School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

Critically Appraised Topic Project

EVIDENCE TABLE WORKSHEET

Name: Jerold L. Garrett and Mariana E. Hall
Date: October 1st, 2014
Focus Question: What intervention strategies have been shown to promote psychological, emotional, social, and physical well-being in
siblings of pediatric cancer patients?
Rationale for inclusion/exclusion criteria applied to determine which articles should be included in the evidence table:
Articles should have been published no earlier than 2000
Articles should focus on siblings of children who specifically have cancer
Articles should address interventions for the siblings
Sample subjects should be under 21 years of age
Articles should have full text available
Only articles written in English
Articles should be Academic Peer reviewed journals
Author/ Year
Study
Objectives
Level/Design/
Subjects

Packman, Fine, Chesterman, Van Zuphten, Golan, and Amylon, 2004

To explore whether participation in a summer camp for siblings of pediatric cancer patients results in improvements in
posttraumatic stress symptoms (PSS), anxiety, quality of life (QOL), and self-esteem.
Level IV Cohort
Design: Pre-test/post-test Pre-test: 4-8 weeks prior to camp. Post-test: 12-26 weeks after camp.
Subjects: 77 children 6-17 years old. Only the sibling closest in age to the patient included

Intervention/
Outcome
Measures

Results

Study
Limitations

Implications for
OT

Camp Okizu SIBS Camp

Provides peer interaction
Facilitated discussion in which children shared tips on coping
Adult mentors provided positive feedback and ensured at least one experience of success per week.
Outcome Measures:
Coddington Life Event Scale (CLES) for Children and adolescents: measured stress
UCLA PTSD Index for DSM-IV: measured posttraumatic stress symptoms (PTSS)
Revised Children Manifest Anxiety Scale (RCMAS): measured qnxiety
Pediatric Quality of Life Inventory (PedsQL): measured quality of Life
Rosenberg Self-esteem Scale (RSE): measured self-esteem
Human Figure Drawing assessment (HFD): measured emotional problems
Statistically significant decrease in PTSS, anxiety, and emotional problems.
Improvements in the physical health domain of QOL.
Statistically significant improvements in emotional health, social functioning, and school functioning domains of
QOL.
Statistically significant improvements in self- esteem.
Convenience sample
No comparison group
RSE assessment wording was modified to match cognitive level of children.
Conducted by graduate students under expert supervision rather than directly by the expert.
Post-camp data collected soon after September 11, 2001 may have decreased the magnitude of intervention effect on
PTSS.
HFD assessment may be too subjective.
Most participants were from middle class families.
Only included subjects fluent in English.
18 participants became bereaved by the second time of data collection.
The clinical and community-based practice of OT:
Summer camps can be an effective means of normalizing the life experience of siblings of pediatric cancer patients
Program development:

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 of the camp. 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, arts and crafts can also serve to boost self-confidence when the just right challenge is provided
Societal Needs:
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 interventions with added focus on
addressing trauma
Healthcare delivery and policy:
Health care policies should cover occupational therapy services in therapeutic summer camp settings as a valid
psychosocial intervention.
Education and training of OT students:
Students should have coursework that prepares them to develop, organize, and implement psychosocial therapeutic
camping interventions
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.

Author/ Year
Study
Objectives
Level/Design/
Subjects

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 in turn leads to lowered self-esteem.

Houtzager, Grootenhuis, & Last, 2001

Determining whether support groups lessen anxiety in siblings of children with cancer.
Level IV: Cohort
Design: Pre-test, post-test design
Subjects: 24 participants. 7-18 years old. 15 girls and 9 boys.

Intervention/
Outcome
Measures
Results
Study
Limitations
Implications for
OT

Intervention: Support group conducted by 2 psychologists in 5 weekly sessions.

Outcome measures: State Trait Anxiety Inventory for Children (STAIC)
Significant decrease in anxiety in 50% of participants.
Small convenience sample. No control group.
The clinical and community-based practice of OT:
Group programs with an emphasis in enhancing cancer knowledge and confidence can be useful in reducing anxiety
and depression.
Program development:
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.
Societal Needs:
Anxiety levels in this population are relatively high in comparison to typical children. 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.
Healthcare delivery and policy:
Policies should offer coverage of support group interventions for this population.
Education and training of OT students:
Students should receive coursework that prepares them to develop and facilitate group protocols.
Refinement, revision, and advancement of factual knowledge or theory:
Knowledge and education about cancer, its treatment, and side effects reduces uncertainty and thus relieves anxiety,
sleep problems, physical complaints, and psychological distress.

