Academic Edi o : William A cese
Recei ed: 20 Decembe 2024
Re ised: 15 Janua y 2025
Accep ed: 16 Janua y 2025
Published: 21 Janua y 2025
Ci a ion: Fe az, A.; Fa ia, S.;
Je ónimo, M.; Pe ei a, M.G. Pa en al
Psychological Adjus men in Pedia ic
Acu e Lymphoblas ic Leukemia: The
Media ing Role o Family Func ioning
and Resilience. Cance s 2025,17, 338.
h ps://doi.o g/10.3390/
cance s17030338
Copy igh : © 2025 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license
(h ps://c ea i ecommons.o g/
licenses/by/4.0/).
A icle
Pa en al Psychological Adjus men in Pedia ic Acu e
Lymphoblas ic Leukemia: The Media ing Role o Family
Func ioning and Resilience
Ana Fe az 1, Susana Fa ia 2, Mónica Je ónimo 3and M. G aça Pe ei a 1,*
1Psychology Resea ch Cen e (CIPsi), School o Psychology, Applied Psychology Depa men ,
Uni e si y o Minho, 4710-057 B aga, Po ugal; [email p o ec ed]
2Cen e o Ma hema ics (CMAT), Depa men o Ma hema ics, Uni e si y o Minho,
4800-058 Guima ães, Po ugal; [email p o ec ed]
3Pedia ic Oncology Depa men , Hospi al Pediá ico, Cen o Hospi ala e Uni e si á io de Coimb a,
3000-602 Coimb a, Po ugal; [email p o ec ed]
*Co espondence: [email p o ec ed]
Simple Summa y: Pa en s o child en wi h acu e lymphoblas ic leukemia o en ace
challenges o hei psychological well-being due o he na u e o he disease and hei
pa en al esponsibili ies. Many expe ience clinically signi ican psychological dis ess,
while o he s seem o adap . Key ac o s in his adap a i e p ocess include amily esilience,
amily unc ioning, and pa en al coping s a egies. This longi udinal s udy aims o explo e
how psychological well-being, pa en al dis ess, coping s a egies, and amily unc ioning
and esilience change o e ime. The s udy also examines he media o oles o amily
unc ioning and esilience and coping s a egies in he ela ionship be ween pa en al
dis ess and psychological well-being. The indings highligh ha bo h indi idual and
amily ac o s in luence psychological well-being du ing ea men . S eng hening amily
esilience and unc ioning is c ucial o suppo ing pa en s, and a amily-cen e ed app oach
in heal hca e is impo an in add essing he challenges hey ace.
Abs ac : Backg ound/Objec i es: Acu e lymphoblas ic leukemia (ALL) is he mos com-
mon pedia ic cance , wi h in ense ea men s a ec ing bo h child en and hei amilies.
Limi ed in o ma ion is a ailable on pa en al dis ess and psychological well-being du ing
he i s ea men yea , wi h mos s udies ocusing on indi iduals a he han he amily
sys em. This s udy explo es longi udinal changes in pa en al dis ess (psychological mo -
bidi y and auma ic s ess symp oms), coping s a egies, amily esilience and unc ioning,
and psychological well-being. The s udy also examines he media ing oles o amily
esilience, amily unc ioning, and coping s a egies in he ela ionships be ween pa en al
dis ess and psychological well-being. Me hods: A p ospec i e s udy was conduc ed wi h
46 pa en s o child en newly diagnosed wi h ALL, assessing pa en al dis ess, amily unc-
ioning and esilience, coping, and psychological well-being ac oss h ee ea men phases:
consolida ion (T0), delayed in ensi ica ion (T1), and main enance (T2).
Resul s: Pa en al
dis ess and amily esilience signi ican ly dec eased om T0 o T2, while pa en al coping
imp o ed o e ime. Family unc ioning de e io a ed om T0 o T1, s abilizing he ea e .
Psychological well-being ollowed a non-linea ajec o y, ini ially declining om T0 o T1
and imp o ing om T1 o T2. Media ion analyses e ealed ha amily esilience and amily
unc ioning pa ially media ed he ela ionships be ween pa en al dis ess and psycho-
logical well-being. Pa en al coping did no eme ge as a media o .
Conclusions: Pa en al
psychological adjus men in he con ex o ALL is dynamic and in luenced by indi idual
and amily ac o s. In e en ions ha s eng hen amily unc ioning and esilience a e c u-
Cance s 2025,17, 338 h ps://doi.o g/10.3390/cance s17030338
Cance s 2025,17, 338 2 o 17
cial o suppo ing pa en al psychological well-being du ing ea men . A amily-cen e ed
app oach in heal hca e deli e y is essen ial o add ess indi idual and sys emic challenges.
