Original Article

Effect of Play‑based Occupational Therapy

on Symptoms of Hospitalized Children with
Cancer: A Single‑subject Study
Ahmad Mohammadi1, Afsoon Hassani Mehraban1, Shahla A. Damavandi2
1
Department of Occupational Therapy, Iran University of Medical Sciences, 2Department of Pediatric Oncology,
Ali‑Asghar Hospital, Iran University of Medical Sciences, Tehran, Iran

Corresponding author: Afsoon Hassani Mehraban, PhD

Associate Professor, Occupational Therapy Department, Rehabilitation Research Center

School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran

Tel: 0098 021 22228051 ext. 389; Fax: 0098 021 22220946

E‑mail: [email protected]

Received: November 30, 2016, Accepted: February 14, 2017

ABSTRACT
Objective: Cancer is one of the four leading causes of death Nine, 30–45 min play‑based occupational therapy sessions took
in children. Its courses of diagnosis and treatment can place for each child. Children filled out the Faces Pain Scale, Visual
cause physiologic symptoms and psychological distress that Fatigue Scale, and Faces Anxiety Scale before and after each
secondarily affect children’s quality of life and participation intervention session. Results: Pain, anxiety, and fatigue levels
in daily activities. The aim of this study was to investigate the decreased in both participants. Furthermore, the results showed
effect of play‑based occupational therapy on pain, anxiety, and a relationship between pain, anxiety, and fatigue variables in
fatigue in hospitalized children with cancer who were receiving these children. Conclusions: Play‑based occupational therapy
chemotherapy. Methods: Two hospitalized children with acute can be effective in improving pain, anxiety, and fatigue levels in
lymphoblastic leukemia at least 4 months after diagnoses who hospitalized children with cancer receiving chemotherapy.
received two courses of chemotherapy participated in this pilot
study. Takata Play History and Iranian Children Participation Key words: Chemotherapy, childhood cancer, hospitalization,
Assessment Scale were used to develop intervention protocol. play‑based occupational therapy

Introduction cough, anorexia, nervousness, irritability, and anxiety.[2,3]

The incidence of childhood cancer in Iran is 48–112 and
Cancer is a rare condition in children <15 years old,
51–144/million among girls and boys in multi‑geographical
which despite medical advances still one of the four leading
causes of death in children.[1] The most common symptoms
This is an open access article distributed under the terms of the
associated with pediatric cancer are pain, fatigue, lethargy,
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DOI: Cite this article as: Mohammadi A, Mehraban AH, Damavandi SA. Effect
10.4103/apjon.apjon_13_17 of play-based occupational therapy on symptoms of hospitalized children
with cancer: A single-subject study. Asia Pac J Oncol Nurs 2017;4:168-72.

168 © 2017 Ann & Joshua Medical Publishing Co. Ltd | Published by Wolters Kluwer - Medknow
 Mohammadi, et al.: Play‑based Occupational Therapy for Children with Cancer

