Palliative and Supportive Care (2017), 15, 575– 586.
# Cambridge University Press, 2017 1478-9515/17
doi:10.1017/S1478951516001115

Effect of a group intervention for children and theirparents who have cancer

MARIKO KOBAYASHI, M.A., C.C.P.,1,2 SUE P. HEINEY, PH.D., R.N., F.A.A.N.,3
KAORI OSAWA, M.S.W.,4 MIWA OZAWA, M.D., PH.D.,5 AND EISUKE MATSUSHIMA, M.D., PH.D.1
1

Section of Liaison Psychiatry and Palliative Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical
and Dental University, Tokyo, JapanThe Open University of Japan, Chiba, Japan
3
College of Nursing, University of South Carolina, Columbia, South Carolina
4Tokyo Kyosai Hospital, Tokyo, Japan
5
St. Luke’s International Hospital, Tokyo, Japan
2(RECEIVED July 9, 2015; ACCEPTED December 28, 2016)

ABSTRACT
Objective: Although support programs for children whose parents have cancer have been
described and evaluated, formal research has not been conducted to document outcomes. We
adapted a group intervention called CLIMBw, originally developed in the United States, andimplemented it in Tokyo, Japan, for school-aged children and their parents with cancer. The
purpose of this exploratory pilot study was to examine the feasibility, acceptability, and impact of
the Japanese version of the CLIMBw Program on children’s stress and parents’ quality of lifeand psychosocial distress.
Methods: We enrolled children and parents in six waves of replicate sets for the six-weekgroup intervention. A total of 24 parents (23 mothers and 1 father) diagnosed with cancer and 38
school-aged children (27 girls and 11 boys) participated in our study. Intervention fidelity,
including parent and child satisfaction with the program, was examined. The impact of the
program was analyzed using a quasiexperimental within-subject design comparing pre- andposttest assessments of children and parents in separate analyses.
Results: Both children and parents experienced high levels of satisfaction with the program.
Children’s posttraumatic stress symptoms related to a parent’s illness decreased after theintervention as measured by the Posttraumatic Stress Disorder–Reaction Index. No difference
was found in children’s psychosocial stress. The Functional Assessment of Chronic Illness
Therapy scores indicated that parents’ quality of life improved after the intervention in all
domains except for physical well-being. However, no differences were found in parents’
psychological distress and posttraumatic stress symptoms.
Significance of results: Our results suggest that the group intervention using the CLIMBw
Program relieved children’s posttraumatic stress symptoms and improved parents’ quality oflife. The intervention proved the feasibility of delivering the program using manuals andtraining. Further research is needed to provide more substantiation for the benefits of the
program.
KEYWORDS: Group intervention, Children, Parental cancer, Posttraumatic stress,
Quality of life

INTRODUCTION
As in other developed nations, the number of patientswith cancer in Japan continues to increase with every year. One of every two people will be affected bycancer, it being the cause of death for one in every

Address correspondence and reprint requests to Mariko
Kobayashi, Section of Liaison Psychiatry and Palliative Medicine,
Graduate School of Medical and Dental Sciences, Tokyo Medical and
Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519,
Japan. E-mail: mkobayashi@ouj.ac.jp.

575
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three (Ministry of Health, Labour, and Welfare,2014). In 2008, the number of newly diagnosed
patients with cancer in Japan was approximately
750,000, 153,000 (20.4%) of which were aged between 20 and 59 years, and thus likely to have minors
living at home (Foundation for the Promotion ofCancer Research, 2013). The most prevalent cancer
among women was breast cancer, which is rising inthe 30– 59 age bracket. The parent diagnosed withcancer and spouse experience personal stress andanxiety related to the illness and disruption of theirnormal roles, as well as the functioning of the entire
family. Patients with cancer are faced not only withthe real-life problem of managing a household during
their illness but also with the issue of how to tell theirchildren about the cancer and address the psychological impact of their cancer on their children (Barnes
et al., 2000; Semple & McCance, 2010).
Many researchers have conducted descriptive
studies on school-aged and adolescent children livingwith a parent who has cancer. These studies examined the emotional and behavioral problems andthe psychological functioning of children following amother’s cancer diagnosis (Hoke, 2001; Thastum
et al., 2009; Visser et al., 2005; Watson et al., 2006).
According to a review by Osborn (2007), no clear correlation was noted between the psychological functioning of children and most medical parameters
related to mothers with cancer, such as the time
elapsed since the diagnosis and the treatment regimen. As for school-aged children, boys showed more
emotional problems following a parent being diagnosed with cancer (Visser et al., 2005), and boys ofmothers with breast cancer were more socially sensitive and isolated than their comparable peers (Vannatta et al., 2008).
Cancer may cause posttraumatic stress symptoms
in both patients and children. Foran-Tuller et al.
(2012) examined the impact of a mother’s breast cancer diagnosis on her child’s internal, external, andposttraumatic stress symptoms, based on maternalreports. They found that mothers with cancer perceived their children to have more symptoms of
PTSD than the mothers without cancer, and theyemphasized the importance of assessing PTSD inchildren whose mothers have cancer (Foran-Tuller
et al., 2012). Furthermore, using a Japanese sample,
Ozawa (2014) surveyed 138 children and found that
31% of those aged 6 – 14 years and 21% of adolescents
aged 15 – 18 years reported having posttraumaticstress symptoms related to their parent’s cancer.
Several interventional programs for children whoseparents had cancer have been developed and evaluated but have not been empirically substantiatedthrough research (Su & Ryan-Wenger, 2007). Niemela
and colleagues (2010) examined five such studies andKobayashi et al.

