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Symptom networks of internalizing and externalizing problems in children with leukemia: a network analysis and
Zilong Ma1, Xinyan Guo1, Liwen Min1
1School of Nursing and Health, Zhengzhou University, No. 100 Science Avenue, Zhengzhou, Henan, 450001, China.
Insights
Internalizing and externalizing problems in children with leukemia form a connected system. Targeting symptoms like impulsivity and peer victimization may reduce overall symptom burden, guiding future interventions.
Area of Science:
- Pediatric Oncology
- Psychology
- Network Analysis
Background:
- Children with leukemia often exhibit internalizing and externalizing problems.
- The interactions between these symptoms are not well understood.
- Network analysis can explore symptom associations and identify intervention targets.
Purpose of the Study:
- To examine the network structure of internalizing and externalizing problems in children with leukemia.
- To identify central and bridge symptoms within this network.
- To simulate the impact of symptom perturbations on the overall symptom burden.
Main Methods:
- Used data from 1,126 children with leukemia in rehabilitation.
- Assessed emotional and behavioral problems using the parent-reported Strengths and Difficulties Questionnaire (SDQ).
- Estimated an Ising network model and identified central/bridge symptoms using expected influence metrics and simulation analyses (NIRA).
Main Results:
- "Motor fidgeting," "peer victimization," and "low mood" were identified as highly central symptoms.
- "Motor fidgeting" and "peer victimization" connected internalizing and externalizing problems.
- Simulated alleviation of "impulsivity" reduced overall symptom burden by 19.71%; aggravation of "motor fidgeting" increased it by 22.76%.
Conclusions:
- Internalizing and externalizing problems in pediatric leukemia patients form an interconnected system.
- Findings suggest targeting impulse control, peer relationships, and emotion regulation may be key for interventions.
- Results are hypothesis-generating and require further investigation for causal intervention effects.
Background:
Children with leukemia commonly experience internalizing and externalizing problems, yet their symptom-level interactions remain unclear. Network analysis provides a framework to examine associations among co-occurring symptoms and to explore potential intervention-relevant targets within a system-level context.
Methods:
A total of 1,126 children with leukemia in the rehabilitation phase were included. Emotional and behavioral problems were assessed using the parent-reported Strengths and Difficulties Questionnaire (SDQ). Symptom endorsement rates were calculated, and an Ising network model based on binary data was estimated. Central and bridge symptoms were identified using expected influence metrics. Simulation analyses were conducted using the NodeIdentifyR algorithm (NIRA) to model symptom perturbations within the network. These simulation-based perturbations were applied in the overall network and internalizing-externalizing subnetworks to examine system-level responses.
Results:
"Motor fidgeting," "peer victimization," and "low mood" showed the highest centrality, with "motor fidgeting" and "peer victimization" also linking internalizing and externalizing problems. In simulation analyses, simulated alleviation of "impulsivity" was associated with the largest reduction in overall symptom burden (19.71%), whereas simulated aggravation of "motor fidgeting" showed the largest increase (22.76%). Externalizing-to-internalizing simulations showed patterns broadly consistent with the overall network structure. In internalizing-to-externalizing simulations, "low peer acceptance" showed the largest simulated reduction in externalizing symptoms (9.75%), whereas "low mood" showed the largest simulated increase (12.79%).
Conclusions:
Internalizing and externalizing problems in children with leukemia form an interconnected symptom system. Simulation findings highlight symptom-specific patterns related to impulse control, peer relationships, and emotion regulation, which may inform early psychosocial monitoring and provide a basis for mechanism-informed future intervention strategies in pediatric oncology. These findings should be interpreted as hypothesis-generating evidence derived from cross-sectional data rather than as evidence of causal intervention effects.
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