The Psychosocial Consequences of Childhood and Adolescent Cancer in the Transition to AdulthoodABSTRACT
Introduction: Childhood and adolescence cancer impacts the life of an entire social and family circle with a strong psychic repercussion on an individual who is in full development.
Objective: To analyze the impacts on mental health after the recovery of patients who had cancer during childhood and adolescence and are now in adulthood.
Method: Cross-sectional, descriptive, qualitative approach study conducted through semi-structured interviews with nine participants who underwent treatment at the Liga Mossoroence de Estudos e Combate ao Câncer (LMECC). The Bardin Analysis methodology was used to analyze the data.
Results: It was observed that mental health was impacted in cancer patients during and after treatment and even when cured, who fear the future and death since diagnosis, and deny reality as a form of self-preservation. Additionally, the process triggers abrupt changes in the patient's routine, altering their perception of themselves and the world, significantly impacting their quality of life. On the other hand, learning also occurs, showing that the oncological process can bring positive experiences.
Conclusion: Psychological follow-up, even after cancer recovery, is of utmost importance for patients, as this pathology is frequently related to the development of mental disorders as depression and anxiety.
Key words:
Neoplasms/psychology; Child; Adolescent; Mental Health; Quality of Life/psychology
RESUMO
Introdução: O câncer infantojuvenil afeta profundamente o indivíduo em desenvolvimento e seu entorno familiar e social, uma forte repercussão psíquica sobre um indivíduo que está em pleno desenvolvimento.
Objetivo: Analisar as consequências na saúde mental após a recuperação de pacientes que tiveram câncer na infância e adolescência e que agora estão na vida adulta.
Método: Estudo transversal, descritivo, com abordagem qualitativa, realizado por meio de entrevistas semiestruturadas com nove participantes que realizaram tratamento na Liga Mossoroense de Estudos e Combate ao Câncer (LMECC). Para a análise dos dados, utilizou-se a metodologia de análise de Bardin.
Resultados: Observou-se que a saúde mental é abalada em pacientes oncológicos durante e após o tratamento, mesmo quando curados, uma vez que, desde o diagnóstico, os pacientes vivenciam o medo do futuro e da morte, bem como negação da realidade como forma de autoproteção. Além disso, o processo desencadeia mudanças abruptas na rotina do paciente, alterando sua percepção de si e do mundo, influenciando significativamente sua qualidade de vida. Por outro lado, há também um aspecto de aprendizado, indicando que o processo oncológico pode trazer experiências positivas.
Conclusão: O acompanhamento psicológico, mesmo após a recuperação do câncer, é de suma importância para os pacientes, pois essa patologia está frequentemente relacionada ao desenvolvimento de transtornos mentais, como depressão e ansiedade.
Palavras-chave:
Neoplasias/psicologia; Criança; Adolescente; Saúde Mental; Qualidade de vida/psicologia
RESUMEN
Introducción: El cáncer en la infancia y la juventud impacta intensamente al individuo en desarrollo y su entorno familiar y social, con una fuerte repercusión psíquica en un individuo que se encuentra en pleno desarrollo.
Objetivo: Analizar las consecuencias en la salud mental después de la recuperación de pacientes que tuvieron cáncer en la infancia y adolescencia y que actualmente se encuentran en la vida adulta.
Método: Estudio transversal, descriptivo, con enfoque cualitativo, realizado mediante entrevistas semiestructuradas con nueve participantes que realizaron tratamiento en la Liga Mossoroense de Estudios y Combate al Cáncer (LMECC). Para el análisis de los datos se utilizó la metodología de análisis de Bardin.
Resultados: Se observó que la salud mental se ve impactada en pacientes oncológicos durante y después del tratamiento, incluso cuando se encuentran curados, ya que desde el diagnóstico los pacientes experimentan miedo al futuro y a la muerte, así como la negación de la realidad como forma de autoprotección. Además, el proceso desencadena cambios abruptos en la rutina del paciente, alterando su percepción de sí mismo y del mundo, lo que impacta significativamente en su calidad de vida. Por otro lado, también existe un aspecto de aprendizaje, indicando que el proceso oncológico puede generar experiencias positivas.
Conclusión: El acompañamiento psicológico, incluso después de la recuperación del cáncer, es de suma importancia para estos pacientes, puesto que esta patología está frecuentemente relacionada con el desarrollo de trastornos mentales, como depresión y ansiedad.
