Most caregivers were mothers (88%). The remaining caregivers were fathers (4%), uncles, grandparents, and stepfathers (8%). Among the children, 27% had experienced more than one relapse, and the most prevalent diagnoses were leukemia (45% in the RG and 30% in the RMG) and brain tumors (18% in the RG and 8% in the RMG). Other sociodemographic and medical characteristics are described in Table 1.

Significant differences between the groups were detected for children’s age [F (2, 133) = 4.19; p = 0.02]; specifically, the CG had a higher age than the RG (p = 0.01; Cohen’s d = 0.66), and the RMG had a higher family income than the other groups [Kruskal-Wallis (2) = 21.96; p = 0.00]. Statistically significant differences were also observed between the two cancer groups for the time in the current situation [t (78.07) = 15.35; p = 0.00; Cohen’s d = -2.99] and time in treatment [t (22.91) = 4.05; p = 0.00; Cohen’s d = 1.17]. The time elapsed in the current situation was longer in the RMG, and treatment duration was longer in the RG. However, considering the groups´ characteristics, these differences were expected.

Regarding the children’s psychological adjustment, as reported by their parents/caregivers, Table 2 shows statistically significant differences in the subscales of atypicality, social skills, and leadership, as well as in the general scale of adaptive skills. Thus, both RG and RMG displayed significantly less atypicality than the CG. The cancer groups (RG and RMG) also presented more social skills and leadership than the control group. In the general scales, the cancer groups showed significantly higher adaptive skills than the control group.

Table 3 shows the correlations between family cohesion and children’s psychological adjustment in each analyzed group. In this table, statistically significant negative correlations can be observed in the RMG, indicating that higher family cohesion is associated with fewer externalizing problems, fewer internalizing problems, and fewer behavioral symptoms.

Correlations between sociodemographic and psychological adjustment variables can be seen in Table 4. Children in the RMG who were younger tended to exhibit fewer adaptive skills. It is also observed that a lower level of parental/caregiver education is associated with more internalizing problems. Also, lower family income is related to more externalizing problems, more internalizing problems, and more behavioral symptoms.

Regarding medical characteristics, Table 5 shows the correlations between these variables and measures of children’s psychological adjustment. Children in the RG who underwent treatment for a longer duration tended to present more internalizing problems, and those who experienced more than one relapse tended to have more externalizing problems, more internalizing problems, and more behavioral symptoms.

This research investigated the psychological adjustment of children in cancer relapse from the perspective of their parents/caregivers, comparing their adjustment with those of children in cancer remission and children with no history of the disease. Contrary to the study’s first hypothesis, which posited that children with relapsed cancer would have worse psychological adjustment than those from the survivors/remission group and the healthy/control group, the results showed that, according to the clinical scales, these patients did not significantly differ from the other groups, except in the atypicality subscale, where they scored lower than the others. Furthermore, children in cancer relapse exhibited more social skills, leadership, and adaptive abilities than the children in the control group.

This result is consistent with the literature, which did not find psychological adjustment problems in children with cancer relapse (Compas et al., 2014; Grootenhuis & Last, 2001; Okado et al., 2015). Thus, children in cancer relapse may possibly feel depressed or anxious sometimes, but they manage to overcome adversities and the majority demonstrate feelings of optimism and well-being (Bragado-Álvarez, 2009).

However, the results of this research go further, demonstrating that children with cancer relapse not only do not exhibit behavioral problems but also adapt better than children with no history of cancer. The same is true for children in cancer remission (“survivors”), who showed better psychological adjustment than the “healthy” children, presenting more adaptive abilities, leadership, and social skills, as well as less atypicality, refuting the second hypothesis of this study, which suggested that they would have similar adjustment to the children in the control group.

Therefore, it can be concluded that children who survive cancer not only do not show indications of adjustment problems but also seem to demonstrate a significant adaptive repertoire after oncological treatment, as observed in other research (Kazak & Noll, 2015; Okado et al., 2018; Wakefield et al., 2010). It can be hypothesized, therefore, that due to the skills acquired during the illness process, the treatment may not be as psychologically traumatic as expected (Phipps et al., 2006).

Thus, despite the suffering inherent to the treatment and the challenges faced in the post-treatment period (e.g., potential sequelae, readjustment to daily tasks, and returning to school), such contingencies could also teach or strengthen coping strategies that would be useful for these children to deal with other stressors in their lives; skills which perhaps “healthy” children may not have acquired due to a lack of experience with extreme situations, such as a life-threatening illness (Collins et al., 2019; Larsen et al., 2022).

Possible explanations for the fact that both cancer groups obtained higher scores in adaptive skills than the control group may be related to the learning of coping strategies during the first experience with cancer treatment, as reported by Phipps (2007). Thus, the development of adaptive resources derived from previous experiences, combined with sensitivity to changes in the context of relapse, may facilitate the acquisition of a broader behavioral repertoire and develop greater tolerance to uncontrollable and unpredictable events present in the treatment (Torres & Coelho, 2004).

