Psychology in the Schools, Vol.

46(7), 2009 
C 2009 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/pits.20399

SCHOOL REINTEGRATION FOR CHILDREN AND ADOLESCENTS WITH CANCER:

THE ROLE OF SCHOOL PSYCHOLOGISTS
MEKEL S. HARRIS
University of Houston

As a result of advancements in medical expertise and technology, children and adolescents diag-
nosed with cancer now have opportunities to participate in many typical activities, including school.
To some extent, school reintegration reflects positive adjustment to their illness. Nevertheless, chil-
dren and adolescents with cancer may experience consequences that result in problems with school
functioning and performance, along with other psychosocial difficulties. Accordingly, school per-
sonnel may not be equipped to appropriately intervene with this unique population of students.
One means of offsetting such consequences, and thus facilitating successful school reintegration,
is consultation between children or adolescents, parents and/or caregivers, school personnel, and
health professionals. The eco-triadic model of educational consultation may be useful as a means
of providing indirect and direct services to children and adolescents with cancer. This article pro-
vides a description of the model, describes the model’s application to school psychologists’ work
with this unique population of children, provides checklists to help guide school psychologists’
intervention throughout the school reintegration process, and highlights implications for school
psychology practice.  C 2009 Wiley Periodicals, Inc.

Chronic medical illness, formally defined as illness that has no cure but is not necessarily
terminal, impacts up to 20% of school-age children, with a considerable portion of this population
being significantly affected (Sexson & Madan-Swain, 1993; Vitulano, 2003). Furthermore, it is
estimated that approximately 10% of these children’s medical illnesses may be classified as severe
(Wallander, Thompson, & Alriksson-Schmidt, 2003). One category of chronic medical illness among
children and adolescents is childhood cancer, which affects thousands of children across the United
States each year (ACS Cancer Facts and Figures, 2005). To date, childhood cancer is the fourth
leading cause of death by illness among children and adolescents ages 1 to 19 years, and is only
preceded by unintentional injury, suicide, and homicide (Pollack, Stewart, Thompson, & Li, 2007).
The incidence of childhood cancer peaks during the first year of life and is higher for children
younger than 5 years or older than 14 years. In fact, in 2005 alone, it was estimated that more than
12,000 children would receive some sort of childhood cancer diagnosis (American Cancer Society,
2005). An approximate breakdown of the most common diagnostic classifications of childhood
cancer reveals the following prevalence rates: leukemia (32%), cancers of the nervous system and
brain (18%), soft tissue sarcomas (13%), neuroblastoma (13%), and renal (Wilms’) tumors (9%)
(Ries et al., 1998).
Despite the percentage of children and adolescents affected by cancer, recent medical and
technological advances have afforded families the opportunity to pursue state-of-the-art medical
treatment for their children. Thus, improvements in treatment approaches have resulted in measurable
increases in long-term survival rates for children diagnosed with cancer (Ries et al., 1998). As a
result, children spend less time as inpatient recipients (i.e., within the hospital setting) of medical care
and have increased opportunities to experience a sense of normalcy and social reintegration outside
of the hospital setting. In particular, these children are able to reintegrate into their community school
settings.

Correspondence to: Mekel S. Harris, University of Houston, College of Education, Department of Educational
Psychology, 4800 Calhoun Road, Houston, TX 77004. E-mail: msharris2@uh.edu