settings, respectively. The most common childhood cancers and tooth brushing.[21‑23] To the best of our knowledge, there
consist of leukemia, brain, lymphoma, and bone tumors.[4] is no study on play‑based occupational therapy in children
The invasive, painful, stressful, and prolonged processes of with cancer. Therefore, the purpose of this pilot study was to
diagnosis, hospitalization, and treatment of cancer as well as investigate the effects of play‑based occupational therapy on
drug’s side effects such as pain, fatigue, nausea, vomiting, and pain, anxiety, and fatigue in hospitalized children with cancer
hair loss can negatively influence on the different aspects of who were receiving chemotherapy.
children’s physical, emotional, and psychosocial abilities.[5,6]
These processes may lead to emotional distress, functional Methods
limitations, participation restrictions, and confined adaptive Two children with acute lymphoblastic leukemia,
skills and responses in these children.[7,8] Children hospitalized including a boy (9 years old) and a girl (7 years old)
in pediatric oncology wards may experience negative sign participated in this study. They were diagnosed with cancer
and symptoms such as developmental delay, sleep disorders, at least 4 months ago, and they have been experienced at least
eating disorders, aggression, anxiety, depression, dependency two courses of chemotherapy during hospitalization. Pattern
on caregivers, disruption of daily activities, diminished quality of hospitalization and chemotherapy (Berlin–Frankfort–
of life, and limited participation in social functions.[9,10] Munster protocol) during the past 4 months was stable in
Play is the children’s world. Playing is the basic need the children and during the course of the study.[24,25] We
of the children; they satisfy their internal desire for used a random sampling to select the included participants
participation in the surrounding environment through from children with cancer in pediatric cancer ward in a
playing, so, it is a critical part of their lives, which governmental hospital. Both the parents and children signed
facilitates the development of sensory, motor, and cognitive the consent form for participating in the study.
processes.[11] As a result, children with a life‑threatening Evaluation process included assessment of pain (Faces
disease need playing too, maybe even more than normal Pain Scale), fatigue (Visual Fatigue Scale), and anxiety (Faces
children.[12] Play therapy is a purposeful collection of Anxiety Scale) at the beginning and at the end of each
structured activities based on children’s situation to play‑based occupational therapy session, which were
improve their mental health.[13] Classic play therapy was completed by own children. Their parents completed the
introduced in 1970s, but its application in hospital settings Children’s Takata Play History (TPH) and Iranian Children
was initiated since 1975 with formation of the National Participation Assessment Scale (ICPAS). Information
Association of Hospital Play Staff. [14] Importance of provided by parents was used to develop therapeutic
playing in childhood is highly emphasized in occupational intervention protocol.
therapy in two forms: play as means (i.e., classic play TPH is a semi‑structured interview with parents or
therapy for improving mental health issues) and play as caregivers. It is used to determine play experiences,
end (i.e., play‑based occupational therapy). Play‑based opportunities, and interests of the child for guiding
occupational therapy refers to the use of play to accomplish therapeutic intervention. This tool can be used for
treatment goals (facilitating playful activities) and to 0–16‑year‑old children and examines five play development
develop skills and abilities required for performing daily phases (sensorimotor, symbolic, simple structure, dramatic
life activities.[15] Although the majority of nurses (and and complex structure, competitive games, and recreational
other health‑care professionals) have knowledge about games) through four classes of items regarding playing
therapeutic play and value its use in practice, it is not tools, applied games, playmates, and play time and place.
routinely used in daily practice.[16] Reliability of TPH was reported 0.91 in the total interview
Since the core occupational therapy intervention is and 0.85 in the classes. Test‑retest reliability of the total
meaningful and purposeful activity, the main occupational interview is 0.77 and it is 0.78 for four classes of items.[26]
therapy intervention in children is playing.[17] Diagnosis of a The ICPAS scale is a 69‑item questionnaire in eight
disease with an uncertain prognosis, anxiety of hospitalization, subscales (activities of daily living, instrumental activities
and side effects of drugs may disturb functional performance of daily living, play, leisure, social participation, education,
and especially playing in children with cancer. Different work, and sleep/rest), reported by children and their
studies have investigated play therapy on various populations parents. This tool is designed for 6–12 year‑old children, and
such as hospitalized children with cancer[13,18‑20] which were Cronbach’s alpha values for children and parent versions
usually related to psychological symptoms. Furthermore, are 0.84 and 0.90, respectively. Its test‑retest reliability in
play‑based intervention is applied in children with attention children version is 0.92 and 0.95 for the parent version.[27]
deficit hyperactivity disorder, Down syndrome, and children Wong and Becker (1998) designed Faces Pain Scale,
with poor self‑care skills to improve behaviors such as eating including two parts: figures and numbers. The numerical

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 Mohammadi, et al.: Play‑based Occupational Therapy for Children with Cancer

