Hear How I Feel: Evaluation of a Video Depicting the Experiences of Adolescents and Young Adults with a Parent Diagnosed with Cancer Sheila Damore-Petingola, MSW, RSW Nancy Lightfoot, PhD Chantal Vaillancourt, MA Carole Mayer, MSW, RSW Shawn Steggles, PhD Denise Gauthier-Frohlick, MA, BEd
ABSTRACT. In an effort to heighten the awareness of the high school population, a support group program for young people whose parents were diagnosed with cancer received funding to produce an educational Ms. Damore-Petingola is Senior Social Worker, Supportive Care Program, and Dr. Lightfoot is Senior Epidemiologist and Head, Epidemiology Research Unit, Northeastern Ontario Regional Cancer Centre, Sudbury, Ontario. Ms. Vaillancourt, formerly a Research Officer, Supportive Care Program, is currently Analyst, Centre for Education Statistics, Statistics Canada, Ottawa, Ontario. Ms. Mayer is Program Coordinator of Clinical Services, Sudbury Regional Breast Health Program, Sudbury, Ontario. Dr. Steggles is Program Leader, Supportive Care Oncology Program, and Director, Supportive Care Oncology Research Unit, and Ms. Gauthier-Frohlick is a Research Officer, Supportive Care Oncology Research Unit, Supportive Care Program, Northeastern Ontario Regional Cancer Centre. Address correspondence to Ms. Damore-Petingola, Supportive Care Program, Northeastern Ontario Regional Cancer Centre, 41 Ramsey Lake Road, Sudbury, Ontario P3E 5J1, Canada (E-mail: [email protected]). The authors wish to acknowledge the invaluable assistance of Dr. Carol Kauppi, Laurentian University School of Social Work, and Ms. Jennifer Bennett, Research Officer, Research Program, Northeastern Ontario Regional Cancer Centre, Sudbury. Journal of Psychosocial Oncology, Vol. 20(4) 2002 http://www.haworthpress.com/store/product.asp?sku=J077 2002 by The Haworth Press, Inc. All rights reserved. 10.1300/J077v20n04_04
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video titled Hear How I Feel. This article reports on the evaluation of the video by 146 high school teachers, guidance counselors, and students; elementary school teachers; university undergraduate social work students; and health care and social service providers. A qualitative analysis of the evaluations indicated that high school teachers and guidance counselors were reluctant to use the video in the high school setting because they could not respond expertly to emotions that might be elicited. The findings suggest that youths desire a forum in which difficult issues can be addressed, teachers and guidance counselors need training that would enhance their skill in responding to students’ emotional responses, and cancer patients and their families have psychosocial needs that must be met. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: 2002 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Impact of parent’s cancer on adolescents, anticipatory grief, group therapy, peer support, video as educational tool A parent’s diagnosis of cancer has significant implications for adolescents, their families, and the educational and social networks in which they engage. The importance of professionally facilitated support groups for this population and educational tools, such as videotaped presentations, contribute to an understanding of cancer and its impact on this age group. In January 1995, the Ontario Ministry of Health solicited proposals from people experiencing a diagnosis of cancer and their families through a Community Cancer Support Grant Program. The Young Adult Support Group, a professionally facilitated peer support group at the Northeastern Ontario Regional Cancer Centre in Sudbury, Ontario, submitted a proposal titled “The Impact of Cancer on Young Adults Whose Parents Are Diagnosed with Cancer (Video Tape Production).” As a result, a video titled Hear How I Feel was produced as an educational tool for teachers, guidance counselors, and high school students (Baton Broadcasting, 1996). This article reports the findings from an evaluation of the video by 146 participants (high school students, elementary and high school teachers, guidance counselors, university undergraduate social work students, and health care and social service providers). REVIEW OF THE LITERATURE Impact of a Parent’s Cancer Diagnosis on Adolescents It has long been recognized that cancer has a severe impact not only on the patient but also on the entire family. In particular, studies have shown that ado-
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lescents and young adults have specific problems in relation to this issue and that they require attention and understanding (Adams-Greenly, Beldoch, & Moynihan, 1986; Nelson et al., 1994; Welch, Wadsworth, & Compas, 1996; Wellisch, 1979). Larrocque and Hendren (1997) noted that prevention of emotional disorders among young people is particularly important. The adolescent’s emotional adjustment is affected by the ill parent’s anxiety (Heiney et al., 1997). Adolescent children of cancer patients have significantly higher levels of anxiety when compared with their school peers (Heiney et al., 1997; Nelson et al., 1994) and with younger children of cancer patients (Compas et al., 1994; Heiney et al., 1997; Welch, Wadsworth, & Compas, 1996). In general, adolescents are emotionally involved with the parent who has cancer (Christ, Siegel, & Sperber, 1994), and the illness brings them additional responsibilities (Berman, Cragg, & Kuenzig, 1988; Christ, Siegel, & Sperber, 1994). However, adolescent daughters feel less comfortable about their mother’s illness than do their older daughters (Wellisch et al., 1992) and they report more stressful events reflecting family responsibilities (Grant & Compas, 1995). For adolescent sons of cancer patients, these responsibilities can lead to higher anxiety because sons have less time to spend with peers and in sports and leisure activities (Nelson et al., 1994). Finally, these demands on adolescents’ time lead to guilt caused by negative feelings accompanying such limitations (Christ, Siegel, & Sperber, 1994). Interventions and Coping Strategies Stevenson (1990) discussed the value of verbalizing difficult issues as being twofold. First, the articulation of painful issues provides people with a sense of control over the situation, thereby reversing the potential for the situation to control them. Second, talking has the potential to act as a catharsis and may help a person explore new solutions. Compas et al. (1996) reported that dual-focused coping strategies in adolescents were correlated with few intrusive thoughts about their parent’s cancer and more avoidance of these intrusive thoughts, which, in turn, were correlated with higher levels of anxiety and depression. This finding indicates the importance of having adolescents and young adults verbalize their feelings: When avoidance leads to higher levels of anxiety, being able to communicate openly should lead to lower levels. In addition, speaking for themselves is important for youth because their parents have a tendency to underevaluate their problems (Heiney et al., 1997; Welch et al., 1996). Listening by peers has been demonstrated to provide an “effective first step” in responding to adolescents experiencing life changes. Stevenson (1990) found that adolescents need the leadership of a responsible adult to help with
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this peer support. The groups that have shared leadership between a professional and peers have been identified as having the highest rate of participation (Hustins & Kelly, 1990). Social Support Literature about social support demonstrates the potentially positive impact that peers have (Trickett & Schmid, 1993), and peers from group interventions provide a powerfully important influence (Larrocque & Hendren, 1997). A professionally facilitated support group allows for therapeutic intervention should the need arise when group members share painful feelings (Stevenson, 1990). In addition, clients feel less threatened by the adult therapist when they meet the therapist in the context of a group of peers (Toseland & Siporing, 1986, cited in Gillespie & Ikhlas, 1998). However, the peer support group should have certain characteristics in addition to being facilitated by a professional: The group members must be emotionally healthy (though at risk for emotional problems) and be dealing with a life crisis, and the groups should be formed for both preteens and adolescents (Larrocque & Hendren, 1997). Stevenson (1990) reported that after the family, the school is the most important environment in the lives of adolescents. By the nature of their presence, this milieu would provide the forum for provision of information and resources on parental illness. This forum would meet the needs expressed by members of the Young Adult Support Group. Videos as Educational Resources We are unaware of any articles that provide information on the effectiveness of videotaped productions as an educational tool for adolescent children of cancer patients. However, videos have demonstrated their effectiveness in cancer education. Meade (1996) studied a series of videotapes used in cancer education and noted that they offer a consistent form of teaching and are a familiar medium to most patients. Several articles also provide support for the effectiveness of videos as an educational tool regarding cancer when targeting specific populations, including women (McDaniel & Rhodes, 1998), women of color (McAvoy & Raza, 1991; Yancey et al., 1995), and people with lower levels of literacy (Meade, McKinney, & Barnas, 1994). A video also was a successful educational tool for adolescents in relation to skin cancer (Hughes, Altman, & Newton, 1993) and for use of broader issues related to a specific topic, such as blood pressure and broader promotion of cardiovascular health (Meagher & Mann, 1990). Extrapolating from these studies supported the idea that a video on adolescent issues with regard to having a parent with cancer, prepared by adolescents
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who were in this situation, had the potential to serve as an educational tool for their peers. In addition, this same video, titled Hear How I Feel, had the potential to be an effective educational tool for other adolescent children of cancer patients. We deduced that the video could be used for teaching purposes, and we hypothesized that all professional groups and other viewers would use it unconditionally and find its content useful. METHOD The Video In testimonial style, five young people whose parents had a diagnosis of cancer addressed the issues of communication with family, role changes, early maturity, and expression of emotions, such as fear, anger, guilt, and sadness. The young people in the film ranged in age from 16 to 22 years (M = 18.6 years, SD = 5.8 years). They discussed various methods of dealing with stress and coping with a parent’s illness and potential death. They spoke of participating in a professionally facilitated support group for young people whose parents had been diagnosed with cancer and identified what was helpful and not helpful from others. Procedure Requests for presentation of Hear How I Feel and training in how to respond to the needs of children in similar situations originated from schools, hospitals, and social service organizations. The video was presented to 10 separate audiences for teaching purposes between May 1996 and January 1997. Seven presentations were made in Sudbury, two in Toronto, and one in Chapleau, Ontario. During the presentations, the social worker and facilitator for the video project was in attendance and introduced the work. During five of the presentations, one or more of the young people featured in the video copresented with the project’s facilitator. In instances when a young adult was not in attendance for the copresentation, the reason was unavailability in two cases and the inability to cover the costs of travel when the video was presented out of town in three cases. After viewing the video, members of each audience were provided with a survey developed specifically for the study. The purpose of the survey was to
• assess the likelihood that professionals, such as teachers and health care workers, would use the video in the context of their work,
• assess the usefulness of the film’s content for the viewer,
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• identify the tools or resources that would be recommended to accompany the film,
• identify the factors that would deter viewers from recommending the film, and
• identify the work contexts and types of professionals in which viewers expressed discomfort with the film’s content. A pretest (reliability/validity tool) was conducted to assure proper evaluation of the use of the video. All respondents answered questions relating to the usefulness of the video’s content. On the average, members of the audience had 15 minutes to complete the survey after viewing the video. Their written evaluations were returned to the presenter. After each viewing, the audience was encouraged to discuss the film. During these discussions, field notes were taken for future review and consideration. Respondents Evaluations were completed by 146 high school students, high school and elementary school teachers, guidance counselors, social service agency workers, university students in social work, oncology nurses and social workers, and hospital health care providers (nurses, student nurses, chaplains, educators, paramedics, dieticians, and technicians) (see Table 1). Analysis We examined the data using a systematic approach to explore the identified categories. The data were organized in two ways before the analysis. The first way was to review and highlight all references made to “use,” “using,” and “usefulness.” This approach was undertaken by quantitatively tabulating (yes TABLE 1. Breakdown of the Population Surveyed Regarding Reactions to Hear How I Feel (N = 146) Participants Hospital health care providers High school students Oncology health care providers Social service family and youth workers High school teachers and guidance counselors Elementary school teachers University social work students
Number
Percentage
42 27 22 22 11 11 11
29.0 18.5 15.0 15.0 7.5 7.5 7.5
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or no) the components of questions in this category, and statements that provided further information or explanation about the category being studied were identified. These statements were analyzed qualitatively. The second way of organizing the data was to use the Non-numerical Unstructured Data Indexing Searching and Theorizing (NUD*IST, 2000) computer software. We used this program to seek and categorize the themes that included “uncomfortable feelings” and “deter from using.” This software also was used to organize the theme of tools/information recommended by the viewers in preparing materials to accompany the video when it was distributed. RESULTS Virtually all the respondents (97.9%) considered Hear How I Feel to be useful. This result is illustrated in Table 2. Teachers and Guidance Counselors During a pilot presentation of the video to high school teachers and guidance counselors and a pretest of the survey, it became evident that some teachers and counselors were reluctant to show the video in the high school setting. The feedback from their written evaluations and the discussions supported this supposition. The teachers and counselors expressed concern that they did not have the expertise to deal with the emotions the video might elicit in the students. The teachers expressed concern about students who would view the film and were dealing with challenging circumstances, such as the illness or death of a family member, that the teachers were unaware of. In addition, they reported that they believed the content of the video was powerful and would elicit strong emotional response. TABLE 2. Participants’ Responses Regarding Whether the Information in the Video Was Useful (N = 146) Participants Hospital health care providers High school students Oncology health care providers Social service family and youth workers University social work students Elementary school teachers High school teachers and guidance counselors
Yes
No
42 27 22 22 11 10 9
0 0 0 0 0 1 2
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When asked “What would deter you from using this video?” the teachers and counselors’ responses indicated concern about how students would respond to the video and about their own lack of skills and training to address the students’ responses. They further shared their concern that no support was available to deal with the problems that might arise. The major themes gleaned from the analysis of the data from the teachers were (1) their limited ability to deal with the topic, (2) their personal issues and experiences related to the topic, (3) their perception that there was a lack of resources to help students deal with this issue, and (4) their anticipation that students who faced similar situations would be unable to deal with the video’s content. Of the 11 high school teachers and guidance counselors surveyed, 9 reported that they would use the video in the high school setting with conditions (i.e., if skilled professionals were in attendance). The other 2 said that although they would not use the video themselves, they would consider recommending it for use in guidance, health, physical education, and personal life management courses. Of the 11 elementary school teachers surveyed, 10 believed that the information was useful for teachers and students in the school setting. Students All 27 high school students and the 11 social work students said the information in the video would be useful for high school students and teachers. One student’s comments support this result: You MUST show this to teens because: teens often feel lonely, society discourages expressions of intimate feelings and “talking about” sensitive issues–which is extremely harmful and enhances isolation. Therefore, this film is a good way to say yes it’s ok to talk about your fears, etc. Also it helps those youth who find out a friend is experiencing the serious illness of a parent to know how they can be supportive–to listen, without having to feel too afraid to ask what they can do. It is extremely beneficial for teens (who are in a relatively fragile stage in life) to know there is support out there. Health Care Professionals All 42 hospital health care professionals and 22 oncology health care professionals indicated that they found the information useful for them. All 12 counselors who worked with children and families said they would use the video in their work. Following the pretest, one question was changed from “What would deter you from using the video?” to “Is there any information in the video that makes
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you uncomfortable?” Subsequently, all the respondents (n = 135) except the 11 teachers and guidance counselors were asked whether there was any information in the video that made them feel uncomfortable. Nineteen respondents chose not to answer this question. Of the remaining 116 respondents, only 12 (10%) said the video made them feel uncomfortable: These respondents were health care hospital workers, social service workers, and 1 high school student. Three of them identified a personal experience with cancer, and the other 9 said the video’s content was sad, they felt empathy for the young people featured in the video, and the stories conveyed were painful. The following are some examples of their comments: I don’t like to cry in front of people, and I found it hard to refrain, even though it was a full auditorium. (student nurse) *** [The video] makes me sad, and seeing these courageous teens grow up so fast is hard. (social service worker) *** I’ve been there. There’s nothing comfortable about cancer. (clinician) *** Cancer is a disease, and eventually the person . . . is going to die. (high school student) All 12 respondents said they believed the information would be useful to high school teachers and students or they would recommend the video to young adults. However, their verbal and emotional responses highlighted the need to prepare informational materials and offer support or guidance for future viewers who might find the video difficult to watch. The need for a brochure with accompanying information, the opportunity to debrief viewers after the presentation, the need for information about cancer (its presentation and the treatments offered), and the importance of being able to gain access to support and other psychosocial resources if necessary were recurring messages in the evaluations. Additional feedback from respondents included ensuring that viewers knew in advance that the content might be powerful for them and that they had the choice of viewing the video or not. The respondents also referred to the need for French language resources on this issue as well as resources (e.g., books, videos) for a younger audience, such as elementary school children.
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DISCUSSION The results of the study indicated the lack of a committed group of teachers and guidance counselors who would ensure that the video’s intended audience (high school teachers, guidance counselors, and students) would view the video. This result encouraged us to continue the study to determine further what the sources of reluctance were to showing the video in the high school setting. After the pretest, the information acquired with the question “Is there any information in the video that makes you feel uncomfortable?” provided insight concerning why educators might hesitate to use the resource. With this information, the project committee could prepare accompanying materials accordingly. The fact that all the high school and social work students reported that the information contained in the video would be useful for high school teachers and students supports what Cragg and Berman (1990) and Stevenson (1990) reported–that difficult issues are best addressed and talked about openly and that adolescents should be provided with a forum for discussion. Although 98% of the sampled population regarded the video as useful, the high school teachers and guidance counselors were hesitant to show it in regular classrooms; however, they recommended its use in special circumstances, such as in health and sociology classes. The teachers identified the need for support from psychosocial resource professionals as an informal measure in the event that students became distraught. While considering the teachers and guidance counselors’ responses, we noted that their primary role in education is that of providing opportunities for structured instruction that follows a curriculum expected to prepare students to advance to the next grade level. The training of teachers may not include addressing psychosocial complexities, such as those experienced by students whose parents are seriously ill. Hence, teachers and guidance counselors may not be comfortable with or trained to address the psychosocial distress of students facing tragic circumstances. Furthermore, teachers do not have time to address individual students’ issues because of the demanding curricula. We also considered that such exposure might bring a teacher’s past or present painful experiences to the surface. The responses of high school and social work students differed from those of the high school teachers and guidance counselors. Students identified their need to have such information as soon as possible. Their responses indicated a wish to address and discuss difficult issues and a desire to learn how to deal with and respond to their friends and classmates whose parent had cancer. Their desire for information and their interest in responding to classmates reinforces the idea that they are a suitable age group to be addressing these issues. When adolescents and young adults view Hear How I Feel in an effort to help
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their peers, they may be more likely to respond to peers with sensitivity and empathy. Health care workers in hospital and oncology settings reported that the information in the video enhanced their knowledge of the clinical population they provided service to and would be useful for adolescents and young adults for whom connection with health care providers may be difficult and at times awkward. Counselors indicated they would use the video in their work, and hospital and oncology health care workers appreciated the availability of Hear How I Feel as a resource. The respondents’ answers to the survey questions indicated that the content of the video might evoke a strong emotional response and, as members of a video project committee, we considered this factor when developing the packaging of the video and accompanying printed materials. Finally, as a result of respondents’ suggestion, we have initiated preliminary efforts to translate the video and brochure into French to meet the needs of Canada’s French-speaking population. IMPLICATIONS FOR RESEARCH AND CLINICAL PRACTICE The results of the study suggest that teachers and guidance counselors should receive education and training that strengthens their confidence and enhances their skills in responding to adolescents and young adults facing a parent’s cancer and other adversities. A major aspect of this training is identifying and gaining access to resources for this population. We anticipate that with training and the opportunity to express their concerns, teachers and guidance counselors will permit–and in fact facilitate–discussion of difficult issues in the high school setting. In the long term, we hope that the educational setting will be an environment in which students experiencing difficult circumstances will be free to meet with teachers to resolve learning difficulties, receive validation of their feelings, and be encouraged to express them. Such an environment could promote opportunities for improved learning. Professionals with expertise in psychosocial oncology could provide such training for teachers and guidance counselors. In the province of Ontario, application for credit hours could be pursued with the Ontario College of Teachers as a means of maintaining one’s teacher certification. Psychosocial intervention should be available and accessible to cancer patients and their families and, in particular, to the adolescents and young adults with a parent diagnosed with cancer. Students and teachers should have the opportunities to be aware of, gain access to, and receive psychosocial support from social workers and psychologists employed by boards of education and community cancer agencies.
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The study suggests the need to evaluate further the effectiveness of the video and its accompanying materials and to ensure that teachers in fact have the resources and skills they need to respond to these youth. Finally, the research findings reported in this article suggest the need for continued dialogue with educators, students, and health care professionals as well as with young people experiencing a diagnosis of cancer in the family. REFERENCES Adams-Greenly, M., Beldoch, N., & Moynihan, R. (1986). Helping adolescents whose parents have cancer. Seminars in Oncology Nursing, 2, 133-138. Baton Broadcasting, MCTV (Producer), & The Young Adult Support Group. (1996). Hear How I Feel. Videotape available from the Northeastern Ontario Regional Cancer Centre, Supportive Care Program, 41 Ramsey Lake Road, Sudbury, Ontario, P3E 5J1. Berman, H., Cragg, C. E., & Kuenzig, L. (1988). Having a parent die of cancer: Adolescents’ grief reactions. Oncology Nursing Forum, 15, 159-163. Christ, G. H., Siegel, K., & Sperber, D. (1994). Impact of parental terminal cancer on adolescents, American Journal of Orthopsychiatry, 64, 604-613. Compas, B. E., Worsham, N. L., Epping-Jordan, J. E., Grant, K. E., Mireault, G., Howell, D. C., & Malcarne, V. L. (1994). When mom or dad has cancer: Markers of psychological distress in cancer patients, spouses and children. Health Psychology, 13, 507-515. Compas, B. E., Worsham, N. L., Ey, S., & Howell, D. C. (1996). When mom or dad has cancer: II. Coping, cognitive appraisals, and psychological distress in children of cancer patients. Health Psychology, 15, 67-75. Cragg, C. E., & Berman, H. A. (1990). Adolescents’ reactions to the death of a parent. In J. D. Morgan (Ed.), The dying and the bereaved teenager (pp. 42-49). Philadelphia, PA: Charles Press. Gillespie, J. G., & Ikhlas, M. (1998). Groups in the community context. In K. C. Stoiber & T. R. Kratochwill (Eds.), Handbook of group intervention for children and families (pp. 29-46). Boston, MA: Allyn & Bacon. Grant, K. E., & Compas, B. E. (1995). Stress and anxious-depressed symptoms among adolescents: Searching for mechanisms of risk. Journal of Consulting and Clinical Psychology, 63, 1015-1021. Heiney, S. P., Bryant, L. H., Walker, S., Parrish, R. S., Provenzano, F. J., & Kelly K. E. (1997). Impact of parental anxiety on child emotional adjustment when a parent has cancer. Oncology Nursing Forum, 24, 655-661. Hughes, B. R., Altman, D. G., & Newton, J. A. (1993). Melanoma and skin cancer: Evaluation of a health education programme for secondary schools. British Journal of Dermatology, 128, 412-417. Hustins, K., & Kelly, C. (1990). The role of the professional in an adolescent support group for those with cancer. In J. D. Morgan (Ed.), The dying and the bereaved teenager (pp. 22-32). Philadelphia, PA: Charles Press.
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Larrocque, C., & Hendren, R. L. (1997). Individual and group interventions. In R. T. Ammerman & M. Hersen (Eds.), Handbook of prevention and treatment with children and adolescents: Intervention in the real world context (pp. 91-105). New York: John Wiley & Sons. McAvoy, B. R., & Raza, R. (1991). Can health education increase uptake of cervical smear testing among Asian women? British Medical Journal, 302, 833-836. McDaniel, R. W., & Rhodes, V. A. (1998). Development of a preparatory sensory information videotape for women receiving chemotherapy for breast cancer. Cancer Nursing, 21, 143-148. Meade, C. D. (1996). Producing videotapes for cancer education: Methods and examples. Oncology Nursing Forum, 23, 837-846. Meade, C. D., McKinney, P., & Barnas, G. P. (1994). Educating patients with limited literacy skills: The effectiveness of printed and videotaped materials about colon cancer. American Journal of Public Health, 84, 119-121. Meagher, D., & Mann, K. V. (1990). The effect of an educational program on knowledge & attitudes about blood pressure by junior high school students: A pilot project. Canadian Journal of Cardiovascular Nursing, 1(5), 15-22. Nelson, E., Sloper, P., Charlton, A., & While, D. (1994). Children who have a parent with cancer: A pilot study. Journal of Cancer Education, 9(1), 30-36. NUD*IST (Qualitative Data Analysis Software, Version N5). (2000). QSR-N5 QSR International Pty Ltd. Melbourne, Australia: Qualitative Solutions and Research Pty, Ltd. www.qsrinternational.com Stevenson, R. G. (1990). Teen suicide: Sources, signals and prevention. In J. D. Morgan (Ed.), The dying and the bereaved teenager (pp. 125-139). Philadelphia, PA: Charles Press. Toseland, R. W., & Siporin, M. (1986). When to recommend group treatment: A review of the clinical and research literature. International Journal of Group Psychotherapy, 36, 171-201. Trickett, E. J., & Schmid, K. H. (1993). The school as a social context. In P. H. Tolan & B. J. Cohler (Eds.), Handbook of clinical research and practice with adolescents (pp. 173-202). New York: John Wiley & Sons. Welch, A. S., Wadsworth, M. E., & Compas, B. E. (1996). Adjustment of children and adolescents to parental cancer–parents’ and children’s perspectives. Cancer, 77, 1409-1418. Wellisch, D. (1979). Adolescent acting out when a parent has cancer. International Journal of Family Therapy, 1, 230-243. Wellisch, D. K., Gritz, E. R., Schain, W., Wang, H. J., & Siau, J. (1992). Psychological functioning of daughters of breast cancer patients. Part II: Characterizing the distressed daughter of the breast cancer patient. Psychosomatics, 33, 171-179. Yancey, A. K., Tanjasiri, S. P., Klein, M., & Tunder, J. (1995). Increased cancer screening behavior in women of color by culturally sensitive video exposure. Preventive Medicine, 4, 142-148.
Received: December 10, 2001 Revised: March 20, 2002 Accepted: April 31, 2002
ABSTRACT. In an effort to heighten the awareness of the high school population, a support group program for young people whose parents were diagnosed with cancer received funding to produce an educational Ms. Damore-Petingola is Senior Social Worker, Supportive Care Program, and Dr. Lightfoot is Senior Epidemiologist and Head, Epidemiology Research Unit, Northeastern Ontario Regional Cancer Centre, Sudbury, Ontario. Ms. Vaillancourt, formerly a Research Officer, Supportive Care Program, is currently Analyst, Centre for Education Statistics, Statistics Canada, Ottawa, Ontario. Ms. Mayer is Program Coordinator of Clinical Services, Sudbury Regional Breast Health Program, Sudbury, Ontario. Dr. Steggles is Program Leader, Supportive Care Oncology Program, and Director, Supportive Care Oncology Research Unit, and Ms. Gauthier-Frohlick is a Research Officer, Supportive Care Oncology Research Unit, Supportive Care Program, Northeastern Ontario Regional Cancer Centre. Address correspondence to Ms. Damore-Petingola, Supportive Care Program, Northeastern Ontario Regional Cancer Centre, 41 Ramsey Lake Road, Sudbury, Ontario P3E 5J1, Canada (E-mail: [email protected]). The authors wish to acknowledge the invaluable assistance of Dr. Carol Kauppi, Laurentian University School of Social Work, and Ms. Jennifer Bennett, Research Officer, Research Program, Northeastern Ontario Regional Cancer Centre, Sudbury. Journal of Psychosocial Oncology, Vol. 20(4) 2002 http://www.haworthpress.com/store/product.asp?sku=J077 2002 by The Haworth Press, Inc. All rights reserved. 10.1300/J077v20n04_04
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video titled Hear How I Feel. This article reports on the evaluation of the video by 146 high school teachers, guidance counselors, and students; elementary school teachers; university undergraduate social work students; and health care and social service providers. A qualitative analysis of the evaluations indicated that high school teachers and guidance counselors were reluctant to use the video in the high school setting because they could not respond expertly to emotions that might be elicited. The findings suggest that youths desire a forum in which difficult issues can be addressed, teachers and guidance counselors need training that would enhance their skill in responding to students’ emotional responses, and cancer patients and their families have psychosocial needs that must be met. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: 2002 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Impact of parent’s cancer on adolescents, anticipatory grief, group therapy, peer support, video as educational tool A parent’s diagnosis of cancer has significant implications for adolescents, their families, and the educational and social networks in which they engage. The importance of professionally facilitated support groups for this population and educational tools, such as videotaped presentations, contribute to an understanding of cancer and its impact on this age group. In January 1995, the Ontario Ministry of Health solicited proposals from people experiencing a diagnosis of cancer and their families through a Community Cancer Support Grant Program. The Young Adult Support Group, a professionally facilitated peer support group at the Northeastern Ontario Regional Cancer Centre in Sudbury, Ontario, submitted a proposal titled “The Impact of Cancer on Young Adults Whose Parents Are Diagnosed with Cancer (Video Tape Production).” As a result, a video titled Hear How I Feel was produced as an educational tool for teachers, guidance counselors, and high school students (Baton Broadcasting, 1996). This article reports the findings from an evaluation of the video by 146 participants (high school students, elementary and high school teachers, guidance counselors, university undergraduate social work students, and health care and social service providers). REVIEW OF THE LITERATURE Impact of a Parent’s Cancer Diagnosis on Adolescents It has long been recognized that cancer has a severe impact not only on the patient but also on the entire family. In particular, studies have shown that ado-
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lescents and young adults have specific problems in relation to this issue and that they require attention and understanding (Adams-Greenly, Beldoch, & Moynihan, 1986; Nelson et al., 1994; Welch, Wadsworth, & Compas, 1996; Wellisch, 1979). Larrocque and Hendren (1997) noted that prevention of emotional disorders among young people is particularly important. The adolescent’s emotional adjustment is affected by the ill parent’s anxiety (Heiney et al., 1997). Adolescent children of cancer patients have significantly higher levels of anxiety when compared with their school peers (Heiney et al., 1997; Nelson et al., 1994) and with younger children of cancer patients (Compas et al., 1994; Heiney et al., 1997; Welch, Wadsworth, & Compas, 1996). In general, adolescents are emotionally involved with the parent who has cancer (Christ, Siegel, & Sperber, 1994), and the illness brings them additional responsibilities (Berman, Cragg, & Kuenzig, 1988; Christ, Siegel, & Sperber, 1994). However, adolescent daughters feel less comfortable about their mother’s illness than do their older daughters (Wellisch et al., 1992) and they report more stressful events reflecting family responsibilities (Grant & Compas, 1995). For adolescent sons of cancer patients, these responsibilities can lead to higher anxiety because sons have less time to spend with peers and in sports and leisure activities (Nelson et al., 1994). Finally, these demands on adolescents’ time lead to guilt caused by negative feelings accompanying such limitations (Christ, Siegel, & Sperber, 1994). Interventions and Coping Strategies Stevenson (1990) discussed the value of verbalizing difficult issues as being twofold. First, the articulation of painful issues provides people with a sense of control over the situation, thereby reversing the potential for the situation to control them. Second, talking has the potential to act as a catharsis and may help a person explore new solutions. Compas et al. (1996) reported that dual-focused coping strategies in adolescents were correlated with few intrusive thoughts about their parent’s cancer and more avoidance of these intrusive thoughts, which, in turn, were correlated with higher levels of anxiety and depression. This finding indicates the importance of having adolescents and young adults verbalize their feelings: When avoidance leads to higher levels of anxiety, being able to communicate openly should lead to lower levels. In addition, speaking for themselves is important for youth because their parents have a tendency to underevaluate their problems (Heiney et al., 1997; Welch et al., 1996). Listening by peers has been demonstrated to provide an “effective first step” in responding to adolescents experiencing life changes. Stevenson (1990) found that adolescents need the leadership of a responsible adult to help with
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this peer support. The groups that have shared leadership between a professional and peers have been identified as having the highest rate of participation (Hustins & Kelly, 1990). Social Support Literature about social support demonstrates the potentially positive impact that peers have (Trickett & Schmid, 1993), and peers from group interventions provide a powerfully important influence (Larrocque & Hendren, 1997). A professionally facilitated support group allows for therapeutic intervention should the need arise when group members share painful feelings (Stevenson, 1990). In addition, clients feel less threatened by the adult therapist when they meet the therapist in the context of a group of peers (Toseland & Siporing, 1986, cited in Gillespie & Ikhlas, 1998). However, the peer support group should have certain characteristics in addition to being facilitated by a professional: The group members must be emotionally healthy (though at risk for emotional problems) and be dealing with a life crisis, and the groups should be formed for both preteens and adolescents (Larrocque & Hendren, 1997). Stevenson (1990) reported that after the family, the school is the most important environment in the lives of adolescents. By the nature of their presence, this milieu would provide the forum for provision of information and resources on parental illness. This forum would meet the needs expressed by members of the Young Adult Support Group. Videos as Educational Resources We are unaware of any articles that provide information on the effectiveness of videotaped productions as an educational tool for adolescent children of cancer patients. However, videos have demonstrated their effectiveness in cancer education. Meade (1996) studied a series of videotapes used in cancer education and noted that they offer a consistent form of teaching and are a familiar medium to most patients. Several articles also provide support for the effectiveness of videos as an educational tool regarding cancer when targeting specific populations, including women (McDaniel & Rhodes, 1998), women of color (McAvoy & Raza, 1991; Yancey et al., 1995), and people with lower levels of literacy (Meade, McKinney, & Barnas, 1994). A video also was a successful educational tool for adolescents in relation to skin cancer (Hughes, Altman, & Newton, 1993) and for use of broader issues related to a specific topic, such as blood pressure and broader promotion of cardiovascular health (Meagher & Mann, 1990). Extrapolating from these studies supported the idea that a video on adolescent issues with regard to having a parent with cancer, prepared by adolescents
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who were in this situation, had the potential to serve as an educational tool for their peers. In addition, this same video, titled Hear How I Feel, had the potential to be an effective educational tool for other adolescent children of cancer patients. We deduced that the video could be used for teaching purposes, and we hypothesized that all professional groups and other viewers would use it unconditionally and find its content useful. METHOD The Video In testimonial style, five young people whose parents had a diagnosis of cancer addressed the issues of communication with family, role changes, early maturity, and expression of emotions, such as fear, anger, guilt, and sadness. The young people in the film ranged in age from 16 to 22 years (M = 18.6 years, SD = 5.8 years). They discussed various methods of dealing with stress and coping with a parent’s illness and potential death. They spoke of participating in a professionally facilitated support group for young people whose parents had been diagnosed with cancer and identified what was helpful and not helpful from others. Procedure Requests for presentation of Hear How I Feel and training in how to respond to the needs of children in similar situations originated from schools, hospitals, and social service organizations. The video was presented to 10 separate audiences for teaching purposes between May 1996 and January 1997. Seven presentations were made in Sudbury, two in Toronto, and one in Chapleau, Ontario. During the presentations, the social worker and facilitator for the video project was in attendance and introduced the work. During five of the presentations, one or more of the young people featured in the video copresented with the project’s facilitator. In instances when a young adult was not in attendance for the copresentation, the reason was unavailability in two cases and the inability to cover the costs of travel when the video was presented out of town in three cases. After viewing the video, members of each audience were provided with a survey developed specifically for the study. The purpose of the survey was to
• assess the likelihood that professionals, such as teachers and health care workers, would use the video in the context of their work,
• assess the usefulness of the film’s content for the viewer,
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• identify the tools or resources that would be recommended to accompany the film,
• identify the factors that would deter viewers from recommending the film, and
• identify the work contexts and types of professionals in which viewers expressed discomfort with the film’s content. A pretest (reliability/validity tool) was conducted to assure proper evaluation of the use of the video. All respondents answered questions relating to the usefulness of the video’s content. On the average, members of the audience had 15 minutes to complete the survey after viewing the video. Their written evaluations were returned to the presenter. After each viewing, the audience was encouraged to discuss the film. During these discussions, field notes were taken for future review and consideration. Respondents Evaluations were completed by 146 high school students, high school and elementary school teachers, guidance counselors, social service agency workers, university students in social work, oncology nurses and social workers, and hospital health care providers (nurses, student nurses, chaplains, educators, paramedics, dieticians, and technicians) (see Table 1). Analysis We examined the data using a systematic approach to explore the identified categories. The data were organized in two ways before the analysis. The first way was to review and highlight all references made to “use,” “using,” and “usefulness.” This approach was undertaken by quantitatively tabulating (yes TABLE 1. Breakdown of the Population Surveyed Regarding Reactions to Hear How I Feel (N = 146) Participants Hospital health care providers High school students Oncology health care providers Social service family and youth workers High school teachers and guidance counselors Elementary school teachers University social work students
Number
Percentage
42 27 22 22 11 11 11
29.0 18.5 15.0 15.0 7.5 7.5 7.5
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or no) the components of questions in this category, and statements that provided further information or explanation about the category being studied were identified. These statements were analyzed qualitatively. The second way of organizing the data was to use the Non-numerical Unstructured Data Indexing Searching and Theorizing (NUD*IST, 2000) computer software. We used this program to seek and categorize the themes that included “uncomfortable feelings” and “deter from using.” This software also was used to organize the theme of tools/information recommended by the viewers in preparing materials to accompany the video when it was distributed. RESULTS Virtually all the respondents (97.9%) considered Hear How I Feel to be useful. This result is illustrated in Table 2. Teachers and Guidance Counselors During a pilot presentation of the video to high school teachers and guidance counselors and a pretest of the survey, it became evident that some teachers and counselors were reluctant to show the video in the high school setting. The feedback from their written evaluations and the discussions supported this supposition. The teachers and counselors expressed concern that they did not have the expertise to deal with the emotions the video might elicit in the students. The teachers expressed concern about students who would view the film and were dealing with challenging circumstances, such as the illness or death of a family member, that the teachers were unaware of. In addition, they reported that they believed the content of the video was powerful and would elicit strong emotional response. TABLE 2. Participants’ Responses Regarding Whether the Information in the Video Was Useful (N = 146) Participants Hospital health care providers High school students Oncology health care providers Social service family and youth workers University social work students Elementary school teachers High school teachers and guidance counselors
Yes
No
42 27 22 22 11 10 9
0 0 0 0 0 1 2
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When asked “What would deter you from using this video?” the teachers and counselors’ responses indicated concern about how students would respond to the video and about their own lack of skills and training to address the students’ responses. They further shared their concern that no support was available to deal with the problems that might arise. The major themes gleaned from the analysis of the data from the teachers were (1) their limited ability to deal with the topic, (2) their personal issues and experiences related to the topic, (3) their perception that there was a lack of resources to help students deal with this issue, and (4) their anticipation that students who faced similar situations would be unable to deal with the video’s content. Of the 11 high school teachers and guidance counselors surveyed, 9 reported that they would use the video in the high school setting with conditions (i.e., if skilled professionals were in attendance). The other 2 said that although they would not use the video themselves, they would consider recommending it for use in guidance, health, physical education, and personal life management courses. Of the 11 elementary school teachers surveyed, 10 believed that the information was useful for teachers and students in the school setting. Students All 27 high school students and the 11 social work students said the information in the video would be useful for high school students and teachers. One student’s comments support this result: You MUST show this to teens because: teens often feel lonely, society discourages expressions of intimate feelings and “talking about” sensitive issues–which is extremely harmful and enhances isolation. Therefore, this film is a good way to say yes it’s ok to talk about your fears, etc. Also it helps those youth who find out a friend is experiencing the serious illness of a parent to know how they can be supportive–to listen, without having to feel too afraid to ask what they can do. It is extremely beneficial for teens (who are in a relatively fragile stage in life) to know there is support out there. Health Care Professionals All 42 hospital health care professionals and 22 oncology health care professionals indicated that they found the information useful for them. All 12 counselors who worked with children and families said they would use the video in their work. Following the pretest, one question was changed from “What would deter you from using the video?” to “Is there any information in the video that makes
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you uncomfortable?” Subsequently, all the respondents (n = 135) except the 11 teachers and guidance counselors were asked whether there was any information in the video that made them feel uncomfortable. Nineteen respondents chose not to answer this question. Of the remaining 116 respondents, only 12 (10%) said the video made them feel uncomfortable: These respondents were health care hospital workers, social service workers, and 1 high school student. Three of them identified a personal experience with cancer, and the other 9 said the video’s content was sad, they felt empathy for the young people featured in the video, and the stories conveyed were painful. The following are some examples of their comments: I don’t like to cry in front of people, and I found it hard to refrain, even though it was a full auditorium. (student nurse) *** [The video] makes me sad, and seeing these courageous teens grow up so fast is hard. (social service worker) *** I’ve been there. There’s nothing comfortable about cancer. (clinician) *** Cancer is a disease, and eventually the person . . . is going to die. (high school student) All 12 respondents said they believed the information would be useful to high school teachers and students or they would recommend the video to young adults. However, their verbal and emotional responses highlighted the need to prepare informational materials and offer support or guidance for future viewers who might find the video difficult to watch. The need for a brochure with accompanying information, the opportunity to debrief viewers after the presentation, the need for information about cancer (its presentation and the treatments offered), and the importance of being able to gain access to support and other psychosocial resources if necessary were recurring messages in the evaluations. Additional feedback from respondents included ensuring that viewers knew in advance that the content might be powerful for them and that they had the choice of viewing the video or not. The respondents also referred to the need for French language resources on this issue as well as resources (e.g., books, videos) for a younger audience, such as elementary school children.
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DISCUSSION The results of the study indicated the lack of a committed group of teachers and guidance counselors who would ensure that the video’s intended audience (high school teachers, guidance counselors, and students) would view the video. This result encouraged us to continue the study to determine further what the sources of reluctance were to showing the video in the high school setting. After the pretest, the information acquired with the question “Is there any information in the video that makes you feel uncomfortable?” provided insight concerning why educators might hesitate to use the resource. With this information, the project committee could prepare accompanying materials accordingly. The fact that all the high school and social work students reported that the information contained in the video would be useful for high school teachers and students supports what Cragg and Berman (1990) and Stevenson (1990) reported–that difficult issues are best addressed and talked about openly and that adolescents should be provided with a forum for discussion. Although 98% of the sampled population regarded the video as useful, the high school teachers and guidance counselors were hesitant to show it in regular classrooms; however, they recommended its use in special circumstances, such as in health and sociology classes. The teachers identified the need for support from psychosocial resource professionals as an informal measure in the event that students became distraught. While considering the teachers and guidance counselors’ responses, we noted that their primary role in education is that of providing opportunities for structured instruction that follows a curriculum expected to prepare students to advance to the next grade level. The training of teachers may not include addressing psychosocial complexities, such as those experienced by students whose parents are seriously ill. Hence, teachers and guidance counselors may not be comfortable with or trained to address the psychosocial distress of students facing tragic circumstances. Furthermore, teachers do not have time to address individual students’ issues because of the demanding curricula. We also considered that such exposure might bring a teacher’s past or present painful experiences to the surface. The responses of high school and social work students differed from those of the high school teachers and guidance counselors. Students identified their need to have such information as soon as possible. Their responses indicated a wish to address and discuss difficult issues and a desire to learn how to deal with and respond to their friends and classmates whose parent had cancer. Their desire for information and their interest in responding to classmates reinforces the idea that they are a suitable age group to be addressing these issues. When adolescents and young adults view Hear How I Feel in an effort to help
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their peers, they may be more likely to respond to peers with sensitivity and empathy. Health care workers in hospital and oncology settings reported that the information in the video enhanced their knowledge of the clinical population they provided service to and would be useful for adolescents and young adults for whom connection with health care providers may be difficult and at times awkward. Counselors indicated they would use the video in their work, and hospital and oncology health care workers appreciated the availability of Hear How I Feel as a resource. The respondents’ answers to the survey questions indicated that the content of the video might evoke a strong emotional response and, as members of a video project committee, we considered this factor when developing the packaging of the video and accompanying printed materials. Finally, as a result of respondents’ suggestion, we have initiated preliminary efforts to translate the video and brochure into French to meet the needs of Canada’s French-speaking population. IMPLICATIONS FOR RESEARCH AND CLINICAL PRACTICE The results of the study suggest that teachers and guidance counselors should receive education and training that strengthens their confidence and enhances their skills in responding to adolescents and young adults facing a parent’s cancer and other adversities. A major aspect of this training is identifying and gaining access to resources for this population. We anticipate that with training and the opportunity to express their concerns, teachers and guidance counselors will permit–and in fact facilitate–discussion of difficult issues in the high school setting. In the long term, we hope that the educational setting will be an environment in which students experiencing difficult circumstances will be free to meet with teachers to resolve learning difficulties, receive validation of their feelings, and be encouraged to express them. Such an environment could promote opportunities for improved learning. Professionals with expertise in psychosocial oncology could provide such training for teachers and guidance counselors. In the province of Ontario, application for credit hours could be pursued with the Ontario College of Teachers as a means of maintaining one’s teacher certification. Psychosocial intervention should be available and accessible to cancer patients and their families and, in particular, to the adolescents and young adults with a parent diagnosed with cancer. Students and teachers should have the opportunities to be aware of, gain access to, and receive psychosocial support from social workers and psychologists employed by boards of education and community cancer agencies.
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The study suggests the need to evaluate further the effectiveness of the video and its accompanying materials and to ensure that teachers in fact have the resources and skills they need to respond to these youth. Finally, the research findings reported in this article suggest the need for continued dialogue with educators, students, and health care professionals as well as with young people experiencing a diagnosis of cancer in the family. REFERENCES Adams-Greenly, M., Beldoch, N., & Moynihan, R. (1986). Helping adolescents whose parents have cancer. Seminars in Oncology Nursing, 2, 133-138. Baton Broadcasting, MCTV (Producer), & The Young Adult Support Group. (1996). Hear How I Feel. Videotape available from the Northeastern Ontario Regional Cancer Centre, Supportive Care Program, 41 Ramsey Lake Road, Sudbury, Ontario, P3E 5J1. Berman, H., Cragg, C. E., & Kuenzig, L. (1988). Having a parent die of cancer: Adolescents’ grief reactions. Oncology Nursing Forum, 15, 159-163. Christ, G. H., Siegel, K., & Sperber, D. (1994). Impact of parental terminal cancer on adolescents, American Journal of Orthopsychiatry, 64, 604-613. Compas, B. E., Worsham, N. L., Epping-Jordan, J. E., Grant, K. E., Mireault, G., Howell, D. C., & Malcarne, V. L. (1994). When mom or dad has cancer: Markers of psychological distress in cancer patients, spouses and children. Health Psychology, 13, 507-515. Compas, B. E., Worsham, N. L., Ey, S., & Howell, D. C. (1996). When mom or dad has cancer: II. Coping, cognitive appraisals, and psychological distress in children of cancer patients. Health Psychology, 15, 67-75. Cragg, C. E., & Berman, H. A. (1990). Adolescents’ reactions to the death of a parent. In J. D. Morgan (Ed.), The dying and the bereaved teenager (pp. 42-49). Philadelphia, PA: Charles Press. Gillespie, J. G., & Ikhlas, M. (1998). Groups in the community context. In K. C. Stoiber & T. R. Kratochwill (Eds.), Handbook of group intervention for children and families (pp. 29-46). Boston, MA: Allyn & Bacon. Grant, K. E., & Compas, B. E. (1995). Stress and anxious-depressed symptoms among adolescents: Searching for mechanisms of risk. Journal of Consulting and Clinical Psychology, 63, 1015-1021. Heiney, S. P., Bryant, L. H., Walker, S., Parrish, R. S., Provenzano, F. J., & Kelly K. E. (1997). Impact of parental anxiety on child emotional adjustment when a parent has cancer. Oncology Nursing Forum, 24, 655-661. Hughes, B. R., Altman, D. G., & Newton, J. A. (1993). Melanoma and skin cancer: Evaluation of a health education programme for secondary schools. British Journal of Dermatology, 128, 412-417. Hustins, K., & Kelly, C. (1990). The role of the professional in an adolescent support group for those with cancer. In J. D. Morgan (Ed.), The dying and the bereaved teenager (pp. 22-32). Philadelphia, PA: Charles Press.
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Larrocque, C., & Hendren, R. L. (1997). Individual and group interventions. In R. T. Ammerman & M. Hersen (Eds.), Handbook of prevention and treatment with children and adolescents: Intervention in the real world context (pp. 91-105). New York: John Wiley & Sons. McAvoy, B. R., & Raza, R. (1991). Can health education increase uptake of cervical smear testing among Asian women? British Medical Journal, 302, 833-836. McDaniel, R. W., & Rhodes, V. A. (1998). Development of a preparatory sensory information videotape for women receiving chemotherapy for breast cancer. Cancer Nursing, 21, 143-148. Meade, C. D. (1996). Producing videotapes for cancer education: Methods and examples. Oncology Nursing Forum, 23, 837-846. Meade, C. D., McKinney, P., & Barnas, G. P. (1994). Educating patients with limited literacy skills: The effectiveness of printed and videotaped materials about colon cancer. American Journal of Public Health, 84, 119-121. Meagher, D., & Mann, K. V. (1990). The effect of an educational program on knowledge & attitudes about blood pressure by junior high school students: A pilot project. Canadian Journal of Cardiovascular Nursing, 1(5), 15-22. Nelson, E., Sloper, P., Charlton, A., & While, D. (1994). Children who have a parent with cancer: A pilot study. Journal of Cancer Education, 9(1), 30-36. NUD*IST (Qualitative Data Analysis Software, Version N5). (2000). QSR-N5 QSR International Pty Ltd. Melbourne, Australia: Qualitative Solutions and Research Pty, Ltd. www.qsrinternational.com Stevenson, R. G. (1990). Teen suicide: Sources, signals and prevention. In J. D. Morgan (Ed.), The dying and the bereaved teenager (pp. 125-139). Philadelphia, PA: Charles Press. Toseland, R. W., & Siporin, M. (1986). When to recommend group treatment: A review of the clinical and research literature. International Journal of Group Psychotherapy, 36, 171-201. Trickett, E. J., & Schmid, K. H. (1993). The school as a social context. In P. H. Tolan & B. J. Cohler (Eds.), Handbook of clinical research and practice with adolescents (pp. 173-202). New York: John Wiley & Sons. Welch, A. S., Wadsworth, M. E., & Compas, B. E. (1996). Adjustment of children and adolescents to parental cancer–parents’ and children’s perspectives. Cancer, 77, 1409-1418. Wellisch, D. (1979). Adolescent acting out when a parent has cancer. International Journal of Family Therapy, 1, 230-243. Wellisch, D. K., Gritz, E. R., Schain, W., Wang, H. J., & Siau, J. (1992). Psychological functioning of daughters of breast cancer patients. Part II: Characterizing the distressed daughter of the breast cancer patient. Psychosomatics, 33, 171-179. Yancey, A. K., Tanjasiri, S. P., Klein, M., & Tunder, J. (1995). Increased cancer screening behavior in women of color by culturally sensitive video exposure. Preventive Medicine, 4, 142-148.
Received: December 10, 2001 Revised: March 20, 2002 Accepted: April 31, 2002