579
580 Harris

S CHOOL R EINTEGRATION F OR C HILDREN AND A DOLESCENTS WITH C ANCER

Practitioners concur regarding the importance of school reintegration among children and
adolescents with cancer (e.g., Madan-Swain & Brown, 1991; McCarthy, Williams, & Plumer, 1998;
Sexson & Madan-Swain, 1993, 1995). The topic’s relevance to school psychologists cannot be
underestimated, especially in light of research indicating that children with childhood cancer do
experience consequences that result in problems with school functioning, educational development,
and performance (Barrera, Shaw, Speechley, Maunsell, & Pogany, 2005; Fryer, Saylor, Finch, &
Smith, 1989; Wallander & Varni, 1998). In addition, some research suggests that these children are at
increased risk for maladjustment and psychopathology when compared to healthy peers (Eiser, 1990;
Wallander & Varni, 1998). Empirical research studies to support the efficacy of school reintegration
for children with chronic medical illnesses are limited, however, primarily due to methodological
issues (Diedrick & Farmer, 2005; Kaffenberger, 2006; Mayer et al., 2005). For example, in their
review of published research in the area of comprehensive school reintegration programs (i.e.,
those targeting family, school, and child outcomes) among children and adolescents with cancer
from 1977 to 1998, Prevatt, Heffer, and Lowe (2000) highlighted the use of anecdotal rather than
empirical analyses in five of the six studies. Nevertheless, review of one comprehensive school
reintegration program (e.g., Katz, Rubenstein, Hubert, & Blew, 1988; Katz, Varni, Rubenstein,
Blew, & Hubert, 1992) provides empirical data to support improvements in children’s self-concept,
along with interpersonal and behavioral functioning, following a school reintegration program
intervention. More recent research evaluating the efficacy of a school reintegration program among
children with burns found that these children reported improvements in interpersonal relationships
and peer support (Rosenberg et al., 2006). Thus, it appears that school reintegration serves an
important rehabilitative goal for children and adolescents and acts as a moderator for children’s
overall adjustment.
Attending school is regarded as the “work of childhood” (Varni, Katz, Colegrove, & Dolgin,
1994, p. 24) and is important in fostering children’s educational and psychosocial competencies.
Die-Trill and Stuber (1998) discussed school reintegration as a criterion for adequate adjustment
to illness among children and adolescents with cancer. For example, children are frequently pro-
vided opportunities to achieve academic mastery through completion of assignments and classroom
projects within the school setting. In addition, psychosocial competencies are enhanced through
social interactions with peers, teachers, and other school personnel. Favorable outcomes for children
and adolescents who successfully reintegrate into the school milieu include (a) experience of nor-
malization, (b) development of mastery and control (Bessell, 2001; McCombs, 1991), (c) increased
self-esteem (Die-Trill & Stuber, 1998), and (d) lessened identification as patients (Chekryn, Deegan,
& Reid, 1987; Ross, 1984).
Seminal work in the area of school reintegration among children with cancer began in the 1970s
(Katz, Kellerman, & Rigler, 1977). Approaches to school reintegration, although similar in encourag-
ing positive academic and psychosocial outcomes, varied conceptually and programmatically from
one program to another until the 1990s. At one end of the spectrum, programs initially subscribed
to an independent functions model, with supportive school reintegration services occurring in a less
systematic manner, focused primarily on anecdotal evidence (Deasy-Spinetta, 1984). In the 1990s,
Katz et al. (1992) evaluated the efficacy of a comprehensive school reintegration intervention among
children with cancer, which was later formulated into a general school reintegration plan (Nessim
& Katz, 1995; Sexson & Madan-Swain, 1993). Services provided included supportive counseling
for children and families, educational presentations to schools, and systematic consultation between
hospital and school personnel. In general, the intervention emphasized an increased understanding of
cancer, its related treatment, and medical and psychosocial side effects. Data collected from children,

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 School Reintegration for Children and Adolescents with Cancer 581

parents, and school personnel provided support for the ecological validity of the intervention for
children newly diagnosed with cancer. In addition, “their empirical data [lent] support to the validity
of establishing [interdisciplinary] relationships when helping the student with cancer reintegrate into
the school system” (Shields, Heron, Rubenstein, & Katz, 1995, p. 185). One means of establishing
and maintaining such relationships is through ongoing consultation between and among all parties
involved in the child’s care throughout the school reintegration process.

C ONSULTATION M ODELS FOR P ROMOTING S CHOOL R EINTEGRATION

Explicit models of consultation, particularly consultation aimed at school reintegration for
children and adolescents with cancer, are scarce. Among the consultation models that do exist,
expectations of the consultation process differ, depending on the setting (e.g., medical vs. school)
and rationale for use (Rosenthal, 1993). Stabler (1988) highlighted three types of educational con-
sultation, which can be applied within the context of a medical setting; that is, medical personnel
consulting with hospital-based clinical or school psychologists. The author’s delineation of various
forms of consultation, although meaningful to psychologists working within a medical context, is
not directly relevant to psychologists working outside this environment (e.g., school-based psychol-
ogists) who also interact with children and adolescents diagnosed with cancer. Given the increased
likelihood of community school reintegration as a result of improved cancer treatments, consultative
models germane to this unique population of children and applicable to school-based psychologists
must be used.

