esteem. Bolstering these results are results from a study of 21 cancer survivors ages 11-21 conducted by Pendley, Dahlquist, and Dreyer (1997). This study showed that the more the subject perceived that his or her appearance was affected by cancer, the worse he or she tended to rate social adjustment, which included feelings of loneliness and social anxiety.

Other Psychological Effects

Psychological issues related to physical appearance are not the only issues that a child with cancer or a cancer survivor may experience. Kazak (1994) acknowledges that "the data are clear in stating that most childhood cancer survivors do not have clinically significant psychological difficulties and most function well. However, a troubling subset of survivors do have significant difficulties, which we do not presently understand very well" (p. 179). Researchers have found a variety of these psychological difficulties in children affected by cancer. These reactions and conditions include anxiety and panic (both chronic and acute) (Kazak et. al, 1997); inhibited and withdrawn behavior; fear of trying new things; low emotional expressiveness (Stehbens, Kisker, & Wilson, 1983); behavior problems (Carpentieri, Mulhern, Douglas, Hanna, & Fairclough, 1993); an excessive number of unfounded somatic complaints (Mulhern et al., 1989); intense stress (Kazak & Christakis, 1996); post-traumatic stress disorder (PTSD) (Stuber, Nader, Yasuda, Pynoos, & Cohen, 1991); frustration and discouragement related to school difficulties (Kazak, Christakis, Alderfer, & Coiro, 1994); peer relationship difficulties (La Greca, 1990); loss of independence (especially during adolescence); concern about ability to attract the opposite sex; and worries about the future in relation to career and relationships (Stevens & Dunsmore, 1996). Varni, Katz, Colegrove and Dolgin (1994) offer a reason for these psychological difficulties; they state that "the chronic strains of childhood cancer, such as treatment-related pain; nausea and vomiting; visible side effects such as hair loss, weight gain or loss, and physical disfigurement; and repeated absences from school and peers, interact to negatively impact social and psychological adjustment""(p. 20).

There are numerous factors, however, which seem to predict better psychological adjustment for children with cancer. As mentioned earlier, the less they believe their physical appearance is affected by cancer, the better their adjustment seems to be (Pendley et al., 1997). Furthermore, having high levels of support from the family, classmates, the school, and the hospital predicts better adjustment (Kazak, 1994; Varni et al., 1994). Furthermore, social skills training has been shown to improve adjustment; "social skills training is hypothesized to facilitate adaptation by teaching the child a set of social skills that are particularly relevant to cancer and its treatment" (Varni, Katz, Colegrove, & Dolgin, 1993, p. 753). Additional factors that are related to positive adjustment are the use of successful coping strategies; the absence of learning difficulties; the absence of functional and physical limitations; and not coming from a single-parent home (Kazak, 1994; Kazak, Christakis, Alderfer, & Coiro, 1994; Mulhern et al., 1989).

Cognitive and Neuropsychological Effects

Currently, data are mixed regarding the long-term effects of various cancer treatments on cognitive abilities. However, studies show that certain treatments may have an adverse effect on IQ. In a review of the literature regarding this area, Mulhern (1994) reports that research on children with ALL and brain tumors shows that having CRT may be related to a decrease in IQ scores. He reports that these effects seem to be increased if the child received CRT at a young age and if the child is female. In addition, the more time that passes since treatment, the more impaired intellectual functioning seems to become. Furthermore, having a brain tumor in certain vulnerable parts of the brain may cause neurological impairments as well. Mulhern (1994) reports specific neuropsychological difficulties in children who have received these treatments, which include difficulties with higher conceptual abilities, memory functioning, visual-motor functioning, visuographic abilities, and fine motor skills. Brown and Madan-Swain (1993) report these difficulties in their review of literature on the topic, as well as various signs of attention deficit hyperactivity disorder (ADHD), such as distractibility, impulsivity, and concentration problems.

