Psycho-Social and Emotional Impacts of Cancer
Many childhood fighters and survivors experience an identity paradox perpetuated by no longer being the ‘sick kid’ while not yet returning to their pre-cancer health. This liminal period can cause feelings of not “fitting in.” Fighters and survivors of cancer are vulnerable to social isolation and peer victimization, which can lead to a variety of mental health issues. Young survivors of cancer are at a higher risk for developing depression and anxiety due to disruptions in their social-emotional development trajectory, high levels of symptom burden, and the continuous fear of developing an aggressive disease.1
All of these factors have the potential to hinder a child’s school re-entry experience and result in an extremely arduous transition. To assist easing them back into the school system, it is imperative that school faculty/staff are educated on possible signs fighters and survivors of cancer may display when experiencing these mental health issues. This portion of the ABC’s of School Re-entry program’s goals include: (1) providing basic background information on common mental health struggles, (2) indicators that a child may be struggling with social or mental health struggles and (3) possible reasons why survivors may be encountering these obstacles.
- Park, E. M., & Rosenstein, D. L. (2015). Depression in adolescents and young adults with cancer. Dialogues in clinical neuroscience, 17(2), 171–180.
Depression in Children
Many pediatric fighters and survivors of cancer suffer from chronic health conditions, including cognitive and mental health struggles. More specifically, depression has been a focus of concern in research. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), defines a Major Depressive Episode as the presentation of five or more symptoms from the following list within a period of two weeks, with at least one of those five symptoms being either a depressed mood or loss of interest or pleasure.1
Possible secondary symptoms:1
- Appetite or weight changes
- Sleep difficulties (sleeping more or less)
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Diminished ability to think or concentrate
- Feelings of worthlessness or excessive guilt
Among young children, depression may present as frequent tantrums or irritability, increased talk about fears or worries, frequent stomach aches or headaches, sleeping too much or too little, frequent nightmares, difficulty making friends, or struggling academically.2 Within an adolescent population, signs of depression can include loss of interest in activities, decreased energy, changes in sleeping patterns, avoiding social activities, excessive diet or exercise, self-harm behaviors, and/or risky behaviors.2 Symptom manifestation and expression varies among age differences which may reflect developmental changes in cognitive, emotional, biological, and social competencies among children and adolescents. It is important to note that although these are common behavioral manifestations of depression, each child is unique.
Depression and Chemotherapy
Treatment for childhood cancer can often last for multiple years with the latter stages of treatment occurring while the child has returned to school. A common side effect of chemotherapy is increased fatigue. This fatigue is multidimensional with emotional, cognitive, and physical components. Studies have shown that while at their most fatigued, children and adolescents undergoing chemotherapy also report related symptoms such as increased levels of depressed mood and other changes to their affect.3 Additionally, they report increased physical complaints such as nausea, vomiting, and sleepiness.3 This is important to note for school officials as patients, who continue to undergo chemotherapy while returning to school, may experience a multitude of symptoms, such as fatigue and nausea, that have been shown to present similarly to symptoms of depression. This highlights the necessity of open conversation between the child and key stakeholders regarding their mood, and reintegration experience. The multidimensional interaction of emotional and physical components can deeply impact a child’s cognitive performance in school.
Depression and Academic/Social Disruptions
Survivors can experience a variety of treatment-related difficulties that impact their overall school experience, including their academic achievement. Regarding academic achievement, survivors are more likely to have a specific learning disability, frequently miss school, and/or repeat a grade, which all lead to disruptions in their school life.4 These disruptions make it difficult for child or adolescent survivors to sustain a high level of educational attainment, which may have been present before a diagnosis. Studies have shown that academic disruptions can lead to higher levels of psychological distress and depression.5
Survivors experience an impact to their social involvement which extends from the time of diagnosis throughout survivorship. With the loss of peer social support, survivors report that they lacked close friends or were less likely to confide in their friends.6 In addition to academic disruptions, the disruptions in social relationships in the school environment have consequences such as struggling with identity formation and life transitions.7 McKenzie and Crouch (2004) explain that survivors feel as though they cannot express their true feelings about their experience and diagnosis. Instead, discussions revolve around the positive and uplifting stories while avoiding topics such as the difficulty of treatment and the possibility of death. Fighters and survivors often alter their feelings, remain positive, and appear as normal as possible to protect close friends and family. Consequently, they may feel that they must become their own emotional support. By internalizing unpleasant and difficult thoughts and emotions, survivors may develop internalizing disorders such as anxiety or depression.