showed that only one program targeted both children
and parents (Greening, 1992). Family-centered interventions have been researched, most of them involving children and parents, but these did not offer
peer group support, a critically important approachfor school-aged children (Thastum et al., 2006;
Schmitt et al., 2007; Romer et al., 2007; John et al.,2013; Davey et al., 2013). For example, Lewis and coworkers (2006) created the Enhancing Connections
Program for mothers diagnosed with breast cancer
to promote family adjustment and parenting. They
tested the efficacy of this intervention in a randomized
controlled trial and found that the program improved
mothers’ and children’s depressed mood, mothers’
parenting skills, and children’s behavioral emotional
adjustment by intervening with the mother only (Lewis et al., 2015).
Based on past studies, there is a paucity of research that documents the impact of peer group interventions for children whose parents have cancer
while concurrently examining parental outcomes.
The purpose of our exploratory pilot study conductedin Japan was to examine the feasibility of a group intervention for children and their parents with cancer,
and the impact on the child’s stress and the parent’s
quality of life (QoL) and psychosocial distress. The
Japanese version of the CLIMBw Program, to be described below, is a group program that was designed
for school-aged children whose parents have cancer.
The specific aims of the current study were to: (1) examine the feasibility and acceptability of the Japanese version of the CLIMBw group intervention,and (2) evaluate the outcome of a program involving
both children and their parents with cancer. To ourknowledge, our study represents the first time thata group intervention for children and parents withcancer was conducted in Japan. It is therefore important to provide preliminary pilot data for future interventional research. This is especially critical forchildren in Japan who are faced with parental cancer, as many more Japanese families are impacted
than families in other highly developed countries.
METHODSIntervention Description
The group intervention, called the CLIMBw Program, an acronym for Children’s Lives Include Moments of Bravery, was developed in the UnitedStates for use with school-aged children of patientswith cancer (van Dernoot, 2015). Japanese psychosocial oncology professionals attended a two-day training workshop in the United States and offeredadditional CLIMBw training in Japan in cooperation
with the Hope Tree.

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Group intervention for children and cancer patients

The program follows a standard training manualmodified from the U.S. manual (Heiney et al.,2006). The original English-language manual wastranslated into Japanese. In consultation withchild-life specialists, we changed terms and concrete
examples to ones that better reflect Japanese culture
and school life. An overview of the Japanese versionof the CLIMBw Program is described below (alsosee Kobayashi, 2014; Osawa, 2014). The children’s
program is grounded in the principles of mental
health promotion. The goals of the program are to improve a child’s ability to cope with a parent’s cancer
and to reduce the stress related to their parent’s cancer. The program was designed for school-aged children who are aware that their parents have cancer.
The six two-hour closed-group sessions were held
weekly. During each session, the children worked
on art activities as a group. The sessions followed astandard format beginning with a warm-up, proceeding to the “feeling of the day” activity, a goal activity,
and, finally, closure. The goals and activities ofeach session for children are explained in Table 1.
Throughout all sessions, children were encouraged
to share their feelings about a parent’s illness. The
children’s group intervention was led by professionals who had experience working with oncology or
pediatric patients. The group leaders included a social worker, a psychologist, and a child-life specialist,
all of whom had attended the CLIMBw training
workshop. Each session included assistants who
were experienced in working with children, such as
child-life specialists, nurses, and graduate studentsof psychology.
We held concurrent parent group sessions separate from those with the children. These were led
by a psychologist facilitator and an assistant who
was either a nurse or a graduate student of psychology. The goals for our parent group were to reduceparents’ anxiety and distress related to their child’s

stress, and also to improve communications between
parents and children. In the parental group, we explained the aims and content of the program. We emphasized that having conversations with theirchildren about the artwork from each child session
might improve communication with the children.
During open discussion time, we encouraged parents
to share their feelings about their and their children’ssituations. At the beginning of each subsequent session, the facilitator asked parents about how theyand their children talked about the child’s art activity. We also requested that the parents share about
the children’s emotional state at home or at schooland regarding family experiences during the past
week. As parents shared in open discussions, someof the issues that emerged were how to talk about
cancer-related issues with their children and how tocommunicate with the personnel at the child’s school.
Participants
We enrolled children and parents in six waves of replicate sets between August of 2010 and December of2012. The study inclusion criteria were: (1) a parent
diagnosed with cancer and undergoing treatment,and (2) school-aged children between the ages of 6
and 12 whose parents had cancer and who had been
informed previously that the parent had cancer. The
exclusion criteria were: (1) patients with terminalstage cancer, (2) patients with cancer and concurrent
serious mental health issues, and (3) school-aged
children with severe mental health or mental retardation disorders.
Setting and Procedures
Our study was conducted in Tokyo. The first group intervention was held at the Graduate School of the International University of Health and Welfare inTokyo, and the remaining five group interventions