Palabras clave:
Neoplasias/psicología; Niño; Adolescente; Salud Mental; Calidad de Vida/psicología
INTRODUCTION
Childhood and adolescence cancer brings consequences to the social circle of an individual still under the responsibility of someone else, a strong psychic repercussion on a person in full development, construction of him/herself and their future1.
As much as the healing process is followed by extreme joy, many patients are insecure with the quality of their future life. Large part of the participants of the study by Bitsko et al.2 suffered from psychic disorders as depression, anxiety and/or post-traumatic stress disorder.
Psychological impact is frequently associated with physical consequences during treatment or after healing. The development of physical sequelae associated with the limitation of activities of the daily life or self-esteem affects the mental health directly. High prevalence of unsatisfaction with the appearance due to the sequelae is an example, which affects the social living and consequently their psychosocial aspects3.
Despite the advances of oncologic treatment, studies analyzing the subjective aspects are still scarce in the scientific literature4,5. In face of the rising incidence of childhood and adolescence cancer and its long-term consequences, this study investigates the physical, cognitive, psychological and social sequelae of adult survivors diagnosed until 19 years old whose objective is to analyze the late consequences on the mental health of these individuals after recovery.
METHOD
Cross-sectional, descriptive, qualitative study conducted at "Liga Mossoroense de Estudos e Combate ao Câncer (LMECC)" in Mossoró, state of Rio Grande do Norte (RN). The study population consisted in individuals who have been affected by childhood and adolescence cancer and were healed. The first contact was made by phone and WhatsApp, inviting them to join the study. To expand the sample, it was adopted the snow ball method, investigating the interviewees knowledge they had of the persons who lived the process with them.
Nine participants were interviewed through an open-question questionnaire to analyze and understand how they coped with cancer, the support they received during and after the treatment and investigate the depth of their understanding of the theme.
The interviewees were individuals diagnosed with cancer in childhood, healed (completed the antineoplastic treatment at least for five years without evidence of clinical or radiological relapse according to LMECC charts) and those treated at LMECC with charts filed at the institution. Patients in treatment and minors in treatment or not were excluded. Bardin's content analysis was adopted to investigate the qualitative data and identify the main characteristics of the theme. The methodology is divided in analysis, codification and categorization.
The Ethics Committee of the "Universidade do Estado do Rio Grande do Norte" approved the study, report number 5,970,319 (CAAE (submission for ethical review): 67048623.3.0000.5294), in compliance with Directive number 466/127 of the National Health Council (CNS). All the participants signed the informed consent form (ICF). To keep the anonymity, each participant was assigned the term "patient".
RESULTS
The study population consists in nine adults survivors of childhood and adolescence cancer (diagnosed until 19 years old), healed (end of the treatment ≥5 years without relapse), treated at LMECC/Mossoró-RN. Current age: 18-35 years (mean age 26 years); sex: women (5), men (4); types of cancer: leukemia (4), lymphoma (2), sarcoma (2), brain tumor (1). Sample: snow-ball methodology through semi-structured interviews until theoretical saturation. The results presented in thematic categories are portrayed in Chart 1.
Most of the patients when diagnosed with cancer undergoes a drastic change of several aspects of life and are overwhelmed by intense feelings that pull them out of themselves.
And… you know when a drastic thing happens, a movie appears in your mind, time halts, you see your life in seconds? This is exactly what I felt. When she called to give me the results she said: Listen "Patient 1", I have good and bad news, which one you want first? I said: The bad first, after comes the good one and you relax. Then she said: The bad news is that you have leukemia. So far, I don't know what the good one was because my world stopped, I went into an ecstasy (Patient 1).
[…] And for me, it was a blow, because you go there, receives the diagnosis, the doctor explains and back then I was a child, had to absorb all that, they showed where I was going to stay. […] I'm not saying depression, but I was a recluse, didn't eat, didn't talk with anyone, lying down in my bed and it was difficult to do the treatment because I felt bad, didn't sleep and this got even worse (Patient 2).
And… I got the diagnosis when I was very young, you know? I was 17, nearly 18, for a youngster to receive news you don't expect, but it could happen, for sure. You think is a death sentence. […] you have to change your life abruptly. The life you had before was gone, it will not be the same after the diagnosis … (Patient 3).
