Positive interventions in seriously-ill children: Effects on well-being after granting a wish

Abstract

We examined whether a positive intervention (i.e. granting a wish) could promote positive psychological and physical changes (e.g. reduced nausea and pain) in seriously-ill children. Children and their parent were randomly assigned to a wish group (completed measures 2–3 days before the wish and 3 weeks later) or to a waiting-list control group (with an equivalent time-lag and receiving the wish after the assessment). Wish intervention significantly increased levels of positive emotions, satisfaction with life, personal strengths, and reduced rates of nausea compared with the control group. Mothers in the wish group also perceived positive changes in children’s benefit finding and quality of life.

Keywords

benefit finding childhood cancer positive affect positive intervention quality of life satisfaction with life

Introduction

The onset of a serious illness and the subsequent periods of hospitalization are recognized as negative life events that may be potentially traumatic for children (Phipps et al., 2007). Diagnosis procedures and lengthy treatments may have negative implications on patients’ quality of life (Hedström et al., 2004). Moreover, although survival rates have been increased through the use of improved treatments, nausea and pain are still among the most prevalent symptoms in hospitalized children with cancer (Miller et al., 2011). Thus, there is a growing interest in assessing and promoting the well-being and quality of life among children with life-threatening illnesses (Klassen et al., 2011).

However, most of the studies are usually based on the idea that good quality of life is the absence of symptoms (Varni et al., 2007). This approach focuses on psychological difficulties or distress associated with illness while ignoring some positive factors that may also promote well-being and ultimately improve treatment outcomes (Hedström et al., 2004). Thus, positive interventions should aim to do more than just reduce negative symptoms (e.g. anxiety or depressive symptoms) or buffer the negative effects of the stress event on well-being. They may also promote positive responses such as positive emotions (PE) or personal growth, or build positive psychological resources (Tugade and Fredrickson, 2002).

Research on well-being has thus far been adult-centric and hedonism-centric (Diener and Lucas, 1999; Ryff, 2014). However, current research from a positive perspective has yielded several constructs that are particularly relevant in life-threatening illness research: positive affect (Pressman and Cohen, 2005), satisfaction with life (Diener and Chan, 2011), eudaimonic well-being (Ryff et al., 2004), benefit finding (Phipps et al., 2007), beliefs in a just world (Park et al., 2008), dispositional optimism (Carver and Scheier, 2001), or personal strengths (Peterson et al., 2006). Most of these constructs have been broadly studied in adults, but less so in pediatric research.

Based on the assumption that well-being is associated with the mental and physical health of patients, there has been a rapid growth of interventions in pediatric settings (Koller and Gryski, 2008). A paradigmatic example is wish-granting interventions, which have the aim of fulfilling a wish expressed by the ill child. Unfortunately, there are no controlled studies that have evaluated the efficacy of granting wishes to children with a life-threatening illnesses. Interestingly, some studies have shown positive outcomes after clown interventions for hospitalized children. These findings suggest a decrease in the child’s and the parent’s distress and an increase in children’s cooperation with medical procedures (Costa and Arriaga, 2010; Vagnoli et al., 2007). However, it is not clear as to whether these positive outcomes are generalizable to wish-based interventions. Granting a wish is a distinctive intervention as it taps not only hedonic components of well-being but may also satisfy children’s psychological needs (Bornstein et al., 2003) and, therefore, could have a more sustained effect than episodic hedonic interventions. Recent research has shown that well-being is a multifaceted construct (e.g. Hervás and Vázquez, 2013), and thus, a variety of different approaches should be combined in order to better understand it. Specifically, this intervention could exert its effects on three domains: subjective well-being (positive and negative emotions, general life satisfaction, multidimensional life satisfaction, and general quality of life), psychological resources (benefit finding, beliefs in the benevolence of the world, personal strengths, and optimism), and clinical outcomes (depression and health-related quality of life).

The aim of this research is to investigate whether granting wishes promotes positive psychological responses and positive physical changes (i.e. reductions in pain and nausea) in children with a life-threatening illness. Based on a well-established wish-granting program, we designed a study that could provide an adequate control group to compare the effects of this naturalistic intervention. First, we hypothesized that children in the wish group would report less negative emotions (NE), more positive emotions (PE), higher levels of life satisfaction, and higher general quality of life than children in the waiting-list control group. Second, we also hypothesized that the wish would concurrently improve psychological resources (i.e. benefit finding, beliefs in the benevolence of the world, optimism, personal strengths). Third, given the previous evidence that links well-being with better health (Diener and Chan, 2011) and given the recent findings supporting complementary and alternative therapies for managing physical symptoms (Karagozoglu et al., 2013), we expected that fulfilling a wish would have positive consequences for children’s perceived health. Finally, since parents are potentially valuable sources of information about the well-being of children with chronic illness, we also expected that parents in the wish group would perceive more positive changes in their children’s well-being than parents in the control group.