Eco-Triadic Model of Educational Consultation

The eco-triadic model of educational consultation was specifically designed to address the
needs of children and adolescents with cancer and can be directly applied to psychologists working
within school settings (Shields et al., 1995). Fundamentally, the model serves as a means of provid-
ing indirect and direct services to the child, an extension of the original triadic model proposed by
Tharp and Wetzel (1969). Theoretical underpinnings of the triadic model are rooted in principles of
behaviorism, targeting the direct roles that individuals assume within the consultative relationship
to assist clients in achieving behavioral change. Specifically, Tharp and Wetzel outlined those indi-
viduals involved throughout the consultation, including (a) a consultant to facilitate the consultation
process, (b) a mediator to provide direct services to an identified client, and (c) the target client with
a problem behavior. Application of the triadic model to school reintegration among children and
adolescents with cancer would involve the school psychologist as the consultant, who would assist
parents (mediators) in the provision of services to children and adolescents (targets). Shields et al.
(1995) asserted, however, that the use of a linear approach to service provision is not appropriate
for this unique population and suggested a more comprehensive process involving direct service and
collaboration between and among parties involved in children’s care. As such, the eco-triadic model
implies the use of a social-ecological theoretical approach to understanding the mediating factors
involved throughout the consultative process (Bronfenbrenner, 1979). Bronfenbrenner’s ecological
systems theory involves the exploration of children’s functioning within the context of the systems
of relationships that comprise their environment and offers a proactive option to address various
systems of care for the child with cancer (Kazak & Beele, 1993). Shapiro and Manz (2004) affirmed
the use of the eco-triadic model as a “framework for guiding pediatric psychologists in conducting
multisystemic collaboration for children with chronic illness” (p. 60).
Emphasis on the systems with which the child interacts affords a comprehensive perspective
for all persons involved in the child’s care and provides opportunities for improved support net-
works. The eco-triadic model highlights identification of an educational consultant, a member of the

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582 Harris

interdisciplinary team, to coordinate the consultative relationships and, thus, help make the child’s
transition from hospital to school as seamless as possible. Clinical consensus (Brown, 1999; Edwards
& Davis, 1997) supports the notion that comprehensive school coordination for children with chronic
medical illnesses necessitates an interdisciplinary approach that includes caregivers; school person-
nel, including school psychologists; and medical staff. Furthermore, in a presidential address to the
Society of Pediatric Psychology, Brown (2002) discussed the importance of ongoing collaboration
among professionals interfacing with children with chronic illnesses and asserted the need for addi-
tional attention to the “reciprocal influences” affecting these children (p. 195). Such approaches to
school reintegration, according to these professionals, encourage decision making through joint col-
laboration and consultation among all members of the interdisciplinary team. School psychologists
are a vital component of this team and are in a unique position to facilitate and monitor the school
reintegration process. The eco-triadic model emphasizes development of consultative relationships
and provision of indirect services to the three ecosystems relevant to children with cancer: home,
hospital, and school.

Consultant–Home Relationship. Within the home ecosystem, school psychologists serving as

the educational consultant must be aware of the child’s familial relationships and their impact on the
child’s adjustment to cancer diagnosis and school reintegration. Underlying the child’s adaptation to
diagnosis and related familial relationship issues is the premorbid functioning level of the family. The
quality and nature of the parent–child and child–sibling relationships prior to the cancer diagnosis
has direct bearing on post-diagnosis outcomes (Katz, 1980; Pless & Pinkerton, 1975). For example,
families with a poorer level of premorbid functioning (e.g., poor communication skills, heightened
tensions) are at an increased risk for inferior outcomes following diagnosis. Essentially, premorbid
familial interactions tend to persist and intensify as ongoing stressors manifest throughout the cancer
experience.
Furthermore, the developmental tasks typically expected of children may be countered by
periods of emotional regression as a result of the cancer diagnosis (Vitulano, 2003). Children and
adolescents, forced to endure emotional and physical consequences as a result of treatment, along
with physical isolation, may exhibit overreliance on parents and/or siblings throughout their cancer
treatment. The consequent regressive behaviors may prove challenging and burdensome to families
as they explore new ways of interacting with their children. In an attempt to set or maintain limits
with their children, parents may not respond in a manner that is fitting from the child’s perspective;
hence, tensions in the parent–child relationship may emerge or intensify. As a compounding issue,
continual emphasis on the ill child’s needs affects other members in the family, namely, siblings.
Siblings of children with cancer may grow to resent the special attention paid to their ill sibling and
exhibit an array of emotional and/or behavioral reactions (Labay & Walco, 2004). Fromer (1995)
discussed the impact of parental focus on the child with cancer, specifically as this focused attention
alters the shape of the entire family system. School psychologists’ awareness of such issues within
this ecosystem affords them greater insight and increases their ability to effectively communicate
concerns with members of the other major ecosystems relevant to the eco-triadic model: hospital
and school.