Denial is one form of dealing with negative news. For a while, the individual is unable to believe what he/she is going through. It is a self-defense mechanism, the patient denies the reality in light of the bombardment of news, imminent life changes, he/she flees from the process.
It was kind of not believing, it didn't sank in, think this is not what is happening at all, then we move on, and it actually hit me when the chemotherapy symptoms appeared and only then I saw what was happening … (Patient 4).
In case of a severe disease and high rates of mortality, the treatment starts very quickly, the patients’ life changes abruptly and radically.
[…] Actually, it was all very fast when I got the diagnosis, I was in pain […]. Then I got the diagnosis and it went very fast, I did the exams at the Liga and it was all very fast (Patient 2).
[…] I was at my grandmother's …felt a pain in my leg, my thigh… the only hospital was the Tarcísio Maia… They did a blood test, saw my white cells, my platelets were low and referred me to oncology […]. Did a biopsy the next day, they suspected of leukemia [..] and in the end of the day I was diagnosed with acute lymphoblastic leukemia (Patient 5).
[…] basically, I went home, got my things and was admitted to begin the treatment (Patient 1).
The process disease-illness comprehends not only the physiology of the disease and fighting the pathology, but also the psychosocial dimensions of the individual, including their emotional experiences, subjective perceptions and coping mechanisms.
I always say, it's 50% psychological and 50% drug-related, because I actually saw persons with good mental status, they wanted to live their lives, went through the end, the treatment was a success. But those who said it is over, there is no way out, it is done, they went down (Patient 4).
The reaction to the diagnosis of a severe disease is totally individual, each person reacts differently. One of these reactions can be identified as reclusion and social isolation, not even the patient knows how to react to the diagnosis.
[…] one week without talking to anyone at home … ordered food by WhatsApp, didn't want to talk … some days I didn't want to see anyone […] didn't want to talk with anyone […] (Patient 6).
I suffered a lot, it was not cancer alone, it was the loneliness, everyone went away […] I pulled away because of the hospital, admission, […] I kind of kept to myself […] (Patient 7).
But there are persons who are compelled to isolate themselves because of the treatment and they react negatively when they are in isolation.
And I couldn't go to the movies, couldn't be with other persons because someone could have a flu, no symptoms but passed to me and I had to avoid contact with many people, movies, shopping, shows, these things […] I wanted to go out … didn't like to stay home too much, no, I had to stay home when I took the medication because I couldn't go out, but all I wanted was to go out, walk, go to the beach, didn't want to stay home (Patient 8).
It is known that oncologic treatment causes hair loss with many consequences mostly for women, for them, hair is part of their self-esteem.
[…] I got bald 4 times, the first time I suffered, but the other 3, couldn't care less, my daughter said I looked like a Ninja Turtle [laughs] […] when you take corticoids, you swell. I put on red glasses, which one wears red glasses? It's Michelangelo? Don't know, I looked like a Ninja Turtle […] (Patient 6).
And there is something that makes your come back more difficult, your appearance, some can deal better with this, but I couldn't deal with the glances, staring at me bald, I'm very shy, used a wig. My coming back was problematic because of this (Patient 4).
Although it is widely known that hair loss occurs most of the times in oncologic treatment, it is a tough and long coping to see yourself in that place. Further to the hair loss, body changes caused by the treatment work as a social block, creating ruptures in the body image and changes of the daily life2.
[…] when I went to a medical appointment, I care for my appearance, to look well, my main concern when I submitted to chemotherapy was my hair, I was scared [face expression of mistrust]… I passed the hand and the hair came falling down, I was desperate, but I did not lose it all … D X told my mother: cut her hair, shave it all, because if she sees the first tuft falling, she will collapse, but mom did not do this, thank God, because it didn't fall, it was thinner, dry, but there were no gaps, it was well arranged but thinner (Patient 7).
[…] I did the first chemotherapy, my hair was fine, but I had to wear mask and for me it was not nice be in a room, in elementary school everyone judges you, I had to keep the mask, couldn't have contact, the persons kept talking to me about the situation, so I decided to quit school (Patient 2).
While facing a pathology, many patients search for spiritual support to help them go through the process more safely and calm, an additional push to continue the treatment.
After receiving the cancer diagnosis, the whole family dynamics changes and suffers with the pathology since it is a high mortality disease.
[…] and my parents… I think my father […] and my mother were unable to overcome it all so far. My father aged 10 years, and my mother … […] it's a heavy blow, it doesn't affect only you, the whole family too, food, living with the family (Patient 6).