Methods

Participants

Children and their parents recruited in hospitals were invited to participate in our study. A participant flow diagram describing the recruitment process is presented in Figure 1. Finally, seventy-eight children with severe physical illnesses participated in the study. Children ages ranged from 5 to 18 years (mean: 11.68; standard deviation (SD): 3.39 years). All children were Caucasian and 45 children were males (57.7%).

Figure 1.

Participant flow diagram describing recruitment process.

Moreover, 38 fathers and 86 mothers were also interviewed. The mean age was 43.08 and 40.75, respectively. Among them, 80.4 percent are married or living with partner. Of fathers, 73.7 percent and of mothers, 48.2 percent are working.

Procedure

All participants were involved in a wish-granting program.¹ Parents were contacted and informed about this study. Those who agreed to participate signed an informed consent. Children also provided verbal consent to participate in the study, which was presented as a study on well-being. Once they agreed to participate, children and their parents were randomly assigned before assessment to one of the two groups: the wish group or a waiting-list control group. A timeline with the procedure design is presented in Supplementary Figure 1. Children and parents from the wish group completed self-report measures at Time 1 (T1: 2–3 days before fulfilling the wish) and at Time 2 (T2: 3 weeks after fulfilling the wish). All measures were used at both T1 and T2. The waiting-list control group was assessed following an equivalent time-lag. Children in the control group received the wish after the assessment. T2 questionnaires were completed by 75 children, 36 fathers, and 83 mothers (96%, 95%, and 96% of T1 participants, respectively). There were no significant differences in any of the main characteristics of the sample between those who completed the second measure and those who did not (all p > 0.05).

In order to ensure that the children understood the scales’ response format, we used different strategies: (1) we incorporated a pre-test protocol to determine the cognitive competence of participants to use and understand Likert-format scales (Cummins and Lau, 2005). Children under 8 were trained (when needed) in ordering magnitudes, scaling concrete objects and scaling abstract references (i.e. emotion faces). Whenever children showed any problem with Likert-format scales, we used a reduced-choice format; (2) for some questionnaires (e.g. quality of life scales), we used age group versions (ages 5–7; ages 8–12; ages 13–18). They are parallel forms with minor differences in the test instructions and wording which are structured to be more appropriate for young children, children, and teens. For instance, young children version (ages 5–7) used a reduced-choice Likert-format scale and visual aids (i.e. faces); (3) furthermore, to maximize the children’s understanding of the multiple response options, we also used visual cards and thermometer images so that children could physically point out their answer if needed. The thermometer scale option has shown a good reliability for children below 9 years of age (Cremeens et al., 2007). Finally, instruments were administered verbally when needed.

Measures

To explore a wide array of dimensions related to well-being, participants completed a number of questionnaires.²

Subjective well-being

Positive and negative emotions (Positive and Negative Emotional Style Scale, PNES; Cohen et al., 2006). It contains 12 adjectives (six positive and six negative). It was complemented with 10 additional positive adjectives to cover a wider spectrum of emotional relevant responses (e.g. grateful, safe, hopeful) and four negative adjectives related to loneliness and tiredness (Pressman and Cohen, 2012). Children were asked to what extent (0 = “nothing” to 4 = “extremely”) they felt each emotion on the day of the assessment. In the current sample, both the PE scale (α = .92) and the NE scale (α = .87) showed strong internal consistency.

General Life Satisfaction (The Student Life Satisfaction Scale, SLSS; Huebner, 1991) consists of seven items measuring overall satisfaction with life (e.g. “In my life things are going well”). Items are answered on a 4-point Likert-type scale ranging from 0 = “never” to 3 = “almost always”. Internal consistency was α = .78.

Domains of Life Satisfaction (The Brief Multidimensional Students’ Life Satisfaction Scale, BMSLSS; Seligson et al., 2003). This scale assesses six different aspects of life such as family, school, personal relationships, self-esteem, neighborhood, and general satisfaction. We also included 11 additional relevant dimensions (e.g. standard of living, health, life achievements, and personal safety) from the Personal Well-being Index (Cummins and Lau, 2005). Each item was answered on a 10-point Likert-type scale ranging from 0 = “lowest level of satisfaction” to 10 = “highest levels of satisfaction”.

General Quality of life. We used The Pediatric Quality of Life Scale, PedsQoL (Varni et al., 2002), a 23-item scale to assess quality of life in children and adolescents. We used two parallel forms: a patient self-report and parent proxy-report instrument (Varni et al., 2007). This questionnaire assesses how often in the past month (from 0—“never” to 4—“almost always”) children have had problems in the physical, social, school, and emotional domains. Items were inverted. Cronbach’s alphas were .89, .84, and .87 for children, fathers, and mothers, respectively. The intra-class correlation coefficient was .82 for father–child agreement and .71 for mother–child agreement.

Psychological resources

Benefit finding. The Benefit Finding Scale for Children, BFSC (Phipps et al., 2007) includes 10 items (e.g. Having had my illness has helped me become a stronger person) depicting potential benefits of the illness rated on 5-point Likert-type scales (1 = “not true at all” to 5 = “very true for me”). Parents also completed a version with items related to their children (e.g. This illness has helped my child become a stronger person). The level of internal consistency was α = .90 for children, α = .85 for fathers’ report, and α = .87 for mothers’ report. The intra-class correlation coefficient for father–child agreement was .11 and .43 for mother–child agreement. The intra-class correlation coefficient for father–mother agreement was .45.