Keywo ds: pedia ic acu e lymphoblas ic leukemia; pa en al dis ess; psychological
well-being; amily esilience; amily unc ioning; pa en al coping; amily-cen e ed ca e
1. In oduc ion
Acu e lymphoblas ic leukemia (ALL) is he mos common ea ly childhood ype o
cance , cha ac e ized as an agg essi e o m o leukemia ma ked by an o e p oduc ion o
lymphocy es in he bone ma ow and blood [
1
]. O e he las wo decades, ad ancemen s in
clinical ials, suppo i e ca e [
2
], and he apeu ic app oaches ha e signi ican ly imp o ed
ou comes o hese child en, esul ing in highe su i al a es [
3
]. A key ac o in his
p og ess is he use o isk s a i ica ion, based on pa ien cha ac e is ics, cell biology, and
ini ial ea men esponse h ough minimal esidual disease (MRD) assessmen [
4
].
In 2019
,
14 Eu opean coun ies adop ed he ALLToge he p o ocol, which inco po a es MRD and
gene ic p o iling o mo e p ecise isk s a i ica ion [
5
,
6
]. This collabo a i e p o ocol,
wi h i s mul i-phase ea men plan (induc ion, consolida ion 1, consolida ion 2, delayed
in ensi ica ion, consolida ion 3, and main enance), ailo s ea men in ensi y acco ding o
he g oup isk (s anda d isk, in e media e isk, and high isk) [
7
], op imizing he apy and
ul ima ely imp o ing su i al and quali y o li e (QoL) [
8
]. None heless, cance diagnosis
emains a sou ce o ea , o en leading o majo changes in he pa en s’ li es [
2
], usually
conside ed li e-changing [
9
]. Thus, he demands o diagnosis and subsequen ea men
s a egies impac pa en s’ ca egi ing oles and well-being [10].
ALL emains a li e- h ea ening condi ion [
11
], wi h pa en s pe cei ing a se ious h ea
o hei child’s li e and he ea men p ocess as complex and in asi e [
12
]. Th oughou he
ea men p ocess, pa en s expe ience equen hospi al isi s and admissions, in asi e and
pain ul p ocedu es, and heal h c ises, alongside dis up ions in hei physical, emo ional,
and social li es due o ea men [
13
]. The ea men las s 2 o 3 yea s, wi h in ensi e
he apy du ing he i s ew mon hs [
14
], placing amily membe s a g ea e isk o dis ess
compa ed o amilies coping wi h o he cance diagnoses [15].
As p ima y ca egi e s, pa en s play a c ucial ole in hei child en’s adjus men , sup-
po ing hei coping wi h illness and ea men while minimizing psychological e ec s [
16
].
Thei psychological well-being is a key ac o o e ec i e pa en ing in e en ion [
17
].
Howe e , s udies on pa en al psychological adjus men and well-being show mixed esul s,
pa icula ly du ing he i s yea o ea men , when heigh ened dis ess is common [
18
].
Pa en ing is o en pe cei ed as demanding and s ess ul, leading o physical and psycho-
logical consequences [
19
] such as symp oms o anxie y, dep ession [
20
,
21
], pos - auma ic
s ess [
21
,
22
], dis ess [
23
], bu nou [
24
], sleep dis u bances [
23
], and psychosocial and
inancial bu dens [
25
,
26
]. Addi ionally, pa en s also ace signi ican dis up ions in social
in e ac ions [
27
], wo k- ela ed conce ns, and changes in amily dynamics [
22
], u he
nega i ely a ec ing hei QoL [28] and psychological well-being [29].
A ecen sys ema ic e iew emphasized he associa ion be ween pa en al dis ess a
diagnosis and subsequen adjus men [
30
], wi h men al heal h issues po en ially las ing
o yea s a e diagnosis [
31
]. S udies ha e shown ha pa en s o child en wi h leukemia
o en epo low psychological well-being while ca ing o hei ill child [
32
,
33
]. The e-
o e, hese pa en s may be conside ed “hidden pa ien s”, equi ing special a en ion o
p e en physical and emo ional consequences [
34
]. Howe e , limi ed desc ip i e in o ma-
ion is a ailable in mos s udies ega ding pa en al dis ess h oughou he i s yea o
Cance s 2025,17, 338 3 o 17
ea men [35,36]
, unde lying he need o longi udinal s udies ega ding pa en al dis ess
in childhood ALL [30].