[…] me and my family lost our ground until we found out it was not a sentence […] because when the news come, you and them think it is a death sentence (Patient 3).
The possible consequences from cancer are physical sequalae that directly change the quality of life, influencing how they see themselves in the world, affecting them physically and psychologically.
I can say that I got back 85% of my balance, I can go everywhere, kind of wobbling, they think I'm drunk, but this is what I can manage. [short laugh] My face is still paralyzed, not much, it was more, today it is worse when I smile and it destroys my self-esteem (Patient 3).
I have a motor limitation in my arm, the illness affected the humerus … my prosthetics impedes me to raise the arm and stretch, don't have this strength, it was very present for a while. I managed to adapt myself, in the first years it was difficult, couldn't even show my arm. […] I believe this was caused by the treatment, but it is not going to restrain me … It even pushes you up, try to find other ways (Patient 2).
The oncologic process is quite negative that influences how patients see the world in the perspective of an individual with a severe disease and expectations about the future.
Yes, cancer is this thing, many die, but those who survive, it eats you inside out. There isn't anyone who had cancer who isn't anxious, that has not psychological problems. […] Since then, I continue with psychological support because I need, I'm very anxious. I would like to quit, but I can't, anxiety stopped, but it won't, so … (Patient 7).
It wasn't then, but now I'm beginning to feel anxious, depression begins, I talked with a professional, they said it could be everything I tried to avoid feeling, kind of repressed feeling … (Patient 9).
After the oncologic experience, many patients begin to have a continuous and excessive concern with their health.
I even talked with the psychologist recently after the treatment. After many years, if I catch a flu, if some spot appears in my skin, a red light pops up. Start thinking what is the cause of this, I'm concerned […]. We kind of fear to get it all back (Patient 1).
But my emotional is damaged, to be quite honest … at any moment, it can surface again, ‘hey I'm here’. I had no symptoms until I found the tumor, not even a headache, nobody can ensure it won't come back: a Superman, if the tumor bounces back, you will feel this, then you go to the doctor and try to resolve this as fast as you can … (Patient 7).
If any little thing changes, I'm stressed, I think is the fear too for what you went through, for what the oncologic patient suffers, there is this fear […] so far, I was able to let go many things but there is this fear of relapse, but I keep going, I still fear the relapse of something that is a signal of something, this fear lives with me (Patient 3).
The cancer, the oncologic patient, there is this patient, despite everyone saying they don't have, ‘will it come back, will I have it again" […] because so far is this thing: until the next myelogram I'm cool, living as much as I can until the next exam, because if the next goes wrong, I have lived what I was able to live as best as I could (Patient 4).
Apparently, fear of death and procedures lived during the neoplastic period change completely how life is seen, changing the individual inside out.
[…] It changed my vision of life, I value more the health questions, of being well in your own house, with your family, healthy, and also your mind … I kind of became mentally stronger because back in the day I complained for anything. And after the disease, no, it's ok, this is normal, some people are worse and they don't complain. […] The simple things are what I value the most, be with my family, be healthy, care for what actually matters (Patient 1).
Today, I'm different than what I was before the cancer, it is a fact. Before the cancer, I was usually very scared, kept to myself, less sociable, insecure. Cancer made me stronger, I say, I would not erase this part of my life if I had to choose, I would go through it all again, for becoming a person I am today. […] Today I'm more sure of myself because I know my strength, sometimes you don't know because you have never lived that experience before, but when your only choice is to be strong, you know the strength you have and you become a confident person of yourself … (Patient 4).
I fought four years to live. Today, I wouldn't go through some things. I had this advice and I live this today, if I love, I say, I love, I say no, I'm not afraid of being involved, I don't live what I don't want, but I'm not afraid of loving, to say I love … This is what I tell everyone I know, if you want to do, do it, because you are here today, tomorrow you are in a hospital and if you are young, being there, is a prison of your time … (Patient 6).
Despite all the difficulties lived through the neoplastic process, cancer, by itself, is not able to erase the happiness from someone's life who is affected by this pathology. Although the treatment is painful and wearing, the spirit of the child was alive for a few moments, when it was possible to feel joy and have positive memories from the process, create strong bonds and grow up along the journey.