Not only does CRT seem to have an effect on learning ability, but certain chemotherapeutic agents may cause side effects that impact learning as well. Children with brain tumors, ALL, and solid tumors who have received chemotherapy reported fatigue, decreased energy, motor weakness, hearing impairment, and irritability (Armstrong & Horn, 1995). However, the side effects of the chemotherapy may not be all that affects learning; the chemotherapy itself may also negatively affect cognitive abilities. Brown et al. (1996) compared children who had received chemotherapy that affected the CNS to children who had received chemotherapy that did not affect the CNS. Their results showed that those who had received the CNS chemotherapy had poorer academic achievement, as measured by tests in reading, spelling, and arithmetic.

Educational Implications

Under P.L. 94-142, children with identified disabilities are entitled to a free and appropriate public education. Students with cancer may fall under the category of "orthopedically impaired" or "other health impaired", since children with cancer may have "limited strength, vitality, or alertness due to chronic or acute health problems_which adversely affect educational performance" (P.L. 94-142, 1975). In addition, children with cancer may be eligible to receive related services that will help them to benefit fully from their educational experience, such as audiology and speech pathology, counseling and psychological services, medical services, occupational and physical therapy, and school health services (e.g., services provided by the school nurse).

Students with academic difficulties may be eligible to receive assistance in a special education program. Kazak et al. (1994) report that 25% of their sample of long-term cancer survivors received special school services related to learning problems. The need for the availability of special education for this population becomes clear when one considers that almost 30% of adult cancer survivors report having academic difficulties (Lansky, List, & Ritter-Sterr, 1986).

Contributing to the learning problems which many students with cancer face is the high rate of absenteeism that may result from hospitalizations, treatments, and treatment side effects. Children with leukemia report missing up to 10-20 weeks of school in one year, and as a result, many children repeat grades (Deasy-Spinetta, 1981; Mulhern et al., 1989).

Given the documented psychosocial problems and academic difficulties, thorough attention must be given to all aspects of the difficulties that face children with cancer. It is beneficial to look at the issues surrounding childhood cancer in light of the systems in which the child exists, namely the family and the school.

School reentry is one issue in which both the family and the school play important roles. Returning to a normal routine as soon after diagnosis as possible is crucial for the child with cancer, as this normalcy has a significant effect on a child's general adjustment and self-esteem. School to a child is like work to an adult, and when a child is out of school for a long period of time, he or she may experience reactions such as depression, apathy, and poor self-concept, as if he or she was "unemployed" (Katz, 1980).

The Role of the Family

Family members of a child with cancer may suffer various forms of distress in regards to the child's illness. Parents report feelings of uncertainty, loneliness, low self-esteem, symptoms of PTSD, and distress related to the adjustment of the child's siblings (Kazak et al., 1997; Van Dongen-Melman et al., 1995). These problems may be exacerbated if the parents are of low SES, have no religious affiliation, have chronic illness in another family member, and have other concurrent stresses in their life (Van Dongen-Melman et al., 1995).

Parents' attitudes about school reentry may reflect this distress, and they may delay or discourage school reentry based on their feelings of uncertainty about the child's future. In addition, parents may feel that the emotional and physical effort of returning to school will be "too much" for the child (Lansky et al., 1983). In addition, research has shown that both parent and child may display separation anxiety which manifests itself as school phobia; the child may express somatic complaints, which the parent responds to by allowing the child to stay home from school, and this pattern of absenteeism becomes a cycle in which the child ultimately refuses to attend school at all (Lansky et al., 1975).

Researchers have provided guidelines for parents to follow in order to facilitate a successful school reentry after cancer diagnosis and treatment. First, parents should provide the school with accurate and up-to-date medical information, and they should communicate effectively and regularly with school personnel regarding the child's condition. Also, parents should encourage and facilitate continued interactions with classmates and peers. Parents should ensure that the child keeps up with his or her school assignments. Finally, parents should encourage the child to participate in ordinary tasks, responsibilities, and school activities (Sexson & Madan-Swain, 1993; Spinetta & Deasy-Spinetta, 1986). By following such guidelines, parents not only facilitate a return to the normal routine, but they also show the child that they have an optimistic expectation that the child will survive (Deasy-Spinetta & Spinetta, 1980).