Author/ Year
Study
Objectives
Level/Design/
Subjects

Intervention/
Outcome
Measures

Results
Study
Limitations
Implications for
OT

Barrera, Chung, Greenberg, & Fleming, 2002.

To describe Siblings Coping Together (SCT) program and present preliminary results about its effectiveness to address
depression, anxiety, and behavior problems
Level IV
Design: pilot pre-test/post-test
Subjects: 17 subjects, 6-18 years old organized into 3 age groups. Participants had to agree to attend all sessions and be
fluent in English
Intervention: 2 hour weekly group sessions for 8 weeks with activities and themes to address goals.
Outcomes: Depression, anxiety, behavior, impact of cancer, and intervention satisfaction
Outcome measures: Childrens Depression Inventory, StateTrait Anxiety Inventory for Children (STAIC), STAIC
Parent Form, Sibling Perception Questionnaire, Sibling Group Satisfaction Questionnaire, Questionnaire for parents,
Group Process Log, and Child Behavior Checklist.
Reduction in anxiety, depression, and fear of the illness as well as satisfaction with the intervention.
Small sample size. Childrens reports differed from those of the parents.
The clinical and community-based practice of OT:
Group programs with an emphasis in enhancing cancer knowledge and confidence can be useful in reducing anxiety
and depression.
Program development:
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:
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 should offer coverage of support groups for this population.
Education and training of OT students:
Occupational therapy student should receive coursework that prepares them to develop and facilitate group protocols.
Refinement, revision, and advancement of factual knowledge or theory:
Knowledge and education about cancer, its treatment, and side effects reduces uncertainty and thus relieves anxiety,
sleep problems, physical complaints, and psychological distress.
Author/ Year
Study
Objectives
Level/Design/
Subjects

Intervention/
Outcome
Measures

Sidhu, Passmore, & Baker, 2006.

Determining the effect of peer support camps in siblings of children with cancer.
Level IV
Design: Pre-test, post-test, follow-up design. Pretest: before camp. Posttest: 4 days after camp. Follow-up: 8 weeks
after camp. Pre-camp focus groups: parents helped develop the camp protocol. Post-camp focus group: parents reported
behavioral changes after the intervention.
Subjects: Siblings of pediatric cancer patients undergoing treatment at Princess Margaret Hospital (PMH). Sample
consisted of 26 participants 813 years of age from 31 families. Participants needed to have adequate literacy level.
Intervention:
4-day peer support camp including developmentally appropriate activities covering topics based on the literature,
clinical experience, and qualitative data collected from parents during focus groups
Opportunities to develop peer support networks and social competency.
Age appropriate information about cancer, treatment, and impact on the family.
Facilitated activities that encourage expression of feelings and time out strategies to cope with stressors.
Psychoeducation, activity participation, and cognitive behavior therapy principles with protocols for ease of
replication.
Outcome measures:
Behaviour Assessment for Children (BASC): measured problem behaviors

Results

Study
Limitations
Implications for
OT

Self-Perception Profile for Children (SPP-C): measured self-perception

Sibling Perception Questionnaire: measure self-perception
Self-Report of Personality (SRP): measured personality traits
Emotional Symptoms Index (ESI): measured emotional problems
Decreased anxiety and improved social competence.
Improvements in the (BASC) scores
Significant reduction in the fear of disease.
No control group.
Only participants fluent in English were included.
The clinical and community-based practice of OT:
Summer camps can be an effective means of normalizing the life experience of siblings of pediatric cancer patients.
Program development:
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 of the camp experience. 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, arts and crafts can also serve to boost self-confidence when the just right challenge is
provided.
Societal Needs:
Siblings of pediatric cancer patients are at risk for mental health problems, including depression, anxiety and PTSD
Healthcare delivery and policy:
Health care policies should cover occupational therapy services in therapeutic summer camp settings as a valid
psychosocial intervention.
Education and training of OT students:
Occupational therapy students should receive coursework that prepares them to develop, organize, and implement

psychosocial therapeutic camping interventions

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 in turn produce physical pain and illness.
Author/ Year
Study
Objectives
Level/Design/
Subjects

Intervention/
Outcome
Measures
Results
Study
Limitations
Implications for
OT

Barrera, Chung, & Fleming, 2005.