Positive aspects, thank God, I always say that God did not allow to be more traumatic in my life, I'm not romanticizing cancer, I suffered a lot, but… I think that the moments that remained were the good ones, whether I liked it or not, I did not want to stick to the trauma, of recalling the bad moments.[…] That is why, today, I live with persons with cancer, go to the hospital where I was treated and I do not feel bad, I go the the rooms where I did the treatment and I don't feel bad because what matters the most to me were the moments when I was with my boyfriend and we enjoyed ourselves eating or when I was with my mother and we were watching tv, even at the hospital, we tried to make the most of it, I always remember this (Patient 4).
You are socializing with other persons in a very difficult moment, many times you want to keep to yourself, then someone comes and brings joy, a music teacher who tries to teach you to play an instrument, a violin, as much as I didn't like, I learned because I was there with other persons at my side who had cancer with me.[…] It marked me positively, it was a very positive experience living with everyone, I didn't want anyone with me, but people were there hugging me (Patient 5).
I have many good memories. Earlier I was traumatized, if someone talked about the disease, I cried, didn't want to talk but today I talk openly, of course I feel like crying, but for me it was very good, made me grow as a person, it is very agreeable.[…] These days in the past, I went there as an intern, did some practices and I was very happy, met my old nurses, they talked to me, they were happy and I felt happy for being there … Being there taking care of them, some of them asked what was that scar in my arm and I told the whole story of my life, they were happy for me, patients and nurses, it was something very agreeable working in that area, trying, if God wants, I will be there at the post (Patient 2).
During treatment, many patients are curious about their exams and this encourages learning as a way to understand the results better.
During my treatment, I was always very curious about everything … if anyone of my family does a blood test, I have to see the results, otherwise I go crazy, I was always very curious to know. This test was altered, what is this? I think this is helping me at college because my curiosity helped me to learn many things (Patient 7).
And when you are in treatment, we are kind of a doctor, when we get a blood test, we know what the results mean, the platelets, lymphocytes, anything … When they hand us the results, I look up at the internet, you are concerned with your own health (Patient 1).
Whenever the doctor was talking with my mom, she said I was smart, she could talk to me because I go it all right, since I was 11 years old, I did many things on my own, the doctor told me everything, I knew everything that was happening during the treatment (Patient 3).
School is an environment that not only favors cognitive development but also the ethical, moral and social formation of the individual. Thus, despite the limitations, it is essential the reinsertion of cancer survivors in this space, not only the professional formation but mostly the citizenship and mitigation of the socio-cognitive gaps resulting from cancer.
At start, when I came back, it was not 100%, could not hug, had to kept to myself, it was complicated, but it was good to get back, I felt better and it helped (Patient 2).
Could not follow school in the first year, I decided to do the grade again (Patient 5).
Life changed because I was unable to continue attending the school (Patient 1).
Frequently the oncologic process imposes limitations to agglomerations and physical contact which corroborates the harm caused in children and adolescents, development of social living skills and engaging in interpersonal relations. Therefore, after healing, the deficit of developing these skills reinforces the harm in establishing affectionate relations and insertion in the job market, for instance.
Yes, because I had no … friends, if you will […] I had to start from scratch. In fact, at my college, only now I'm beginning to be what I used to be, but it was quite tough (Patient 7).
My dad and my mom talked to me a lot because I cried ‘can't mingle in, can't talk with anyone, the worlds get jumbled up.’ […] It is a huge shock […] when you step back into society, they don't know you had cancer, don't know you are more sensitive, that you went through a process and the world is still frightening (Patient 6).
When you are healed from cancer, you kind of live still in that process of, if it relapses and if it doesn't relapse? Can I live a normal life? Study? Can I train? Am I pushing and putting my health at risk? It is this thing hanging on, this fear (Patient 1).
DISCUSSION
The results showed that, after the shock of the diagnosis, the feelings of anguish and sadness as a predominant protective individual response found in the narratives, trigger the denial of reality.
The denial of the reality lived, in case of the neoplastic diagnosis, as the interviews have shown, is the protective aspect most commonly adopted by the patients reiterated by the narratives and experiences. This scenario also entails severe psychic suffering that many times can trigger physical symptoms responsible for reinforcing and even aggravating the conditions created by cancer8.
The level of distress of these patients is directly proportional to what they know about the situation9. Deal with children and adolescents is a delicate task because it is a population undergoing intense neural development, the threshold of perception is extremely subjective requiring individual analysis.