Childhood fighters and survivors of cancer are at risk for social and academic deficits, which can act as sources of distress and be a risk depression. This highlights the need for early intervention among pediatric cancer patients in order to limit the social and academic disruptions during school reintegration. By providing a smooth and cohesive transition, survivors will have greater success in both academic performance and mental health along the way.
- American Psychiatric Association Diagnostic and statistical manual of mental disorders: 5th Edn. Washington, DC: (2013)
- (2019, May). Child and Adolescent Mental Health. Retrieved from https://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/index.shtml.
- Whitsett, S. F. (03/2008). Chemotherapy-related fatigue in childhood cancer: Correlates, consequences, and coping strategies. Sage Publications. doi:10.1177/1043454208315546
- Kaye, E. C. (06/2017). Development of depression in survivors of childhood and adolescent cancer: A multi-level life course conceptual framework. Springer. doi:10.1007/s00520-017-3659-y
- Zeltzer, L. K., Recklitis, C., Buchbinder, D., Zebrack, B., Casillas, J., Tsao, J. C., … Krull, K. (2009). Psychological status in childhood cancer survivors: a report from the Childhood Cancer Survivor Study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 27(14), 2396–2404. doi:10.1200/JCO.2008.21.1433
- Barrera, M. , Shaw, A. K., Speechley, K. N., Maunsell, E. and Pogany, L. (2005), Educational and social late effects of childhood cancer and related clinical, personal, and familial characteristics. Cancer, 104: 1751-1760. doi:10.1002/cncr.21390
- Norma Mammone D’Agostino PhD & Kim Edelstein PhD (2013) Psychosocial Challenges and Resource Needs of Young Adult Cancer Survivors: Implications for Program Development, Journal of Psychosocial Oncology, 31:6, 585-600, DOI: 10.1080/07347332.2013.835018
- McKenzie, H. (04/2004). Discordant feelings in the lifeworld of cancer survivors. Sage Publications. doi:10.1177/1363459304041067
Young survivors of cancer are at a higher risk for developing anxiety due to disruptions in their social-emotional development trajectory, high levels of symptom burden, and fear of once again developing an aggressive disease (Park & Rosenstein, 2015). Childhood fighters and survivors experience significant medical related distress at a young age, which can be exacerbated by fears related to transitioning into survivorship, including school re-entry. This section will cover a brief description of anxiety and implications on pediatric patients transitioning out of the treatment phase into survivorship phase.
What is Anxiety?
Anxiety is described as an emotion that consists of feelings of tensions, unsettling thoughts, and physical changes such as increased heart rate and blood pressure1. Experiencing some degree of anxiety is normal; however, if the anxiety becomes prolonged to where an individual consistently experiences intrusive thoughts or concerns, an individual is diagnosed with an anxiety disorder1. Generalized Anxiety Disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as:
- Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities.
- The individual finds it difficult to control the worry
- The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some of the symptoms having been present for more days than not for the past 6 months)
- Restlessness, feeling keyed up or on edge.
- Being easily fatigued.
- Difficult concentrating or mind going blank
- Muscle tension
- Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
- The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
There are many factors that can lead to anxiety, such as traumatic events or situations in which an individual is uncertain of the outcome and often times feels endangered. However, the most direct contributor to anxiety is stress.
Anxiety and Stress
Stress is defined as the body’s reaction to a change that requires an individual to adjust or respond2. Similar to anxiety, stress is normal, as it is caused by aspects of one’s surroundings, body, or thoughts known as stressors2. There are two types of stress; acute stress or chronic stress.
Acute stress is the body’s immediate response to a difficult situation and can lead to an anxiety disorder if one experiences a severe instance of acute stress3. The second type of stress, chronic stress, occurs when an individual is consistently exposed to stressors that lead to a prolonged experience of stress, which can also cause an anxiety disorder3. Apart from these types of stress, if one experiences stress and their stress is left untreated, an individual experiences distress, which is considered a negative stress reaction2. Distress leads to an imbalance in the body’s state of equilibrium, not only resulting in anxiety, depression, or panic attacks, but also upset stomach, high blood pressure, chest pain, and difficulty sleeping2. Stress and anxiety are strongly correlated, while anxiety is often simply defined as a reaction to stress that not only impacts one’s psychological state, but also one’s biological functions4.