The Role of the Teacher

The teacher plays a crucial role in facilitating a smooth transition back into the classroom for the child with cancer. There are several aspects to this role, one of which is knowledge of all relevant information about the child and his or her illness. The teacher should be aware of the type of cancer that the child has, its symptoms, the prognosis, and the treatments and their side effects. Also, the teacher should be aware of the wishes of the parents and the child regarding what they want the classmates and other school personnel to know about the child's illness. Additionally, the teacher should be knowledgeable regarding the effects of the disease and treatments, and how these effects can affect certain skills needed for learning, such as attention, memory, nonverbal skills, language skills, and motor skills. The teacher should be aware of the psychological effects of cancer and be prepared to deal with issues such as anxiety, behavior problems, emotional difficulties, peer relationship difficulties, and frustration related to school difficulties. Finally, the teacher should receive a schedule of upcoming medical appointments, so that they can help the child prepare ahead for absences (Nessim & Katz, 1995).

The teacher also is instrumental in preparing the class for the child's return. The teacher should have a classroom presentation given by a hospital/school liaison regarding the child's disease, the purpose of which is to explain what is going on, answer questions, and clarify stereotypes about cancer (Goodell, 1984; Katz, 1985; Nessim & Katz, 1995). If the child is currently unable to attend school, the teacher can facilitate classmate support by encouraging contact with the child (Chekryn, Deegan, & Reid, 1986).

The teacher should use the knowledge that he or she has about the effects of treatments in his or her teaching methods and disciplinary practices. The child may show academic and behavioral problems that are a result of treatment, and thus the teacher will need to adjust to the needs of the individual student. However, the teacher should maintain appropriate expectations regarding the child's schoolwork (Henning & Fritz, 1983).

The Role of Peers

Peer support is extremely important to the child with cancer during school reintegration. As mentioned previously, higher perceived social support from classmates is correlated with higher psychosocial adjustment for children with cancer. LaGreca (1989) agrees with this assertion; i.e., the more the disease interferes with the social functioning of the child, the more it may compromise the general psychosocial adaptation of the child. Furthermore, peers are likely to influence treatment and medication compliance; i.e., a child is more likely to ignore treatment and medication rules if they interfere with social situations (LaGreca, 1989).

Thus, dissemination of information to peers is crucial. If peers are knowledgeable and informed about the disease, they seem to be more likely to accept and interact with children with cancer (Mabe, Riley, & Treiber, 1987). Children's knowledge about the disease varies according to individuals and developmental level; elementary school students are likely to ask questions such as "What is cancer?" "Can he/she die from it?" "Can I get cancer?" "Can he/she still play?" "Can we talk about it or should we ignore it?" Middle school and high school students tend to ask harder, more theoretical questions (Peckham, 1993; Sexson & Madan-Swain, 1993). Children tend to have many misconceptions about the disease, and these conversations are crucial to dispelling myths that may affect the way in which peers treat the child.

The Role of the School Psychologist

Nessim and Katz (1995) delineate the role of the school psychologist during school reintegration as follows: a) to educate parents, medical personnel and school personnel about the special needs of the child; b) to teach parents how to gain access to services within the educational system; c) to help teachers provide an effective learning environment based on the child's individual needs; d) to educate peers about the child's situation so that they can be accepting and supportive; and e) to work directly with the child or adolescent to ensure adjustment, both academically and socially.

Nessim and Katz also suggest some more specific functions that the school psychologist should perform before the child's return to school. If possible, the school psychologist should conduct a pre-treatment baseline assessment of cognitive and academic functioning and then a post-treatment assessment. In addition, periodic assessments should be done as well in the years following treatment. The purpose of the continuous testing is to assess the possible effects of the treatment, as well as to determine if treatments negatively affect abilities that emerge at different developmental periods (Armstrong & Horn, 1995; Nessim & Katz, 1995). Not only should the school psychologist assess cognitive abilities, but he or she should also assess psychosocial functioning. It is important to identify children and teens that are at-risk for poor psychosocial adjustment, so that they can receive prompt and appropriate intervention.

In addition to assessment, Nessim and Katz recommend that the school psychologist act as a liaison between the regular classroom teacher and home or hospital teachers in order to ensure that educational services are adequately received during absences. It is important that the student stay as current as possible in his or her studies; Lansky, Lowman, and Vats (1975) found that daily inpatient teaching in hospitals improved school performance, decreased anxiety about school return, and positively influenced the overall experience of children with cancer. In addition, encouraging the child to keep up with his or her studies may "assure him that health professionals believe treatment might be successful and that it is appropriate to plan for the future" (Battista, 1986).