Consultant–Hospital Relationship. The extent to which medical personnel are aware of func-
tioning within other ecosystems may afford them flexibility in medical service provision. For ex-
ample, medical personnel may be able to negotiate medical treatment or treatment schedules to
accommodate families struggling within the home environment. Similar outcomes may be possible
for children experiencing neurocognitive and/or social delays within the school context as a result of
intensive medical treatment. School psychologists play an essential role in communicating relevant

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 School Reintegration for Children and Adolescents with Cancer 583

information to medical personnel in order to assist children and families. Conversely, school psy-
chologists must continually be aware of the hospital ecosystem and communicate children’s medical
concerns with children and their families, along with school personnel. Awareness of the course of
medical treatment and its associated risk factors is essential. For example, in the initial stages of
diagnosis, children with cancer may spend several hours per day in the medical setting, participat-
ing in various diagnostic and/or laboratory examinations, in addition to consultation with medical
personnel. As a result, they are likely to exhibit chronic absenteeism from school, which may affect
their reintegration into the school milieu and engagement with peers (Bessell, 2001). As children
with cancer progress through the intermediate and latter stages of their treatment, time spent in
the medical institution is typically reduced, although children may still have frequent and ongoing
visits with their medical teams. Again, school psychologists play a central role in sharing such
information with school personnel as a means of educating team members and planning appropriate
educational and psychosocial interventions. Katz et al. (1992) evaluated the effect of a school rein-
tegration intervention on parents’ and teachers’ ratings of childhood cancer survivors’ internalizing
and externalizing problems, social competency, and overall self-esteem when compared to a control
group of children. Throughout their intervention, emphasis was on (a) identifying children’s medical
diagnoses and addressing prognostic issues, (b) planning for possible short- and long-term effects of
treatment through collaboration with hospital personnel, (c) educating school personnel and class-
mates regarding the cancer diagnosis, and (d) delineating roles among school personnel. Findings
suggested that children in the intervention group experienced significantly less problem behaviors
and greater self-esteem and social competence following the intervention, thus providing poten-
tial support for the consultant–hospital relationship. School psychologists’ ongoing consultation
with medical personnel is important in the development and implementation of school reintegration
activities for children diagnosed with cancer.

Consultant–School Relationship. In addition to the expectation that school psychologists serve

as liaisons between the two aforementioned ecosystems, they must also be well versed on issues per-
tinent to the school milieu and effectively communicate this with the home and hospital ecosystems.
Rosenthal (1993) concurred by stating, “effective consultations . . . involve knowledge of not only
the medical problems and the medical system, but also the school system” (p. 391). In particular,
school psychologists must be familiar with educational law as it pertains to children with chronic
medical illnesses, as well as appropriate educational interventions for children within this unique
population. Equally, school psychologists must be knowledgeable regarding the impact of the child’s
diagnosis on the school ecosystem, particularly as it relates to the child’s educational performance.
This is especially important because children and adolescents with cancer may experience an array
of neurocognitive sequelae (Brown et al., 1996).
For example, Copeland, Moore, Francis, Jaffe, and Culbert (1996) documented the prevalence of
neurocognitive late effects (i.e., subtle learning difficulties that manifest months to years following
treatment). This phenomenon occurs principally among children diagnosed with central nervous
system tumors and is associated with their treatment regimens. A landmark psychosocial study by
Meadows et al. (1981) found that children with ALL who received high-dose chemotherapy and
cranial radiation treatment (i.e., treatment directly into the brain) experienced patterns of deficits
on intellectual and neurocognitive tests when compared to control groups who received no cranial
radiation. Furthermore, a study examining attentional functioning among survivors of brain tumors
who receive radiation therapy revealed that they tend to experience deficits in processing speed and
decreased focused attention skills over time (Merchant et al., 2002). Other cognitive impairments
include deficits in working memory and information processing (Espy et al., 2001), motor speed and
perception (McIntosh et al., 1976; Palmer et al., 2001), and planning/organizational skills (Reeves

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584 Harris

et al., 2007). The disruption of these critical neurocognitive processes likely impedes children’s
learning and ultimately affects their educational performance. For example, Reeves et al. (2007)
discussed the prevalence of slow cognitive tempo (e.g., lethargy, disorganization, problems with
attention and concentration) and its association with lower IQ and achievement scores, particularly
in reading.
In addition to neurocognitive impairments, children with cancer may also have physical im-
pairments (e.g., visual or hearing deficits, problems with ambulation) that may affect their ability
to successfully navigate the school environment and, therefore, affect educational outcomes. For
example, they may experience bouts of limited physical strength and vitality, which certainly impacts
their ability to concentrate and effectively engage in classroom instruction. To this end, school psy-
chologists play an essential role in overseeing the implementation, ongoing review, and evaluation
of individualized education and health plans for this unique population of children.