Despi e some s udies showing ha anxie y, dep ession, and auma ic s ess symp oms
end o dec ease o e ime, many ca egi e s con inue o expe ience clinically signi ican
psychological dis ess (e.g., [
35
,
36
]). Con e sely, o he s udies sugges success ul adap a-
ion and coping [
37
], highligh ing he absence o majo psychosocial di icul ies among
pa en s [
38
]. Key ac o s in his adap a i e p ocess include amily esilience [
39
,
40
], amily
unc ioning [41,42], and pa en al coping s a egies [33].
Family esilience is a po en ial esou ce wi hin he amily sys em [
39
] ha helps pa -
en s app oach challenges, main aining s abili y and a oiding dis up ions in amily li e [
43
].
The e o e, esilience is c ucial o managing cance - ela ed challenges e ec i ely [
44
], be-
ing di ec ly ela ed o psychological well-being [
45
]. Howe e , he abili y o be esilien
changes h oughou li e and in he p esence o a s esso e en [
46
], wi h some ami-
lies s ill s uggling wi h esilience challenges [
47
]. In his way, longi udinal s udies a e
needed o unde s and he dynamic changes in amily esilience o e ime and ac oss
ea men phases [48].
Family unc ioning, i.e., he way he amily as a whole deals and esponds o a child’s
illness, impac s he amily’s adjus men o a s esso e en [
41
], being posi i ely ela ed
o well-being [
49
]. Howe e , amily con lic s a e mo e p e alen in amilies o child en
wi h cance compa ed o amilies o heal hy child en [
50
]. As a esul , amilies wi h
poo unc ioning may be mo e suscep ible o adjus men challenges, as hey s uggle o
manage illness and pa en ing demands [
41
]. Resea ch ound ha amily unc ioning in
childhood cance is nega i ely impac ed, pa icula ly in he i s yea a e diagnosis [
50
],
bu esilience can help es o e amily unc ioning [
39
]. Al hough he e is g owing awa eness
o he impo ance o amily unc ioning in he con ex o pedia ic cance , mos s udies
ocus on indi idual-le el ac o s, neglec ing he amily-sys em pe spec i e [51].
Coping s a egies a e also cen al o s udies on he psychological well-being o pa en s
ca ing o child en wi h leukemia (e.g., [
33
]). Pa en s adop se e al s a egies o manage
ca egi ing challenges, which can imp o e o e all well-being [
52
]. Resea ch has shown
ha low emo ional coping (i.e., less cogni i e a oidance, less accep ance o esigna ion,
and less emo ional discha ge) is linked o be e psychological well-being [
53
], while
ac i e coping s a egies educe pa en al dis ess a yea a e he diagnosis [
9
]. A sel -
o ien ed pa en al coping app oach, compa ed o ea men - o child en’s daily ca e-o ien ed
s a egies, uniquely con ibu ed o pa en s’ psychological well-being [
33
]. Thus, iden i ying
ca egi e coping s a egies is essen ial o de eloping in e en ions o imp o e ca egi e s’
psychological well-being [54].
The i s yea o ea men is a pa icula ly ulne able ime o pa en s [
35
], making i
c ucial o unde s and he ajec o y o hei psychological well-being, dis ess (psychological
mo bidi y and auma ic s ess symp oms), coping s a egies, amily unc ioning, and
amily esilience. While mos s udies ely on c oss-sec ional designs, limi ed in o ma ion
is a ailable on how amilies and hei membe s adap o e ime [
55
]. Mo eo e , ew
s udies ha e explo ed pa en al psychological well-being in his con ex [
9
]. Conside ing
he c ucial ole o he amily in childhood cance [
51
], mo e a en ion should be di ec ed o
he impac o amily esou ces on pa en al adjus men ollowing hei child’s diagnosis [
42
],
such as amily unc ioning and amily esilience. Fu he mo e, coping s a egies emain
insu icien ly explo ed in he con ex o amily adap a ion o childhood cance despi e
hei po en ial signi icance [
56
]. Add essing hese gaps could p o ide aluable insigh s o
he de elopmen o amily-cen e ed psychological in e en ions aimed a enhancing he
psychological well-being o pa en s o child en wi h ALL. S udies ha e emphasized he
Cance s 2025,17, 338 4 o 17
unique challenges aced by amilies o child en wi h hema ologic cance s (e.g., ALL) and
he impo ance o ailo ed suppo esou ces [57].