At the time of the child's return, the school psychologist has additional functions to perform (Nessim & Katz, 1995). First, the school psychologist should arrange conferences with relevant individuals to ensure a smooth transition back to the school. He or she should meet first with the family, to prepare them for the child's return and inquire about their wishes and needs. Then he or she should meet with medical personnel and school personnel, so that this information can be communicated as well as specific information regarding medical and educational issues. This step is important to establish the school psychologist's role as the liaison during the reentry process. Teachers want to know specific medical information about the student's illness, side effects the child has experienced, learning difficulties that may occur, psychological effects of the illness on the child, and how to talk with the student about cancer (Fryer, Finch, Saylor, & Smith, 1989). Thus, the school psychologist should obtain this information from the parents and medical personnel so that they can disseminate it to the teachers and other relevant school personnel.

Second, the school psychologist should function as an aid to parents during this process. He or she should help them gain access to available school services, as well as aid them in going through the IEP process, if necessary. Additionally, he or she can discuss other possible interventions that may become necessary as the child progresses through school, such as social skills training or additional tutoring.

Third, the school psychologist should set up the classroom presentation, the purpose of which, as stated earlier, is to provide information to classmates, dispel stereotypes about cancer, and to help the peers to be less anxious and more supportive of their classmate with cancer. During the presentation, the school psychologist should describe the patient's hospital experiences, provide the class with information about the child's specific illness and treatments, discuss social support and teasing, and establish the patient as the expert on his or her disease and treatment. It is important to keep in mind developmental issues when conducting a classroom presentation (Katz, Rubinstein, Hubert, & Blew, 1988).

Finally, due to the vast amount of psychological issues that the child with cancer and his or her family may experience, the school psychologist should either provide counseling or refer the child and family to counseling. This counseling may consist of support groups, individual counseling, or social skills training. In addition to providing support to the child and family, the school psychologist may need to offer support to school personnel as well. Chekryn, Deegan, and Reid (1987) found that teachers expressed feelings of shock, worry, uncertainty and frustration regarding having a child with cancer in their classroom. Some teachers sought out the school nurse for support and information; however, teachers reported that a lack of visibility, a lack of accessibility, and a lack of rapport prevented them from receiving support from the school nurse. Thus, the school psychologist should establish him or herself as a source of support and information for teachers.

A Successful Reintegration Program

Nessim and Katz (1995) have developed The Cancervive Teacher's Guide for Kids with Cancer, which goes along with the School Reintegration Program developed by Ernest Katz. This program is research-based and extremely comprehensive, and consists of the school psychologist functioning in the capacities suggested above by Nessim and Katz. The accompanying guide acts as a resource for teachers who have a student with cancer. It addresses a variety of relevant topics, such as medical information about cancer, cancer treatment, emotional impact of cancer, role of school personnel in school transition, possible academic effects of treatment, how to deal with classmate reactions, coping with medical crises, and follow-up for cured youths. In addition, the guide provides a sample classroom presentation and a list of resources for information on cancer.

Studies evaluating the program showed that it was highly effective. Children with cancer who were a part of this project showed fewer behavior problems; less internalizing behavior; fewer symptoms of depression; greater perceived social, academic, and physical competence; less anxiety; and greater levels of developmentally appropriate behavior (Nessim and Katz, 1995). Furthermore, evaluations of the program by teachers, parents, and children have been very positive (Katz, Varni, Rubenstein, Blew, and Hubert, 1992).

Conclusion

More and more children survive cancer each year due to improvements in medical technology and treatments. These cancer survivors face not only the issues that surround the illness and its treatments, but also medical and physical, psychological, cognitive and neuropsychological, and social issues. As the child returns to school, he or she must face these issues that inevitably impact school adjustment and performance. Without intervention, these issues may have negative, long-lasting effects. Thus, it is crucial that a comprehensive plan involving the family, peers, the teacher, and the school psychologist be implemented for the school reintegration process of a child with cancer.

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