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Journal for Specialists in Pediatric Nursing

ORIGINAL ARTICLE

Examining the perceived social support and psychological symptoms among adolescents with leukemia Hicran Çavus¸og˘lu and Hatice Sag˘lam Hicran Çavus¸og˘lu, RN, MS, PhD, is Professor; and Hatice Sag˘lam, RN, MS, is a Research Assistant, Hacettepe University Faculty of Nursing, Sihhiye, Ankara, Turkey

Search terms Adolescent, leukemia, nursing, psychological symptom, social support. Author contact [email protected], with a copy to the Editor: [email protected] Disclosure: The authors report no actual or potential conflicts of interest. Funding: No external or intramural funding was received. First Received May 25, 2014; Final revision received November 1, 2014; Accepted for publication November 3, 2014.

Abstract Purpose. The purpose was to determine the perceived social support and psychological symptoms of adolescents with leukemia. Design and Methods. The sample consisted of 70 adolescents with leukemia. The Brief Symptom Inventory (BSI), Multidimensional Perceived Social Support Scale (MPSSS), and a demographical data form were used for data collection. Results. Scores of the Global Severity Index, Positive Symptom Distress Index (PSDI), and Positive Symptom Total (PST) of the BSI were higher than those of the healthy adolescents with the same age in other studies. There was a negative relationship between the MPSSS and negative selfimage, depression, anxiety, PSDI, and PST of the BSI. Practice Implications. It would likely be beneficial to increase adolescents’ perceived social support in order to decrease psychological symptoms.

doi: 10.1111/jspn.12101

Cancer is associated with various psychological symptoms and may have long-term effects on the psychosocial well-being of children (Bruce, 2006; Li, Lopez, Joyce Chung, Ho, & Chiu, 2013; Patenaude & Last, 2001). Ruland, Hamilton, and Schjodt-Osmo (2009) found that adolescents with cancer who were 10 to 18 years old experienced both physical and psychological symptoms. Psychological symptoms were more complex and prevalent with advancing development (Ruland et al., 2009). Adolescents with cancer experience anxiety, depression, hopelessness, social isolation, disruption of body image, and school and peer-related issues during the illness (Hedström, Kreuger, Ljungman, Nygren, & Von Essen, 2006; Liang, Chiang, Chien, & Yeh, 2008). Previous studies showed that the level of depression (Çavus¸og˘lu, 2001; Larsson, Mattson, & von Essen, 2010; Li et al., 2013) and anxiety (Hokkanen, Eriksson, Ahonen, & Salantera, 2004; Von Essen, Enskar, Kreuger, Larsson, & Sjoden, 2000) were higher among children and adolescents with cancer than their healthy peers. 76

Diagnosis of cancer and its treatment usually cause interference with the adolescent’s normal development, school activities, and social interactions during the illness (Bruce, 2006; Li et al., 2013).Cancer in childhood may disrupt normal developmental processes and cause psychosocial problems in adolescent survivors of childhood cancers (Jóhannsdóttir et al., 2011). Disruptions of development because of illness could affect the mental and emotional health of adolescents (Abrams, Hazen, & Penson, 2007; Jóhannsdóttir et al., 2011; Özbaran & Erermis¸, 2006). Their ability to cope with these problems depends partially on having a strong social support system (Woodgate, 2006). Social support can be defined as the support provided to individuals by their family, friends, or other people (Haluska, Jessee, & Nagy, 2002). Several studies have emphasized the importance of social support being provided for adolescents with cancer (Corey, Haase, Azzouz, & Monahan, 2008; Kyngas et al., 2001). Social support provides an opportunity for adolescents to share their thoughts, fears, and Journal for Specialists in Pediatric Nursing 20 (2015) 76–85 © 2014, Wiley Periodicals, Inc.

H. Çavus¸og˘lu and H. Sag˘lam

Examining the Perceived Social Support and Psychological Symptoms Among Adolescents With Leukemia

emotions in order to cope with their illness and treatment-related issues (Kyngas et al., 2001; Woodgate, 2006). For this reason, social support is important for decreasing depression, anxiety, low self-esteem, and hopelessness among adolescents with cancer (Haluska et al., 2002; Woodgate, 2006). In a study by Corey and colleagues (2008), it was determined that anxiety, ambiguity, and hopelessness were less common among adolescents with cancer who had a sufficient social support system during diagnosis and treatment. If adolescents do not have adequate social support, they are negatively affected in being able to deal with the stress or the illness itself (Goodall, King, Ewing, Smith, & Kenny, 2012). Health personnel, especially nurses, play a key role in the treatment and management of illness because they are available to assess patients 24 hr a day and to define actual or potential threats to health. In addition, nurses assist with recovery, facilitate independence, help meet physical and psychosocial needs and improve quality of life for patients. Therefore, it is important for nurses to take into consideration psychological symptoms and perceived social support on an individual basis in order to decrease the negative effects of the illness and treatment. The research questions of this descriptive and comparative study are as follows: • What are the psychological symptoms and social support systems of the adolescents with leukemia? • Are there any differences when we compare psychological symptoms of adolescents with leukemia and healthy adolescents? • Are there any relationships between psychological symptoms and social support? DESIGN AND METHODS Sample and setting

This study was conducted in pediatric hematology polyclinics in Ankara Pediatric HematologyOncology Training and Research Hospital (state hospital), Hacettepe University I˙hsan Dog˘ramacı Children’s Hospital, and Ankara University Children’s Hospital. The study sample was comprised of 140 13- to 19-year-old adolescents with diagnosed leukemia who applied to Hacettepe University I˙hsan Dog˘ramacı Children’s Hospital, Ankara University Children’s Hospital, and Ankara Pediatric Hematology-Oncology Training and Research Journal for Specialists in Pediatric Nursing 20 (2015) 76–85 © 2014, Wiley Periodicals, Inc.

Hospital in 1 year. Those hospitals were included in the study because most adolescents with leukemia seek care at these institutions. When hospital records were examined it was determined that the eligible population was 30 adolescents at the Hacettepe University I˙hsan Dog˘ramacı Children’s Hospital, 40 at Ankara University Children’s Hospital, and 70 at Ankara Pediatric HematologyOncology Training and Research Hospital. We calculated the sample size according to the following formula:

n=

NZα2 2 p (1 − p ) d 2 ( N − 1) + Zα2 2 p (1 − p )

where n = sample size calculated, N = population size, p = percentage picking a choice, expressed as decimal, Z = Z value (e.g., 1.96 for 95% confidence level), and d = deviation magnitude. Using d = 0.1, it was determined we would need 57 adolescents; using d = .08, only 72 adolescents were needed. As a result of this calculation, it was deemed appropriate to include 70 adolescents in the sample. The total study sample comprised 70 adolescents who applied to these three hospitals between March 1 and September 1, 2011 (16 at Hacettepe University I˙hsan Dog˘ramacı Children’s Hospital, 22 at Ankara University Children’s Hospital, and 32 at Ankara Pediatric Hematology-Oncology Training and Research Hospital). These three hospitals treat children who come from Ankara as well as the other cities in Turkey. No formal support groups were available for adolescents because there were too few nurses. There are no psychologists in any of these three hospitals’ hematology and oncology clinics. However, psychological consultation is available upon physician’s advice. Inclusion criteria. According to the World Health Organization, an adolescent is a person between 10 and 19 years of age (WHO, 2001). The validity and reliability tests were conducted in Turkey for the Brief Symptom Inventory (BSI) on adolescents older than 13 years of age and for the Multidimensional Perceived Social Support Scale (MPSSS) on adolescents older than 12 years of age. For this reason, our sample consisted of adolescents between the ages of 13 and 19 years. Adolescents who were diagnosed with leukemia at least 1 year previously were included in the sample. We thought that this period was sufficient for adolescents to understand the nature of the disease and psychosocial problems associated with living with leukemia. To make the sample more homogeneous, we did not include 77

Examining the Perceived Social Support and Psychological Symptoms Among Adolescents With Leukemia

adolescents who had high-risk acute lymphoblastic leukemia (ALL) or acute myeloblastic leukemia (AML). Instruments

Demographic data form. This form included questions related to the demographic characteristics of the adolescents/young adults (i.e., age, gender, education level, diagnosis, the stage of the illness, treatment methods, and time since diagnosis). Brief Symptom Inventory (BSI). This instrument was developed by Derogatis in 1992 to determine psychological symptoms as a result of studies conducted with the Symptom-Checklist 90-Revised (SCL-90-R). The BSI contains nine subscales. It is a self-report instrument in which participants rate the extent to which they have been bothered (0 = not at all; 4 = extremely) in the past week by various symptoms. A study by Derogatis (1992) found that the Cronbach’s alpha coefficients ranged between .76 and .85 across the nine subscales. The scale was translated to Turkish by S¸ahin and Durak in 1994. A factor analysis showed that the Turkish version of the instrument consisted of five subscales (anxiety, depression, somatization, negative self-image, and hostility). Validity and reliability tests were conducted by S¸ahin, Batıgün, and Ug˘urtas¸ (2002) for adolescents, and it was reported that the instrument was valid and reliable for adolescents older than 13 years. Internal consistency (Cronbach’s alpha coefficients) of the subscales ranged between .70 for depression and .88 for somatization (S¸ahin et al., 2002). In our study, Cronbach’s alpha coefficients ranged from .92 for the total scale and between .70 (for hostility) and .84 (for depression) for the subscales. The BSI contains 53 items, and each item is given a score between 0 and 4; thus, scores can range from 0 to 212. The total scale score shows the frequency of the symptoms. In addition to this, the BSI includes three global indices of distress (Derogatis, 1992; Savas¸ır & S¸ahin, 1997). Global indices of BSI

The BSI’s global indices measure the overall psychological distress level, the intensity of symptoms, and the number of self-reported symptoms. The Global Severity Index (GSI) shows the overall psychological distress level. The Positive Symptom Total (PST) 78

H. Çavus¸og˘lu and H. Sag˘lam

shows the number of self-reported symptoms. The Positive Symptom Distress Index (PSDI) shows the intensity of symptoms. Global Severity Index (GSI) is calculated by taking the mean of all of the subscale scores. Positive Symptom Total (PST) is derived by counting the number of items endorsed at a level higher than zero. Positive Symptom Distress Index (PSDI) is derived by summing all of the item values and then dividing by the Positive Symptom Total. MPSSS. This social support scale was developed by Zimet, Dahlem, Zimet, and Farley in 1988. It is a short scale and subjectively evaluates the sufficiency of social support gained from three different sources. The scale is comprised of 12 items and three subscales consisting of supports provided by family, a special person (significant other), and friends (Zimet, Dahlem, Zimet, & Farley, 1988). The MPSSS was translated to Turkish by Eker, Arkar, and Yaldız in 2001.The validity and reliability tests of the scale on adolescents (ages 12–22) were conducted by Çakir and Palabiyikog˘lu in 1997. In this study, Cronbach’s alpha coefficients were calculated as follows for the total scale and subscales; .76 for total scale, .84 for family, .83 for friends, and .82 for a special person. Factor structure, validity, and reliability of the revised form of the scale were reexamined by Eker et al. in 2001. In this study, internal consistency of the scale and the subscales were between .80 and .95. In our study, Cronbach’s alpha coefficients ranged from .87 for the total scale to .92 for family, .93 for friends, and .95 for a special person. Each item of the scale ranges from 1 (definitely yes) to 7 (definitely no); thus, subscale scores can range from 4–28, and the total score can range from 12 to 84. The total score of each subscale is calculated by adding the four-item scores together, whereas the total score of the scale is calculated by adding the sums of all the subscales together. A high score suggests high social support (Çakir & Palabiyikog˘lu, 1997; Eker, Arkar, & Yaldız, 2001). Data collection

The data were collected over 6 months between March 1 and September 1, 2011. The demographic data form, BSI, and MPSSS were completed using a face-to-face interview method. Adolescents with leukemia between 13 and 19 years of age, who came to the hematology outpatient clinics during the data collection period, and who were diagnosed with leukemia at least 1 year previously, were included in Journal for Specialists in Pediatric Nursing 20 (2015) 76–85 © 2014, Wiley Periodicals, Inc.

H. Çavus¸og˘lu and H. Sag˘lam

Examining the Perceived Social Support and Psychological Symptoms Among Adolescents With Leukemia

the sample. Interviews took between 40 and 45 min for each subject. Interviews were carried out at the three pediatric hematology outpatient clinics in the waiting hall during patient waiting times. Analysis procedures

Independent variables consisted of demographic characteristics of the adolescents and dependent variables included the scores acquired from the BSI and the MPSSS. Descriptive statistics such as percentage, mean +/− SD, and median (maximum–minimum) were used for reporting scale scores. The Mann– Whitney U and Kruskal–Wallis tests were used for comparisons between the dependent and independent variables, and post-hoc analyses were conducted. We used the Bonferonni post-hoc test to analyze the difference between the mean scores of the global indices of the BSI of our study and the other studies on healthy adolescents. The difference between the mean scores of family, friends, and a special person (significant other) of the social support scale was examined by Friedman’s test and post-hoc analysis in dependent groups. Before we analyzed the correlations between and within the scores of perceived social support and brief symptom inventory, we used the Shapiro–Wilks test to analyze whether the scale scores displayed normal distribution. Because neither of the scale scores was normally distributed, we used the Spearman correlation coefficient. Data were analyzed in IBM SPSS Statistics 20 (http://ibm-spss-statistics.soft32.com).

Table 1. Descriptive Characteristics of the Adolescents With Leukemia Descriptive characteristics (N = 70) Gender Female Male Age 13–14 15–19 Education level Primary school High school Diagnosis ALL AML Stage of the illness Remission Treatment Relapse Treatment method Chemotherapy Radiotherapy and chemotherapy Time since diagnosis 1 year 2–4 years 5–9 years Interruption in education 1 year 2–4 years Total

n

%

18 52

25.7 74.3

13 57

18.6 81.4

29 41

41.4 58.6

49 21

70.0 30.0

16 49 5

22.9 70.0 7.1

57 13

81.4 18.6

34 21 15

48.6 30.0 21.4

55 15 70

78.6 21.4 100.0

Note: ALL, acute lymphoblastic leukemia; AML, acute myeloblastic leukemia.

Before conducting the study, official permission was obtained from the three hospitals and approval was obtained from the Hacettepe University NonInterventional Clinical Researches Ethics Board. The researchers explained the study to the adolescents and their parents, and written consent/assent from the adolescents and parental permission were obtained when the adolescents were younger than 18 years of age. We guaranteed that information they provided would be treated confidentially and that they had the right to withdraw from the study whenever they desired. None of the adolescents refused to participate in the study.

study, the adolescents included 18 females and 52 males with an age range of 13 to 19 years (M = 15.88 years, SD = 1.77). As shown by the larger number of males in this study, males are more likely to be diagnosed with leukemia than females in the adolescent period (Yaris¸, 2007). Regarding education level, 41.4% were in primary school, and 58.6% were in high school. Of the adolescents, 70% had been diagnosed with acute lymphoblastic leukemia and 30% had acute myeloblastic leukemia. The time since diagnosis ranged between 1 year and 9 years. Of the sample, 81.4% had received chemotherapy, and 18.6% had received radiotherapy and chemotherapy, 70% were in the treatment stage of the illness, and 78.6% had experienced interruption in their education for at least 1 year because of the illness.

RESULTS

Psychological symptoms

Table 1 shows the descriptive characteristics of the adolescents/young adults with leukemia. In this

The mean scores of the BSI indicated that hostility, depression, anxiety, and somatization were the top

Ethical aspects

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Psychological symptoms N = 70

Mean

SD

Median

Minimum/ maximum

Anxiety Depression Somatization Negative self Hostility Global Severity Index (GSI) Positive Symptom Total (PST) Positive Symptom Distress Index (PSDI)

0.82 0.92 0.80 0.68 1.00 0.83 27.02 1.63

0.46 0.55 0.42 0.45 0.49 0.41 11.41 0.38

0.92 0.91 0.83 0.62 1.00 0.86 25.50 1.54

0.08/2.00 0.00/3.25 0.00/1.78 0.00/2.08 0.14/2.29 0.17/2.13 5.00/49.00 1.06/2.60

four psychological symptoms for adolescents (Table 2). In a study carried out to determine the psychological conditions of 935 first-year, healthy university students (Demirel, Eg˘lence, & Kaçmaz, 2011), the scores of the GSI, PSDI, and PST were lower than in our study. In the validity and reliability study of the BSI conducted on 559 healthy adolescents in Turkey, it was determined that the GSI, PSDI, and PST were lower than in our study (S¸ahin et al., 2002). Table 3 shows the comparisons of the mean scores of the three global indices for our study compared with the studies of S¸ahin and colleagues (2002) and Demirel and colleagues (2011). The difference between the mean scores of the GSI (t = 13.438, p < .001) and the PSDI (t = 28.49, p < .001) in our study and the study of Demirel and colleagues (2011) was found to be statistically significant. In addition, the difference between the mean scores of the PST in our study and the study of S¸ahin and colleagues (2002) were also statistically significant (t = 2.542, p < .0112).

GSI

Studies used BSI on adolescents Adolescents with leukemia in our study Demirel et al., 2011 (first year healthy university students) S¸ahin et al., 2002 (healthy adolescents)

M

Table 2. Mean Scores of Brief Symptom Inventory

In our study, no significant differences were observed between gender, interruption period in education, stage of the illness, treatment methods, diagnosis of ALL, or AML, time since diagnosis, and the mean BSI scores. Perceived social support

Adolescents reported greater perceived social support from family than from friends or a special person (Table 4). There was a statistically significant difference between social support from family and friends (p < .001) and between family and a special person (p < .001). Furthermore, the mean scores of social support from family (M = 28.00; ± 0.00), friends (M = 24.40; ± 6.98) and a special person (M = 18.40; ± 10.03) were greater in the relapse period than in the other stages of the illness. In the relapse period, the mean scores of perceived social support from families (p < .022) was statistically significant. A special person

PST SD

H. Çavus¸og˘lu and H. Sag˘lam

PSDI

N

M

70 935

0.83 ± 0.41 0.17 ± 0.1

27.02 ± 11.41 26.49 ± 12.8

SD

M

1.63 ± 0.38 0.33 ± 0.13

SD

559

0.75 ± 0.50

23.52 ± 10.78

1.59 ± 0.53

Table 3. Comparisons of the Mean Scores of the Global Indices of the BSI and Other Studies on Healthy Adolescents

BSI, Brief Symptom Inventory; GSI, Global Severity Index; PSDI, Positive Symptom Distress Index; PST, Positive Symptom Total.

Perceived social support N = 70

Mean

SD

Median

Minimum/maximum

Family Friend A special person Total

25.35 19.97 18.58 63.91

4.46 6.45 7.25 12.97

28.00 19.50 19.50 65.00

7.00/28.00 4.00/28.00 4.00/28.00 28.00/84.00

80

Table 4. Mean Scores of Perceived Social Support Scale

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Examining the Perceived Social Support and Psychological Symptoms Among Adolescents With Leukemia

H. Çavus¸og˘lu and H. Sag˘lam

meant someone (boy/girlfriend, relatives, neighbors, health personnel, teacher) except the family and friends. In this study, adolescents more highly valued social support from family than from friends or a special person. When examined by age, gender, education level, diagnosis of ALL or AML, treatment methods, interruption period in education, and time since diagnosis, no significant differences were found in perceived social support from family, friends, or a special person.

Relationship between psychological symptoms and social support

The results of correlations between the brief symptom inventory and the perceived social support scale are provided in Table 5. There was a negative relationship between total perceived social support and negative self-image (r = −.441), depression (r = −.488), anxiety (r = −.498), hostility (r = −.374), GSI (r = −.506), and PST (r = −.435; p < .001). Furthermore, a negative relationship was found between social support from friends and negative self-image (r = −.546), depression (r = −.495), anxiety (r = −.602), hostility (r = −.380), GSI (r = −.543), and PST (r = −.415; p < .001). No relationship was found between social support from family, a special person, and psychological symptoms.

DISCUSSION Psychological symptoms

The level of psychological symptoms was significantly higher in adolescents with leukemia in our study than for healthy adolescents in studies by Demirel and colleagues (2011) and S¸ahin and colleagues (2002). Several studies found that adolescents with cancer had both physical and psychological symptoms, but that they had more psychological and school-related issues (such as interruption in their education, academic failure, not attending school activities), anxiety, somatization, and depression (Li et al., 2013; Ruland et al., 2009). In the adolescent period, significant physical and emotional changes occur, and diagnosis of leukemia at that time has a major impact on adolescents’ physical, psychological, and mental development. Cancer diagnosis and the treatment period are associated with various types of psychological distress and cause interference with adolescents’ normal daily activities and social interactions (Bruce, 2006). The long treatment period with leukemia often leads to difficult life experiences for adolescents (such as separation from family and friends, understanding the implications of leukemia, and not knowing how to plan for their future; Patenaude & Last, 2001). In one study, adolescent survivors of childhood cancers (13–18 years old) reported higher

Table 5. Relationship Between Perceived Social Support (PSS) and Brief Symptom Inventory (BSI) Correlations between PSS and BSI N = 70

Test * significance level

PSS Total

PSS Family

PSS Friend

PSS Special person

Somatizaton

r p r p r p r p r p r p r p r p

−0.315 .008 −0.441 .000 −0.488 .000 −0.498 .000 −0.374 .001 −0.506 .000 −0.435 .000 −0.162 .181

−0.228 .057 −0.260 .030 −0.240 .045 −0.311 .009 −0.359 .002 −0.313 .008 −0.184 .127 −0.325 .006

−0.234 .051 −0.546 .000 −0.495 .000 −0.602 .000 −0.380 .001 −0.543 .000 −0.415 .000 −0.354 .003

−0.270 .024 −0.204 .091 −0.353 .003 −0.250 .037 −0.212 .079 −0.310 .009 −0.305 .010 0.017 .887

Negative self Depression Anxiety Hostility Global Indices-GSI Global Indices-PST Global Indices-PSDI

*Spearman correlation coefficient was used. p < .001. GSI, Global Severity Index; PSDI, Positive Symptom Distress Index; PST, Positive Symptom Total.

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levels of psychological distress (Jóhannsdóttir et al., 2011). Researchers reported that diagnosis and time since diagnosis did not affect the levels of psychological distress in that study. Perceived social support

Normally, adolescents are in the process of becoming independent and autonomous from their parents, but the diagnosis of cancer increases adolescents’ dependence on their parents and causes separation from their peers (Abrams et al., 2007; Woodgate, 2006). Diagnosis of cancer and its treatment cause a breakdown of an adolescent’s social support systems (Woodgate, 2006). In several studies, adolescents with cancer emphasized the importance of having social support to cope with the illness (Kyngas et al., 2001; Woodgate, 2006). One of the main sources of social support for adolescents with cancer comes from their parents. Family members play a significant role in providing social support during the illness. Similarly, in other studies, it was found that strong social support from family reduced distress (Abrams et al., 2007; Haluska et al., 2002). A cancer diagnosis brings adolescents a lot closer to their families during difficult times. In our study, the mean score of perceived social support from family was significantly higher than that of friends and a special person. Similarly, Haluska and colleagues (2002) emphasized that family support is more important than peer support. In addition to this, it was found that social support from family, friends, and a special person was greater in the relapse period than in the other stages of the illness. When a relapse occurs, it stimulates feelings of despair and tension, and it negatively affects expectations, plans, and hopes of the adolescents for the future. In the relapse period, adolescents need more social support for alleviating the negative impacts of the recurrence of the illness and reorganizing their expectations and plans for the future. It was seen that social support from families was the main source of support for adolescents with leukemia, especially in the relapse period. As noted by Zebrack (2011), family support is the most important contributor to positive adjustment for adolescents with cancer. For adolescents, school is one of the cornerstones of development because it provides social contact and allows them to gain many skills for successful functioning. Interruptions in school attendance during treatment are critical periods for adolescents’ psychosocial development. They may use their peers 82

H. Çavus¸og˘lu and H. Sag˘lam

to facilitate reentry to school and maintain social support (Abrams et al., 2007). For this reason, it is important to facilitate connections with peers during the illness. Also, telephones and social networking provide them opportunities to attend social activities with their peers (Goodall et al., 2012). However, little is known about adolescents’ utilization of psychosocial support services. One study of psychosocial service referral in a pediatric oncology center emphasized that among 395 patients older than 15 years, 30% were referred to and used psychological support (Clerici, Massimino, Casanova, & Cefalo, 2008). Another study reported that adolescents are increasingly using social support services such as free telephone advice from a cancer nurse and support groups (Zebrack, Hamilton, & Smith, 2009). Adolescents’ use of social support services may be related to psychological distress. Adolescents need to feel that they are still loved by others despite their changing behaviors and psychological symptoms (Woodgate, 2006). Unfortunately, in Turkey, social support services for adolescents with cancer are not commonly available. Relationship between psychological symptoms and social support

Our study showed a negative relationship between total perceived social support and social support from friends and negative self-image, depression, anxiety, hostility, the GSI, and the PST (Table 5). Similarly, in previous studies, it was found that adolescents with more social support reported less psychological distress (Abrams et al., 2007; Haluska et al., 2002). In our study, adolescents perceived higher levels of social support from their parents. Adolescents generally try to separate themselves from their parents, but if they have a chronic disease they still need parental support. In a 2002 study by Haluska and colleagues, adolescents with cancer also perceived parental relationships as more supportive. In the adolescent period, friends are also the primary and most consistent sources of social support in coping with the illness (Goodall et al., 2012; Smith, Davies, Wright, Chapman, & Whiteson, 2007; Varni, Katz, Colegrove, & Dolgin, 1994; Zebrack, Chesler, & Kaplan, 2010). The need for intimacy, independence, and autonomy are major characteristics during adolescence. Therefore, adolescents view their friends as a valuable source of social support. At the same time, having one special friend was more important to the adolescents than having many friends who were not as supportive. A special person Journal for Specialists in Pediatric Nursing 20 (2015) 76–85 © 2014, Wiley Periodicals, Inc.

H. Çavus¸og˘lu and H. Sag˘lam

Examining the Perceived Social Support and Psychological Symptoms Among Adolescents With Leukemia

can make adolescents less lonely, more positive, and comforted (Zebrack, 2011). However, social support from a special person was not reported at a high level in this study. Friends are able to help adolescents with cancer facilitate reentry to social life after treatment. For this reason, helping adolescents maintain their friendships is an important factor in supportive care (Goodall et al., 2012). Nurses should encourage adolescents with cancer to maintain their social relations with their friends and family. Leukemia has effects on an adolescent’s entire life. Lack of social support systems can have a negative influence on adolescents’ abilities to cope with the illness (Varni et al., 1994). During the illness, social support is a protective factor that facilitates coping, reduces the deleterious effects of the illness, and has a significant effect on mental health (Corey et al., 2008). Perception of high levels of social support can help adolescents with cancer overcome the feeling that they are alone (Zebrack, 2011). In Turkey, support groups and support programs in pediatric hematology and outpatient clinics are not commonly available. There were no psychologists in the outpatient clinics of the three hospitals. During the illness and treatment, nurses need to understand and communicate with the adolescents with leukemia about their psychosocial experiences. In general, nurses provide the first line of assessment and inform physicians when psychological services are necessary.

provide support for maintaining adolescents’ social relationships with friends and family. On the other hand, if adolescents have inadequate social support and have emotional distress, nurses consult with physicians about the potential for comprehensive psychological services. Our results may help to guide nurses in their assessment and interventions for providing positive social support and better psychosocial outcomes for adolescents.

Limitations

References

The results of this study should be interpreted with caution because of the small number of participants and the homogeneity of the sample. For this reason, our results cannot be widely generalized. Although treatments and prognosis of ALL and AML are very different, we could not find any differences for psychological symptoms and social support between them. None of the participants in our study had high risk ALL or AML.

Abrams, A. N., Hazen, E. P., & Penson, R. T. (2007). Psychosocial issues in adolescents with cancer. Cancer Treatment Reviews, 33(7), 622–630. doi:10.1016/j.ctrv.2006.12.006 Bruce, M. (2006). A systematic and conceptual review of posttraumatic stress in childhood cancer survivors and their parents. Clinical Psychology Review, 26(3), 233–256. Çakir, Y., & Palabiyikog˘lu, R. (1997). Validity and reliability study of social support and multidimensional scale of perceived social support among young individuals. Journal of Crisis, 5(1), 15–24. Çavus¸og˘lu, H. (2001). Depression in children with cancer. Journal of Pediatric Nursing, 16(5), 380–384. Clerici, C. A., Massimino, M., Casanova, M., & Cefalo, G. (2008). Psychological referral and consultation for adolescents and young adults with cancer treated at a pediatric oncology unit. Pediatric Blood & Cancer, 51, 105–109. doi:10.1002/pbc.21484 Corey, A. L., Haase, J. E., Azzouz, F., & Monahan, P. O. (2008). Social support and symptom distress in

CONCLUSION

Results from this study showed that adolescents who had social support system experience had fewer psychological symptoms. If psychological symptoms remain undetected and social support is not provided, psychological distress may become a barrier to physical recovery. Nurses are in an important position to recognize psychological symptoms and to Journal for Specialists in Pediatric Nursing 20 (2015) 76–85 © 2014, Wiley Periodicals, Inc.

How might this information affect nursing practice?

It is important to develop appropriate interventions that can promote psychological and social well-being of adolescents. Helping adolescents with leukemia to maintain physical and psychological health, and social well-being is an important role of nurses. Nurses are qualified to provide psychosocial support in outpatient and inpatient settings. They can help in maintaining a sense of normalcy in the adolescent’s life during the illness. Developing support groups, social networking sites, and encouraging peer interactions and visitors can also be helpful for adolescents with leukemia. For further research on this subject, larger sample sizes are suggested for analysis of the impact of gender, treatment methods, type of diagnosis (AML, ALL), and time since diagnosis on psychological distress and perceived social support.

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