This s udy is g ounded on Li neh’s [
58
] model o psychosocial adap a ion o ch onic
disease, which aims o unde s and he adap a ion p ocess wi hin he con ex o ch onic
illnesses. Acco ding o his model, adap a ion is a dynamic p ocess in luenced by a ious
ac o s, anging om indi idual cha ac e is ics o amily and social con ex s. Based on his
amewo k, he p esen s udy had he ollowing aims:
1.
To assess changes o e ime in pa en al psychological mo bidi y, auma ic s ess
symp oms, coping s a egies, amily unc ioning and esilience, and psychological
well-being while con olling o being on lea e;
2.
To explo e he media o ole o amily unc ioning, amily esilience, and coping
s a egies be ween psychological mo bidi y and psychological well-being;
3.
To explo e he media o ole o amily unc ioning, amily esilience, and coping
s a egies be ween auma ic s ess symp oms and psychological well-being.
2. Ma e ials and Me hods
2.1. S udy Design
This longi udinal s udy wi h h ee assessmen momen s is pa o a Po uguese mul i-
cen ic p ojec add essing he amily expe ience o childhood ALL. The s udy was con-
duc ed a h ee majo Po uguese cance hospi als, be ween Feb ua y 2022 and Augus 2024.
This s udy ecei ed app o al om he E hics Commi ee o Resea ch in Social and Human
Sciences o a majo public uni e si y (CEICSH 067/2021) and he E hics Commi ees o he
h ee hospi als whe e da a collec ion ook place (024/CES; CES.13/022; UIC/1474), and i
was pe o med acco ding o he Decla a ion o Helsinki. The pa icipan s we e in o med
abou he s udy and p o ided w i en in o med consen .
2.2. Pa icipan s
A o al o 50 pa en s and hei child en me he eligibili y c i e ia, and 46 ag eed o
pa icipa e in he p esen s udy. Child en we e eligible i hey we e diagnosed wi h ALL
o he i s ime, we e six yea s o younge a he ime o diagnosis, and we e ecei ing
ea men acco ding o he ALLToge he p o ocol. Ins i u ionalized child en, hose wi h
a p e ious
clinical his o y o oncological disease, and hose classi ied in he high- isk g oup
du ing he inal s a i ica ion we e excluded. Eligibili y c i e ia o pa en s we e o be he
child’s p ima y ca egi e , a leas 18 yea s old, and li e a e.
2.3. Ins umen s
2.3.1. Sociodemog aphic and Clinical Ques ionnai e
This ques ionnai e was de eloped o his s udy o assess pa en s’ and child’s sociode-
mog aphic a iables (e.g., sex, age, and ma i al s a us) as answe ed by he pa icipan s and
child’s clinical a iables (e.g., ime since diagnosis, du a ion o hospi aliza ion, and isk
g oup) as answe ed by heal hca e p o essionals.
2.3.2. Psychological Well-Being Scale (PWS) [59,60]
We u ilized a sel - epo scale ha assesses psychological well-being ac oss six di-
mensions: au onomy, en i onmen al mas e y, pe sonal g ow h, posi i e ela ions wi h
o he s, pu pose in li e, and sel -accep ance. I comp ises 18 i ems a ed on a i e-poin
Like scale anging om 1 o 5, wi h highe sco es indica ing highe le els o psycholog-
ical well-being. C onbach’s alphas o he Po uguese e sion anged om 0.36 o 0.50.
Only he o al scale was used in he p esen s udy, wi h a C onbach’s alpha o 0.84 and
McDonald’s omega o 0.82.
Cance s 2025,17, 338 5 o 17
2.3.3. Hospi al Anxie y and Dep ession Scale (HADS) [61,62]
This ques ionnai e e alua es psychological mo bidi y h ough 14 i ems equally di-
ided in o wo subscales: anxie y and dep ession. Each i em is a ed on a ou -poin Like
scale, anging om 0 o 3. High sco es indica e g ea e psychological mo bidi y. In he
Po uguese e sion, C onbach’s alpha was 0.76 o he anxie y subscale and 0.81 o he
dep ession subscale. In he p esen s udy, only he o al scale was used, wi h a C onbach’s
alpha o 0.89 and McDonald’s omega o 0.88.
2.3.4. Impac o E en Scale-Re ised (IES-R) [63,64]
This sel - epo scale e alua es auma ic s ess symp oms caused by a auma ic e en ,
ac oss 22 i ems di ided in o in usion, a oidance, and hype a ousal subscales. Pa icipan s
answe ed on a i e-poin Like scale, anging om 0 o 4, wi h highe sco es indica ing
g ea e auma ic s ess symp oms. In he Po uguese e sion, C onbach’s alpha anged
om 0.89 o 0.91. Only he o al scale was used in his s udy, wi h a C onbach’s alpha and
McDonald’s omega o 0.93.