Table 1. Content of the CLIMBw Program for the children’s group
Session
1
2
3
4
5
6

Goal
Decrease isolation by sharing cancer story
with other children and learn about
feelings using happy as exemplar
Increase the child’s knowledge about
cancer and its treatment
Normalize feelings of sadness
Assist the child in identifying strengths
and normalizing anxiety
Assist the child in expressing andmanaging anger in healthy ways
Facilitate communication with the parent
who has cancer

Feeling of the day

Activity

Happy“All about me” Introduce themselves

Confused“What is cancer?”
Learn about cancer and its treatment“Feeling mask”
Make a mask to express sad feelings“Strong box”
Make a box to feel strength“Anger cube”
Make a cube to deal with anger“Get well card”
Write a get well note to parent with cancer

Sad
ScaredMad

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578
were conducted at the Tokyo Kyosai Hospital. Before
we began our research, the study was approved by
the research ethics committee of the International
University of Health and Welfare.
Study team members recruited parents and children from three hospitals in Tokyo where the authors
have affiliations, and through information on the
Hope Tree website (http://www.hope-tree.jp/). The
Hope Tree is a volunteer organization of oncology professionals that was established in 2008 to disseminate information about supporting children whoseparents have cancer. After potential participants
were identified through team member referral or
self-referral via the website, they were screened forstudy inclusion. We (first author M.K. and third author K.O.) interviewed parents directly or by telephone to explain the goals and details of the
program and to describe what was entailed in research participation. During this interview, we completed a family assessment to ascertain the parent’s
diagnosis, treatment, and family situation. In addition, we assessed the children’s situation and theirunderstanding of their parent’s cancer. After the interview, parents were mailed an information packet
regarding the study that included a letter, a flyer
about CLIMBw, and a copy of the informed consent
form. Informed written consent to participate inour study was obtained from parents and children
prior to the first intervention session.
We used several approaches to examine the feasibility of the intervention and assure intervention fidelity—that is, purity, participant satisfaction, anddosage. Purity establishes if the intervention is delivered consistently and as planned (Gearing et al.,2011). The group facilitators followed the Japaneseversion of the script, manual, and time schedule foreach session. After sessions, the group facilitators conducted meetings to identify any concerns or problems
within the group, and strategies for handling theseconcerns were discussed and implemented. We gathered information about child and parent participants’
perceptions of the value of the group to obtain participant satisfaction. In addition, we measured the dosage of the intervention by recording attendance data.
Children and parents were evaluated at two timepoints: (1) one week before the group interventionand (2) within three days after the group intervention. Parent participants provided demographic andmedical information about themselves and their children at baseline.

Kobayashi et al.

We used two measures for children and three for parents, as described below, pre- and post-intervention.
In addition, we asked them to answer a questionnaire
about their satisfaction with the program. We chose
instruments for assessment of the children that focused on emotions associated with stress, particularly posttraumatic stress reactions, because of the
documented association between parental cancer
and these problems. Further, the CLIMBw Program
was specifically designed to decrease stress and help
children learn positive ways to cope with such negative emotions as anger. Similarly, our parental instruments were chosen to fit our outcomes.
Children’s Assessment
The Public Health Research Foundation-Type Stress
Inventory (PSI). The PSI (Sakano et al., 2007) is aself-report questionnaire for school-aged childrenthat was developed and standardized in Japan. We
used the stress response (SR) and social support(SS) scales to assess children’s psychosocial stress.
The SR has 12 items and is divided into 4 subscales:(1) physical (e.g., feel tired); (2) depression/anxiety(e.g., feel lonely); (3) irritation (e.g., become irritated); and (4) helplessness (e.g., cannot concentrate). Each scale score ranged from 0 to 12, withhigher scores indicating worse physical and emotional outcomes. In addition, the SS subscale rates
a child’s perception of the support that they receivefrom their parents, teachers, and friends in their
daily lives—for example, “When you are feeling
down, [your father] will encourage you.” Scores range
from 0 to 9, with higher scores indicating better relationships.
The Posttraumatic Stress Disorder – Reaction
Index (PTSD – RI). The PTSD –RI is a self-reportquestionnaire utilized to assess the frequency of
PTSD symptoms in school-aged children and adolescents (Pynoos et al., 1987; Stuber et al., 1991). We
employed the Japanese version of the PTSD –RI,
which has 18 items, rated from 0 (“none of thetime”) to 3 (“most of the time”). The children wereasked to rate each item with respect to their parents’
illness or cancer as the potentially traumatic event.
Total scores ranged from 0 to 54, with higher scoresindicating a more severe level of reaction. The standardization of the Japanese version of PTSD –RI was
performed by Izumi (2008), who employed illustrations for each item so that younger children could
more easily answer the PTSD –RI questions.