Beliefs in the benevolence of the world. We created a 10-item Beliefs in the Benevolence of the World Scale based upon Janoff-Bulman’s (1989) model. It includes items assessing beliefs of living in a benevolent and just world (e.g. There are more good people than bad people in the world). Each item is answered on a 5-point Likert-type scale ranging from 0 (“not true at all”) to 4 (“very true for me”). In our study, the level of internal consistency was α = .74.

Optimism. The Youth Life Orientation Test, YLOT (Ey et al., 2005) is a measure of dispositional optimism for children. The 16-item measure (with two filler items) contains seven optimism and seven pessimism items, using a 5-point rating scale ranging from 0 (“strongly disagree”) to 4 (“strongly agree”). We added one item specifically related to the child’s illness (i.e. I think I am going to recover from my illness). Cronbach’s alpha for optimism was .79 and for pessimism .77.

Personal Strengths. The Values in Action Inventory of Character Strengths for Youth, VIA-Y (Park and Peterson, 2006) is a 198-item scale that allows for the evaluation of 24 personal strengths. In order to keep the protocol as short as possible, we selected strengths (i.e. love, vitality, gratitude, love of learning, and perseverance) that have shown the highest correlations with LS in a large sample of children (N = 1200) with similar demographic characteristics (Gimenez, 2010). The resulting scale contains 25 items. We used the highest-loading items on each scale. Each item is answered on a 5-point Likert-type scale ranging from 1 (“not true at all”) to 5 (“very true for me”). Levels of internal consistency of subscales were α = .56, .78, .84, .73, and .76, respectively.

Clinical outcomes

Health-related quality of life. We used The Health-Related Pediatric Quality of Life Scale, HPedsQoL (Varni et al., 2002), a 27-item scale to assess health-related quality of life in children and adolescents with an illness. As with the General Quality of Life Scale, we used a children self-report version and a parent proxy-report version. This scale assesses how often in the past month children have experienced different problems related to their disease (e.g. concerns about their physical appearance). Here we report data on the only two physical health subscales: pain and nausea (assessed by using a 5-point Likert-type scale ranging from 0—“never” to 4—“almost always”). Items were inverted. Cronbach’s alphas were .86, .88, and .87 for children, fathers, and mothers, respectively. The intra-class correlation coefficient was .59 for father–child agreement and .73 for mother–child agreement.

Depression. We used the abbreviated 7-item version of The Center for Epidemiologic Studies-Depression Scale, CESD-7 (Santor and Coyne, 1997) which measures the severity of symptoms of depression during the past week (e.g. “I felt that I could not shake off the blues even with the help from my family or friends”) using a 4-point Likert-type scale ranging from 0 (“never”) or rarely to 3 (“almost always”). Internal consistency was α = .87.

Medical status: Doctors provided information about the children’s diagnosis, severity (measured by a scale from 0 to 10), the stage of disease (i.e. active treatment/off treatment/relapse/palliative), and perceived probability of survival at 1 and 5 years.

Data analysis

Chi-square (with Fisher’s exact test corrections when needed) and t-tests were used to confirm initial equivalence of groups in demographic variables. A series of repeated measures mixed between–within subject ANOVAs were conducted to compare scores on the measures of well-being between the wish group and the waiting-list control group across two time periods (T1 and T2). We used repeated-measures ANCOVAs in order to include potential control variables such as covariates in our analyses. We further examined the univariate F tests for each dependent variable (confidence intervals adjusted by the Bonferroni procedure). SPSS 20 was used for all analyses.

Results

The main characteristics of the sample (i.e. child’s and parent’s age, gender, diagnosis, time since diagnosis and severity) did not differ between groups (all p > 0.05; Table 1). Only age and months since diagnosis showed significant correlations with some of the variables included in the study. Age was also related to satisfaction with life (r = −.43, p < .001) and vitality (r = −.25, p = .03). Time since diagnosis was related to satisfaction with life (r = −.29, p = .02) and vitality (r = −.29, p = .03).

Table 1.

Characteristics of Wish group (WG) versus Control group (CG).