2.3.5. Family Assessmen De ice–Gene al Func ioning (FAD-GF) [65,66]
As a single indica o , he global scale o he FAD e alua es he pe cep ion o o e all
amily unc ioning h ough wel e i ems, wi h six i ems on heal hy and six i ems on
unheal hy amily unc ioning. Sco ing is calcula ed h ough a ou -poin Like scale,
anging om 1 o 4. The highe he sco e, he mo e p oblema ic he amily’s o e all
unc ioning is pe cei ed o be. In he Po uguese e sion, C onbach’s alpha was 0.79.
In he
p esen s udy, C onbach’s alpha and McDonald’s omega we e bo h 0.93.
2.3.6. Family Ha diness Index (FHI) [67,68]
This sel - epo ins umen , consis ing o 20 i ems a ed on a ou -poin scale anging
om 0 o 3, e alua es he in e nal s eng hs and du abili y o he amily uni when dealing
wi h s ess o ad e si y h ough h ee subscales: commi men , challenge, and con ol.
A highe
sco e indica es g ea e amily esilience. C onbach’s alpha o he o e all scale
was 0.76 in he Po uguese e sion. C onbach’s alpha and McDonald’s omega, in his s udy,
we e 0.88 and 0.87, espec i ely.
2.3.7. Coping Heal h In en o y o Pa en s (CHIP) [69,70]
This ins umen assesses coping s a egies and s yles among pa en s o child en wi h
se e e o ch onic illnesses, h ough 44 i ems. Th ee coping pa e n subscales a e included:
(I) main enance o amily in eg a ion, coope a ion, and an op imis ic de ini ion o he
si ua ion; (II) main enance o social suppo , sel -es eem, and psychological s abili y; and
(III) unde s anding he medical si ua ion h ough communica ion wi h o he pa en s and
consul a ion wi h medical s a . I ems a e a ed on a Like scale om 0 o 3, wi h highe
sco es indica ing highe le els o pa en al coping. In he Po uguese e sion, C onbach’s
alphas we e ound o be 0.80, 0.82, and 0.76 o each scale, espec i ely, and 0.89 o he
o e all sco e. In he p esen s udy, C onbach’s alpha and McDonald’s omega o he o al
scale we e 0.87 and 0.88, espec i ely.
2.4. P ocedu e
Pa icipan s mee ing he inclusion c i e ia we e iden i ied by heal hca e p o essionals
and in o med abou he s udy du ing he ini ial phase o ea men . Those who ag eed
o mee wi h he esea che in pe son we e subsequen ly in i ed o pa icipa e in he
s udy. A e being in o med abou he s udy’s pu pose, da a con iden iali y, olun a y
pa icipa ion, and hei igh o wi hd aw wi hou consequences, pa icipan s who chose o
p oceed p o ided w i en in o med consen . Pa en s’ psychological mo bidi y and au-
Cance s 2025,17, 338 6 o 17
ma ic s ess symp oms, coping s a egies, amily unc ioning and esilience, and pa en al
psychological well-being we e assessed a h ee di e en ea men phases: he i s week
o
consolida ion 1 (T0)
; he i s week o delayed in ensi ica ion (T1); and he i s week o
main enance (T2) (see Figu e 1).
Cance s 2025, 17, x FOR PEER REVIEW 6 o 18
p oceed p o ided w i en in o med consen . Pa en s’ psychological mo bidi y and au-
ma ic s ess symp oms, coping s a egies, amily unc ioning and esilience, and pa en al
psychological well-being we e assessed a h ee diffe en ea men phases: he i s week
o consolida ion 1 (T0); he i s week o delayed in ensi ica ion (T1); and he i s week o
main enance (T2) (see Figu e 1).
Figu e 1. Schema ic o e iew and ch onological imeline o he s udy.
The i s assessmen (T0) was conduc ed in pe son, and pa icipan s answe ed se -
e al ques ionnai es (i.e., sociodemog aphic and clinical, anxie y, dep essi e and auma ic
s ess symp oma ology; amily unc ioning and esilience; and psychological well-being).
