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Procedia - Social and Behavioral Sciences 00 (2011) 000000

Procedia - Social and Behavioral Sciences 30 (2011) 1511 1514

Social and


A Comparison of Vitality between Children with Cancer and

Healthy Children
Manijeh Firoozia, Mohamad Ali Besharatb, Hojatolah Farahanic*
Psychology Department, University of Tehran, Iran

Introduction: A number of randomized trial studies and longitudinal researches emphasize that despite problems in social
adjustment and cognitive damages, children with cancer demonstrate good emotional adjustment. Method: Most of the research
findings in this area are obtained using objective tools such as questionnaires. Vitality of children, as a drawing tool, was used
as basis to draw a comparison between children with cancer and healthy children in this study. Accordingly, 112 children with
cancer (5 girls and 57 boys aged 3 to 12 years) and 123 healthy children (77 girls and 46 boys aged 3 to 12 years) participated in
the study. Results: Findings showed that the vitality of the two groups differed significantly. Perhaps, children with cancer
repress negative emotions and avoid expressing their feelings. Conclusion: Making use of such tools that indirectly examine the
emotional experience of children with cancer would be beneficial. Neglecting this issue can cause children with cancer to be
deprived of receiving supportive counselling.
Key words: children with cancer, healthy children, vitality

1. Introduction
Dramatic increase in the number of the survivors of childhood cancer over the last decades has heightened the need
to investigate the consequences of the disease and its treatment (Bruce, 2006).
Pioneer researches pointed to the cognitive damage impact of malignancy and treatment in children with cancer
(Mulhern, Fairclough, & Ochs, 1991). For example, cancers of the central nervous system (CNS) and treatment side
effects are associated with a number of dysfunctions in neurologic, endocrine, and neurocognitive areas (Naomi,
2011; Saury, & Emanuelson, 2011). At the same time, researchers found out children with cancer would have more
social problems than healthy children. Also, they have difficulty maintaining friendships during treatment course.
After recovery from illness, such survivors are slightly less likely than expected to attend college, and are more
likely to be unemployed and not to get married as young adults do (Gurney, Krull, Kadan-Lottick, 2009; Noll,
Marsland, Cheong, Bukowski, 2010). However, suddenly the direction of researches changed. Studies demonstrated
there were no differences between survivors and control groups in adjustment; even, children with cancer are at
times better treated than healthy children (Phipps, Larson, Long, & Rai, 2006). For instance, children with cancer
did not have an increased prevalence of anxiety in comparison with children without cancer (Wogelius, Rosthoj,
Dahllof, & Poulsen, 2009), there were no significant differences between the depression scores of children with
cancer and those of the children that are healthy (Bragado, Hernndez-Lloreda, Snchez-Bernardos, Urbano, 2008)

. Health Psychologist, graduated from the University of Tehran

. Professor, University of Tehran
. Assistant Professor, University of Tehran

1877-0428 2011 Published by Elsevier Ltd. Selection and/or peer-review under responsibility of the 2nd World Conference on Psychology,
Counselling and Guidance.


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and despite traumatic experiences, most studies have not shown a significant elevation in levels of post-traumatic
stress symptoms (PTSS) in the pediatric cancer population (Langveld, Grootenhuis, Voute, Haan, 2004; Phipps,
Jurbergs, & Long, 2010; Rourke, Hobbie, Schwartz, Kazak, 2007). Investigation about the quality of life was to
some extent dissimilar. The differences between survivors and controls in psychological distress or HRQOL were
not significant; however, survivors with the highest level of treatment intensity, low age at diagnosis, recurrent
malignancy and other factors influenced distress rate and HRQOL (for example, Kazak, DeRosa, Schwartz,
Hobbie, Carlson, Ittenbach, Mao, & Ginsberg, 2010).
Phips (2006) comes up with repressive adaptive style as one pathway to resilience in this population. He
believes adaptive style is a much stronger predictor of psychosocial outcomes. Other researchers suggest patients
who were treated very young, or understood little of what was happening, report a degree of self protection (Dejong,
& Frombonne, 2006). Attention bias is another explanation to good adjustment in children with cancer (Firoozi,
Besharat & Farahani, 2011). In the other words, children with cancer do not pay attention to negative stimuli.
Perhaps, the confusion among findings originates from focusing on measures of maladjustment and depression,
rather than from health components. Far less attention has been paid to positive psychological aspects. Vitality is
defined as a subjective feeling of aliveness that arises from feelings of freedom, autonomy support, and intrinsic
motivation (Ryan, & Frederick, 1997). In this study, we investigate psychological vitality in children with cancer. If
malignancy and its treatments do not affect emotional adjustment, children with cancer and control group must be
identical in vitality.
2. Methods
2.1. Participants
One hundred and twelve (girls=55; boys=57) children with Acute Lymphoblastic Leukemia (ALL) participated
in this study. Potential participants were identified from the list of Outpatient Chemotherapy Room and were
selected randomly. Eligibility criteria for inclusion in the original study were: (1) the child was between 3 and 12
years of age; (2) the child was diagnosed with Acute Lymphoblastic Leukemia (ALL) (3) the child was undergoing
chemotherapy. From the initial list of potential participants, three children did not take part in the research. One
hundred and twenty three healthy children (girls=77; boys=46), that were almost identical to experimental group,
had been selected from four schools.
2.2. Procedure
Samplings of experimental group were picked out from among patients admitted in a specialized pediatric
oncology center (Mahak Hospital). The control group were chosen from among four elementary schools in Tehran.
Both groups were matched by age, gender and socioeconomic status. Before performing the test, parents signed the
Consent Form to participate in this research. The test was carried out between 9 to 11 am every day (for the control
of time), except holidays. The control group like the children with cancer group performed the test individually. In
this investigation, A4 white papers and 24 count sets of colored pencils were utilized. We requested children to draw
themselves and asked them to explain about their paintings.
2.3. Measure
Childrens Vitality Test is a drawing test for measuring subjective vitality that is reflected in the drawings created
by children (Firoozi, & Besharat, 2010). This test has four components and seven items. For example, forcing on the
paper shows the level of energy, and colors indicate emotional disruption or emotional vitality. Every item takes
score in 3-point scales based on the protocol. Also, Cronbach's alpha for the test was calculated 0.83; p<0.05 that is
3. Result
The prediction of the difference between children with cancer and the control group in vitality level was
supported. Children with cancer demonstrated a significantly low level of vitality on the total score than the controls
(7.8 vs 15.9; p<.001). Table 1 shows that they force on paper more weakly than the healthy group do (1.3 vs 2.1;