	Children		Fathers		Mothers
	WG	CG	WG	CG	WG	CG
N	41	37	20	18	43	43
Age, M (SD)	11.49 (3.25)	11.89 (3.56)	44.89 (6.65)	41.11 (7.02)	41.17 (7.24)	40.63 (6.71)
Gender
Male	58.5%	56.7%

Diagnosis
Cancer	33%	32%	42%	39%	30%	34%
Transplants	6.4%	9%	5%	5%	3%	6%
Other diseases	12.8%	6.4%	5%	3%	10%	3%
Months since diagnosis, M (SD)	54.74 (61.16)	33.23 (52.84)	42.11 (61.10)	27.28 (47.36)	54.44 (63.30)	31.13 (51.97)
Severity from 0 to 10; M (SD)	6.35 (2.77)	6.13 (2.73)	7.88 (1.64)	7.13 (1.81)	6.70 (2.80)	6.68 (2.36)
Stage of the disease
Active treatment	23.1%	27.1%	21.3%	26.0%	22.2%	26.0%
Off-treatment	18.6%	14.6%	15.8%	15.8%	18.8%	14.8%
Relapse	7.7%	7.7%	11.3%	9.8%	9.3%	9.8%
Prognosis
Unfavorable	9.4%	9.4%	6.2%	18.7%	10.9%	10.9%
Favorable	9.4%	9.4%	18.7%	18.7%	6.5%	8.7%
Intermediate life risk	31.1%	31.1%	25%	12.5%	32.6%	30.4%
Mean probability of survival from 0 to 100, M (SD)
1 year	79.75 (23.9)	83.41 (12.9)	73.75 (19.2)	78.13 (13.6)	74.13 (29.7)	79.57 (17.6)
5 years	70.20 (28.2)	68.24 (17.0)	63.13 (22.5)	58.75 (14.6)	64.96 (29.7)	64.35 (18.8)

With regard to psychological variables, there were no statistically significant differences between groups in T1, except for optimism (t(64) = −2,39, p = .02) and beliefs in the benevolence of the world (t(73) = −2,74, p = .008), the wish group showing higher values in both variables. Therefore, age, months since diagnosis, optimism, and beliefs in the benevolence of the world were included as covariates in all subsequent repeated-measures ANCOVAs analyses.

Positive intervention effects: children report

With regard to PE and NE, there was a significant interaction between group and time for PE, F(1, 71) = 4.93, p = .03, partial eta squared = .07 (Table 2). Post-hoc comparisons using Bonferroni tests indicated that, in T2, children in the wish group showed higher PE scores than the control group. More relevant for our study, in comparing PE scores between T1 and T2, the wish group showed a significant increase in that period whereas the control group did not change (Figure 2).

Table 2.

Changes in subjective well-being, psychological resources, and clinical outcomes in children: Wish group (WG) versus Control group (CG).

Measures	Minimum–maximum	Time	Control group		Wish group		F	Partial eta squared
Measures	Minimum–maximum	Time	M	SD	M	SD	F	Partial eta squared
Subjective well-being
Positive emotions	0–4	T1	2.19	.76	2.53	.65	4.93*	.07
Positive emotions	0–4	T2	2.20	.71	2.90	.50	4.93*	.07
Negative emotions	0–4	T1	.51	.74	.14	.24	.10	.02
Negative emotions	0–4	T2	.39	.74	.11	.17	.10	.02
General satisfaction with life, SLSS	0–3	T1	1.93	.58	1.97	.53	3.11	.06
General satisfaction with life, SLSS	0–3	T2	1.96	.53	2.24	.58	3.11	.06
Multidimensional satisfaction with life, MSLSS	0–10	T1	8.23	1.08	8.44	1.17	6.05*	.08
Multidimensional satisfaction with life, MSLSS	0–10	T2	8.19	1.21	8.99	.94	6.05*	.08
General quality of life, PedsQoL	0–4	T1	2.64	.69	2.77	.55	.26	.01
General quality of life, PedsQoL	0–4	T2	2.77	.55	2.98	.58	.26	.01
Psychological resources
Benefit finding, BFSC	1–5	T1	3.99	.83	4.10	.64	1.54	.03
Benefit finding, BFSC	1–5	T2	4.37	.77	4.39	.74	1.54	.03
Perseverance, VIA-Y	1–5	T1	3.57	.73	3.65	.88	.71	.00
Perseverance, VIA-Y	1–5	T2	3.59	.65	3.70	.87	.71	.00
Vitality, VIA-Y	1–5	T1	3.88	.82	3.99	.68	3.51	.07
Vitality, VIA-Y	1–5	T2	3.83	.71	4.12	.59	3.51	.07
Gratitude, VIA-Y	1–5	T1	4.27	.47	4.46	.51	7.86**	.13
Gratitude, VIA-Y	1–5	T2	4.22	.50	4.65	.34	7.86**	.13
Love, VIA-Y	1–5	T1	4.21	.53	4.43	.45	4.33*	.08
Love, VIA-Y	1–5	T2	4.19	.45	4.52	.37	4.33*	.08
Love of learning, VIA-Y	1–5	T1	3.92	.83	4.20	.68	.09	.00
Love of learning, VIA-Y	1–5	T2	3.89	.68	4.16	.66	.09	.00
Clinical outcomes
Pain, HPedsQoL	0–4	T1	2.75	1.08	2.85	1.17	2.74	.04
Pain, HPedsQoL	0–4	T2	2.81	.99	3.27	.74	2.74	.04
Nausea, HPedsQoL	0–4	T1	2.61	1.06	2.74	.93	5.32*	.10
Nausea, HPedsQoL	0–4	T2	2.57	1.13	3.06	.82	5.32*	.10
Depression, CESD-7	0–3	T1	.51	.61	.47	.62	.34	.01
Depression, CESD-7	0–3	T2	.43	.52	.26	.44	.34	.01

SLSS: The Student Life Satisfaction Scale; BMSLSS: The Brief Multidimensional Student Life Satisfaction Scale; BFSC: Benefit Finding Scale for Children; VIA-Y: Values in Action for Youth; PedsQoL: Pediatric Quality of Life Scale; CESD-7: Center for Epidemiologic Studies-Depression Scale; T1 (Time 1): 2–3 days before fulfilling the wish; T2 (Time 2): 3 weeks after fulfilling the wish.

p < .05.