In he emaining assessmen poin s (T1 and T2), he da a we e collec ed h ough he online
so wa e Qual ics XM, a licensed ool o c ea ing and dis ibu ing ques ionnai es online,
which pa icipan s we e in i ed o comple e indi idually. Fo his pu pose, pa icipan s
we e con ac ed and eminded be o e he da a collec ion momen s o ensu e he easibili y
o all ime poin s. The esea che subsequen ly sen he link o he ques ionnai e. The
mean ime equi ed o comple e he sel - epo ques ionnai es was 20 min.
2.5. Da a Analysis
Sample cha ac e iza ion was pe o med h ough equencies and pe cen ages o ca -
ego ical a iables and means and s anda d de ia ions o con inuous a iables, using IBM
SPPS S a is ics (S a is ical Package o he Social Sciences) e sion 29.
The ollowing s a is ical analyses we e pe o med using he R S a is ical Compu ing
En i onmen [71]. The cou ses o pa en al psychological mo bidi y (anxie y and dep es-
sion symp oms), auma ic s ess symp oms, amily unc ioning, amily esilience, pa en-
al coping, and pa en al psychological well-being o e ime we e modeled using linea
mixed models while con olling o pa en al lea e s a us. The media ion analysis was pe -
o med using R and he media ion package [72]. The boo s apping echnique, in ol ing
5.000 samples, was applied o es ima e he 95% con idence in e als (CI) o he di ec and
indi ec effec s. Indi ec effec s we e conside ed signi ican i he 95% CI did no include
ze o [73].
Figu e 1. Schema ic o e iew and ch onological imeline o he s udy.
The i s assessmen (T0) was conduc ed in pe son, and pa icipan s answe ed se e al
ques ionnai es (i.e., sociodemog aphic and clinical, anxie y, dep essi e and auma ic s ess
symp oma ology; amily unc ioning and esilience; and psychological well-being).
In he
emaining assessmen poin s (T1 and T2), he da a we e collec ed h ough he online
so wa e Qual ics XM, a licensed ool o c ea ing and dis ibu ing ques ionnai es online,
which pa icipan s we e in i ed o comple e indi idually. Fo his pu pose, pa icipan s
we e con ac ed and eminded be o e he da a collec ion momen s o ensu e he easibili y
o all ime poin s. The esea che subsequen ly sen he link o he ques ionnai e. The mean
ime equi ed o comple e he sel - epo ques ionnai es was 20 min.
2.5. Da a Analysis
Sample cha ac e iza ion was pe o med h ough equencies and pe cen ages o
ca ego ical a iables and means and s anda d de ia ions o con inuous a iables, using
IBM SPPS S a is ics (S a is ical Package o he Social Sciences) e sion 29.
The ollowing s a is ical analyses we e pe o med using he R S a is ical Compu -
ing En i onmen [
71
]. The cou ses o pa en al psychological mo bidi y (anxie y and
dep ession symp oms), auma ic s ess symp oms, amily unc ioning, amily esilience,
pa en al coping, and pa en al psychological well-being o e ime we e modeled using
linea mixed models while con olling o pa en al lea e s a us. The media ion analysis
was pe o med using R and he media ion package [
72
]. The boo s apping echnique,
in ol ing
5.000 samples
, was applied o es ima e he 95% con idence in e als (CI) o he
di ec and indi ec e ec s. Indi ec e ec s we e conside ed signi ican i he 95% CI did no
include ze o [73].
3. Resul s
3.1. Sample Cha ac e is ics
The s udy included 46 pa en s (39 mo he s) a baseline (T0), wi h a mean age o
35.41 yea s
(SD = 6.77). Mos pa en s li ed in u ban a eas (54.3%) and we e ma ied (58.7%)
Cance s 2025,17, 338 7 o 17
o li ing wi h a pa ne (32.6%). The majo i y had no highe educa ion (54.3%), and 69.6%
o he 42 employed pa en s we e on lea e o ake ca e o he child en. Abou 89% o he
pa en s p o ided mo e han 18 h o ca e daily. The child en had a mean age o 3.48 yea s
(SD = 1.43), wi h 63.0% being gi ls. The sub ype o leukemia was p edominan ly ALL-B
(95.7%). On a e age, child en had been hospi alized o 21.96 days (SD = 9.25) and we e
diagnosed 31.65 days (SD = 5.90) be o e he assessmen .
Pa icipan s who d opped ou a e T0 and T1 did no signi ican ly di e om hose
who emained in he s udy ega ding hei sociodemog aphic and clinical cha ac e is-
ics. The sociodemog aphic and clinical cha ac e is ics o pa en s and child en a each
assessmen ime poin (T0, T1, and T2) a e p esen ed in Tables 1and 2, espec i ely.