Determining the effectiveness of group interventions to reduce emotional and behavioral problems in siblings of children
with cancer.
Level: IV, Cohort
Design: Pretest/posttest design
Subjects: 42 siblings 6 to 14 years old living within 100 miles of the hospital where the research study was conducted
with a brother or sister currently receiving cancer services.
Intervention: Group met once a week for 6 weeks.
Outcome Measures: 2 baseline assessments and 2 post-intervention assessments.

Adolescent girls had higher rates of depression than boys. Younger boys had the highest decrease in depression after
the intervention.
No control group
Transportation problems for the parents
Small sample size
The clinical and community-based practice of OT:
Group programs with an emphasis in enhancing cancer knowledge and confidence can be useful in reducing anxiety
and depression.
Program development:
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:
Siblings experience behavioral problems, sleeping problems, and premature emotional maturity due to their

experience.
Healthcare delivery and policy:
Policies should offer coverage of support groups for this population.
Education and training of OT students:
Occupational therapy students should receive coursework that prepares them to develop and facilitate group
protocols.
Refinement, revision, and advancement of factual knowledge or theory:
Knowledge and education about cancer, its treatment, and side effects reduces uncertainty and thus relieves anxiety,
sleep problems, physical complaints, and psychological distress.
Author/ Year
Study
Objectives
Level/Design/
Subjects

Intervention/
Outcome
Measures

Prchal, Graf,Bergstraesser, Landolt, 2012)

Examining the effectiveness of a 2-session psychological intervention for siblings of pediatric cancer patients who had
been recently diagnosed.
Level: I Pilot Randomized control trial
Design: group assignments were randomized by families. The intervention group was compared to a control group
which received a conventional psychosocial intervention.
Subjects: 30 participants 6-17 years of age recruited from 2 childrens hospitals in Switzerland. Participants had a
sibling recently diagnosed and undergoing medical treatment either inpatient or outpatient.
Intervention: 2-session psychological intervention for siblings of pediatric cancer
Outcome Measures:
Standardized individual interviews
Medical knowledge about cancer
Social Support Scale
KIDSCREEN-27
UCLA PTSD
Spence Childrens Anxiety Scale (SCAS)
Socioeconomic Status (SES)

Results

Study
Limitations

Implications for
OT

Medical Variables
Siblings in the intervention group experienced better psychological well-being, medical knowledge, and social
support
The intervention had no effects on anxiety or PTSS
Small sample
Measures for social support and medical knowledge were developed by the researchers and had poor internal
consistency
Other psychometric properties were not evaluated.
Only participants fluent in German were included
The clinical and community-based practice of OT:
Even a brief individual two-session psychological intervention provided at the hospital can have benefits.
Program development:
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, implementing cognitive
behavioral therapy (CBT) to talk about coping strategies. Parents should be provided with a psychoeducational
booklet with information about how to support siblings.
Societal Needs:
Individual therapy might be more appropriate and effective for mental health issues experienced by siblings of
pediatric cancer patients, such as PTSD. Providing early preventative therapy within 2 months of the ill sibling
diagnosis might be more effective to avoid worsening symptoms of PTSD
Healthcare delivery and policy:
Expanding the definition of mental health providers to include occupational therapists will make individual
psychosocial treatments more widely available.
Education and training of OT students:
Occupational therapy students should receive coursework that prepares them to identify and treat mental health

diagnoses such as PTSD as well as utilize effective interventions such as cognitive behavioral therapy (CBT).
Refinement, revision, and advancement of factual knowledge or theory:
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.
Author/ Year
Study
Objectives
Level/Design/
Subjects
Intervention/
Outcome
Measures
Results
Study
Limitations

Implications for
OT

Wu, Prout, Roberts, Parikshak, & Amylon, 2011.

To evaluate summer camp experiences and improve existing services for children and families.
Level: IV, Cohort
Design: Data was collected by distributing questionnaires to the campers and parents.
Subjects: 89 families, 56 cancer patients, and 73 siblings. All children had attended a camp the previous summer.
Intervention: participation in a summer camp experience.
Outcomes:
Child Youth Care Forum: assessed consumer satisfaction with the camp experience.
Response options included illustrated facial expressions and word ratings.
There was a significant correlation between sibling and patient ratings on satisfaction scores
The camp experience helped to lower anxiety scores.
Convenience Sample
No control group
Treatment was not described in detail
The study failed to identify what aspect of camp was beneficial.
8 bereaved siblings included
The clinical and community-based practice of OT:
Summer camps can be an effective means of normalizing the life experience of siblings of pediatric cancer patients.
Program development:
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 of camp. 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.
Societal Needs:
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:
Health care policies should cover occupational therapy services in therapeutic summer camp settings as a valid
psychosocial intervention.
Education and training of OT students:
Occupational therapy students should complete coursework that prepares them to develop, organize, and implement
psychosocial therapeutic camping interventions.
Refinement, revision, and advancement of factual knowledge or theory:
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 in turn leads to lowered self-esteem.
Author/ Year
Study
Objectives
Level/Design/
Subjects
Intervention/
Outcome
Measures