Study Measures
Patient demographic data and treatment-related
data were obtained through self-report. Standardized
questionnaires were used to measure study outcomes.

Parents’ Assessment
Functional Assessment of Chronic Illness Therapy–
Spiritual Well-Being (FACIT–Sp). The FACIT–Sp

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Group intervention for children and cancer patients(Cella et al., 1993; Webster et al., 1999) is a self-rating
questionnaire for any type of patient with cancer,
which includes an additional spirituality scale. Thismeasure was developed and standardized by Cellaet al. (1993). It consists of general questions divided
into four primary QoL domains: (1) physical well-being (7 items); (2) social/family well-being (9 items);(3) emotional well-being (6 items); and (4) functional
well-being (7 items); as well as spirituality (12 items).
Higher scores indicate better quality of life. This
questionnaire can measure the comprehensive andspiritual quality of life of a patient with cancer. The
reliability and validity of the Japanese version of
the FACIT– Sp for patients with cancer were confirmed by Noguchi et al. (2004).
The Hospital Anxiety and Depression Scale(HADS). The HADS (Zigmond & Snaith, 1983) is a
4-point, 14-item, self-report questionnaire used to assess psychological distress. It includes two subscales:anxiety and depression. Each subscale has 7 items,
and total scores range from 0 to 42, with higherscores indicating higher levels of psychological distress. The reliability and validity of the Japanese version of the HADS were confirmed by Kugaya andcoworkers (1998).
The Impact of Event Scale – Revised (IES – R). The
IES– R (Weiss & Marmar, 1997) is a 22-item self-report measure that assesses subjective distress causedby traumatic events. In our study, participants wereasked to rate each item in relation to their cancer
and its treatment, referring to their condition during
the past seven days. IES – R assesses three dimensions of PTSD symptoms: intrusion, avoidance, andhyperarousal. Total scores range from 0 to 88, withhigher scores indicating more severe levels of reaction. The reliability and validity of the Japanese version of the IES – R were confirmed by Asukai et al.
(2002).
Feasibility and Intervention Fidelity
Measurement
A member of the study team kept an attendance log
for the child and parent programs. Children andtheir parents completed the program evaluationquestionnaire assessing their satisfaction with the
CLIMBw Program after the group intervention. The
questionnaires were originally developed by Heiney(2006) in English, which we translated and modified
slightly when creating the Japanese version. The
children’s questionnaire includes 10 items, and theparent’s questionnaire includes 20 items with spacefor free-form descriptions. These questionnaires assess the satisfaction and acceptability of the inter-

vention. The items are rated on a Likert-type scalefrom 0 (never/not at all) to 4 (exactly/very much).
Analyses
The impact of the group program was analyzed using
a quasiexperimental within-subject design that compared pre- and posttest assessments of children andparents in separate exploratory analyses to determine changes in the children’s stress and the parents’
QoL and psychosocial distress.
Descriptive statistics were utilized to summarize
all demographic and medical characteristics of theparents and children. Pre- and post-intervention differences were examined using dependent-samples t
tests on children’s stress and parents’ QoL and psychosocial distress. Additional analyses included
Pearson’s chi-squared tests and independent-samples t tests. All tests were two-tailed, and the threshold for statistical significance was set at a value of p 
0.05. All data were analyzed using the Statistical
Package for Social Sciences software (v. 22.0, SPSS
Inc., Chicago, IL).
RESULTS
SampleOur study enrolled 32 parents (25 patients and 7
spouses) and 39 children as group participants.
Among these participants, the study sample for theevaluation was composed of 24 parent/patients (23mothers and 1 father) who were diagnosed with cancer and 38 of their school-aged children (27 girls and
11 boys). We excluded 7 spouses and 1 sister (older
than 12 years old) from the questionnaire study,and 1 mother failed to submit her questionnaire.
Parents were aged 36 –49 years (mean + SD ¼
43.0 + 3.6), and the children were 6–12 years old(mean + SD ¼ 8.5 + 1.8). Table 2 describes the study
participants at baseline. Some 75% of the adult participants were married and lived together, and therest were either single or separated. A total of 11 parents reported having a single child, 9 had 2 children, and 4 had 3 children. Some 13 of the 24parents revealed that they were employed full- or
part-time. Most parents were diagnosed with breast
cancer (n ¼ 19), while the remaining 5 parents werediagnosed with cancer of the stomach (n ¼ 2), uterus(n ¼ 2), and esophagus (n ¼ 1). A total of 15 parents(62.5%) were diagnosed with stage I or stage II cancer, 3 each were diagnosed with stage III cancer ora relapse, and 3 were diagnosed with a cancer of unknown stage. Some 22 parents (91.7%) were undergoing treatment at the time of the group intervention,and 2 had finished their treatment.