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p<.001). They more frequently applied negative color like black and complex black and red or yellow (1.7 vs 2.9;
p<.001). The content of the drawings in the cancer group was almost negative (more self-rejecting and selfdestroying than self-loving) and the difference between the two groups was significant (2.2 vs 3.8; p<.05). However,
in the structure of portraits such as the size and details, there was no significant difference (4.1 vs 4.07; p> .05).
Table 1: comparison between children with cancer and fitted healthy children in vitality

Components of vitality in drawing

children with cancer


healthy children

independent T













total score
** P<0/01







4. Conclusion
Prior researches have shown children with cancer report fewer symptoms of emotional problems, in many cases
significantly fewer than their healthy peer controls (Phipps, Larson, Long, & Rai, 2006). Results of the present paper
did not confirm the previous findings; that is, children with cancer demonstrated lower vitality in comparison to the
controls. The reduction in the level of children's vitality is the result of several factors: first, most participants in the
experimental group were treated with chemotherapy. Fatigue and insomnia are among the side effects of
chemotherapy (Judy, & Rollins, 2009) which both deplete psychological energy and lead to decreasing vitality. In
addition, the chemical effects of these drugs on the body cause mobility to decrease and energy to exhaust. Second,
most children in the hospital are undergoing painful treatments such as injections (Kazak, et al., 2010). Separately,
pain acts as a risk factor for reducing vitality. Third, to prevent the illness from degeneration, parents do not allow
children to do physical activity in the hospital or occasionally at home and encourage sedentary behaviors. Reducing
opportunities for the physical activity leads to losing energy (Hills, King, Armstrong, 2007). Fourth, children in the
hospital are isolated from family members and friends. Limitations to communicate with friends cause depression
and as a result: energy exhaustion.
There are some justifications which clarify the difference between our findings and other results. First, most of
the researches in the field of pediatric psycho-oncology are designed based on self report and other report. In this
study, we used childrens vitality test which is a drawing test to reflect the real feelings of children. Second, many
studies have focused on the psychological characters of survivors of c hildhood cancer and have paid less attention to
children in the hospital. Findings may not be generalizable to hospitalized children population. In addition, maybe
defence mechanisms (for example, repressive adaptation (Phipps, 2006)) play an important role to deny reality.
Perhaps children with worse physical condition had lost their lives before adulthood. Third, lack of psychopathology
such as PTSD or depression does not reflect emotional health. Concentrating on positive variables (for instance,
vitality) provides useful knowledge about children with cancer and puts forward diverse treatment strategies to
improve their quality of life. And the final explanation, sometimes children express their emotional problems in
different ways, such as lack of interest to play, longing for snacks, nagging, or stopping speaking (mothers reported
when we were collecting data). Therefore, self report is not enough to conclude that children with cancer are
completely well adjusted.
This paper proposes two implications. First, hospitalized children with cancer demonstrate less vitality in
comparison to their peers; therefore, based on this finding, future researches should be more focused on the
identification of the risk factors involved. Second, intervention and treatment plans must be designed to elevate
vitality, for example, improving hospital environments, providing children with the opportunity to play, designing
special computer games, and providing happiness to mothers are all among the techniques that can improve vitality
in children with cancer.


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We all the authors wish to thank the children with cancer who participated in this study.
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