Moreover, it is also possible that repeated exposure to previously conditioned aversive stimuli may produce greater habituation to the hospital context. Such habituation could fulfill an educational function, providing the child with new knowledge and experiences about the illness, which would reduce uncertainty (Szulczewski et al., 2017). Thus, it can be assumed that habituation to the constant stress in the hospital context could promote a more effective coping response to the situation, an increase in adaptive skills, and a reduction in emotional symptoms (Bennet et al., 2018).

Other studies also suggest that the support received from the healthcare team and parents during relapse, the hospital’s ludic resources, and the observation of other patients’ coping strategies may help these children develop new skills, expanding their behavioral coping repertoire (Arriaga et al., 2020; Schepers et al., 2018). Therefore, according to a socio-environmental model, it seems that the tendency to develop a certain psychopathological disorder would be more related to the psychosocial and environmental context, to previous adjustment history, and to personality characteristics rather than the cancer itself as a triggering event (Kazak & Noll, 2015; Phipps, 2007).

The family environment can also contribute to a better psychological adjustment of cancer patients. Thus, as found in this study, children in cancer remission with more cohesive families tended to exhibit fewer externalizing problems, fewer internalizing problems, and fewer behavioral symptoms. A family atmosphere that is supportive, united, and that fosters sharing experience, can help the child readjust to the routine and demands of the post-treatment period (Ghriwati et al., 2021; Okado et al., 2021). However, this effect was not observed in the group of children in cancer relapse, possibly due to the stressors present in the relapse situation, which could interfere with the parents’/caregivers’ perception of family cohesion. Nevertheless, this assumption requires investigation in future research.

Furthermore, certain risk groups related to demographic and medical variables were observed. Identifying risk factors is essential to offer appropriate interventions to meet the needs of this population and prevent potential adverse outcomes (Brinkman et al., 2018). In this regard, it was found that the youngest children in cancer remission tended to exhibit fewer adaptive skills, consistent with the results of Raghubar et al. (2019). Likely, the level of cognitive development in younger children may lead to greater difficulty in understanding the disease and medical recommendations during follow-up (Schepers et al., 2018).

It was also observed that lower parental/caregiver education level and lower family income were associated with more adjustment problems in cancer remission patients, corroborating other research (Kazak et al., 2015; Raghubar et al., 2019; Quast et al., 2018). Thus, some studies indicate that low-income families with lower levels of education tend to provide an environment with insufficient diversity for the child’s development (Crosnoe et al., 2010; Davis-Kean et al., 2021). It is assumed that this scenario, combined with the restrictions and sequelae of oncological post-treatment, may lead to greater difficulties in psychological adjustment among cancer survivors.

More adjustment problems were also found in children who had experienced a higher number of relapses, as reported by Okado et al. (2018). This result is not surprising, given that relapse indicates a poorer prognosis, a higher level of uncertainty and uncontrollability of outcomes, as well as more aggressive treatment, which can lead to greater difficulty in adaptation (Szulczewski et al., 2017; Wechsler et al., 2021).

Finally, children in the relapse group who were undergoing treatment for a longer period showed more internalizing problems, in the same direction as the results reported by Hsiao et al. (2018). It is possible that prolonged treatment reduces stimulation and opportunities for patient´s action, not providing the necessary conditions for displaying behaviors that were previously reinforced in their natural environment (Gariépy & Howe, 2003; Nijhof et al., 2018).

This study has some limitations, such as the use of a single data source. However, some studies indicate that parents/caregivers are more reliable and accurate informants than children, not only for identifying problematic behaviors but also for pointing out adaptive skills (Gresham et al., 2018; Phares, 1997). Nevertheless, future studies could benefit from using multiple sources of information, particularly from reports of other adults who interact with the child. Another limitation relates to the small sample size of the relapse group. However, this is an inherent problem in research with this population, which tends to have high rates of refusal (Gerhardt et al., 2007).

Despite these limitations, this study contributed to the understanding of the psychological adjustment of pediatric cancer patients. The results emphasize that not only do children in cancer relapse and remission adapt well to the demands of oncological treatment, but they also exhibit higher levels of adaptive skills (social and leadership skills) compared to children who have never had this illness.

On the other hand, the results of the present study suggest that it would be more beneficial for future research to focus on studying the coping skills of children with cancer rather than solely analyzing psychopathological problems. In this regard, several researchers question conventional psychopathological models and advocate for a model that is more focused on children’s behavioral potentialities, the situational demands and the contextual factors that are specific to this population (Kazak et al., 2015; Raiff et al., 2020; Stegenga et al., 2020). Such model could potentially benefit the care of children with cancer, as the healthcare team could propose more targeted and effective interventions based on their needs, considering that behavioral potentialities can be used for modeling other behavioral repertoires (Leme et al., 2009).

Some important contributions of this research are related to the use of a comparative group composed of “healthy” children and the identification of risk factors in children in cancer relapse or remission. Clinical implications derived from the results refer to the possibility of identifying risk factors that allow an early screening of psychological symptoms, as well as the encouragement to design intervention strategies aimed at preventing future psychological problems that may arise during the course of the disease, thus ensuring a good adaptation of the children and their parents throughout the entire process (Kazak et al., 2015).