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Kobayashi et al.

Table 2. Participant descriptive characteristics
Parents(n ¼ 24)
Characteristics
Age
Mean + SD, years
Range
GenderFemaleMale
Education
High schoolSome college
Bachelor’s degree or higher
Marital status
MarriedSeparated
Divorced
WidowedNumber of children
1
2
3
Employment status
Full-timePart-time
Unemployed
Cancer site
BreastStomachUterineEsophagus
Cancer stageI
II
III
RelapseUnknown
Time since cancer diagnosis
Mean + SD, months
Range
Age at first cancer diagnosis
Mean + SD, years
Range
Treatment during intervention
Undergoing treatment
PosttreatmentnChildren(n ¼ 38)%n43.0 + 3.6
36– 49%8.5 + 1.8
6– 12

23
1

95.8
4.2

1
11
12

4.2
45.8
50.0

18
3
2
1

75.0
12.5
8.3
4.2

11
9
4

45.8
37.5
16.7

7
6
11

29.1
25.0
45.8

19
2
2
1

79.1
8.3
8.3
4.2

6
9
3
3
3

25.0
37.5
12.5
12.5
12.5

27
11

71.1
28.9

34.2 + 36.8
3 –11739.7 + 5.1
32– 4722
2

Exploratory Outcomes
Feasibility, Acceptability, and Intervention
FidelityChild participant attendance (n ¼ 38) at the six totalgroup sessions ranged from 3 to 6 sessions, with amean + SD attendance of 5.34 + 0.85 sessions anda median of 6. Similarly, patient/parent participants(n ¼ 25) attended 5.44 + 0.82 sessions, with a median of 6. Attendance records indicated that the

91.7
8.3

majority of children (89.5%) and their parents(91.7%) attended 5 or more program sessions.
According to the program evaluation, both children and parents experienced high levels of satisfaction on all the items except one (29 of 30 items). The
mean scores for each item for children ranged from
3.43 to 3.95 (10 items, selected from 0 to 4)—for example, “Making crafts helped me express feelings”(3.43) and “I’m glad I attended group” (3.84). The
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Group intervention for children and cancer patients

example, “It helped my child cope better” (3.73) and“Staff were compassionate and caring” (3.97). Only
“Location of services was convenient” (2.78) received
a low evaluation.
Some of the verbatim feedback on program evaluation from parents included the following: “The children’s anxiety are cleared, and they can deal with their
feelings in their own ways”; “The bond between us
deepened, and I feel my child grew up in many aspects”; “Learning about cancer and knowing it’s not
only my child whose parent has cancer helped mychild most”; “Thanks to staff, I was able to get backto my everyday life”; and “All my children attended
as siblings, and they became closer. I am feelingmuch lighter now as a parent.”
Comparison of Scores on Measures of Pre- andPost-Intervention
Our aim was to evaluate the impact of the Japaneseversion of the CLIMBw Program on selected childand parent variables. These data should be interpreted cautiously, as all analyses were exploratory
in nature. Tables 3 and 4 present the mean + SD values for each study measure for children and parents
at baseline and post-intervention, as well as the results of comparative t tests.
On the PTSD – RI, we found a significant decline
from a mean + SD of 18.22 + 7.67 at pre-intervention to 14.76 + 8.72 at post-intervention for posttraumatic stress symptoms (t ¼ 22.72, p ¼ 0.010). In
particular, we noted significant declines in the following items ( p , 0.01): “feeling it’s my fault theevent happened” and “remember the event suddenly
and feel terrible,” in relation to their parents’ cancer

as the potentially traumatic event. However, as forchildren’s stress response and social support, no significant differences were found on the PSI.
Parental QoL measured by the FACIT–Sp significantly improved after the group intervention ( p ,0.05) on four of five QoL dimensions. Improvement
occurred in social/family well-being (SWB: t ¼ 2.31,
p ¼ 0.030); emotional well-being (EWB: t ¼ 2.21,
p ¼ 0.037); functional well-being (FWB: t ¼ 2.47,
p ¼ 0.021); and spiritual well-being (SP: t ¼ 2.21,
p ¼ 0.038). No significant changes were identified
on the physical well-being subscale. Examples of
the items that significantly improved ( p , 0.05) are
as follows: “I am satisfied with family communication
about my illness” (SWB); “My work (including workat home) is fulfilling” (FWB); and “My illness has
strengthened my faith or spiritual beliefs” (SP). An
example for reduction was “I am losing hope in thefight against my illness” (EWB). No significant difference was found between pre- and posttest HADS
scores (total: t ¼ 20.40, p ¼ 0.690). Similarly, IES–
R scores did not change significantly (total:
t ¼ 20.19, p ¼ 0.849).
Factors Related to Children’s Posttraumatic Stress
Symptoms
As mentioned above, the mean PTSD –RI scores forchildren declined significantly after the intervention,
but some remained with a higher level. Therefore, after primary analysis, we identified the children’s postintervention PTSD–RI scores as the main outcomeand examined which factors were related to them.
We divided the child participants into two groups—“the high group” and “the low group”—based on the

