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  • Pediatric Research and Positive Psychology: The Case of Pediatric Oncology

  • By Lora Scagliola, M.A., and Christie Rizzo, Ph.D.

    November 2010 Vol. 26, No. 11

    Following World War II, psychology became a science largely devoted to the repair of damage using a disease model of human functioning. As a result, the idea of a well-adjusted, fulfilled individual became a supremely neglected area of research (Seligman, 2002). In recent years positive psychology has challenged the historical bias toward risk-based models by opening investigations to not only fix what is wrong, but to build qualities in individuals that support personal, social, and community success.

    November 2010 Vol. 26, No. 11

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    This article was published in the Brown University Child and Adolescent Behavior Letter
    in cooperation with Bradley Hospital.

    Thus, from a positive psychology perspective, research and practice are concerned with both the elimination of risk factors, as well as the development of protective factors.

    Psychology research has long been successful in identifying risk factors for negative outcomes during childhood and adolescence. However, a risk-based approach has its limitations, as many at-risk adolescents emerge from chronically challenging circumstances with psychological health, and go on to become productive and well-adjusted adults. Risk-based approaches are not fully able to explain the mechanisms underlying this process. To that end, positive psychology research attempts to understand the mechanisms by which protective factors may buffer risk and negative clinical outcomes (e.g., psychosocial maladjustment, suicide), as well as potentially extending our empirical understanding and interventions.

    When viewing development from a positive psychology perspective, an essential precept is the promotion of positive development in youth who face adverse circumstances, as well as the overall promotion of subjective well-being (i.e., happiness). Subjective well-being is comprised of cognitive and affective components including relatively high levels of positive effect, low levels of negative effect, and the overall cognitive appraisal that one's life is good, also termed, life satisfaction. Park (2004) proposes that positive youth development programs can use life satisfaction as an indicator of program effectiveness.

    One reason why life satisfaction is a promising indicator is that it is often related to typical outcomes targeted in prevention programs, such as good physical health, healthy self-esteem, optimism, and self-efficacy, and is also related to reductions in behavioral and emotional problems. (Incidentally, while life satisfaction is believed to be relatively stable, one's life satisfaction can be increased with psychological invention, such as therapy targeting depressive symptoms following a negative life event [e.g., loss].)

    Other protective factors that would benefit from further empirical investigations include social competence, family cohesion, pro-social behaviors, positive self-appraisals, and the presence of specific "signature strengths," such as optimism and gratitude.

    Although there are many areas of pediatric research that could be approached from a positive psychology perspective, pediatric oncology is one area that is increasingly adopting a positive psychology focus. The experience of diagnosis, treatment, and survivorship of pediatric cancer is considered a challenging and potentially traumatic experience for children and their families. Children with cancer face enormous burden and stress including the displacement from one's peer group, school activities, and family life; pain, fear of death, threats of relapse; treatment-related physical and neurological late-effects; realization of long-term consequences; and second malignancy.

    Given the diverse nature of the stressful circumstances surrounding cancer treatment, and the many opportunities for risk and resilience factors to emerge, pediatric oncology provides a fertile ground for positive psychology research.

    The case of pediatric oncology

    While increased difficulties in daily adjustment and overall well-being have been hypothesized by much of psychosocial research, studies have not consistently demonstrated increased distress and adjustment problems in children receiving treatment for cancer, or in survivors of childhood cancer. Rather, results indicate that children with cancer and those who have survived report low levels of psychological distress, depression, anxiety, and post-traumatic stress (Phipps, 2005); and in general, children who have had cancer appear to adjust well over time.

    A review by Phipps (2005) presents abundant data supporting the view that most children who have had cancer experience healthy adjustment and lack major psychosocial distress in the years following treatment. For instance, the majority of published studies demonstrate that children who have had cancer report low levels of depressive symptomalogy when compared to children who have never had cancer. More recent studies have focused on outcomes thought to be more specific to the cancer experience (e.g., post-traumatic stress disorder). While PTSD symptoms may be elevated among parents whose children have had cancer, lower levels of symptoms continue to be reported within the pediatric population in those individuals without preexisting psychological difficulties

    The obvious question is why do pediatric cancer patients so often escape negative outcomes? In addition to the personal characteristics described above, there are a number of contextual variables that may contribute to resilience and healthy psychosocial adjustment in pediatric cancer patients. Specifically, the community context - both medical and social - often rallies behind families faced with this trying situation. As a result, youth who are diagnosed with cancer are presented with a psychosocial buffer for experiencing psychological deterioration and developing mental health disorders.

    Based on this assertion, other child and pediatric populations who lack community support and are faced with stigma for the challenges they experience (such as families of domestic violence or in poverty, individuals with HIV/AIDS, or children who have experienced maltreatment) are likely to experience more difficulty demonstrating resilience. Examining the personal and contextual characteristics of children who have had cancer provides a unique opportunity to study the mechanisms by which resilience can be accomplished. As these mechanisms are identified, they may then be studied within other areas of pediatric psychology.

    Despite the growing evidence that positive psychology research could benefit both prevention and intervention initiatives, few pediatric researchers have delved into positive psychology concepts.

    Implications for clinicians

    In addition to the growing literature on resilience and protective factors among pediatric cancer patients, positive psychology concepts are beginning to be applied in other areas of pediatric psychology. For example, promising results have been found in applying positive youth development concepts to the promotion of sexual health and HIV/STD prevention. A recent review by Gavin and colleagues (2010) indicates that the personal characteristics of confidence, character, connectedness, and competence serve as protective factors for a number of HIV-related risk behaviors such as early sexual debut, pregnancy, and unprotected sex.

    Moreover, positive coping appraisals have been found to buffer the relationship between life stress and suicidality. These findings are particularly interesting for clinicians, as they suggest that treating suicidality is not simply about reducing negative outlooks, but is also about building the potential to view life in a more positive way. Indeed, mental health professionals using cognitive-behavioral methods aim to help individuals change their negative thoughts into more helpful ones. It is noteworthy that mental health clinicians often find that they actively apply positive psychology concepts in treatment, yet few studies have empirically supported the application of these concepts in clinical practice.

    In sum, despite the growing evidence that positive psychology research could benefit both prevention and intervention initiatives, few pediatric researchers have delved into positive psychology concepts. It is not necessary or advisable, of course, to abandon the traditional deficit model of development or psychology in order to do research from a positive psychology framework.

    However, researchers can include variables related to resiliency outcomes in current work to build not only a literature base of protective factors, but also to determine which factors mitigate risk. Research results highlighting both will have tremendous clinical implications, by both reducing mental health symptomalogy and risk, as well as increasing the potential for resilience and health.

    Lora Scagliola, M.A., is a doctoral candidate in school psychology at the University of Rhode Island. She is completing an APA accredited internship at the Alfred I. DuPont Hospital for Children in Wilmington, DE.

    Christie J. Rizzo, Ph.D., of the Bradley Hasbro Children's Research Center, is a staff psychologist at Rhode Island Hospital and an Assistant Professor (Research) in the Department of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University


    Park N: Character strengths and positive youth development. ANNALS Am Acad Polit Soc Sci 2004; 591:40-54.

    Phipps S: Commentary: Contexts and challenges in pediatric psychosocial oncology research: Chasing moving targets and embracing "good news" outcomes. J Ped Psychol 2005; 20:41-45.

    Seligman MEP: Positive psychology, positive prevention, and positive therapy. In C.R. Snyder & S. Lopez (Eds.), Handbook of positive psychology (pp. 3-12). New York, NY: Oxford University Press, 2002.