Figure 2.

Main outcome effects on well-being dimensions. (See score ranges in Table 2 and Supplementary Table 2).

With regard to satisfaction with life, there was a significant interaction between group and time for multidimensional SLSS, F(1,71) = 6.05, p = .02, partial eta squared = .08 (Table 2). Post-hoc Bonferroni tests indicated that, in comparing multidimensional SLSS scores between T1 and T2, the wish group showed a significant increment in that period whereas the control group did not change.

Regarding the personal strengths, there were significant interactions between group and time for gratitude (F(1,69) = 7.68, p = .008, partial eta squared = .13) and love (F(1,69) = 4.33, p < .05, partial eta squared = .08; Table 2). Post-hoc Bonferroni tests indicated that, in T2, children in the wish group showed higher gratitude and love scores than the control group. Specifically, in comparing scores between T1 and T2, the wish group showed significant increments in gratitude and love in that period whereas the control group did not change (Figure 2).

With regard to health-related quality of life, there was only a significant interaction between group and time for nausea (F(1,73) = 5.32, p = .02, partial eta squared = .10; Table 2). Bonferroni tests confirmed that, in T2, children in the wish group showed less nausea than the control group. Specifically, in comparing scores in this domain between T1 and T2, the wish group showed less nausea in that period whereas the control group did not change (Figure 2).

Results reported by fathers³

The means and SDs for the fathers’ reports are shown in Supplementary Table 1. There were no significant interactions between group and time for fathers’ perception of benefit finding (F(1, 34) = 2.67, p > .05, partial eta squared = .07), general quality of life (F(1, 34) = 1.56, p > .05, partial eta squared = .04), or health-related quality of life (F(1, 34) = 1.04, p > .05, partial eta squared = .03).

Results reported by mothers

The means and SDs for the mothers’ reports are shown in Supplementary Table 2. With regard to mothers’ perception of benefit finding, there was a significant interaction between group and time, F(1, 81) = 11.30, p = .001, partial eta squared = .12. Bonferroni tests confirmed that although both wish group and control group showed a significant increment in that period, mothers in the wish group perceived higher benefits in their children in T2 than mothers in the control group (Figure 2).

With regard to general quality of life, there was a significant interaction between group and time, F(1, 81) = 7.85, p = .006, partial eta squared = .09. Bonferroni tests indicated that, in T2, mothers in the wish group perceived better functioning in their children than mothers in the control group. More relevant for our study, in comparing general quality of life scores between T1 and T2, mothers in the wish group showed a significant increment in that period whereas the control group did not change. Specifically, there were significant interactions between group and time for the physical domain, F(1, 81) = 6.27, p = .01, partial eta squared = .07, the school domain, F(1, 81) = 5.05, p = .03, partial eta squared = .06, and the emotional domain,F(1, 81) = 4.32, p = .04, partial eta squared = .05.

With regard to health-related quality of life, there was no significant interaction between group and time, F(1, 81) = 3.02, p = .09, partial eta squared = .04. With regard to specific scales of health-related quality of life, there was only a significant interaction between group and time for concerns about disease, F(1, 81) = 5.56, p = .02, partial eta squared = .06. Post-hoc comparisons using Bonferroni tests indicated that mothers’ perception of their children’s quality of life in this domain was significantly higher in T1 than in T2 whereas there was no time change in mothers of the control group.

Discussion

This study analyzed the effects of a positive intervention on children’s well-being and several domains of positive functioning as assessed by themselves and their parents. According to our first hypothesis, we expected that granting a wish would reduce NE and increase PE, life satisfaction, and general quality of life. Although our results did not confirm our predictions for NE, we found that wish-granting promotes PE and that its resultant effects last for at least several weeks. According to the broaden-and-build theory of PE (Fredrickson, 1998, 2001), PE work by helping to build durable physical, intellectual, and social resources that are essential to promoting adaptive coping responses following traumatic circumstances (Cohn et al., 2009; Tugade and Fredrickson, 2002).

Furthermore, with regard to life satisfaction and general quality of life, our results showed that this intervention improves a multidimensional composite score of life satisfaction. This finding has relevant implications given the previous evidences that link satisfaction with life to more positive functioning (Gilman and Huebner, 2006).