Table 3. Comparison of pre- and post-intervention scores for assessment measures among children
PreMeasure
PSI stress response
Physical
Depression/Anxiety
Irritation
Helplessness
PSI social support
FatherMotherTeacher
Friends
PTSD–RI (n ¼ 37)
Total

Post-/pre- differencea

Post-

Mean

SD

Mean

SD

Mean

CI95%

t

p

2.84
1.92
2.84
2.13

2.07
2.17
2.77
2.06

2.39
2.11
2.55
2.45

2.46
2.24
2.60
2.56

20.45
0.18
20.29
0.32

[21.01, 0.11][20.44, 0.80][21.33, 0.76][20.50, 1.14]

21.62
0.60
20.56
0.78

0.114
0.551
0.578
0.440

6.00
7.68
6.84
5.61

3.16
2.03
2.14
3.09

5.45
7.39
6.03
5.53

3.16
2.44
2.80
3.08

0.55
0.29
0.82
0.08

[21.70, 0.59][21.09, 0.51][21.76, 0.13][21.04, 0.89]

20.98
20.74
21.74
20.17

0.335
0.467
0.089
0.869

18.22

7.67

14.76

8.72

23.46

[26.04, 20.88]

22.72

0.010

N ¼ 38; SD ¼ standard deviation; CI95% ¼ 95% confidence interval; PSI ¼ Public Health Research Foundation TypeStress Inventory; PTSD– RI ¼ Posttraumatic Stress Disorder Reaction Index.
aChange in mean score between the pre- and post-intervention assessments; dependent-samples t test, two-tailed
significance.

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Table 4. Comparison of pre- and post-intervention scores for assessment measures among parents
PreMeasure
FACIT– Sp
Physical well-being
Social/family well-being
Emotional well-being
Functional well-being
Spiritual well-being
FACT–G total
FACIT– Sp total
HADS
Anxiety
Depression
Total
IES –R
Intrusion
Avoidance
Hyperarousal
Total

Post-/pre- differencea

Post-

Mean

SD

Mean

SD

Mean

CI95%

t

p

18.71
17.49
13.01
17.96
26.42
67.17
93.54

7.02
5.13
6.58
5.87
11.66
19.87
29.48

19.84
18.92
14.67
19.94
29.43
73.36
102.79

6.43
4.70
4.96
4.82
9.70
15.36
23.23

1.13
1.42
1.66
1.98
3.01
6.19
9.24

[20.38, 2.65][0.15, 2.70][0.11, 3.21][0.32, 3.64][0.19, 5.83][2.40, 9.99][3.49, 15.00]

1.55
2.31
2.21
2.47
2.21
3.38
3.32

0.136
0.030
0.037
0.021
0.038
0.003
0.003

6.92
6.38
13.46

4.40
5.09
8.91

7.17
5.71
13.00

4.84
4.80
8.67

0.25
20.67
20.46

[21.11, 1.61][22.03, 0.70][22.81, 1.89]

0.38
21.01
20.40

0.707
0.322
0.690

7.00
7.29
5.54
19.83

6.36
5.94
4.89
15.51

6.33
7.17
6.67
20.17

5.59
5.60
5.48
15.35

20.67
20.13
1.13
0.33

[22.12, 0.79][21.44, 1.19][20.50, 2.75][23.25, 3.92]

20.95
20.20
1.44
0.19

0.353
0.846
0.164
0.849

N ¼ 24; SD ¼ standard deviation; CI95% ¼ 95% confidence interval; FACIT–Sp ¼ Functional Assessment of Chronic
Illness Therapy –Spiritual Well-Being; FACT–G ¼ Functional Assessment of Cancer Therapy –General; HADS ¼
Hospital Anxiety and Depression Scale; IES– R ¼ Impact of Event Scale– Revised.
aChange in mean score between the pre- and post-intervention assessments; dependent-samples t test, two-tailed
significance.

cutoff point for post-intervention PTSD – RI scores. A
total of 13 children were placed in “the high group,”with scores of 17 or higher, subdivided into “moderate” (17 – 26), “severe” (27– 39), and “most severe”(.40) levels; 24 children were placed in “the lowgroup,” with scores of 16 or lower, subdivided into“slight” (8 – 16) and “normal” (0 – 7) levels of posttraumatic stress symptoms. Independent-samples t test
and Pearson’s chi-squared tests were performed to
explore the relevant factors prior to the intervention(Table 5). According to these results, we have notfound significant differences between the two groups

among most demographic items (e.g., child’s age,child’s gender, having brothers/sisters or not, afflicted parent’s age, and education), except among
parents’ marital status (married, living together ornot) ( p ¼ 0.012), and among PTSD –RI scores before
the intervention ( p ¼ 0.012).
DISCUSSION
The purpose of this pilot study was to examine thefeasibility and acceptability and evaluate the outcome of the Japanese version of the CLIMBw group