Table 1. Pa en s’ sociodemog aphic and clinical cha ac e is ics a T0, T1, and T2.
T0 (n= 46) T1 (n= 42) T2 (n= 39)
Ca ego ical Va iables n(%) n(%) n(%)
Sex
Male 7 (15.2) 6 (14.3) 5 (12.8)
Female 39 (84.9) 36 (85.7) 34 (87.2)
Residen ial a ea
U ban 25 (54.3) 23 (54.8) 21 (53.8)
Ru al 21 (45.7) 19 (45.2) 18 (46.2)
Ma i al s a us
Single 4 (8.7) 4 (9.5) 2 (5.1)
Ma ied 27 (58.7) 24 (57.1) 22 (56.4)
Li ing wi h pa ne 15 (32.6) 14 (33.3) 15 (38.5)
Educa ion
Wi h highe educa ion 21 (45.7) 19 (45.2) 21 (53.8)
Wi hou highe educa ion 25 (54.3) 23 (54.8) 18 (46.2)
Employmen s a us
Unemployed 4 (8.7) 5 (11.9) 4 (10.3)
Employed 42 (91.3) 37 (88.1) 35 (89.7)
On lea e 32 (69.6) 27 (73.0) 25 (71.4)
Financial impac
No 30 (65.2) 17 (40.5) 17 (43.6)
Yes 16 (34.8) 25 (59.5) 22 (56.4)
Ch onic illness
No 37 (80.4) 34 (81.0) 32 (82.1)
Yes 9 (19.6) 8 (19.0) 7 (17.9)
Medica ion
No 34 (73.9) 32 (76.2) 29 (74.4)
Yes 12 (26.1) 10 (23.8) 10 (25.6)
Daily hou s o ca e
<6 h 0 (0) 1 (2.4) 1 (2.6)
6–12 h 0 (0) 4 (9.5) 4 (10.3)
12–18 h 5 (10.9) 4 (9.5) 8 (20.5)
>18 h 41 (89.1) 33 (78.6) 26 (66.7)
P esence o o he in o mal
ca egi e
No 5 (10.9) 6 (14.3) 8 (20.5)
Yes 41 (89.1) 36 (85.7) 31 (79.5)
Con inuous a iables Min–Max Mean (SD) Mean (SD) Mean (SD)
Age 23–52 35.41 (6.77) 35.19 (7.00) 35.56 (6.66)
Cance s 2025,17, 338 8 o 17
Table 2. Child en’s sociodemog aphic and clinical cha ac e is ics a T0, T1, and T2.
T0 (n= 46) T1 (n= 42) T2 (n= 39)
Ca ego ical Va iables n(%) n(%) n(%)
Sex
Boy 17 (37.0) 16 (38.1) 14 (35.9)
Gi l 29 (63.0) 26 (61.9) 25 (64.1)
Numbe o siblings
0 24 (52.2) 21 (50.0) 20 (51.3)
1 16 (34.8) 16 (38.1) 15 (38.5)
2 6 (13.0) 5 (11.9) 4 (10.3)
ALL sub ype
ALL B 44 (95.7) 40 (95.2) 37 (94.9)
ALL T 2 (4.3) 2 (4.8) 2 (5.1)
Induc ion ype
Induc ion A 31 (67.4) 28 (66.7) 29 (74.4)
Induc ion B 12 (26.1) 12 (28.6) 9 (23.1)
Induc ion A + C 3 (6.5) 2 (4.8) 1 (2.6)
Risk g oup
S anda d NA 12 (28.6) 11 (28.2)
In e media e low NA 14 (33.3) 15 (38.5)
In e media e high NA 16 (38.1) 13 (33.3)
Clinical complica ions
No 13 (28.3) 7 (16.7) 2 (5.1)
Yes 33 (71.7) 35 (83.3) 37 (94.9)
Con inuous a iables Mean (SD)
Min–Max
Mean (SD)
Min–Max
Mean (SD)
Min–Max
Age 3.48 (1.43)
1.25–6.00
3.39 (1.37)
1.25–6.00
3.49 (1.46)
1.25–6.00
Numbe o hospi aliza ions 1.46 (0.66)
1–3
4.90 (1.75)
7–12
7.18 (2.57)
3–16
Time since diagnosis (in days) 31.65 (5.90)
27–57
145.19 (20)
119–192
256.23 (58.81)
167–373
Hospi aliza ions du a ion (in days) 21.96 (9.25)
7–58
35.62 (14.01)
7–84
44.44 (15.31)
22–93
No e: NA = no applicable.