Wellisch, Crater, Wiley, Belin, & Weinstein, 2006

To assess the immediate and long term effects of a camping experience on mood, social interactions, and relationships of
pediatric cancer patients and their siblings.
Level: IV, Cohort
Design: 3 follow up tests after the camp experience
Subjects: 66 children (31 patients and 35 siblings) 7-17 years old. Time since diagnosis 9-166 months
Intervention: The camping experience was the intervention
Outcomes:

Results
Study
Limitations
Implications for
OT

Negative Mood
Interpersonal Problems
Ineffectiveness
Anhedonia
Negative Self-Esteem
Outcome Measures: 1) Childrens Depression inventory, 2) Things you did at camp, 3) Youth self-report
Significant improvements on negative mood & interpersonal problems when comparing baseline to follow up.
Statistically significant improvements on anhedonia
No control group
Small sample size
Long period of time between the culmination of the camp experience and the surveys.
The clinical and community-based practice of OT:
Summer camps can be an effective means of normalizing the life experience of siblings of pediatric cancer patients.
Program development:
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 of the camp. 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
Societal Needs:
Siblings of pediatric cancer patients are at risk for mental health problems, including depression, anxiety and PTSD.
Healthcare delivery and policy:
Health care policies should cover occupational therapy services in therapeutic summer camp settings as a valid
psychosocial intervention.
Education and training of OT students:

Occupational therapy students should be offered coursework that prepares them to develop, organize, and implement
psychosocial therapeutic camping interventions.

Refinement, revision, and advancement of factual knowledge or theory:

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 in turn leads to lowered self-esteem.
Author/ Year
Study
Objectives
Level/Design/
Subjects

Intervention/
Outcome
Measures

Jenholt Nolbris & Ahlstrm, 2014

To find out the impact of a person-centered intervention that combines education, learning, and reflection via internet
and cell phone, on the experience of siblings of pediatric cancer patients.
Level: IV, Cohort
Design: Qualitative Phenomenology with pre-test and post-test.
Subjects: 14 participants spanning 11 families were recruited from a hospital based on the following inclusion criteria:
Being the sibling of a patient newly diagnosed with cancer
The sick child had been receiving treatment for no more than 1 month
Speaking Swedish fluently
Having internet, computer, or cellphone.
Being 9-22 years old
Person-centered care (PCC) revolves around the patients life in partnership with healthcare practitioners via virtual
communication and e-health. PCC is an adjunct to the See-Hear-Do method (SHDM), an education program that uses
cartoons and is regularly provided in Sweden to pediatric cancer patients and their families in order to increase their
cancer related knowledge.
The See-Hear-Do method was used to teach each sibling individually.
Lectures provided by nurses. Prompts were used to facilitate the siblings writing of a reflection journal sent via email/cellphone to one of the authors who provided feedback.
Outcomes: 5 themes
Grasping for knowledge
Thinking for hours and having nightmares,
Physical pain

Results

Study
Limitations

Implications for
OT

Being emotional
Waiting for a normal, good life despite the uncertain future.
Outcome Measures: Audio recorded semi-structured interviews conducted by one of the authors over the telephone
before and after the intervention.
Specific knowledge about cancer treatment and its side effects increased.
Sleep improved moderately for most siblings.
Bodily pain and emotional regulation problems decreased.
Siblings longed for the 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, and others struggled with thinking ahead due to uncertainty.
Siblings reported being grateful to have been contacted and not forgotten.
Convenience sample
Small sample
Several participants came from the same family
Only siblings who had computers could participate.
Three of the siblings had dyslexia but they reported that they were able to express everything they experienced in
their answers.
Some families could not afford to pay for transportation to the city in order for these siblings to participate. Other
families had no time to spare, or were afraid to participate due not having a residence permit.
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.
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.
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.
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.
Education and training of OT students:
Occupational therapy students should be offered courses that prepare then to address the psychosocial needs of other
family members, in particular siblings.
Refinement, revision, and advancement of factual knowledge or theory:
Knowledge and education about cancer, its treatment, and side effects reduces uncertainty and thus relieves anxiety,
sleep problems, physical complaints, and psychological distress.