Table 5. Comparison between PTSD – RI high and low group post-intervention scores among childrenChild age
Parent age*
PTSD –RI Score (pre)Child gender, male
Brothers/sisters
Marital status*
Parent education* (bachelor’s degree)

Total

PTSD– RI (post)high a (n ¼ 13)

PTSD– RI (post)
low b (n ¼ 24)

8.41 + 1.77
42.51 + 3.82
18.22 + 7.67
10 (26.3%)
25 (65.8%)
30 (78.9%)
22 (57.9%)

8.62 + 1.89
43.83 + 4.51
21.85 + 7.65
3 (21.4%)
10 (71.4%)
8 (57.1%)
7 (50.0%)

8.29 + 1.73
42.04 + 3.46
16.25 + 7.07
7 (29.2%)
15 (62.5%)
22 (91.7%)
15 (62.5%)

Value of p
0.603
0.200
0.031
0.601
0.576
0.012
0.452

N ¼ 37; PTSD– RI ¼ Posttraumatic Stress Disorder– Reaction Index; cutoff scores ¼ 16/17.
High group is 17 or higher in moderate/severe/most severe levels.
b
Low group is 16 or lower in slight or normal level.
The data were analyzed using an independent-samples t test or Pearson’s chi-squared test, two-tailed significance.
* Parental data were double-counted when more than one child participated in the intervention.
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Group intervention for children and cancer patients

intervention on children’s stress and parents’ psychosocial distress. Our results should be considered tentative, as all of our analyses were exploratory innature.
Our findings suggest that the intervention was
well-received. Both children and parents were verysatisfied with the program, as indicated by their evaluation questionnaires and also by their consistent attendance. The intervention seems to be highly
acceptable for participants, and its feasibility has
been confirmed.
The children’s posttraumatic stress symptoms related to their parents’ illness measured by the
PTSD – RI decreased after the intervention. Throughthe group activities, we provided an opportunity forchildren to express and cope with their feelings about
their parents’ cancer and thus reduce stress. Our results suggest that the program had a positive impact
on decreasing children’s stress.
However, when we looked at the results in more detail, a third of the children remained with a high levelof posttraumatic stress symptoms (higher than the cutoff of 16 points by the PTSD–RI) after the intervention.
After dividing participants into two groups (high andlow) and analyzing the related factors, we found thatparents’ marital status and the baseline PTSD score
were related. Being a single parent and having ahigh PTSD score at baseline may be related to children’s stress. Thus, some special care for these children
may be needed, or perhaps supplemental follow-up sessions might be effective. Foran-Tuller et al. (2012) emphasized the importance of PTSD assessment inchildren whose mothers had cancer and stated that
the PTSD variable was the strongest explanatory outcome. Our findings are in line with that study, although
the sources of the reports were different. They employed mothers’ reports to assess children’s posttraumatic stress symptoms, and their results were basedon mothers’ perceptions. Our approach may yield astronger assessment, having been obtained from thechildren themselves using the PTSD–RI for children.
In contrast, no significant differences were foundin the children’s stress response (SR) and social support (SS) scores measured by the PSI between baseline and post-intervention. When baseline SRscores were compared with general data for elementary school children, the child participants had
higher scores, but the scores did not exceed the normal range (Sakano et al., 2007). The children’s SSscores were high enough even at baseline. Social support may increase when a parent is diagnosed withcancer; but this may not be the case over the longer
period of treatment. The timing of our assessment
may have captured this increased attention but
may not measure the long-term support needs ofthe children of cancer survivors.

583
As for parents, the FACIT–Sp results show that
their QoL was improved after the intervention for
all except the physical domain (i.e., social/family,
emotional, functional, and spiritual well-being).
The lack of change in physical well-being is not surprising, since most parents were undergoing treatment (chemotherapy, radiation therapy, or hormone
therapy) during their study participation. This fact
may explain why parents’ QoL improvement was regarded as an outcome of the group intervention.
In contrast, parents’ psychological distress (anxiety and depression) measured using the HADS did
not show a significant decrease. In fact, half of thesample had reported high levels on the HADS atboth the beginning and end of the intervention. Davey et al. (2013) reported similar results on depressive symptoms from their intervention study. One
possible reason for the lack of decline is that the intervention period was too short to improve depression. In addition, it is possible that the intervention
did not adequately target the depressive symptoms(Davey et al., 2013). In the future, longer sessions
or sessions specifically designed to address depression might better address this symptom. We also
did not see a decrease in parental posttraumaticstress symptoms measured by the IES –R.
Overall, parental psychological distress did not
significantly change after the group intervention;
however, their QoL, which focused on emotionaland social well-being in daily life, improved greatly.
Thus, group intervention can help participants asparents but may not counter the personal sufferingthat results from a diagnosis of and treatment forcancer. Semple and McCance (2010) found three predominant themes from a literature review pertaining
to a parent’s experience with cancer: (1) being a goodparent, (2) telling the children, and (3) maintaining
normal routines at home. We suppose that group participation allows the parent to maintain his/her identity as a parent by talking and sharing with others
about their parenting concerns in a peer group.
Finally, we considered the significance of the intervention for both children and parents. The CLIMBw
Program is a peer group intervention for schoolaged children (aged 6–12 years). During thisdevelopmental stage, children begin to seek more independence from their parents and want to spend
more time with their peers (Heiney & Hermann,2013). The children in the CLIMBw intervention
may have felt less isolated, since they could share
their experiences and emotions about their parents’cancer with peers within a secure setting. As a result,
their posttraumatic stress symptoms related to theirparents’ cancer declined. A major concern that parents expressed after a cancer diagnosis is “parenting”(Semple & McCance, 2010). Worrying about their