The development of individualized approaches suited to the patient reality is essential to improve the receptivity of the diagnosis and to cope with the situation and mitigate the risk of developing other physical and psychic signs and symptoms7. Understand the specificity of the condition is a key tool to change the prognosis of the patient who usually tends to feel the sensation of imminent death, loneliness and finitude since the diagnosis due to poor preparation and follow-up as the narratives have shown.
Since the beginning of the oncologic experience, the institution's health professionals should transmit credibility, trust and humanization to the patient, helping them to go through this process in a positive manner. The initial reaction of the patient is closely related to past hospital experiences that, if negative, can impact the adherence to the treatment and receptivity by the health team10.
The interviews revealed that, during the treatment, mainly for adolescents, the adverse events affected their self-esteem directly, most of the time an obstacle to return to the regular life. As a prevalent disease with systemic consequences, cancer can cause several late sequelae or even during treatment, as, for example, partial or total mastectomy in case of breast cancer11. While losing part of the body as a consequence of the oncologic treatment, the patient's self-esteem and self-image are affected, limiting the exposure of parts of the body as the narratives have shown12.
In addition to the self-perception, the patients report functional limitations due to the loss of limbs during the treatment, impacting their activities of daily life and labor tasks13.
Beyond the physical consequences, many patients report mental problems after the oncologic process as anxiety and depression, frequent in all the patients who lived this experience. During this period, the patients are doubtful about their health, their life at risk and finitude challenged constantly, entailing insecurity and fear of death with impacts on their mental health and even after healed2.
Any sign of health problem is a constant warning in the patients’ life. Even after healed, they report that any sign, as a flu, for instance, recalls the process they lived and the fear of relapse. They live in a constant warning scenario due to the possibility of relapse after being healed2. Most of them claim they attempted to be more present with their families and friends and see life lightly; there is a perception of change of personality, becoming more tolerant with themselves and the others14.
Further to the change of how life is seen and their presence in the world, many patients revealed they have learned the language health professionals use and an understanding of their own health status when listening to a specialist as a result of developing new skills since they are placed in new contexts that encourage them to develop new abilities15.
The post-treatment period and isolation is quite challenging for oncologic patients since they need to readjust to a different scenario than the habitual, requiring reinsertion and finding their space in face of changes they found after the reclusion period. It was possible to observe that the interviewees had difficulties in their return to school, lacking behind the other children who followed the regular schedule, sometimes abandoning school or repeating a grade. A qualitative meta-synthesis ratified this scenario where physical, psychological and social barriers are part of the return to school16.
CONCLUSION
During oncologic treatment, the patients’ mental health can potentially change the prognosis; if the patient is mentally healthy, it helps not only the clinical evolution but also their social reinsertion. However, it was possible to observe that the majority of the study patients with neoplasm in childhood and adolescence suffers psychosocial consequences along the process and, in many cases, they persist through adulthood.
Cancer, the fear of having the disease, the treatment-related effects, difficulties of social reinsertion, physical sequelae of the pathology and the uncertainty lived daily cause important repercussions on the patients’ lives, in addition to fear of death that devastates the individual during the treatment; if they survive, their health concerns increase if compared to pre-cancer.
Regardless of the contributions to understand the psychosocial experiences of survivors of childhood and adolescence cancer, there are limitations arising from the qualitative design: a) the sample size (n=9), although Bardin's theoretical saturation was achieved, it limits the scope of the findings and impedes the population generalizability; b) limited geographical scope to cancer survivors treated at LMECC/Mossoró-RN without comparison with other regions or public services; c) exclusive dependence on semi-structured interviews without validation of observant participant, memory recalls or complementary documental analysis.
These limitations suggest the necessity of future studies with diversified samples, methodological triangulation and longitudinal design to capture evolutive trajectories of the psychosocial consequences.
Future studies must be conducted with larger samples to obtain more information on late consequences of cancer, mainly those mental-related. Additionally, it is necessary to establish a communication network among assistance health units with attention to updated contact data to maintain the bonds with these individuals.
DATA AVAILABILITY STATEMENT
All the content underlying the text is contained in the manuscript.
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Edited by
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Associate editor:
Pedro Senise Maroun. Orcid iD: https://orcid.org/0009-0007-6465-8417
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Scientific-editor:
Anke Bergmann. Orcid iD: https://orcid.org/0000-0002-1972-8777