These results partially confirm our hypothesis. The wish did not cause significant decreases in NE or depression, perhaps due to a floor-effect (i.e. very low scores on these negative dimensions found in both groups). Research has consistently shown that although a significant minority has some difficulties with adjustment and/or symptoms of psychological distress, the majority of children with a chronic illness show good levels of adjustment (Zebrack and Chesler, 2002). Thus, well-being based interventions probably have a limited effect in decreasing distress (Pai et al., 2006).

As for our second hypothesis, we expected that granting a wish would promote positive functioning and other psychological resources (i.e. benefit finding, personal strengths, beliefs in the benevolence of the world, and optimism). Results revealed that the children in the wish group reported significantly higher gratitude and love after the granting of the wish than those in the comparison group. Children in the wish group became more aware of the support provided by others and this awareness could have lead to a sense of thankfulness and love in response to fulfilling a wish. Gratitude and love are two of the strengths most robustly associated with life satisfaction (Park et al., 2004). Gratitude appears to be a powerful resilience factor that may help people to cope with traumatic experiences (Fredrickson et al., 2003). Several studies have shown that interventions promoting gratitude reduce negative affect and increase levels of positive affect, life satisfaction, and optimism about the future (Bono and McCullough, 2006; Emmons and McCullough, 2003). Thus, a grateful attitude may be beneficial to improve physical health status and may also help the individual find positive meaning in negative circumstances (Emmons and McCullough, 2003). In a study with healthy children and adolescents, Froh et al. (2009) found a positive association between gratitude and positive affect, satisfaction with life, optimism, social support, prosocial behavior, and physical health.

On the other hand, loving and feeling loved provides emotional security and confidence that allow children to more effectively cope with daily stress (Hazan, 2004). Caring ties can buffer people from adversity and pathology as well as enhance their health and well-being (Fredrickson, 2013). A recent study showed that perceived positive social connections account for the upward spiral between PE and health benefits, such as increases in vagal tone (Kok et al., 2013).

As for our third hypothesis, we expected that our intervention would have some impact on children’s physical symptoms. Our results showed that the children in the wish group reported significantly lower levels of nausea after wish than those in the comparison group. This result is consistent with research showing that music therapy or visual imagery has positive effects on reducing nausea and other side effects in adult patients with chronic illnesses (Karagozoglu et al., 2013).

As for our fourth hypothesis, we expected that parents in the wish group would perceive positive changes in their children’s well-being. Specifically, mothers in the wish group reported positive changes in benefit finding and general quality of life in children, especially in physical, school, and emotional domains. Mothers in the wish group also reported a perceived decrease in their child’s concerns about the disease. This result supports previous research on clown interventions that showed a significant decrease in children’s concerns about the hospitalization, the medical procedures, and the illness and its negative consequences (Costa and Arriaga, 2010). Those dimensions are particularly relevant in children with life-threatening illnesses, given the different pathways in which BF and quality of life may improve physical and psychological health (Bower et al., 2009; Hedström et al., 2004). These findings are also relevant because although the PE promoted by granted wishes can be considered as transient and ephemeral, it may have an effect on increasing or maintaining people’s subsequent psychological well-being by channeling more effective coping resources (Tugade and Fredrickson, 2002). Furthermore, perception of the child’s distress is one of the most common explanations for parental anxiety (Lamontagne et al., 2003). Thus, parents’ perception of positive changes may be an indicator of actual changes in the children but may also serve to promote well-being of the parents themselves. This in turn may contribute to creating or maintaining upward spirals of PE within the turmoil of adverse experiences (Tugade and Fredrickson, 2002).

Our study has some limitations. First, our sample includes some very young children. Protocol was carefully designed to facilitate the understanding by children of all ages (i.e. providing visual aids such as faces or thermometers, reading each item to the child when needed, or pre-testing cognitive competence). However, we cannot be completely sure that all the children understood what they were being asked. Second, extremely-ill children or those who lacked the necessary language skills, attention span, or cognitive abilities to complete a questionnaire were excluded to ensure the quality of the study, but this may limit generalization of results. Third, it is noticeable that effect sizes of the intervention on the measures were relatively small. Yet, it is still remarkable that a rather small-scale and limited intervention may have a significant effect on children’s well-being.

Despite these limitations, we believe that our study has some important contributions to the current literature in the field. This is, to our knowledge, the first controlled study of this kind of intervention for ill children. In contrast to other studies that have assessed similar naturalistic interventions (e.g. clown interventions), we used a pre–post test comparison-group design. This procedure allowed us to evaluate changes in outcomes while controlling for potential baseline differences between groups. Second, positive interventions, like the one analyzed in this research, are increasingly being integrated into pediatric oncology care and this study supports its efficacy in several parameters related to positive functioning. Since healthcare policy should rest on empirically supported interventions, our results can foster a renewed interest in funding research on positive interventions.

Third, most of the studies on psychological interventions in these clinical contexts are usually focused on the psychological distress associated with childhood chronic illness. Yet, an exclusive focus on the detrimental effects of the illness may bias the psychological assessment process and may impede the observation of changes in other relevant areas of psychological functioning. Multidimensional assessment including a wide array of well-being measures provides a more accurate picture of children’s responses to potentially stressful events.

