School of Occupational Therapy

Touro University, Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET

Focused Question:
What psychosocial intervention strategies have been shown to promote psycho-emotional well-being and
improved quality of life in siblings of pediatric cancer patients?
Prepared By:
Jerold L. Garrett and Mariana E. Hall
Date Review Completed:
October 1st, 2014
Clinical Scenario:
Siblings of pediatric cancer patients undergoing cancer treatment
Summary of Key Findings:
Summary of Levels I, II and III:
Individual psychological intervention:
2 individual sessions: Prchal, Graf, Bergstraesser, Landolt, 2012.
Medical Knowledge: increased in both, control and intervention group but the intervention group had greater
effects.
Social Support: significantly better on the intervention group.
Health related quality of life: improvements for both groups but the intervention group had greater
improvements in psychological well-being. According to parents both groups improved but improvements for
the intervention group were not significant.

Summary of Level IV and V:

Summer Camps:
Packman, Fine, Chesterman, Van Zuphten, Golan, and Amylon, 2004.
Statistically significant decreases in post- traumatic stress symptoms (PTSS), anxiety, & emotional problems.
Statistically significant improvements in physical health were modest. Improvements in emotional health,
social functioning, school functioning, and self-esteem.
Sidhu, Passmore, & Baker, 2006.
Decreased anxiety. Improvements in behavior, social competence, and social acceptance.
Wu, Prout, Roberts, Parikshak, & Amylon, 2011.
Decreased anxiety.
Wellisch, Crater, Wiley, Belin, & Weinstein, 2006.
Significant improvements on negative mood & interpersonal problems. Statistically significant decreases in
anhedonia.
Support Groups:
Houtzager, Grootenhuis, & Last, 2001.
Significant decrease in anxiety in 50% of the sample. Parents reported decreased tension and more compliant
behaviors. Participants reported feelings of reassurance due to being with other children and were enthusiastic
about the visit of the pediatric oncologist.
8 week sessions: Barrera, Chung, Greenberg, & Fleming, 2002.
Significant reduction in anxiety and depression. Reduction in fear of the illness. Children reported the program
was helpful in improving knowledge of pediatric cancer, expressing their feelings to others, and getting along with other
members of the family. Parents reported reduction of childrens anxiety, improvements in their behavior, increased
expression of feelings, and reduction of family distress. Group Logs revealed that participants preferred a general
discussion over discussion in pair. Teens were more likely to mask feelings, complain about increased chores, and talk
more to friends about their problems. Younger children were more likely to express their feelings and be afraid of
upsetting parents with their worries about cancer.

Barrera, Chung, and Fleming, 2005.

Decreases in depressive symptoms. At baseline adolescent girls had higher rates of depression. Younger boys
experienced the highest decreases in depression.

Contributions of Qualitative Studies:

Individual Virtual Intervention
Jenholt Nolbris & Ahlstrm, 2014
Increase in specific knowledge about cancer treatment and its side effects.
Improvements in quality and quantity of sleep but some participants still had some sleep problems when the
sick sibling was at the hospital due to worry. No longer experiencing bodily pain or discomfort but some still
had headaches occasionally. Siblings were happier but felt sad occasionally and had intrusive thoughts about
the cancer that made them feel like they were going crazy. Some still got angry at their parents and healthy
sibling and felt lonely when the sick child was in the hospital, or screaming at home, and they were asked to
leave the room. Siblings longed for the cancer treatment to end, and for the sick child to return to their normal

life. Some siblings avoided thinking about the future and lived in the moment.
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Bottom Line for Occupational Therapy Practice:

The clinical and community-based practice of OT:
E-health is an effective modality to deliver therapeutic interventions that provide therapeutic education and
emotional support to siblings of pediatric cancer patients.
Even a brief individual two-session psychological intervention provided at the hospital can have benefits.
Summer camps can be an effective means of normalizing the life experience of siblings of pediatric cancer
patients.
Group programs with an emphasis in enhancing cancer knowledge and confidence can be useful in
reducing anxiety and depression.
Program development:
Intervention programs for this population should provide specific medical information about cancer and its
treatment and implement practice of coping skills, as well as offer relevant education for parents.
Individualized intervention programs should be tailored to the developmental cognitive level of children
and include: medical information of body function, illness mechanism, location, and chemotherapy. The
intervention should also include discussion of the participants greatest stressors since the cancer diagnosis
and implement cognitive behavioral therapy (CBT) to talk about coping strategies. Parents should be
provided with a psychoeducational booklet with information about how to support siblings.
Summer camp interventions should begin with a discussion facilitated by the occupational therapist where
children share tips on how they cope with their situation so as to promote the development of peer support
networks at the very beginning. Occupational therapists can both, serve as mentors and train other staff
mentors on reinforcement of positive behaviors, effective ways of providing positive feedback, and
ensuring that each child has at least one experience of success during the week. Traditional camp activities
such as archery, swimming, boating, sports, and arts and crafts can also serve to boost self-confidence
when the just right challenge is provided.
Interventions should include opportunities for children to socialize with peers and preferably include a
pediatric oncology guest speaker to provide skilled education with regards to the cancer diagnosis.
Developing a manual to facilitate consistency in delivery of this program will increase access and
consistent provision of support group interventions for this population.
Societal Needs:
The high cost and current shortages in health care practitioners could be minimized through the use of
virtual modalities by including interactive media such as Skype. E-Health is a cost effective treatment
modality that can be used in conjunction with therapeutic education, journal reflection, and regular virtual
communication with supportive practitioners.
Siblings of pediatric cancer patients are at risk for mental health problems, including depression, anxiety
and PTSD.
Siblings also experience behavioral problems, sleeping problems, and premature emotional maturity.
Individual therapy might be more appropriate and effective for these kinds of issues. Providing early
preventative therapy within 2 months of diagnosis might be more effective to avoid worsening symptoms

of PTSD
PTSD rates of 38% are much higher in this population compared to typical children (5.4% -11%) and
although it dropped to 18% post-camp, this rate is still very high, suggesting the need for more intensive
focus on addressing trauma.
Anxiety levels are relatively high in comparison to the general population. For young girls ages 7-12,
anxiety decreased after group interventions, but it still remained significantly higher than the norm.
Anxiety did not decrease as much for siblings of children with a solid tumor or a brain tumor when
compared to siblings of children with leukemia or lymphoma. This suggests the need for more aggressive
interventions strategies for these groups
Families of children diagnosed with cancer may overlook the needs of the healthy siblings. Since 63% of
siblings experience at least transient psychological problems, prompt psychological interventions may
reduce distress, prevent more severe difficulties, and reduce the familys burden.
Healthcare delivery and policy:
Policies that regulate the provision of occupational therapy through virtual modalities should be enacted to
ensure that virtual medical care is covered and it abides by the requirements of confidentiality and HIPPA
guidelines.
Expanding the definition of mental health providers to include occupational therapists will make individual
psychosocial treatments more widely available to this population.
Health care policies should cover occupational therapy services in therapeutic summer camp settings as a
valid psychosocial intervention.
Policies should offer coverage of support groups for this population.
Education and training of OT students:
Occupational Therapist students should be trained to:
Address the psychosocial needs of other family members, in particular siblings.
Identify and treat mental health diagnoses such as PTSD using effective interventions such as cognitive
behavioral therapy (CBT)
Develop, organize, and implement psychosocial therapeutic camping interventions
Develop and facilitate group protocols.
Refinement, revision, and advancement of factual knowledge or theory:
Siblings of pediatric cancer patients experience anxiety due to the uncertainty of the situation. Anxiety
interferes with sleep, and can produce physical pain and illness.
Knowledge and education about cancer, its treatment, and side effects reduces uncertainty and thus relieves
anxiety, sleep problems, physical complaints, and psychological distress.
Siblings can develop PTSD and experience declines in health, school performance, and social functioning,
as well as increased risk for emotional, behavioral, and social problems.
Siblings assume greater responsibility while receiving less attention and rewards, which results in anger
and jealousy towards the cancer patient and guilt over having these feelings, which leads to lowered selfesteem.
Review Process:

Researchers selected articles based on the title as an indicator of the following:

o A focus on siblings rather than the entire family,
o Be specific to a cancer diagnosis for the brother or sister

These criteria resulted in 17 articles.

Abstracts were reviewed
8 studies were discarded due to being purely descriptive of the experience
Researchers met to discuss whether to include qualitative studies and studies on individual interventions
Based on the small number of article available, researchers decided to include these studies
The final selection included 9 articles
Procedures for the Selection and appraisal of articles:
Inclusion Criteria:

Focus on interventions
Both: group and individual interventions
Focus on siblings of pediatric cancer patients
Published between 2000-2014
Full article text available
Available in English
Academic Peer reviewed journals only
Only include child age groups up to 21 years old
Exclusion Criteria:

Articles published before 2000

Articles that focused on chronic conditions other than cancer.
Systematic reviews
Meta analyses
Articles that were purely descriptive of the experience for siblings of pediatric cancer patients
Articles that addressed interventions for the family in general
Search Strategies:
Categories

Key Search Terms

Patient/Client Population

Siblings of pediatric cancer patients

Intervention

Psychosocial

Outcomes

Psychological well-being, emotional well-being, quality of life

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Databases and Sites Searched

Google scholar
CINAHL Plus Full Text
PsycINFO

ERIC
Reference page of relevant articles

Quality Control/Peer Review Process:

Researchers read the 9 articles.