part consists of a 10 cm horizontal line with higher scores b. Choosing the play among formulated plays and its
indicating severe pain. The figures’ part contains six images implementation (30 min)
with children’s face indicating different degrees of pain. c. Planning for the next session based on the feedback
The figures’ part is used for children who do not know provided by the therapist and children (5 min)
the meaning of the numbers or are unable to count 0–10. d. Filling out the forms by children at the end of the
Persian version of this scale with a good reliability (α = 0.82) session (5 min).
has been used in various studies.[28,29]
Visual Fatigue Scale contains five cartoon images showing Results
different levels of fatigue. It is leveled as the absence of Table 1 shows demographic data about two participants
fatigue (0), mild fatigue (1–3), moderate fatigue (4–6), severe in our study. We used visual analysis and celeration
fatigue (7–9), and too severe fatigue (10). Reliability and line chart for evaluating deviation of pain, fatigue, and
validity of this tool have been shown in various studies.[30,31] anxiety scores from midline. Baseline phase comprised the
Anxiety Faces Scale includes a visual part with pretest values (beginning of each treatment session) and
five cartoon faces and scores of 1–5. The final score is intervention phase comprised the posttest values (end of
interpreted as lack of anxiety (1), low anxiety (2), moderate each treatment session).
anxiety (3), high anxiety (4), and severe anxiety (5). The
psychometric properties of Persian version have been Discussion
reported by Borhani et al.[32] The results of the present study suggest the reduction of
A child‑oriented approach based on play was used for pain, anxiety, and fatigue scores in hospitalized children
designing the intervention program according to the history with cancer following play‑based occupational therapy.
and interests of each child. An occupational therapist Using the children’s play history, we facilitated participation
selected plays according to the children’s interests to control of children in choosing and manipulating plays for reducing
symptoms and facilitate daily activities using playing. symptoms (play as means) and increasing their participation
Finally, nine playful activities were formulated for each in playful activities (play as end). Occupational therapy
child, and he/she was allowed to choose one or more using both play as means and play as end in pediatric
activities during the nine play‑based occupational therapy oncology ward could help children to overcome some
sessions. Due to higher flexibility among direct and indirect discomfort situations in the hospital.
approaches in our program, the therapist could implement Trend of pain severity in both participants showed a
necessary changes according to child’s conditions and greater reduction in the intervention phase compared to
treatment progress. the baseline phase [Figures 1 and 2]. Greater reduction of
This study was designed as a single‑subject study using pain during the intervention phase showed that play‑based
A‑B‑A‑B‑A‑B method. This method is a withdrawal design occupational therapy could facilitate compatibility with
and consists of three phases: A ‑ baseline (admission), pain during chemotherapy. Pain reduction trend was also
B ‑ intervention (first hospitalization), A ‑ baseline (first observed within 3‑session periods. The only exception was
recovery), and B ‑ intervention (second hospitalization), for participant 1 in the third session, who reported pain
A (second recovery), and B ‑ intervention (third more than normal because of displacing the needle in the
hospitalization). Any phase of intervention protocol for hand. Other studies on pain in children with cancer were
children included phase of hospitalization (3–5 days) mostly related to impact of play in distracting children
and then hospital discharge phase for recovery and during painful medical procedures.[28,33,34]
As shown in Figure 3, decreasing trend of fatigue
rest (2 weeks). Assessments were done before (as baseline
observed in this study was incremental for participant 1 in
phases) and after (as intervention phases) each treatment
baseline phase. That is, fatigue was increased with progress
session, and the results of baseline and intervention phases
of chemotherapy and increasing days of hospitalization.
were compared. Implementation of intervention protocol
Comparison of fatigue trend in baseline with intervention
was also formulated accordingly and considering minimum
phase indicates fatigue reduction with average decrease of
hospitalization days (3 days). Finally, given three periods
fatigue severity. In participant 2, fatigue in baseline phase
of hospitalization and chemotherapy, nine 30–45 min
treatment sessions were conducted over 7 weeks.
The play‑based occupational therapy session was as Table 1: Participant demographics
follows: Participants Sex Age (year) Onset (month) Hospitalization
a. Filling out the forms for pain, fatigue, and anxiety Participant 1 Girl 7 6 3
assessments (5 min) Participant 2 Boy 9 9 4

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 Mohammadi, et al.: Play‑based Occupational Therapy for Children with Cancer

showed a reductive trend with treatment progress and be possibly associated with their gender, age, knowledge,
increasing hospitalization days [Figure 4]. This condition, and culture. Despite older age of participant 2, he had less
with preserving its reductive trend during intervention information about his disease and lived in a rural area. Our
phase, indicates fatigue severity reduction. Similar to pain results are consistent with the findings of Bazmi and Nersi
results, fatigue reduction trend is observed during 3‑session and Aliloo et al., who studied the impact of play therapy on
periods. Relationship between pain and fatigue can be reduction of anxiety in children with leukemia, suggesting
mentioned about participant 1 who experienced more pain the effectiveness of this intervention on reduction of
in the third session and reported more fatigue in this session. anxiety and feeling insecurity and increasing positive
Participant 2 also reported fatigue more than normal in the emotions.[36,37]
fourth session, which was related to the child’s expectation
for receiving blood test results and early discharge.[35] Conclusion
Reductive trend of anxiety in baseline phase for both The results of this study showed that play‑based
children is well observed [Figures 5 and 6]. Interesting occupational therapy can be helpful in reducing the
point is that anxiety was higher in the first intervention symptoms of hospitalized children with cancer. It seems
session in both participants, possibly due to unfamiliarity that presence of playroom and higher participation of
with therapist and treatment environment. Figures show an occupational therapist or a trained nurse in oncology
the reducing trend of anxiety during the intervention and palliative care are necessary to achieve the desired
period in both participants. In participant 2, anxiety in goals (reducing the unwanted symptoms and improvement
session 4 was reported more than other sessions, which was of participation in daily life activities and finally quality of
possibly because of waiting for early discharge. According life). Further studies need to be done with a larger sample
to the fatigue results in session 4, it can be referred to the size and in different types of childhood cancer.
relationship between anxiety and fatigue. Comparison of
anxiety severity between two children in baseline phase Financial support and sponsorship
indicated lower anxiety level for participant 2, which can This study supported with IUMS funding support.

Figure 1: Participant 1 pain Figure 2: Participant 2 pain

Figure 3: Participant 1 fatigue Figure 4: Participant 2 fatigue

Figure 5: Participant 1 anxiety Figure 6: Participant 2 anxiety

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 Mohammadi, et al.: Play‑based Occupational Therapy for Children with Cancer

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of play based therapy on play behaviour of children with
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172 Asia‑Pacific Journal of Oncology Nursing • Volume 4 • Issue 2 • April-June 2017