Anxiety is not Fear
Often times, the terms anxiety and fear are used interchangeably. However, fear and anxiety, even with their similarities, are referring to different states. Fear is generally seen as a reaction to a specific threat, while anxiety is seen as an unfocused future-oriented fear5. In other words, fear is a form of anxiety that is related to a specific thing or situation6. Hence, it is imperative to clarify that fear constitutes the instant reaction of being afraid, while anxiety refers to the notion of constant uncertainty and tension about a future event or about something from the past7.
Anxiety Developing During the Treatment Process
Understandably, families often focus on helping children physically recover from their cancer before focusing on their mental health. Due to the acute physical health needs of a child, the development of anxiety in pediatric patients goes amiss. During treatment for cancer, pediatric patients are at high risk for developing an anxiety disorder. The development of an anxiety disorder may arise from some of the following reasons8:
- The patient feels concerned about the physical changes that can result from cancer treatment, such as loss of hair, more fatigued appearance, or increased weakness.
- The patient may worry about the efficacy of the treatment and fear that the treatment may not be working.
- The patient may feel distressed for having cancer in the first place.
- The patient may worry about their future after cancer and how they might be treated differently than they were prior to their diagnosis and treatment.
Anxiety’s Negative Implications during Survivorship Phase
After entering the survivorship phase, many pediatric cancer survivors experience hardship in assimilating to their previous environment. The primary source of anxiety comes from their inability to interact with others during treatment, particularly their peers. For example, a study found that childhood cancer survivors were less likely to have friends and also less likely to maintain friends9. With continued isolation, pediatric cancer survivors become at risk of developing generalized anxiety disorder as well as panic disorder. Similarly, another source of anxiety common among pediatric cancer survivors is peer rejection, particularly becoming anxious by the possibility of having peers make fun of them or not accepting them because of their change in appearance10. Anxiety associated with peer rejection may lead to adverse effects on the pediatric cancer survivors’ academic and psychosocial development. Overall, developing an anxiety disorder in the survivorship phase may lead to increased distress, deterioration of health, and exacerbate fears of relapse in condition. It is imperative to focus on creating impactful and proactive school re-entry programs in order to mitigate the risk of anxiety in pediatric cancer survivors.
- Anxiety. (n.d.). Retrieved October 16, 2019, from Https://www.apa.org website: https://www.apa.org/topics/anxiety/index
- What Is Stress? Symptoms, Signs & More. (n.d.). Retrieved October 16, 2019, from Cleveland Clinic website: https://my.clevelandclinic.org/health/articles/11874-stress.
- Identify your stress triggers. (n.d.). Retrieved October 16, 2019, from Mayo Clinic website: https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress-management/art-20044151.
- Anxiety and physical illness. (n.d.). Retrieved October 16, 2019, from Harvard Health website: https://www.health.harvard.edu/staying-healthy/anxiety_and_physical_illness.
- Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic, 2nd ed. New York, NY, US: Guilford Press.
- Horwitz, A. (n.d.). Anxiety | Johns Hopkins University Press Books. Retrieved October 16, 2019, from https://jhupbooks.press.jhu.edu/title/anxiety.
- Anxiety vs. Fear. (n.d.). Retrieved October 16, 2019, from Psychology Today website: https://www.psychologytoday.com/blog/science-choice/201812/anxiety-vs-fear
- Late Effects of Childhood Cancer Treatment (n.d.). Retrieved October 16, 2019, from Cancer website: https://www.cancer.org/treatment/children-and-cancer/when-your-child-has-cancer/late-effects-of-cancer-treatment.html.
- Kazak A.E. et al. (2005). Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: A randomized clinical trial. Journal of Family Psychology, 18(3). pp. 493–504.
- Helms, A.S. et al. (2016). Facilitation of school re-entry and peer acceptance of children with cancer: a review and meta-analysis of intervention studies. European Journal of Cancer Care, 25(1). pp. 170-179.