Consultant–Student Relationship. In addition to the indirect services provided in the home,

hospital, and school ecosystems, the eco-triadic model also emphasizes the provision of direct ser-
vices to children and adolescents with cancer. This relationship is particularly important due to
children’s first-hand experiences with cancer. School psychologists’ awareness of children’s experi-
ences is essential in providing validation and support because children with cancer may experience
an array of social-emotional difficulties on return to school (Barrera, Shaw, Speechley, Maunsell, &
Pogany, 2005; Fryer et al., 1989; Wallander & Varni, 1998). For example, an occasional response
to the constant rigor of medical treatment is children’s overidentification as patients, the conse-
quences of which can be destructive, affecting children’s self-efficacy, psychosocial relationships,
and motivation toward academic performance (Henning & Fritz, 1983).
Along the same lines, children and adolescents diagnosed with cancer typically undergo fre-
quent medical procedures, designed to adequately diagnosis, monitor, and treat their cancer. Some
of these procedures (e.g., lumbar punctures, bone marrow aspirations), although necessary in man-
aging children’s cancer, are unfortunately, painful (Schechter, 1989). Furthermore, children often
experience uncomfortable side effects as a result of medical procedures (Katz, 1980). In the majority
of situations, management of the cancer is dictated by strict medical protocols; thus, children are
not afforded many opportunities to control events related to their medical treatment, subsequent
care, or side effects. An unintended outcome may be the development of learned helplessness
(Deasy-Spinetta, 1984; Katz, 1980; Katz et al., 1992). Likewise, research emphasizes that previ-
ously independent children may experience behavioral and/or academic regression, thus affecting
not only their self-concepts, but also how others relate to them (Vitulano, 2003). Depending on the
developmental age of the child, the implications of such regression vary. Among young children, for
example, regressive patterns may be less noticeable to the child or his or her peers. Among adoles-
cents, however, peer acceptance is critical in the development of the adolescent’s self-concept; thus,
academic and social failure may not be as tolerable.
A separate, but related issue, particularly among adolescents, is physical transformation result-
ing from medical treatment and its relation to body image and peer relationships. Rigorous treatments
designed to cure the cancer may lead to changes in bodily appearance, including hair loss, excessive
weight gain or loss, or physical impairments. Due to changes in appearance, children’s propensity to
pursue peer relationships may be reduced, or become nonexistent, due to apprehension about being
teased by others. Furthermore, children with cancer may become hypervigilant about their physical
appearance, thereby affecting how well they manage social demands within their environment.
Finally, an unfortunate reality among and children and adolescents with cancer is the possibility
of disease relapse and/or progression. Hockenberry-Eaton, Dilorio, and Kemp (1995) investigated
the relationship between longevity of the cancer experience and the presence of a relapse and

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 School Reintegration for Children and Adolescents with Cancer 585

children’s self-perception, cancer stressors, anxiety, and use of coping strategies among children and
adolescents ages 6 through 13 years. Results suggested that longevity of the cancer treatment and
the presence of a relapse were negatively associated with children’s self-perception and positively
associated with reports of anxiety. The institution of strategies to increase children’s self-perception
and decrease children’s anxiety may prove to be important.
Regular school attendance, which offers children opportunities for positive experiences, has the
potential to improve children’s psychosocial outcomes (Die-Trill & Stuber, 1998; Nessim & Katz,
1995).