In conclusion, our results suggest that although it is necessary to provide effective treatments for emotional and behavioral difficulties when they do arise, a further aim should be taken into consideration to promote resilience and positive adjustment. Children who are cared for in terms of both their medical and psychological needs are more likely to adjust positively to any challenges arising from their condition, enabling them to participate more fully in ordinary childhood activities and lead as normal a life as possible. Thus, we encourage the use of this type of positive intervention for children with serious illnesses and we expect a growing presence of studies focusing on positive interventions in children with serious illnesses.

Footnotes

Acknowledgements

The authors would like to thank Fundación Pequeño Deseo (Little Wish Spanish Foundation) for providing contact with the children and for always being available to help. Thanks to Aisha King and Miriam Mower for their assistance in improving the article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Lafourcade-Ponce Foundation.

Notes

References

Bono

McCullough

(2006) Positive responses to benefit and harm: Bringing forgiveness and gratitude into cognitive psychotherapy. Journal of Cognitive Psychotherapy 20: 147–158.

Bornstein

Davidson

Keyes

. (eds) (2003) Well-Being: Positive Development across the Life Course. Mahwah, NJ: Lawrence Erlbaum Associates

Bower

Moskowitz

Epel

(2009) Is benefit finding good for your health? Pathways linking positive life changes after stress and physical health outcomes. Current Directions in Psychological Science 18: 337–341.

Carver

Scheier

(2001) Optimism, pessimism, and self-regulation. In: Chang

(ed.) Optimism and Pessimism: Implications for Theory, Research, and Practice. Washington, DC: American Psychological Association, pp. 31–51.

Cohen

Alper

Doyle

. (2006) Positive emotional style predicts resistance to illness after experimental exposure to rhinovirus or influenza a virus. Psychosomatic Medicine 68: 809–815.

Cohn

Fredrickson

Brown

. (2009) Happiness unpacked: Positive emotions increase life satisfaction by building resilience. Emotion 9: 361–368.

Costa

Arriaga

(2010) The effects of clown intervention on worries and emotional responses in children undergoing surgery. Journal of Health Psychology 15: 405–415.

Cremeens

Eiser

Blades

(2007) Brief report: Assessing the impact of rating scale type, types of items, and age on the measurement of school-age children’s self-reported quality of life. Journal of Pediatric Psychology 32: 132–138.

Cummins

Lau

ADL

(2005) Personal Wellbeing Index: School Children (PWI-SC) (3rd edn). Melbourne, VIC, Australia: Deakin University.

10.

Diener

Chan

(2011) Happy people live longer: Subjective well-being contributes to health and longevity. Applied Psychology: Health and Well-Being 3: 1–43.

11.

Diener

Lucas

(1999) Personality, and subjective well-being. In: Kahneman

Diener

Schwarz

(eds) Well-Being: The Foundations of Hedonic Psychology. New York: SAGE, pp. 213–229.

12.

Emmons

McCullough

(2003) Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social Psychology 84: 377–389.

13.

Hadley

Allen

. (2005) A new measure of children’s optimism and pessimism: The Youth Life Orientation Test. Journal of Child Psychology and Psychiatry 46: 548–558.

14.

Fredrickson

(1998) What good are positive emotions? Review of General Psychology 2: 300–319.

15.

Fredrickson

(2001) The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist 56: 218–226.

16.

Fredrickson

(2013) Love 2.0. New York: Hudson Street Press.

17.

Fredrickson

Tugade

Waugh

. (2003) What good are positive emotions in crises? A prospective study of resilience and emotions following the terrorist attacks on the United States on September 11th, 2001. Journal of Personality and Social Psychology 84: 365–376.

18.

Froh

Yurkewicz

Kashdan

(2009) Gratitude and subjective well-being in early adolescence: Examining gender differences. Journal of Adolescence 32: 633–650.

19.

Gilman

Huebner

(2006) Characteristics of adolescents who report very high life satisfaction. Journal of Youth and Adolescence 35: 311–319.

20.

Gimenez

(2010) La medida de las fortalezas psicológicas en adolescentes (VIA-Y): Relación con Clima Familiar, psicopatología y bienestar psicológico. Doctoral Dissertation, Complutense University of Madrid, Madrid. Available at: http://eprints.ucm.es/11578/

21.

Hazan

(2004) Love. In: Peterson

Seligman

MEP

(eds) Character Strengths and Virtues: A Handbook and Classification. Washington, DC: American Psychological Association and Oxford University Press, pp. 303–324.

22.

Hedström

Skolin

von Essen

(2004) Distressing and positive experiences and important aspects of care for adolescents treated for cancer: adolescent and nurse perceptions. European Journal of Oncology Nursing 8: 6–17.

23.

Hervás

Vázquez

(2013) Construction and validation of a measure of integrative well-being in seven languages: The Pemberton Happiness Index. Health and Quality of Life Outcomes 11: 66.

24.