School has been described as the business of childhood. It can serve as an essential venue for academic, cognitive, social, and emotional development. Childhood cancer patients can oftentimes feel isolated from their peers because no one understands what they are going through. They may feel misunderstood by their peers, due to minimal shared experiences. This can cause young people to isolate themselves from their friends and family members across settings. Despite spending the majority of their waking hours at school, surrounded by their peers, this lack of connectivity can exacerbate feelings of social isolation. After long periods of time without formal school education, school re-entry can be difficult both academically and socially. While academic intervention and support and/are more clearly discussed in the IDEIA, an aspect of school re-entry that is often overlooked is the social connectivity and adjustment. Social connectivity is vital to the development and the success of childhood fighters and survivors because without a supportive environment to learn in, they may not be able to reach their full potential
Current School Models:
Currently, federal legislation guarantees children with disabilities a free and appropriate public education (FAPE) through the Individuals with Disabilities Education Act (IDEA) of 2004, but childhood survivors of cancer do not readily fit into pre-established programs available in schools8. The late psychosocial effects of cancer, such as social isolation, are currently given little attention. Moreover, acute health episodes are typically responded to with impromptu plans, which may inadvertently create further educational boundaries. The category of “other health impairment” (OHI) in IDEA attempts to be inclusive of children with chronic illness; however, regulations require that child be experiencing “limited strength, vitality, or alertness due to chronic or acute health problems” and the lack of vigor must adversely affect the child’s educational performance. This mentality highlights the reactive nature of current legislation, as a chronically ill child must first fail academically before receiving appropriate support. Section 504 of the Rehabilitation Act of 1973 provides another option for childhood cancer survivors to receive accommodations. Any school-age child with a disability, regardless of the nature or severity of the disability, is entitled to a free and appropriate education 8. Through Section 504, students can receive accommodations but are ineligible for special education services such as social skills groups, which are essential for a smooth school re-entry experience. School re-entry programs that target the psycho-social and emotional needs of students are not mandated by law and when provided by a school system are typically reactive 5 .Psychosocial and emotional interventions benefit a student’s school re-entry experience 2 .Specifically, increased social support and increased community education is promising in producing a positive school re-entry experience3 .
In order for childhood cancer patients to thrive in school, they must first feel comfortable in their school environment. Research done by McKenzie and Crouch6 emphasize that childhood survivors experience a sense of separation from their social world due to the permanent branding of the disease. This branding represents one facet of disease burden, as children have reduced contact and connectivity with same age peers. Reduced contact often coincides with high levels of absenteeism and reduced perceived social support. Sociologically, decreased attendance is related to increased alienation from classmates, teachers and school administration4 . Perceived social support is imperative, in accordance with the stress buffer hypothesis, to reduce one’s vulnerability to the negative mental health impacts of stress1 .Thoits posits that in order to support a child with a serious chronic illness one must use deliberate enacted support which meets the individual’s immediate needs. Childhood fighters and survivors of cancer go through a unique life experience which may cause them to have a different outlook on life. High levels of absenteeism prior to re-entry can result in feelings of being different and “out of the loop.” The foundation of friendship is based on support, commonalities, and shared experiences. However, absenteeism and varying life circumstances can lead to social isolation. Many students express a fear of returning to school due to social isolation and perceived low levels of social support. With declining social support from people who have had experienced similar diagnoses (for example children at the hospital), young cancer survivors are given support from individuals they may perceive as misunderstanding them7.
- Cohen, S., & Ashby, T., (1985). Stress, Social Support, and the Bruffering Hypothesis. Psychological Bulletin. 98, 310-357
- Kaffenberger, C.J. (2006). School re-entry for students with chronic illness: A role for professional school counselors. Professional School Counseling, 9(3), 223-230. .
- Katz, E., Kellerman, J., Rigler, D., Williams, K.O., & Siegel, S.E. (1977). School intervention for pediatric cancer patients. Journal of Pediatric Psychology, 2(2), 72- 76. doi: 10.1093/jpepsy/2.2.72
- Katz, E. (2004). The critical role of school in a child’s life. Retrieved October, 6, 2007, from http://curesearch.org
- Lee, S.W. & Janik, M. (2006). Provision of psychoeducational services in the schools: IDEA, Section 504, and NCLB. In L. Phelps (Ed.), Chronic health-related disorders in children: Collaborative medical and psychoeducational interventions (pp. 25-39). Washington, DC: American Psychological Association.
- McKenzie H. & Crouch M. (2004) Discordant feelings in the life- world of cancer survivors. Health 8(2), 139–157.
- Thoits, P. A. (1985). Self-labeling processes in mental illness: The role of emotional deviance.American Journal of Sociology, 91(2), 221-249. http://dx.doi.org/10.1086/228276
- (USDE) U.S. Department of Education. (2007). Free appropriate public education for students with disabilities: Requirements under Section 504 of The Rehabilitation Act of 1973. Washington, DC: Office for Civil Rights
What is peer victimization?
Peer victimization has been mistakenly defined as “bullying,” however, it has a much broader definition. When a child is victimized, they are the occasional target of aggressive acts from their peers.1 Studies have shown that approximately 10-15% of youth are currently experiencing peer victimization.2 These aggressive acts can be expressed in many different forms, such as physical violence, cyberbullying, social exclusion, etc.2 Although the outcomes of peer victimization that receive the most public awareness are those associated with suicidal ideation or behaviors, there are still many other concerning consequences that may arise.2 It is imperative that we, as adults and social support pillars, are educated on what may be occurring behind the scenes in an educational setting and what could occur if no action is taken.
What are the different types of peer victimization?
- Physical: One of the most commonly known forms of peer victimization is physical acts of aggression – some examples include pushing, biting, punching, etc. These acts are broadcasted on various social platforms and shown in numerous TV shows/movies. Physical peer victimization usually emerges very early in childhood and follows a declining trend. Young children have not reached the emotional capacity to regulate and cope with their feelings in a healthy manner. These aggravated feelings tend to come out in a physical manner, developing into physical peer victimization.3
- Social: With recent technological advancements and the prevalence of social media use, social peer victimization has been a large factor in conflicts among peers of this generation. Social peer victimization starts occurring and peaks during pre-adolescence. Even though children in these developmental stages improve emotional regulation, their increased social intelligence leads them to engage in more subtle forms of aggression. These acts of social peer victimization manifest as social exclusion, targeting someone with negative rumors, cyberbullying, etc. Adolescents are more likely to partake in social versus physical peer victimization since they are able to carry out these actions without causing harm to their social status or to themselves.3
- Bullying: Contrary to popular belief, bullying is not the correct term used to describe all peer victimization acts, but a subsection of the umbrella term. Bullying is defined as a continuous, negative peer relationship, where one child uses aggressive behavior to assert a dominant position over the other. There are two factors that are required to constitute something as bullying: (1) there must be a power disparity between the participants and (2) continuous, repetitive action. Studies have shown that there is actually an overall decline in bullying during development. During early childhood, there is much more opportunity to be bullied by upperclassmen. In contrast, older children are able to approach bullying in other ways that reduces their own risk for repetitive victimization.3
- Sexual Harassment: Recently, sexual harassment has started to become a more discussed issue in terms of victimization. Sexual harassment is becoming a common experience for youth, emerging in pre- to early adolescence. Studies have also found that sexual harassment victimization may emerge as early as the fifth grade and its rate of occurrence seems to increase until at least the ninth grade. This trajectory has been explained by two factors: (1) puberty occurs during early adolescence and (2) adolescents start to become more aware of their sexuality which causes a change in friend groups and various types of social behaviors. Straying from normal conditions, such as undergoing puberty earlier/later than others or exploring sexuality, can place a child as the center of victimization.3
What risk factors makes someone prone to peer victimization?
There are many risk factors associated with peer victimization. Keeping an eye out for expression of these risk factors in children can provide the opportunity for early intervention.2
- Higher levels of internalizing/externalizing problems
- Peer rejection
- Poor social competence and social skills
- Social isolation/exclusion
- Low peer status (popularity)
- Parental maltreatment or unhealthy home life4
What are the gender differences in peer victimization?
In addition to the various types of peer victimization, there are also gender differences in the frequency of each type. For example, boys experience more physical victimization than girls. Physical acts of victimization tend to stem from an inability to manage aggressive emotions and boys tend to exhibit more aggressive feelings than girls do. In contrast, girls experience more social victimization than they do physical; however, both boys and girls encounter equal levels of social victimization. Additionally, individuals who stray from social norms pertaining to sexuality are also at a much higher risk for sexual harassment victimization. An example of this is seen in the perpetuation of gender stereotypes – boys are expected to assert dominance over girls and girls are expected to be sexually passive. These victimization differences in gender are imperative components in monitoring possible concealed problems in an educational setting.3
What psychosocial effects come from peer victimization?
Early intervention for peer victimization is crucial so that it does not interfere with the developmental stages and transitions these children are currently experiencing. The negative consequences that arise from long-term victimization may not show themselves until adulthood but can greatly impact their own emotional well-being, self-esteem, relationship quality, etc. These psychosocial outcomes are similar to the risk factors of peer victimization which could lead to the individual becoming entrapped inside a cycle of subsequent victimization.3
- Sense of helplessness
- Lowered self-worth
- Social isolation
- Social anxiety
- Aggressive or delinquent behaviors
- Poor academic/workplace adjustment2
How does peer victimization pertain to recovering pediatric oncology patients?
Adolescence is a crucial time period filled with numerous, rapid transitions in various life domains, as well as the stage in life for peak developmental growth. This calls for an increased importance in the formation and retention of peer relationships.3 Recovering pediatric oncology patients who are trying to assimilate back into the school system are usually coming back from an extended period of leave. Studies have shown that this type of long-term absence is associated with an increase in isolation from peers and school personnel, thus putting them at an increased risk for peer victimization.5 It has been reported that recovering children experience fear upon their return to school, most often fear of rejection, having their diagnosis misunderstood, and fear of losing their social relationships. Some children have even exhibited that they feel more fear returning to school than they did during treatment.6
Upon completion of treatment, these children return to their school with a higher likelihood of having compromised friendships and no longer having the identity of being the “sick kid”. The success young survivors need to feel at school can be traced back to their interactions with their peers. Studies have shown that the public perception of cancer can greatly influence how survivors are treated by their peers. Healthy children are associated with more positive attributes than children with diagnoses.7 These stigmatizations can not only lead to social exclusion by peers, but they can also be detrimental towards a survivor’s self-perception.8 As discussed in the previous psychosocial effects review section, positive correlations have been found between stigma and symptoms of depression while negative correlations have been found between stigma and an individuals’ emotional well-being.9 Higher levels of perceived stigma are also in concordance with more psychological distress, internalizing shame, and a smaller social support system.10 Early intervention is imperative in a child’s journey returning back to school. Any hindrance in this process can lead to social exclusion by peers, thus resulting in impeding the child’s beliefs of successfully thriving emotionally and academically in an educational setting.
- Allyson A. Arana, Erin Q. Boyd, Maria Guarneri-White, Priya Iyer-Eimerbrink, Angela Liegey Dougall, & Lauri Jensen-Campbell. (2018). The Impact of Social and Physical Peer Victimization on Systemic Inflammation in Adolescents. Merrill-Palmer Quarterly, 64(1), 12-40. Retrieved from https://www.jstor.org/stable/10.13110/merrpalmquar1982.64.1.0012
- Troop-Gordon, W. (2017). Peer victimization in adolescence: The nature, progression, and consequences of being bullied within a developmental context. Journal of Adolescence, 55, 116–128. https://doi-org.libproxy.lib.unc.edu/10.1016/j.adolescence.2016.12.012
- Li, J. (2014). The Development of Peer Victimization in Adolescence.
- Shields, A., & Cicchetti, D. (2001). Parental maltreatment and emotion dysregulation as risk factors for bullying and victimization in middle childhood. Journal of Clinical Child Psychology. doi: 10.1207/S15374424JCCP3003_7
- Gottfried, M. A. (2010). Evaluating the relationship between student attendance and achievement in urban elementary and middle schools: An instrumental variables approach. American Educational Research Journal, 47(2), 434-465. doi:10.3102/0002831209350494
- Russo, K., Donnelly, M., and Reid, A. J. M. (2006). Segregation- the perspective of young patients and their parents. Journal of Cystic Fibrosis, 5, 93-99.
- Weins, B.A. & Gilber, B.O. (2000). A reexamination of a childhood cancer stereotype. Journal of Pediatric Psychology, 25(3),151-159
- Thoits, P. A. (2010). Stress and health: Major findings and policy implications. Journal of Health and Social Behavior, 51(1, Suppl), S41–S53.
- Lebel, M., Castonguay, G. Mackness, G., Irish, J., Beziak, A., & Debins, G., M (2013). The psychosocial impact of stigma in people with head and neck or lung cancer. Journal of Psycho-Oncology, 22(1), 140-152.
- Min, A.K., & Jaehee, Y., (2014). Life After Cancer: How does public stigma increase psychological distress of childhood cancer survivors? International Journal of Nursing Studies, 51 (12). DOI: 10.1016/j.ijnurstu.2014.04.00