Strengths and Limitations of the Eco-Triadic Model of Educational Consultation

Research continues to focus on and reflect the importance of identifying and understanding the
educational and psychosocial needs of children and adolescents diagnosed with cancer. Given the
expanding roles of school psychologists, coupled with increased survival rates among children and
adolescents with cancer, training and skills in models of educational consultation remains a valuable
component of comprehensive care for this unique population of children. In a review of school
reintegration programs, Prevatt, Heffer, and Lowe (2000) concluded that effective programs share
the following features: (a) identification of a person to coordinate school reintegration services,
(b) direct service provision to the child with cancer, (c) consultation with medical and school
personnel, and (d) education of the child with cancer’s classmates. Programs must also be guided by
a framework which delineates “the reciprocal influences of systems on chronic illness and chronic
illness on systems for the organization of empirical and theoretical data on pediatric illness” (Brown,
2002, p. 195). To this end, the eco-triadic model of educational consultation serves as an important
tool, affording practitioners the opportunity to identify and appreciate the relationships between and
among the educational consultant and the child with cancer, his or her family, medical team, and
school personnel. Although not yet empirically validated, the model’s theoretical basis in behavioral
principles is substantiated by interventions emphasizing the role of the educational consultant as
a facilitator of comprehensive consultative services. Furthermore, the model’s implicit basis in
social-ecological theory is clarified through interventions emphasizing the interplay of child, family,
hospital, and school systems (Katz et al., 1992; Worchel-Prevatt et al., 1998).
Shields et al. (1995) discussed implications of their model, asserting that “multiple measures
of evaluation can be obtained across the three ecosystems” (p. 196). The authors also described
the importance of obtaining and evaluating both quantitative and qualitative data collected within
each ecosystem of the consultation model. Certainly, evaluation of the programmatic features of the
model is critical in improving consultative efforts between and within ecosystems. Nevertheless,
the authors failed to delineate practical tools for assisting the identified educational consultant in
conceptualizing and intervening within each ecosystem as part of the school reintegration process.
Increased efforts to standardize procedures and strategies for intervention will increase the potential
for reliable application across practitioners and improve subsequent studies in this area of research.
The main purpose of this article is to expand on the eco-triadic model by providing checklists to
assist school psychologists in implementing strategies across ecosystems as they seek to reintegrate
children and adolescents with cancer into their community school settings.

Expansion of the Eco-Triadic Model of Educational Consultation

The interplay of the home, school, and hospital ecosystems is complicated, but can best be
explained through the use of a schematic representation to assist school psychologists fulfilling the
role of the educational consultant (Figure 1).

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586 Harris

Comprehensive
school
reintegration
program,*
education and
emotional
School support, IEP
development,
etc.
Communication
with classmates
Timelines for
and school return, family
personnel Medical regimen,
involvement prognosis, meds, etc.

Educational
Family Hospital
Consultant

Emotional support, resources

Child

Medical regimen
Family concerns,
Family coping treatment regimen
mechanisms,
family
dynamics,
siblings, etc.

FIGURE 1. Schematic representation of the eco-triadic model of educational consultation.

Successful school reintegration for children diagnosed with cancer is best facilitated by a
coordinated effort between and within home, school, and hospital ecosystems. Figure 1 highlights the
educational consultant (in this case, the school psychologist) as a central element in the consultation
process and reflects the dynamic nature of the relationships between ecosystems. For example, the
school psychologist’s relationship with the child involves (a) the provision of emotional support to
the child, (b) exchange of information related to the child’s cancer diagnosis, (c) discussion of the
child’s concerns regarding infection control, and (d) review of the educational and social implications
of school reintegration. Similarly, the school psychologist’s interaction with the child or adolescent
also involves an understanding of the child’s relationships with his or her family, medical team, and
community school. For example, the school psychologist should coordinate with school personnel
to help maintain the child’s relationships with his or her classmates, teachers, and other individuals
involved with the child at school.
Although not delineated in the schematic model, the child’s relationships with his or her family
and hospital personnel are significant relationships that cannot be underestimated. For example,

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 School Reintegration for Children and Adolescents with Cancer 587

Consultant–Home Relationship Checklist

I. Points to Consider Prior to School Reintegration

a. _____ What is the child’s diagnosis ?
b. _____ What is the family’s experience with cancer (if any) ?
c. _____ What did the family’s interactions look like prior to the diagnosis?
d. _____ Does the child with cancer have siblings, and what is the status of this
relationship(s)?
e. _____ Is the family experiencing other stressors (e.g., financial, marital)?
f. _____ How does the family seem to be coping with the child’s diagnosis ?
g. _____ What changes, if any, have occurred with respect to limit-setting for
the child with cancer?
h. _____ What support systems are in place (if any) for the family?
i. _____ How does the family feel about the child returning to school?

II. Points to Consider During School Reintegration

a. _____ How does the family feel about the child returning to school?
b. _____ What is the family’s understanding of the child’s level of involvement
on return to school?
c. _____ How involved does the fa mily want to be in the reintegration process?
d. _____ How will information be shared with the family when the child returns
to school?
e. _____ How knowledgeable is the family about educational services for
children with cancer?
f. _____ What is the status of the family’s relationships ?

III. Points to Consider Following School Reintegration

a. _____ How has the family responded to the child’s return to school ?
b. _____ What level of support does the family need in their interaction with
school personnel?
c. _____ How often will information be shared with the family about the child’s
educational needs?
d. _____ What is the status of the family’s relationships ?