Huebner

(1991) Initial development of the Students’ Life Satisfaction Scale. School Psychology International 12: 231–240.

25.

Janoff-Bulman

(1989) Assumptive worlds and the stress of traumatic events: Applications of the schema construct. Social Cognition 7: 113–136.

26.

Karagozoglu

Tekyasar

Yilmaz

(2013) Effects of music therapy and guided visual imagery on chemotherapy-induced anxiety and nausea-vomiting. Journal of Clinical Nursing 22: 39–50.

27.

Klassen

Anthony

Khan

. (2011) Identifying determinants of quality of life of children with cancer and childhood cancer survivors: A systematic review. Support Care Cancer 19: 1275–1287.

28.

Kok

Coffey

Cohn

. (2013) How positive emotions build physical health: Perceived positive social connections account for the upward spiral between positive emotions and vagal tone. Psychological Science 24: 1123–1132.

29.

Koller

Gryski

(2008) The life threatened child and the life enhancing clown: Towards a model of therapeutic clowning. Evidence-Based Complementary and Alternative Medicine 5: 17–25.

30.

LaMontagne

Hepworth

Salisbury

. (2003) Optimism, anxiety, and coping in parents of children hospitalized for spinal surgery. Applied Nursing Research 16: 228–235.

31.

Miller

Jacob

Hoeckenberry

(2011) Nausea, pain, fatigue, and multiple symptoms in hospitalized children with cancer. Oncology Nursing Forum 38: 382–392.

32.

Pai

Drotar

Zebracki

. (2006) A meta-analysis of the effects of psychological interventions in Pediatric Oncology on outcomes of psychological distress and adjustment. Journal of Pediatric Psychology 31: 978–988.

33.

Park

Edmondson

Fenster

. (2008) Positive and negative health behavior changes in cancer survivors: A stress and coping perspective. Journal of Health Psychology 13: 1198–1206.

34.

Park

Peterson

(2006) Moral competence and character strengths among adolescents: The development and validation of the Values in Action Inventory of Strengths for Youth. Journal of Adolescence 29: 891–909.

35.

Park

Peterson

Seligman

MEP

(2004) Strengths of character and well-being. Journal of Social and Clinical Psychology 23: 603–619.

36.

Peterson

Park

Seligman

MEP

(2006) Greater strengths of character and recovery from illness. Journal of Positive Psychology 1: 17–26.

37.

Phipps

Long

Ogden

(2007) Benefit Finding Scale for Children: Preliminary findings from a childhood cancer population. Journal of Pediatric Psychology 32: 1264–1271.

38.

Pressman

Cohen

(2005) Does positive affect influence health? Psychological Bulletin 131: 925–971.

39.

Pressman

Cohen

(2012) Positive emotion words and longevity in famous deceased psychologists. Health Psychology 31: 297–305.

40.

Ryff

(2014) Psychological well-being revisited: Advances in the science and practice of eudaimonia. Psychotherapy and Psychosomatics 83(1): 10–28.

41.

Ryff

Singer

Love

(2004) Positive health: Connecting well-being with biology. Philosophical Transactions of the Royal Society of London Series B: Biological Sciences 359: 1383–1394.

42.

Santor

Coyne

(1997) Shortening the CES-D to improve its ability to detect cases of depression. Psychological Assessment 9: 233–243.

43.

Seligson

Huebner

Valois

(2003) Preliminary validation of the Brief Multidimensional Students’ Life Satisfaction Scale (BMSLSS). Social Indicators Research 61: 121–145.

44.

Tugade

Fredrickson

(2002) Positive emotions and emotional intelligence. In: Barrett

Salovey

(eds) The Wisdom in Feeling. New York: Guilford, pp. 319–340.

45.

Vagnoli

Bastiani

Turchi

. (2007) Preoperative anxiety in pediatrics: Is clown’s intervention effective to alleviate children discomfort? Algia Hospital 2: 114–119.

46.

Varni

Burwinkle

Katz

. (2002) The PedsQL™ in pediatric cancer: Reliability and validity of the Pediatric Quality of Life Inventory™ Generic Core Scales, Multidimensional Fatigue Scale, and Cancer Module. Cancer 94: 2090–2106.

47.

Varni

Limbers

Burwinkle

(2007) Parent proxy-report of their children’s health-related quality of life: An analysis of 13,878 parents’ reliability and validity across age subgroups using the PedsQL™ 4.0 Generic Core Scales. Health and Quality of Life Outcomes 5: 1–10.

48.

Zebrack

Chesler

(2002) Quality of life in childhood cancer survivors. Psycho-Oncology 11: 132–141.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.21 MB

Positive interventions in seriously-ill children: Effects on well-being after granting a wish

Abstract

Keywords

Introduction

Methods

Participants

Procedure

Measures

Subjective well-being

Psychological resources

Clinical outcomes

Data analysis

Results

Positive intervention effects: children report

Results reported by fathers 3

Results reported by mothers

Discussion

Footnotes

Acknowledgements

Declaration of conflicting interests

Funding

Notes

References

Supplementary Material

Results reported by fathers³