3.2. Di e ences o e Time
Pa en s’ psychological mo bidi y signi ican ly dec eased om T0 o T2 (
β
=
−
3.73,
p< 0.01
) and om T1 o T2 (
β
=
−
3.29, p< 0.01). T auma ic s ess symp oms signi ican ly
dec eased om T0 o T1 (
β
=
−
0.66, p< 0.05) and om T0 o T2 (
β
=
−
0.78, p< 0.01).
Family esilience signi ican ly dec eased om T0 o T1 (
β
=
−
2.58, p< 0.05) and om T0
o T2 (
β=−2.24
,p< 0.05), and amily unc ioning sco es signi ican ly inc eased om T0
o T1 (
β= 0.18
,p< 0.05). Pa en al coping s a egies signi ican ly inc eased om T0 o T1
(
β= 4.22
,p< 0.05), om T0 o T2 (
β
= 7.92, p< 0.001), and om T1 o T2 (
β
= 3.07; p< 0.05).
Psychological well-being signi ican ly dec eased om T0 o T1 (
β
=
−
4.26, p< 0.001) and
inc eased om T1 o T2 (β= 3.53, p< 0.05) (Table 3and Figu e 2).
Cance s 2025,17, 338 9 o 17
Table 3. Reg ession coe icien es ima es o he linea mixed-e ec s model.
Response
Va iable
Psychological
Mo bidi y
T auma ic
S ess
Symp oms
Family
Func ioning
Family
Resilience
Pa en al
Coping
Psychological
Well-Being
Fixed e ec s β(SE)β(SE)β(SE)β(SE)β(SE)β(SE)
In e cep
16.48 (1.74) ***
3.68 (0.46) *** 1.38 (0.10) ***
47.05 (1.78) ***
101.41(3.21) *** 74.06 (1.97) ***
T1 −0.44 (1.04) −0.66 (0.27) * 0.18 (0.07) * −2.58 (0.99) * 4.22 (1.95) * −
4.26 (1.09) ***
T2 −3.73 (1.06) ** −0.78 (0.28) ** 0.12 (0.07) −2.24 (1.01) * 7.92 (1.98) *** −0.73 (1.11)
On lea e 2.02 (1.70) 0.60 (0.45) 0.15 (0.10) 0.38 (1.70) −3.20 (3.14) −
7.20 (1.88) ***
No e. * p< 0.05, ** p< 0.01, and *** p< 0.001; β= es ima e; SE = s anda d e o . On lea e: 0 = no, 1 = yes.
Cance s 2025, 17, x FOR PEER REVIEW 9 o 18
Table 3. Reg ession coefficien es ima es o he linea mixed-effec s model.
Response
Va iable
Psychological
Mo bidi y
T auma ic S ess
Symp oms
Family
Func ioning
Family
Resilience
Pa en al
Coping
Psychological
Well-Being
Fixed effec s β (SE) β (SE) β (SE) β (SE) β (SE) β (SE)
In e cep 16.48 (1.74) *** 3.68 (0.46) *** 1.38 (0.10) *** 47.05 (1.78) *** 101.41(3.21) *** 74.06 (1.97) ***
T1 −0.44 (1.04) −0.66 (0.27) * 0.18 (0.07) * −2.58 (0.99) * 4.22 (1.95) * −4.26 (1.09) ***
T2 −3.73 (1.06) ** −0.78 (0.28) ** 0.12 (0.07) −2.24 (1.01) * 7.92 (1.98) *** −0.73 (1.11)
On lea e 2.02 (1.70) 0.60 (0.45) 0.15 (0.10) 0.38 (1.70) −3.20 (3.14) −7.20 (1.88) ***
No e. * p < 0.05, ** p < 0.01, and *** p < 0.001; β = es ima e; SE = s anda d e o . On lea e: 0 = no, 1 =
yes.
Figu e 2. Schema ic o e iew and ch onological imeline o he s udy.
Figu e 2. G aphical ep esen a ion o di e ences o e ime.
Cance s 2025,17, 338 16 o 17
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Disclaime /Publishe ’s No e: The s a emen s, opinions and da a con ained in all publica ions a e solely hose o he indi idual
au ho (s) and con ibu o (s) and no o MDPI and/o he edi o (s). MDPI and/o he edi o (s) disclaim esponsibili y o any inju y o
people o p ope y esul ing om any ideas, me hods, ins uc ions o p oduc s e e ed o in he con en .