FIGURE 2. Checklist for the consultant–home relationship as part of the eco-triadic model of educational consultation.

children’s relationships with parents and/or siblings may be taxed, as each family member adapts
to the child’s illness and changes in roles within the family structure (Vitulano, 2003). Research
suggests that chronic medical illness frequently acts as a threat to the family’s sense of equilibrium
(Friedrich, 1977) and has direct implications on familial relationship patterns. An appreciation of
this dynamic process is essential to working with children and families dealing with the cancer
diagnosis. Along the same lines, school psychologists must also understand the interaction between
the child and his or her medical team, namely, related to the child’s understanding of his or her
diagnosis, acceptance of and adherence to medical treatment, and recognition of disease outcome
(La Greca & Bearman, 2003).
Although an understanding of the theory and basic framework of the eco-triadic model of
educational consultation is important, so, too, is the development and application of practical tools
for intervening within each ecosystem. This article provides school psychologists with checklists,
outlining points to consider as they interact with children with cancer, their families, hospital
personnel, and community schools. A review of the extant literature reveals a similar endeavor,
although the researchers provided only a general plan for school reintegration (Sexson & Madan-
Swain, 1993) or primarily emphasized the unidirectional relay of information from medical personnel

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588 Harris

Consultant–Hospital Relationship Checklist

I. Points to Consider Prior to School Reintegration

a. _____ What is the child’s diagnosis ? prognosis?
b. _____ How is the child’s cancer type different from/same as other types of
cancer?
c. _____ What medical treatments will the child receive, and what are the short-
and long-term physical or cognitive side effects ?
d. _____ How long will the child receive treatment?
e. _____ What role will the child/family play in the child’s treatment regimen?
f. _____ Will there be noticeable physical impairments as a result of treatment?
g. _____ Are there limitations on what the child can participate in at school?
h. _____ What side effects might affect how the child performs in school?
i. _____ How concerned should the child/family be regarding infection control
issues?
j. _____ What medical records/documentation will be most important to school
personnel?

II. Points to Consider During School Reintegration

a. _____ Have there been changes to the child’s treatment plan?
b. _____ How often will the child be absent from school due to treatment?
c. _____ What role will the child/family play in the child’s treatment regimen?
d. _____ Are there limitations on what the child can participate in at school?
e. _____ What side effects might affect how the child performs in school?
f. _____ What steps should be taken regarding infection control issues?

III. Points to Consider Following School Reintegration

a. _____ Have there been changes to the child’s treatment plan?
b. _____ How often will the child be absent from school due to treatment?
c. _____ What role will the child/family play in the child’s treatment regimen?
d. _____ Are there limitations on what the child can participate in at school?
e. _____ What side effects might affect how the child performs in school?
f. _____ What steps should be taken regarding infection control issues?

FIGURE 3. Checklist for the consultant–hospital relationship as part of the eco-triadic model of educational consultation.

to school-based educators (Deasy-Spinetta, 1997). The decision to highlight home, hospital, and
school contexts is based on the eco-triadic model’s discussion regarding the provision of services
within and among each of these three ecosystems (Shields et al., 1995). Furthermore, one means of
conceptualizing areas of consideration is in a threefold fashion, exploring issues prior to, during, and
after the child or adolescent reintegrates into the community school setting, which is consistent with
literature asserting the importance of evaluating interventions throughout the school reintegration
process (e.g., Power, DuPaul, Shapiro, & Kazak, 2003).
Figures 2 through 4 provide school psychologists with practical questions to consider at each
phase of school reintegration when interacting with the child’s family, medical team, and school.
For example, Figure 2 addresses issues related to the family prior to the child’s diagnosis, along
with current family functioning, considerations relevant to the child’s overall adjustment (Katz,
1980; Pless & Pinkerton, 1975). In addition, consideration of parental stress (Barrera et al., 2004),
parental understanding and acceptance of the child’s medical diagnosis (Vannatta & Gerhardt, 2003),
and changes in parenting (Vitulano, 2003) is important in assisting families as they cope with the
child’s reintegration into the school environment. Figure 3 is an adaptation of issues highlighted in a
checklist by Deasy-Spinetta (1997) and addresses variables related to children’s school attendance,

Psychology in the Schools DOI: 10.1002/pits

 School Reintegration for Children and Adolescents with Cancer 589

Consultant–School Relationship Checklist

I. Points to Consider Prior to School Reintegration

a. _____ Is the child already receiving special education services? If not, should
this be considered to address educational needs?
b. _____ Does someone at the child’s school have prior understanding of cancer
and related effects?
c. _____ Does the child’s school provide school nursing services ? If so, what
experience does the nurse have with children with cancer?
d. _____ Would school personnel/classmates benefit from a presentation/school
visit to address their concerns? If so, when should this take place?
e. _____ Does the child with cancer have a sibling(s) at school?
f. _____ How will the child’s educational/psychosocial progress be monitored
and shared with the child’s family and hospital team?
g. _____ How will peer/teacher communication and support be maintained?

