15.3 Mental Health Effects

TCO IV.B.4 tests mental health effects of pediatric cancer and its treatment: anxiety, depression, post-traumatic stress, steroid mood and psychosis, and delirium. This is the child's brain and safety, not the full family-systems, culture, camp, or grief chapters later in Domain VI. Those chapters own caregiver burden, school-camp integration, and bereavement. Here the CPHON nurse screens, keeps the adolescent and young adult (AYA) alive through a suicidal crisis, and does not call immune effector cell–associated neurotoxicity syndrome (ICANS) "anxiety."

A 3-year-old who panics at the chlorhexidine smell, a 5-year-old on dexamethasone who has not slept and is threatening a sibling, a 12-year-old with new aphasia after chimeric antigen receptor T-cell (CAR-T) therapy, and a 17-year-old who has stockpiled leftover oxycodone after amputation are the pictures.

Anxiety, depression, PTSD, and what you do not invent

Illness anxiety, needle phobia, and procedural anxiety are expected. A preschooler who thrashes at port access and an adolescent who dissociates during lumbar punctures both have treatable procedural distress. Child Life, comfort holds, topical anesthetics, honest preview (no surprise sticks), and short-term benzodiazepines (midazolam, lorazepam as ordered) for selected procedures are the toolkit. Benzodiazepines are not a daily multi-week coping plan for every needle; paradoxical agitation can occur in young children, and daily use creates its own dependence problem. Selective serotonin reuptake inhibitors (SSRIs) are not procedure premedication. They are psychiatry- or psychology-directed treatment for persistent anxiety or depression, with a lag of weeks and an activation and suicidality watch after start—especially in AYA. Nurses do not start an SSRI from a discharge checklist.

Depression is more than a sad day after a scan. Look for anhedonia, persistent irritability in children (depression often looks angry, not tearful), sleep and appetite change, guilt, and a drop in function. A 9-year-old who used to play and now will not get out of bed despite a stable hemoglobin and a normal thyroid-stimulating hormone is a mood patient, not a transfusion candidate from the last section. Post-traumatic stress disorder (PTSD) and acute stress cluster after intensive care, unexpected intubations, and repeated painful procedures: re-experiencing, avoidance of the clinic, hyperarousal, and nightmares. Survivors can meet PTSD criteria months later. Do not force a child back into the procedure room with "you survived the ICU, this is just a poke."

Screen—and do not invent a single required ONCC instrument. Many centers use pediatric symptom checklists, depression and anxiety screens, or trauma screens appropriate to age. Name the construct (mood, trauma, suicide risk), document, and refer. ONCC does not publish a mandatory named questionnaire as the only correct answer. A blank screen because "we do not use that brand of form" is still a missed assessment.

Steroid mood, psychosis, and delirium including ICANS

Corticosteroids—especially dexamethasone—cause irritability, aggression, insomnia, and, in a subset, frank steroid-induced psychosis (hallucinations, paranoia, severe disorganization). A 5-year-old on ALL induction who threatens a sibling and has not slept is a steroid-mood patient and a safety patient. Pad the environment, do not leave younger siblings unsupervised with the child, notify, and do not abruptly stop the steroid. Psychiatry may add a short-term agent; the leukemia protocol still needs the glucocorticoid. This is the same dexamethasone window as the sleep section, now with a violence and reality-testing overlay.

Delirium is an acute fluctuation in attention and awareness. Causes in this population include intensive-care unit (ICU) stays, anticholinergic burden, infection, hypoxia, withdrawal, and ICANS after CAR-T therapy. ICANS presents with delirium, aphasia, impaired handwriting, seizures, and possible cerebral edema. Use protocol ICE-style (Immune Effector Cell-Associated Encephalopathy) neurologic checks as taught in the cellular-therapy chapter; corticosteroids and seizure prophylaxis follow that protocol. Do not treat new aphasia after CAR-T as needle phobia or as a teenager "being dramatic." ICU delirium is prevented with sleep protection, family presence, and minimizing deliriogenic medicines—not with a television left on all night. Full CRS titration lives in the emergency and cellular-therapy chapters; this section's job is to keep delirium on the mental-status list.

Safety: suicidality, especially AYA

Suicide risk is the non-negotiable screen, especially in AYA patients. Isolation from peers during neutropenia, body-image injury (amputation, cushingoid change, alopecia, scars, ostomies, central lines visible in a gym locker), treatment fatigue, preexisting mood disorder, and access to means (including leftover opioids) raise risk. Ask directly about hopelessness, passive death wishes, active ideation, plan, and intent. A 16-year-old who says friends have moved on and who has stockpiled oxycodone is an immediate safety case: one-to-one observation as ordered, remove means, urgent psychiatry, and do not bargain for a quick discharge so they can sleep at home. Younger children can also be suicidal; irritability and giving away possessions are clues, not proof that kids never mean it.

Body image and isolation belong here as mental-health drivers, not as a duplicate of the later social-integration chapter. Mirror the facts: alopecia, steroid facies, weight change, and amputation alter identity. Name the loss, involve psychology, Child Life, and peer supports (camps and school plans live later), and watch social-media comparison in AYA. Neutropenic isolation that cuts a teenager off from every friend for weeks is a suicide-risk context, not only an infection-control success.

Who treats what

Child Life owns procedural coaching, medical play, and developmental coping in the moment. Psychology owns assessment, coping, cognitive-behavioral work, and trauma processing. Psychiatry owns diagnosis, SSRI and other psychotropics, steroid-psychosis management, delirium medication when used, and suicide-risk disposition. Nursing owns the screen, the environment, the one-to-one, the honest question, and the refusal to discharge an unsafe AYA. Do not turn this section into a family-meeting script; Domain VI will cover caregivers, culture, and grief.

The CPHON product is a nurse who asks the suicide question, who calls aphasia after CAR-T by its immunotherapy name, who gets Child Life for the needle and psychiatry for the SSRI, and who does not confuse a Domain VI family meeting with this section's safety work.