Covadonga Chaves, Carmelo Vázquez
and Gonzalo Hervás
Children in the wish group became more aware of the support provided by others and this awareness could have lead to a sense of thankfulness and love in response to fulfilling a wish. Gratitude and love are two of the strengths most robustly associated with life satisfaction (Park et al., 2004). Gratitude appears to be a powerful resilience factor that may help people to cope with traumatic experiences (Fredrickson et al., 2003).
Health-related quality of life. We used The
Health-Related Pediatric Quality of Life
Scale, HPedsQoL (Varni et al., 2002), a
27-item scale to assess health-related quality
of life in children and adolescents with an illness.
As with the General Quality of Life
Scale, we used a children self-report version
and a parent proxy-report version. This scale
assesses how often in the past month children
have experienced different problems related
to their disease (e.g. concerns about their
physical appearance). Here we report data on
the only two physical health subscales: pain
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6 Journal of Health Psychology
and nausea (assessed by using a 5-point
Likert-type scale ranging from 0—“never” to
4—“almost always”). Items were inverted.
Cronbach’s alphas were .86, .88, and .87 for
children, fathers, and mothers, respectively.
The intra-class correlation coefficient was
.59 for father–child agreement and .73 for
mother–child agreement.
Depression. We used the abbreviated 7-item
version of The Center for Epidemiologic
Studies-Depression Scale, CESD-7 (Santor
and Coyne, 1997) which measures the severity
of symptoms of depression during the past
week (e.g. “I felt that I could not shake off the
blues even with the help from my family or
friends”) using a 4-point Likert-type scale
ranging from 0 (“never”) or rarely to 3 (“almost
always”). Internal consistency was α=.87.
Medical status: Doctors provided information
about the children’s diagnosis, severity
(measured by a scale from 0 to 10), the stage
of disease (i.e. active treatment/off treatment/
relapse/palliative), and perceived probability
of survival at 1 and 5 years.
Discussion
This study analyzed the effects of a positive
intervention on children’s well-being and several
domains of positive functioning as assessed
by themselves and their parents. According to
our first hypothesis, we expected that granting a
wish would reduce NE and increase PE, life satisfaction,
and general quality of life. Although
our results did not confirm our predictions for
NE, we found that wish-granting promotes PE and that its resultant effects last for at least several
weeks. According to the broaden-and-build
theory of PE (Fredrickson, 1998, 2001), PE
work by helping to build durable physical,
intellectual, and social resources that are essential
to promoting adaptive coping responses following
traumatic circumstances (Cohn et al.,
2009; Tugade and Fredrickson, 2002).
Furthermore, with regard to life satisfaction
and general quality of life, our results showed
that this intervention improves a multidimensional
composite score of life satisfaction. This
finding has relevant implications given the previous
evidences that link satisfaction with life
to more positive functioning (Gilman and
Huebner, 2006).
These results partially confirm our hypothesis.
The wish did not cause significant decreases
in NE or depression, perhaps due to a floor effect
(i.e. very low scores on these negative
dimensions found in both groups). Research has
consistently shown that although a significant
minority has some difficulties with adjustment
and/or symptoms of psychological distress, the
majority of children with a chronic illness show
good levels of adjustment (Zebrack and Chesler,
2002). Thus, well-being based interventions
probably have a limited effect in decreasing distress
(Pai et al., 2006).
As for our second hypothesis, we expected
that granting a wish would promote positive
functioning and other psychological resources
(i.e. benefit finding, personal strengths, beliefs
in the benevolence of the world, and optimism).
Results revealed that the children in the wish
group reported significantly higher gratitude
and love after the granting of the wish than
those in the comparison group. Children in the
wish group became more aware of the support
provided by others and this awareness could
have lead to a sense of thankfulness and love in
response to fulfilling a wish. Gratitude and love
are two of the strengths most robustly associated
with life satisfaction (Park et al., 2004).
Gratitude appears to be a powerful resilience
factor that may help people to cope with traumatic
experiences (Fredrickson et al., 2003).
Several studies have shown that interventions promoting gratitude reduce negative affect and
increase levels of positive affect, life satisfaction,
and optimism about the future (Bono and
McCullough, 2006; Emmons and McCullough,
2003). Thus, a grateful attitude may be beneficial
to improve physical health status and may
also help the individual find positive meaning
in negative circumstances (Emmons and
McCullough, 2003).
In a study with healthy
children and adolescents, Froh et al. (2009)
found a positive association between gratitude
and positive affect, satisfaction with life, optimism,
social support, prosocial behavior, and
physical health.
On the other hand, loving and feeling loved
provides emotional security and confidence that
allow children to more effectively cope with
daily stress (Hazan, 2004). Caring ties can
buffer people from adversity and pathology as
well as enhance their health and well-being
(Fredrickson, 2013). A recent study showed that
perceived positive social connections account
for the upward spiral between PE and health
benefits, such as increases in vagal tone (Kok
et al., 2013).
As for our third hypothesis, we expected that
our intervention would have some impact on
children’s physical symptoms. Our results
showed that the children in the wish group
reported significantly lower levels of nausea
after wish than those in the comparison group.
This result is consistent with research showing
that music therapy or visual imagery has positive
effects on reducing nausea and other side
effects in adult patients with chronic illnesses
(Karagozoglu et al., 2013).
As for our fourth hypothesis, we expected
that parents in the wish group would perceive
positive changes in their children’s well-being.
Specifically, mothers in the wish group reported
positive changes in benefit finding and general
quality of life in children, especially in physical,
school, and emotional domains. Mothers in the
wish group also reported a perceived decrease in
their child’s concerns about the disease. This
result supports previous research on clown
interventions that showed a significant decrease
in children’s concerns about the hospitalization, the medical procedures, and the illness and its
negative consequences (Costa and Arriaga,
2010). Those dimensions are particularly relevant
in children with life-threatening illnesses,
given the different pathways in which BF and
quality of life may improve physical and psychological
health (Bower et al., 2009; Hedström
et al., 2004). These findings are also relevant
because although the PE promoted by granted
wishes can be considered as transient and
ephemeral, it may have an effect on increasing
or maintaining people’s subsequent psychological
well-being by channeling more effective
coping resources (Tugade and Fredrickson,
2002). Furthermore, perception of the child’s
distress is one of the most common explanations
for parental anxiety (Lamontagne et al., 2003).
Thus, parents’ perception of positive changes
may be an indicator of actual changes in the
children but may also serve to promote wellbeing
of the parents themselves. This in turn
may contribute to creating or maintaining
upward spirals of PE within the turmoil of
adverse experiences (Tugade and Fredrickson,
2002).
Our study has some limitations.
First, our
sample includes some very young children.
Protocol was carefully designed to facilitate the
understanding by children of all ages (i.e. providing
visual aids such as faces or thermometers,
reading each item to the child when needed,
or pre-testing cognitive competence). However,
we cannot be completely sure that all the children
understood what they were being asked.
Second, extremely-ill children or those who
lacked the necessary language skills, attention
span, or cognitive abilities to complete a questionnaire
were excluded to ensure the quality of
the study, but this may limit generalization of
results. Third, it is noticeable that effect sizes of
the intervention on the measures were relatively
small. Yet, it is still remarkable that a rather
small-scale and limited intervention may have a
significant effect on children’s well-being.
Despite these limitations, we believe that our
study has some important contributions to the
current literature in the field. This is, to our
knowledge, the first controlled study of this kind
of intervention for ill children. In contrast to
other studies that have assessed similar naturalistic
interventions (e.g. clown interventions), we
used a pre–post test comparison-group design.
This procedure allowed us to evaluate changes in
outcomes while controlling for potential baseline
differences between groups. Second, positive
interventions, like the one analyzed in this
research, are increasingly being integrated into
pediatric oncology care and this study supports
its efficacy in several parameters related to positive
functioning. Since healthcare policy should
rest on empirically supported interventions, our
results can foster a renewed interest in funding
research on positive interventions.
Third, most of the studies on psychological
interventions in these clinical contexts are usually
focused on the psychological distress associated
with childhood chronic illness. Yet, an
exclusive focus on the detrimental effects of the
illness may bias the psychological assessment
process and may impede the observation of
changes in other relevant areas of psychological
functioning. Multidimensional assessment
including a wide array of well-being measures
provides a more accurate picture of children’s
responses to potentially stressful events.
In conclusion, our results suggest that
although it is necessary to provide effective
treatments for emotional and behavioral difficulties
when they do arise, a further aim should
be taken into consideration to promote resilience
and positive adjustment. Children who are cared
for in terms of both their medical and psychological
needs are more likely to adjust positively
to any challenges arising from their condition,
enabling them to participate more fully in ordinary
childhood activities and lead as normal a
life as possible. Thus, we encourage the use of
this type of positive intervention for children
with serious illnesses and we expect a growing
presence of studies focusing on positive interventions
in children with serious illnesses.