II. Points to Consider During School Reintegration

a. _____ What concerns do school personnel have regarding the child’s
educational and/or social needs?
b. _____ If not already receiving special education services, should this be
considered to address educational needs?
c. _____ How have siblings responded to the child’s return to school (if
applicable)?
d. _____ How are educational/psychosocial progress monitoring systems
working?
e. _____ How will the team respond proactively to absences, changes in child’s
school schedule, etc.?
f. _____ What is the possibility of developing a peer support system?

III. Points to Consider Following School Reintegration

a. _____ What concerns do school personnel have regarding the child’s
educational and/or social needs?
b. _____ If not already receiving special education services, should this be
considered to address educational needs?
c. _____ How are educational/psychosocial progress monitoring systems
working?
d. _____ Are previous interventions (e.g., peer support, physical assistance)
working? If not, how can they be modified?

FIGURE 4. Checklist for the consultant–school relationship as part of the eco-triadic model of educational consultation.

peer and social interactions, education, and medical adherence. Finally, considerations discussed
in Figure 4 are based, in part, on material by Nessim and Katz (1995), which highlights the role
of school psychologists as conduits of information for classroom teachers, as well as overseers of
children’s educational and psychosocial progress throughout the school reintegration process. Figure
4 also encourages consideration of issues related to peer support systems (Katz et al., 1988) and
provision of school nursing services. By no means are the checklists exhaustive; rather, they are
designed to help guide school psychologists throughout the school reintegration process as they
interface with each of the three ecosystems proposed by the eco-triadic model.
What is obvious on review of each checklist is the degree of preparation and consideration of
issues prior to the child reintegrating into the school setting. In particular, the first phase of school
reintegration for each ecosystem involves exploration of existing support systems and the extent to
which involved parties are comfortable with the child’s return to school. The issues dealt with in

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590 Harris

subsequent phases are recurring, emphasizing the importance of continual review and evaluation
of existing intervention plans for the child with cancer. This is particularly true for the consultant–
hospital relationship, as the child’s medical treatment regimen is modified or the child experiences
unanticipated side effects of treatment.

I MPLICATIONS FOR S CHOOL P SYCHOLOGY P RACTICE

Educational intervention for the child or adolescent with cancer represents a significant chal-
lenge for the child or adolescent, his or her family, medical team, and school personnel, including
school psychologists. As children and adolescents with cancer receive state-of-the-art medical treat-
ment, they are in a better position to reintegrate into their community settings and participate in
typical day-to-day activities, including school. One of the most important issues for children and
adolescents with cancer is the need for effective and appropriate intervention throughout the school
reintegration process. As such, school psychologists must be prepared to quickly and appropriately
intervene. The extant literature addressing school reintegration for children with cancer exclusively
highlights the utility of the eco-triadic model of educational consultation as a means of providing
interdisciplinary intervention. This article attempts to expand on this consultation model by pro-
viding a schematic representation of the model, in order to better conceptualize the complexities
involved in intervening with this unique population of children. It also seeks to delineate educational
and psychosocial issues to consider, in the form of checklists, to provide school psychologists with
a framework from which to consider relevant ecosystems and, thus, inform intervention. To this
end, this article has direct application to school psychology practice. Translation of this new aware-
ness into practice may involve school psychologists receiving training in issues relevant to children
and adolescents with cancer. In addition, participation in professional development activities, along
with review of research literature pertinent to this topic, may assist school psychologists in using
provided tools in their interactions with children and adolescents with cancer. Last, but certainly
not least, school psychologists may begin the process of collaboration and consultation with allied
health professionals providing care to children and adolescents with cancer. Involvement in such
interdisciplinary efforts is essential in maximizing school psychologists’ learning in this area and
providing a platform from which to best serve children and adolescents within the school milieu.
Efforts to improve survival rates among children with cancer are futile if those involved in children’s
care are ill prepared to provide them with the tools necessary to effectively manage their return to
the school environment.
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