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584
children’s reactions also adds to parents’ emotional
stress (John et al., 2013). Our findings suggest thatchildren’s stress concerning their parents’ illness decreased after participation in the CLIMBw Program,which may have enhanced parents’ well-being. Anecdotal observations of group facilitators for parent
groups indicated that talking about their cancer-related problems was a difficult obstacle to overcome
before program participation even though their children knew about their diagnosis. However, parents
found that it was much easier to communicate about
their cancer within the family after participating in
the program. Interventions focused on family communications may benefit children and, through improved relationships, enhance parent/patients’ QoL(Watson et al., 2006). Niemela et al. (2012) suggested
that peer group interventions impact the psychological well-being of patients, even when the purpose isto support parenting and children. The strength of
our group intervention, the Japanese version of the
CLIMBw Program, was that we provided concurrent
groups for both children and parents. Further objective study will be necessary on this point.
The group intervention we provided for children
experiencing parental cancer was the first of thistype to be offered in Japan. Moreover, to participate
in this program, children had to know that their parents had been diagnosed with cancer. In Japan, parents have a good deal of difficulty in telling theirschool-aged children about a cancer diagnosis.
Therefore, recruiting participants was difficult anda control-group design could not be adopted. However, our pilot study provides important insights
and information regarding the changes seen in participants from pre- to post-intervention assessments.
As the results of our study suggest, the children who
experienced parental cancer have concerns focusedon their parents’ illness (posttraumatic stress symptoms), even though they might not manifest distressin daily life. The CLIMBw group intervention can
provide an effective opportunity for them to overcome
their concerns. As for the parents, they may improvetheir quality of life (psychosocial and spiritual wellbeing) by means of the intervention.
LIMITATIONS OF THE STUDY
The main limitations of this pilot study are the small
sample size and the lack of a control group. Due to thesmall sample size and examination of multiple outcomes, type I and type II errors are possible. Thus, effects may be over- or underestimated. Without
randomized controls, we cannot provide sufficient evidence for the effects of the intervention. Additional
research with larger samples is required to be able
to generalize these results. Moreover, because of the

Kobayashi et al.

small sample size, we did not assess the impact of
the intervention with respect to sex differences. It
is certainly very important that sex differences be
considered in future research.
Second, we did not assess the long-term effects of
the intervention, so our findings are only relevant to
the possible short-term impact of the group intervention. Third, the instruments we chose to employ may
not have been the best tools for measuring the effectsof the group intervention. For example, we did not examine children’s QoL, coping styles, or family communication styles. Fourth, children may not be able toadequately self-report their symptoms and situations.
Better instrumentation and assessment methods are
required to be applied in future research. Finally,
our study only performed quantitative analyses. Qualitative methods may have provided further enlightenment regarding how to improve clinical practice.
However, this interventional study was the first suchtrial in Japan, so we believe that our work is a valuable step toward improved child support.

CLINICAL IMPLICATIONSThere is an increasing awareness of the importanceof providing support for the children of patientswith cancer by medical professionals in Japan. It
is thought that group intervention for both parents
and children using the CLIMBw Program is an effective approach to supporting children after they
have learned of their parents’ cancer diagnosis.
This is a structured program, so that any medical
professional can easily learn how to administer itusing the training workshop and manualized materials. Moreover, special facilities are unnecessary,and the costs are minimal. We will continue our advocacy to increase hospital presentations of the
CLIMBw Program by helping them launch the program so that more children and patients will beable to attend.

ACKNOWLEDGMENTS
We wish to express our appreciation to Emi Inoue, Eriko
Miura, and Yukiko Murase, child-life specialists who provided valuable guidance in adapting the program for Japanese children. We would like to deeply thank all thechildren and parents who participated and the group facilitators from the Hope Tree for their contributions to ourstudy. We are grateful for the support of Peter van Dernootfrom the Children’s Treehouse Foundation, who allowed
us to adapt the CLIMBw Program. We also thank Sachiko
Ohde from the Center for Clinical Epidemiology at
St. Luke’s International University for her professional
advice.

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Group intervention for children and cancer patients

FUNDING
This study was supported by a research grant, “Child
Support in Clinical Cancer Practice,” from the Japanese Ministry of Health, Labour, and Welfare (2010–2012).

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