Each researcher completed McMaster forms on half of the articles.
McMaster forms were cross checked and edited.
Each researcher inputted data from half of the McMaster forms into the Evidence Table Worksheet.
Each researcher inputted information for half of the articles on this CAT form.
Both researchers reviewed the Evidence Table Worksheet and this CAT form.
Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:

Level of Study Design/Methodology of Selected Articles

Evidence

Individual Intervention
Prchal, Graf, Bergstraesser, Landolt, 2012.
30 participants 6-17 years old
Recruited from 2 childrens hospitals in Switzerland
Randomly assigned to groups
Siblings from the same family were assigned to the same group
Randomization stratified according to sex of sibling closest in age to the patient
The intervention group received a two-session psychological intervention
The control group received a conventional psychosocial intervention.
Assessments were conducted by an interviewer blind to group assignment.
Sessions were conducted by one of the authors: a clinical psychologist.

Number
of
Articles
Selected
1

II

III

IV

Summer Camps
Packman, Fine, Chesterman, Van Zuphten, Golan, and Amylon, 2004
Camp Okizu
77 children 6-17 years old.
Only the sibling closest in age to the patient was included.
Conducted by graduate pediatric psychology students
Human Figure Drawing (HFD) assessment scored by 2 art therapists

independently.
Pre-camp evaluation: 4-8 weeks before camp
Post-camp evaluation: 12-16 weeks after camp.
Wu, Prout, Roberts, Parikshak, & Amylon, 2011.
Camp Okizu
73 siblings comprising 89 families
Child Youth Care Forum assessment
Evaluated satisfaction of a psycho-education camp intervention Health promotion
using cognitive behavior therapy with protocols
Wellisch, Crater, Wiley, Belin, & Weinstein, 2006
Camp Ronald McDonald for Good Times
1 week summer session.
Southern California and Nevada
66 subjects: 31 patients and 35 siblings 7-17 years of age.
Referred by 9 pediatric cancer centers
Pretest, posttest, follow up
Baseline pretest: prior to camp
Follow-up 1 posttest: last day of camp
Follow-up 2 posttest: 46 months later
Measures of depressive symptoms, social, and pleasure/participation
Sidhu, Passmore, & Baker, 2006.
Camp Onwards
31 non-bereaved siblings, aged 813 years of age
Australian oncology facility.
Pretest-posttest and follow up
Pretest: before camp/Posttest: after camp/Follow-up: 8 weeks later.
Parents participated in focus groups to aid in the development of the protocol and
post camp to report behavioral changes
Support Groups
Houtzager, Grootenhuis, & Last, 2001
Historical study of data
24 subjects:718 years of age
Siblings of children treated at Academic Medical Centre in Amsterdam,
Netherlands
5 weekly group sessions for a maximum of 8 children
Led by a well-trained psychologist
Informative parent session prior to the start of the intervention.
Session 1: getting to know each other and useful information
Session 2: changes in life situation
Session 3: emotions related to the illness
Session 4: pediatric oncologist guest speaker
Session 5: visit to the oncology ward
After the last session, parents are invited to an evaluative session and asked about

changes observed in the siblings.

Barrera, Chung, Greenberg, & Fleming, 2002.
Pilot pretest and posttest study
Siblings Coping Together (SCT) manualized intervention program Addresses
depression, anxiety, and behavior problems
17 subjects 6-18 years old organized into 3 groups according to age.
8 weekly sessions of 2 hours each
Conducted at a hospital by a psychology graduate student and a research assistant
under the supervision of certified psychologist.
Session 1: Introduction to the groups rules
Session 2: Medical information on cancer and its treatment
Session 3: Cancer and the family context
Session 4: Siblings feelings
Session 5: Relationships between siblings
Session 6: The school context
Session 7: Hope, coping, and problem-solving
Session 8: Group graduation.
Barrera, Chung, and Fleming, 2005
42 siblings 6 to 14 years old.
Group intervention that met once a week for six weeks.
Pretest and posttest
Sibling Coping Together Program
Art and crafts activities performed around themes such as coping with school and
family life.
0

V
Other

Virtual Individual Interventions

Jenholt Nolbris & Ahlstrm, 2014.
Qualitative Studies
14 siblings in 11 families, 9-22 years old
Pretest and posttest
Audio recorded semi-structured interviews
Conducted by one of the authors over the telephone
20 open-ended questions and follow-up questions
Themes were extracted using qualitative content analysis
Authors read the entire text from all the interviews
Identified meaningful units related to the aim of the study
Sorted units into themes and subthemes.
Findings were discussed until a consensus was reached.
TOTAL:

Limitations of the Studies Appraised:

Levels I, II, and III

Prchal, Graf,Bergstraesser, Landolt, 2012.
Small Sample
All siblings within one family were assigned to the same group.
Only included subjects fluent in German
Immigrant families of lower socioeconomic status were excluded
Measures for social support and medical knowledge were developed by the researchers.
KIDSCREEN-27 scale is not validated for children less than 8 years of age and the youngest participants
were 6 years old.
Standard psychological care was made available to the whole sample.
Levels IV and V
Packman, Fine, Chesterman, Van Zuphten, Golan, and Amylon, 2004
Convenience sample
No comparison group
Only included subjects fluent in English
Most participants were from middle class families.
Conducted by graduate students.
18 participants became bereaved
RSE wording was modified to match childrens cognitive level.
HFD may be too subjective.
Post-camp data collected soon after September 11, 2001
Houtzager, Grootenhuis, & Last, 2001
Small convenience sample.
No control group
Differences in anxiety for gender and age groups in comparison to scores of typical peers were not
validated
Author did not control for anticipatory anxiety
Reduction in anxiety may have been the result of regression to the mean
Barrera, Chung, Greenberg, & Fleming, 2002.
Small sample size
Childrens reports differed from their parents reports.
Sidhu, Passmore, & Baker, 2006.
No control group.
Only subjects fluent in English were included.
Excluded participants with limited literacy
Only children living within 100 miles from the hospital were included.
Barrera, Chung, and Fleming, 2005
Small sample
No control group
Transportation problems
Intervention delivered by the researchers
Wu, Prout, Roberts, Parikshak, & Amylon, 2011.

Convenience Sample
No control group
Treatment was not described in detail
Study did not identify what aspect of camp was beneficial.
8 bereaved siblings were included
Wellisch, Crater, Wiley, Belin, & Weinstein, 2006
No control group
Small sample
Long period of time between the culmination of the camp and the surveys
Other (Qualitative Study)
Jenholt Nolbris & Ahlstrm, 2014.
Small convenience sample
Only subjects who owned computers were included
Only subjects fluent in Swedish were included
3 participants had dyslexia
Families who had transportation problems were excluded
Immigrants with no residence permit were too afraid to participate
Many participants came from the same family
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Articles Selected for Appraisal:

Barrera, M., Chung, J. Y., Greenberg, M., & Fleming, C. (2002). Preliminary investigation of a group
intervention for siblings of pediatric cancer patients. Children's Health Care, 31(2), 131-142.
doi:10.1207/S15326888CHC3102_4
Barrera, M., Chung, J. Y., & Fleming, C. F. (2005). A group intervention for siblings of pediatric cancer
patients. Journal of Psychosocial Oncology, 22(2), 21-39.
Houtzager, B. A., Grootenhuis, M. A., & Last, B. F. (2001). Supportive groups for siblings of pediatric
oncology patients: impact on anxiety. PsychoOncology, 10(4), 315-324.
Jenholt Nolbris, M., & Ahlstrm, B. (2014). Siblings of children with cancer Their experiences of
participating in a person-centered support intervention combining education, learning and reflection:
Pre- and post-intervention interviews. European Journal Of Oncology Nursing, 18(3), 254-260.
doi:10.1016/j.ejon.2014.01.002
Packman, W., Fine, J., Chesterman, B., Van Zutphen, K., Golan, R., & Amylon, M. (2004). Camp Okizu:
Preliminary investigation of a psychological intervention for siblings of pediatric cancer patients.
Children's Health Care, 33(3), 201-215.
Prchal, A., Graf, A., Bergstraesser, E., & Landolt, M., A., (2012). A two-session psychological intervention
for siblings of pediatric cancer patients: a randomized controlled pilot trial. Child & Adolescent
Psychiatry & Mental Health, 6(1), 3-11. doi:10.1186/1753-2000-6-3
Sidhu, R., Passmore, A., & Baker, D. (2006). The effectiveness of a peer support camp for siblings of
children with cancer. Pediatric blood & cancer, 47(5), 580-588.
Wiley, F. M., Belin, T. R., & Weinstein, K. (2006). Psychosocial impacts of a camping experience for
children with cancer and their siblings. PsychoOncology, 15(1), 56-65.
Wu, Y. P., Prout, K., Roberts, M. C., Parikshak, S., & Amylon, M. D. (2011, April). Assessing experiences of

children who attended a camp for children with cancer and their siblings: A preliminary study. In
Child & Youth Care Forum (Vol. 40, No. 2, pp. 121-133). Springer US.
Other References: