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Spiritual pain as part of the hospitalization experience of children and adolescents with acute lymphoblastic leukemia: A phenomenological study

Published:April 13, 2022DOI:https://doi.org/10.1016/j.ejon.2022.102141

      Highlights

      • Children and adolescents with acute lymphoblastic leukemia experience spiritual pain during hospitalization.
      • Needle procedures are the most stressful part of their cancer treatment.
      • The pain they experience during treatment is often underestimated.
      • A more holistic and less nociceptive approach to pain is needed.

      Abstract

      Purpose

      To explore the experience of hospitalization among children and adolescents in treatment for acute lymphoblastic leukemia.

      Methods

      Qualitative phenomenological study informed by grounded theory and involving a convenience sample of children and adolescents attending an oncology unit in Spain. Data were collected through in-depth interviews with seven children aged between 9 and 18 years and analyzed using ATLAS.Ti 7.1. software in order to identify themes in the participants' narratives. Specific strategies were applied to support the validity and reliability of the findings.

      Results

      The analysis of interviews revealed three themes in the participants' accounts of their experience of hospitalization: 1) It's normal to feel afraid when being treated in hospital; 2) Needle procedures are associated with pain, illness, and dying; and 3) Difficulty of expressing the suffering that is experienced in hospital.

      Conclusions

      A core experience among children and adolescents who are hospitalized for cancer treatment is the spiritual pain that results from feeling afraid. These fears are especially associated with the needle procedures that are routinely performed in the diagnosis and treatment of acute lymphoblastic leukemia.

      Keywords

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      References

        • Abela K.
        • Wardell D.
        • Rozmus C.
        • LoBiondo-Wood G.G.
        Impact of pediatric critical illness and injury on families: an updated systematic review.
        J. Pediatr. Nurs. 2020; 51: 21-31https://doi.org/10.1016/j.pedn.2019.10.013
        • Alberts N.
        • Gagnon M.
        • Stinson J.
        Chronic pain in survivors of childhood cancer: a developmental model of pain across the cancer trajectory.
        Pain. 2018; 159: 1916-1927https://doi.org/10.1097/j.pain.0000000000001261
        • Anandarajah G.
        • Hight E.
        Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment.
        Am. Fam. Physician. 2011; 63: 81-89
        • Balint E.
        The possibilities of patient-centered medicine.
        J. Roy. Coll. Gen. Pract. 1969; 17: 269-276
        • Bao P.-P.
        • Zheng Y.
        • Wang C.-F.
        • Gu K.
        • Jin F.
        • Lu W.
        Time trends and characteristics of childhood cancer among children age 0-14 in Shanghai.
        Pediatr. Blood Cancer J. 2009; 53: 13-16https://doi.org/10.1002/pbc.21939
        • Barrio V.
        • Mestre V.
        Evaluación psicológica en niños hospitalizados.
        Revista de Psicología de la Salud. 1989; 1: 83-103
        • Bartel M.
        What is spiritual? What is spiritual suffering?.
        J. Pastor. Care Counsel. 2004; 58: 187-201https://doi.org/10.1177/154230500405800304
        • Behruzi R.
        • Hatem M.
        • Goulet L.
        • Fraser W.D.
        Perception of humanization of birth in a highly specialized hospital: let's think differently.
        Health Care Women Int. 2014; 35: 127-148https://doi.org/10.1080/07399332.2013.857321
        • Bengtsson M.
        How to plan and perform a qualitative study using content analysis.
        NursingPlus One. 2016; 2: 8-14https://doi.org/10.1016/j.npls.2016.01.001
        • Berríos-Rivera R.
        • Rivero-Vergne A.
        • Romero I.
        The pediatric cancer hospitalization experience: reality co-constructed.
        J. Pediatr. Oncol. Nurs. 2008; 25: 340-353
        • Best M.
        • Aldridge L.
        • Butow I.
        • Olver M.
        • Price M.
        • Webster F.
        Assessment of spiritual suffering in the cancer context: a systematic literature review.
        Palliat. Support Care. 2015; 13: 1335-1361https://doi.org/10.1017/S1478951514001217
        • Birnie K.A.
        • Chambers C.T.
        • Fernandez C.V.
        • Forgeron P.A.
        Hospitalized children continue to report undertreated and preventable pain.
        Pain Res. Manag. 2014; 19: 198-204https://doi.org/10.1155/2014/614784
        • BOE [Official Gazette of the Spanish Government]
        Ley Orgánica 3/2018, de 5 de diciembre, de Protección de Datos Personales y Garantía de los derechos digitales.
        2018
        • Boston P.
        • Bruce A.
        • Schereiber R.
        Existential suffering in the palliative care setting: an integrated literature review.
        J. Pain Symptom Manag. 2011; 41: 604-618https://doi.org/10.1016/j.jpainsymman.2010.05.010
        • Bowlby J.
        Maternal Care and Mental Health.
        World Health Organization, Geneva1952
        • Butler R.
        • Rizzi L.
        • Handwerger B.
        The assessment of posttraumatic stress disorder in pediatric cancer patients and survivors.
        J. Pediatr. Psychol. 1996; 21: 499-504https://doi.org/10.1093/jpepsy/21.4.499
        • Calhoun L.
        • Tedeschi R.
        Positive aspects of critical life problems: recollections of grief.
        Omega J. Death Dying. 1990; 1: 265-272https://doi.org/10.2190/QDY6-6PQC-KQWV-5U7K
        • Chapman C.R.
        • Gavrin J.
        Suffering: the contributions of persistent pain.
        Lancet. 1999; 353: 2233-2237https://doi.org/10.1016/S0140-6736(99)01308-2
        • Charmaz K.
        Constructing Grounded Theory: A Practical Guide through Qualitative Analysis.
        SAGE, London2006
        • Cherny N.
        • Coyle N.
        • Foley K.
        Suffering in the advanced cancer patient: a definition and taxonomy.
        J. Palliat. Care. 1994; 10: 57-70https://doi.org/10.1177/082585979401000211
        • Ching-Hon J.
        • Mullighan C.
        Childhood acute lymphoblastic leukemia: progress through collaboration.
        J. Clin. Oncol. 2015; 33: 2938-2948https://doi.org/10.1200/JCO.2014.59.1636
        • Cicogna E.
        • Nascimento L.
        • Aparecida R.
        • Lima D.
        Niños y adolescentes con cáncer: experiencias con la quimioterapia.
        Rev. Latino-Am. Enferm. 2010; 18: 1-9
        • Colville G.
        • Kerry S.
        • Pierce C.
        Children's factual and delusional memories of intensive care.
        Am. J. Respir. Crit. Care Med. 2008; 177: 976-982https://doi.org/10.1164/rccm.200706-857OC
        • Conte P.
        • Walco G.
        • Sterling C.
        • Engel R.
        • Kuppenheimer W.
        Procedural pain management in pediatric oncology: a review of the literature.
        Cancer Invest. 1999; 17: 448-459https://doi.org/10.3109/07357909909021437
        • Creswell J.
        Qualitative Inquiry and Research Design: Choosing Among Five Traditions.
        SAGE, Thousand Oaks, California1998
        • Cummings J.A.
        Pediatric procedural pain: how far have we come? An ethnographic account.
        Pain Manag. Nurs. 2015; 48: 356-365https://doi.org/10.1016/j.pmn.2014.06.006
        • Desandes E.
        • Clavel J.
        • Berger C.
        • Bernard J.-L.
        • Blouin P.
        • Lumley L.
        • Demeocq F.
        • Freycon F.
        • Gembara P.
        • Goubin A.
        • Le Gall E.
        • Pillon P.
        • Sommelet D.
        • Tron I.
        • Laour B.
        Cancer incidence among children in France, 1990-1999.
        Pediatr. Blood Cancer. 2004; 43: 749-757https://doi.org/10.1002/pbc.20148
        • Doupnik S.K.
        • Henry M.K.
        • Bae H.
        • Litman J.
        • Turner S.
        • Scharko A.M.
        • Feudtner C.
        Mental health conditions and symptoms in pediatric hospitalizations: a single-center point prevalence study.
        Academic Pediatrics. 2017; 17: 184-190https://doi.org/10.1016/j.acap.2016.08.009
        • Dreifaldt A.
        • Carlberg M.
        • Hardell L.
        Increasing incidence rates of childhood malignant diseases in Sweden during the period 1960-1998.
        Eur. J. Cancer. 2004; 40: 1351-1360
        • Duffy E.A.
        • Dias N.
        • Hendricks-Ferguson V.
        • Hellsten M.
        Perspectives on cancer pain assessment and management in children.
        Semin. Oncol. Nurs. 2019; 35: 261-273https://doi.org/10.1016/j.soncn.2019.04.007
        • Dworkin R.H.
        Pain insensitivity in schizophrenia: a neglected phenomenon and some implications.
        Schizophr. Bull. 1994; 20: 235-248https://doi.org/10.1093/schbul/20.2.235
        • Enskär K.
        • Ljusegren G.
        • Berglund G.
        • Eaton N.
        • Harding R.
        • Mokoena J.
        • Chauke M.
        • Moleki M.
        Attitudes to and knowledge about pain and pain management of nurses working with children with cancer: a comparative study between UK, South Africa and Sweden.
        J. Res. Nurs. 2007; 12: 501-515https://doi.org/10.1177/1744987107080455
        • Galligan A.J.
        Childhood cancer survivorship and long-term outcomes.
        Adv. Pediatr. 2017; 64: 133-169https://doi.org/10.1016/j.yapd.2017.03.014
        • Geenen M.
        • Cardous-Ubbink M.
        • Leontien C.
        • Kremer M.
        Medical assessment of adverse health outcomes in long-term survivors of childhood cancer.
        JAMA. 2007; 24: 2705-2715https://doi.org/10.1001/jama.297.24.2705
        • Goodenough B.
        • Thomas W.
        • Champion G.D.
        • Perrott D.
        • Taplin J.E.
        • Von Aeyer C.L.
        • Ziegler J.B.
        Unravelling age effects and sex differences in needle pain: ratings of sensory intensity and unpleasantness of venipuncture pain by children and their parents.
        Pain. 1999; 80: 179-190https://doi.org/10.1016/S0304-3959(98)00201-2
        • Grimston M.
        • Butler A.
        • Copnell B.
        Critical care nurses' experiences of caring for a dying child: a qualitative evidence synthesis.
        J. Adv. Nurs. 2018; 74: 1752-1768https://doi.org/10.1111/jan.13701
        • Guba E.G.
        Criterios de credibilidad en la investigación naturista.
        in: La Enseñanza: su teoría y su práctica. AKAL/UNIVERSITARIA, Madrid1981: 148-165
        • Hedén L.
        • Von Essen L.
        • Ljungman G.
        Children's self-reports of fear and pain levels during needle procedures.
        Nursing Open. 2020; 7: 376-382https://doi.org/10.1002/nop2.399
        • Hedström M.
        • Haglung K.
        • Skolin I.
        • Von Essen L.
        Distressing events for children and adolescents with cancer: child, parents, and nurse perceptions.
        J. Pediatr. Oncol. Nurs. 2003; 20: 120-132https://doi.org/10.1053/jpon.2003.76
        • Inaba H.
        • Graves M.
        • Mullighan C.
        Acute lymphoblastic leukaemia.
        Lancet. 2013; 381: 1-7https://doi.org/10.1016/S0140-6736(12)62187-4
        • Jay S.M.
        • Elliott C.H.
        A stress inoculation program for parents whose children are undergoing painful medical procedures.
        J. Consult. Clin. Psychol. 1990; 58: 799-804https://doi.org/10.1037/0022-006x.58.6.799
        • Kahn D.
        • Steeves R.
        The significance of suffering in cancer care.
        Semin. Oncol. Nurs. 1995; 11: 9-16https://doi.org/10.1016/S0749-2081(95)80037-9
        • Kamper R.
        • Van Cleve L.
        • Savedra M.
        Children with advanced cancer: responses to a spiritual quality of life interview.
        J. Spec. Pediatr. Nurs. 2010; 15: 301-306https://doi.org/10.1111/j.1744-6155.2010.00253.x
        • Kato M.
        • Manabe A.
        Treatment and biology of pediatric acute lymphoblastic leukemia.
        Pediatr. Int. 2017; 60: 4-12https://doi.org/10.1111/ped.13457
        • Katz E.R.
        • Kellerman J.
        • Siegel S.
        Behavioral distress in children with cancer undergoing medical procedures: developmental considerations.
        J. Consult. Clin. Psychol. 1980; 48: 356-365https://doi.org/10.1037//0022-006x.48.3.356
        • Kaye E.C.
        • Gushue C.A.
        • DeMarsh S.
        • Jerkins J.
        • Sykes A.
        • Lu Z.
        • Snaman S.
        • Blazin L.
        • Johnson L.M.
        • Levine D.R.
        • Morrison R.R.
        • Baker J.N.
        Illness and end-of-life experiences of children with cancer who receive palliative care.
        Pediatr. Blood Cancer. 2018; 65 (Epub 2017 Dec 8)e26895https://doi.org/10.1002/pbc.26895
        • Kazak A.
        • Alderfer M.
        • Rourke M.
        • Simms S.
        • Streisand J.
        • Grossman M.A.
        Posttraumatic stress, family functioning, and social support in survivors of childhood leukemia and their mothers and fathers.
        J. Consult. Clin. Psychol. 1997; 65: 120-129https://doi.org/10.1037/0022-006X.65.1.120
        • Kellerman J.
        • Zeltzer L.
        • Dash J.
        Adolescents with cancer: hypnosis for the reduction of the acute pain and anxiety associated with medical procedures.
        J. Adolesc. Health Care. 1983; 4: 85-90https://doi.org/10.1016/s0197-0070(83)80024-2
        • Koh K.
        • Kato M.
        • Saito A.
        • Kada A.
        • Kawasaki H.
        • Okamoto Y.
        • Imamura T.
        • Horibe K.
        • Manabe A.
        Phase II/III study in children and adolescents with newly diagnosed B-cell precursor acute lymphoblastic leukemia: protocol for a nationwide multicenter trial in Japan.
        Jpn. J. Clin. Oncol. 2018; 48: 684-691https://doi.org/10.1093/jjco/hyy071
        • Levine D.R.
        • Mandrell B.N.
        • Sykes A.
        • Pritchard M.
        • Gibson D.
        • Symons H.J.
        • Wendler D.
        • Baker J.N.
        Patients' and parents' needs, attitudes, and perceptions about early palliative care integration in pediatric oncology.
        JAMA Oncol. 2017; 3: 1214-1220https://doi.org/10.1001/jamaoncol.2017.0368
        • Linabery A.M.
        • Ross J.A.
        Trends in childhood cancer incidence in the US.
        Cancer. 2008; 112 (1992-2004): 416-432https://doi.org/10.1002/cncr.23169
        • Liossi C.
        Management of paediatric procedure-related cancer pain.
        Pain Rev. 1999; 6: 279-302
        • Litke J.
        • Pikulska A.
        • Wegner T.
        Management of perioperative stress in children and parents. Part I: the perioperative period.
        Anaesthesiol. Intensive Ther. 2012; 44: 165-169
        • Ljungman G.
        • Gordh T.
        • Sorensen S.
        • Kreuger A.
        Pain variations during cancer treatment in children: a descriptive survey.
        J. Pediatr. Hematol. Oncol. 2000; 17: 211-221https://doi.org/10.1080/088800100276389
        • Lopes R.
        • Flores C.
        • Passos R.
        • Calegari D.
        • Cavicchioli A.
        • Bigolin L.
        • Tatsch E.
        Hospitalization perceived by children and adolescents undergoing cancer treatment.
        Revista Gaucha Enfermagem. 2021; 42e20200122https://doi.org/10.1590/1983-1447.2021.20200122
        • López Naranjo I.
        • Fernández Castillo A.
        Transmisión de emociones, miedo, y estrés infantil por hospitalización.
        Int. J. Clin. Health Psychol. 2006; 6: 631-645
        • Lovato E.
        • Minniti D.
        • Giacometti M.
        • Sacco R.
        • Piolatto A.
        • Barberis B.
        • Papalia R.
        • Bert F.
        • Siliquini R.
        Humanisation in the emergency department of an Italian hospital: new features and patient satisfaction.
        Emerg. Med. J. 2013; 30: 487-491https://doi.org/10.1136/emermed-2012-201341
        • Margarita-González A.
        Dolor crónico y psicología: actualización.
        Revista Médica Clínica Los Condes. 2014; 25: 610-617https://doi.org/10.1016/s0716-8640(14)70081-1
        • McCubbin M.
        • Balling K.
        • Possin P.
        • Frierdich S.
        • Bryne B.
        Family resiliency in childhood cancer.
        Fam. Relat. 2002; 51: 103-111
        • Méndez-Venegas J.
        Intervención emocional y conductual para el niño con cáncer y su familia.
        Gaceta Mexicana de Oncología. 2005; 4: 60-64
        • Molinaro M.L.
        • Fletcher P.C.
        Taking lemons and making lemonade: posttraumatic growth from pediatric cancer.
        Clin. Nurse Spec. 2018; 32: 268-278https://doi.org/10.1097/NUR.0000000000000397
        • Moore R.J.
        • Chamberlain R.M.
        • Khuri F.R.
        Communicating suffering in primary stage head and neck cancer.
        Eur. J. Cancer Care. 2004; 13: 53-64https://doi.org/10.1111/j.1365-2354.2004.00444.x
        • Morse J.
        Qualitative Health Research: Creating a New Discipline.
        Left Coast Press, Walnut Creek, CA2012
        • Morse M.
        • Castillo P.
        • Venecia D.
        • Milstein J.
        • Tyler D.
        Childhood near-death.
        Am. J. Dis. Child. 1986; 140: 1110-1114
        • Myrvik M.
        • Burks L.
        • Hoffman R.
        • Dasgupta M.
        • Panepinto J.
        Mental health disorders influence admission rates for pain in children with sickle cell disease.
        Pediatr. Blood Cancer. 2008; 50 (November 2012): 1018-1025https://doi.org/10.1002/pbc
        • Myrvik M.
        • Campbell A.
        • Davis M.
        • Butcher J.
        Impact of psychiatric diagnoses on hospital length of stay in children with sickle cell anemia.
        Pediatr. Blood Cancer. 2012; 58: 239-243https://doi.org/10.1002/pbc
        • Nager A.L.
        • Mahrer N.E.
        • Gold J.I.
        State trait anxiety in the emergency department: an analysis of anticipatory and life stressors.
        Pediatr. Emerg. Care. 2010; 26: 897-901https://doi.org/10.1097/PEC.0b013e3181fe90eb
        • Nakata K.
        • Magadi W.
        • Bonaventure A.
        • Stiller C.
        • Katanoda K.
        • Matsuda T.
        • Miyashiro I.
        • Pritchard-Jones K.
        • Rachet B.
        Childhood cancer incidence and survival in Japan and England: a population-based study.
        Cancer Sci. 2017; 106: 422-434https://doi.org/10.1111/cas.13457
        • Oeffinder K.
        • Mertens A.
        • Sklar C.
        • Kawashima T.
        • Hudson M.
        • Meadows A.
        • Friedman D.
        • Marina N.
        • Hobbie W.
        • Kadan-Lottick N.
        • Schwartz W.
        • Leisenring W.
        Chronic health conditions in adult survivors of childhood cancer.
        N. Engl. J. Med. 2006; 355: 1572-1582https://doi.org/10.1056/NEJMsa060185
        • Park C.L.
        • Chmielewski J.
        • Blank T.O.
        Post-traumatic growth: finding positive meaning in cancer survivorship moderates the impact of intrusive thoughts on adjustment in younger adults.
        Psycho Oncol. 2010; 19: 1139-1147https://doi.org/10.1002/pon.1680
        • Park H.J.
        • Moon E.-K.
        • Yoon J.Y.
        • Oh C.-M.
        • Jung K.-W.
        • Park B.-K.
        • Shing H.-Y.
        • Won Y.-J.
        Incidence and survival of childhood cancer incidence and survival in Korea.
        Cancer Res. Treat. 2016; 48: 869-882https://doi.org/10.4146/crt.2015.290
        • Pérez-Fuentes M.
        • Gázquez J.
        • Molero M.
        • Barragán A.
        • Martos M.
        • Simón S.
        Cuidados de enfermería en pacientes portadores de fístulas arteriovenosas.
        ASUNIVEP, Madrid2018
        • Peterson A.
        • Cline R.
        • Foster T.
        • Penner L.
        • Parrott R.
        • Keller C.
        • Naughton M.
        • Taub J.
        • Ruckdeschel J.
        • Albrecht T.
        Parents' interpersonal distance and touch behavior and child pain and distress during painful pediatric oncology procedures.
        J. Nonverbal Behav. 2007; 31: 79-97https://doi.org/10.1007/s10919-007-0023-9
        • Rennick J.
        • Dougherty G.
        • Chambers C.
        • Stremler R.
        • Childerhose J.
        • Stack D.
        • Harrison D.
        • Campbell-Yeo M.
        • Dryden-Palmer K.
        • Zhang X.
        • Hutchison J.
        • Rennick J.
        Children's psychological and behavioral responses following pediatric intensive care unit hospitalization: the caring intensively study.
        BMC Pediatr. 2014; 14: 1-11https://doi.org/10.1186/1471-2431-14-276
        • Rennick J.
        • Rashotte J.
        Psychological outcomes in children following pediatric intensive care unit hospitalization: a systematic review of the research.
        J. Child Healthc. 2009; 13: 128-149https://doi.org/10.1177/1367493509102472
        • Reti-Sehop
        Cancer Infantil en España. Estadísticas 1980-2016. Valencia: Miniesterio de Sanidad, Servicios Sociales e Igualdad.
        2016
        • Rodgers B.L.
        • Cowles K.V.
        A conceptual foundation for human suffering in nursing care and research.
        J. Adv. Nurs. 1997; 25: 1048-1053https://doi.org/10.1046/j.1365-2648.1997.19970251048.x
        • Ruiz-Benítez M.
        • Coca M.
        El pacto de silencio en los familiares de los pacientes oncológicos terminales.
        Psicooncología: Investigación y Clínica Biopsicosocial en Oncología. 2008; 5: 53-70https://doi.org/10.5209/rev_PSIC.2008.v5.n1.16351
        • Safavi M.
        • Yahyavi S.
        • Narab H.
        • Yahyavi S.
        Association between spiritual intelligence and stress, anxiety, and depression coping styles in patients with cancer receiving chemotherapy in university hospitals of Tehran University of medical science.
        J. Cancer Res. Therapeut. 2019; 15: 1124-1130https://doi.org/10.4103/jcrt.JCRT_382_17
        • Saleh U.
        • Brockopp D.
        Hope among patients with cancer hospitalized for bone marrow transplantation: a phenomenological study.
        Cancer Nurs. 2001; 24: 308-3014
        • Seidman I.
        Interviewing as Qualitative Research. A Guide for Researchers in Education and the Social Sciences.
        Teachers College Press, New York2013
        • Small L.
        • Mazurek B.
        • Sidora-Arcoleo K.
        The effects of gender on the coping outcomes of young children following and unanticipated critical care hospitalization.
        J. Spec. Pediatr. Nurs. 2009; 12: 112-122https://doi.org/10.1111/j.1744-6155.2009.00184.x
        • Sood E.
        • Karpyn A.
        • Demianczyk A.C.
        • Ryan J.
        • Delaplane E.A.
        • Neely T.
        • Frazier A.H.
        • Kazak A.E.
        Mothers and fathers experience stress of congenital heart disease differently: recommendations for pediatric critical care.
        Pediatr. Crit. Care Med. 2018; 19: 626-634https://doi.org/10.1097/PCC.0000000000001528
        • Stack M.
        • Walsh P.M.
        • Comber H.
        • Ryan C.A.
        • O’Lorcain
        Childhood cancer in Ireland: a population-based study.
        Arch. Dis. Child. 2007; 92: 890-897https://doi.org/10.1136/adc.2005.087544
        • Starfield B.
        Is patient-centered care the same as person-focused care?.
        Perm. J. 2011; 15: 63-69https://doi.org/10.7812/tpp/10-148
        • Stayer D.
        Pediatric palliative care: a conceptual analysis for pediatric nursing practice.
        J. Pediatr. Nurs. 2012; 27: 350-356https://doi.org/10.1016/j.pedn.2011.04.031
        • Stinson J.
        • Yamada J.
        • Dickson A.
        • Lamba J.
        • Stevens B.
        Review of systematic reviews on acute procedural pain in children in the hospital setting.
        Pain Res. Manag. 2008; 13: 51-57https://doi.org/10.1155/2008/465891
        • Strang P.
        Existential consequences of unrelieved cancer pain.
        Palliat. Med. 1997; 11: 299-305https://doi.org/10.1177/026921639701100406
        • Strauss A.L.
        • Corbin J.
        Bases de la investigación cualitativa: técnicas y procedimientos para desarrollar la teoría fundamentada.
        Universidad de Antioquia, Medellin2002
        • Stuber M.
        • Nader K.
        • Yasuda P.
        • Pynoos R.
        • Cohen S.
        Stress responses after pediatric bone marrow transplantation: preliminary results of a prospective longitudinal study.
        J. Am. Acad. Child Adolesc. Psychiatr. 1991; 60: 953-957https://doi.org/10.1097/00004583-199111000-00013
        • Tedeschi R.
        • Calhoun L.
        Posttraumatic growth: conceptual foundations and empirical evidence.
        Psychol. Inq. 2004; 15: 1-18https://doi.org/10.1207/s15327965pli1501_01
        • Tedeschi R.G.
        • Calhoun L.G.
        The posttraumatic growth inventory: measuring the positive legacy of trauma.
        J. Trauma Stress. 1996; 9: 455-471https://doi.org/10.1007/BF02103658
        • Uman L.S.
        • Birnie K.A.
        • Noel M.
        • Parker J.A.
        • Chambers C.T.
        • McGrath P.J.
        • Kisely S.R.
        Psychological interventions for needle-related procedural pain and distress in children and adolescents.
        Cochrane Database Syst Rev. 2006; 10: CD005179https://doi.org/10.1002/14651858.CD005179.pub2
        • Williamson H.
        • Harcourt D.
        • Halliwell E.
        • Frith H.
        • Wallace M.
        Adolescents' and parents' experiences of managing the psychosocial impact of appearance change during cancer treatment.
        J. Pediatr. Oncol. Nurs. 2010; 27: 168-175https://doi.org/10.1177/1043454209357923
        • World Medical Association
        Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects, 64th WMA General Assembly.
        2013
        • Zeltzer L.
        • Kellerman J.
        • Ellenberg L.
        • Dash J.
        • Rigler D.
        Psychologic effects of illness in adolescence. II. Impact of illness in adolescents: crucial issues and coping styles.
        J. Pediatr. 1980; 97: 132-138https://doi.org/10.1016/S0022-3476(80)80153-3