The Effects of Structured Cognitive-Behavioral Group Play Therapy on Anxiety and Depression in Children with Cancer: A Pilot Study

Document Type : Original Quantitative and Qualitative Research Paper


1 Assistant Professor, Departmeant of Education, Faculty of educational and sciences psychology, Ferdowsi University of Mashhad, Mashhad, Iran

2 MS in clinical psychology, Islamic Azad University of Nishapur, Nishapur, Iran


Background: Cancer as one of the chronic diseases in children is associated with psychological problems. Utilization of low-risk and cost-effective methods (e.g., play therapy) for controlling emotional distress seems necessary in children.
Aim: to determine the effects of structured cognitive-behavioral group play on anxiety and depression in children with cancer.
Methods: In this quasi-experimental pretest-posttest study, 18 children (8-14 years old) with cancer, hospitalized at Dr. Sheikh Hospital of Mashhad, were selected via available sampling and were randomly allocated into control and intervention groups in 2014. The intervention group received 10 sessions (60 min) of structured cognitive-behavioral group play therapy. Both groups were assessed by the Hospital Anxiety and Depression Scale (HADS) before and after the intervention. For data analysis, covariance analysis, paired t-test and independent t-test were performed, using SPSS version 20.
Results: The mean age of the participants was 10.5±2.4 years in the intervention group and 9.3±1.6 years in the control group. Independent t-test showed that anxiety and depression significantly decreased in the intervention group (6.7±2.1 and 8.1±1.2, respectively), compared to the control group (10±3.1 and 10.2±2.8, respectively) after the intervention (P<0.04).
Conclusion: Structured cognitive-behavioral group play therapy could be effective in reducing anxiety and depression in children with cancer.


Main Subjects

1.   Bazmi N, Nersi M. The Effect of Play Therapy' Techniques on Reduction of Anxiety and Increasing of Positive Feeling as well as General Adjustment Level in Children Suffering Blood Cancer in Tehran City. Q J Psychol Stud 2013;8(4):107-30. (Persian).
2.   Edwards M, Hilton D. Counselling Children with Chronic Medical Conditions. Translated by Riahinia E. Tehran: Nyvand pub; 1997.
3.   White C. Cognitive Behaviour Therapy for Chronic Medical Problems: A Guide to Assesment and Treatment in Practice. Translated by Moloudi R, Fatahi K.Tehran: Arjmand; 2001.
4.   Mahmood Alilo M, Hashemi Nosratabad T, Farshbaf Manei Sefat F. The Effectiveness of Play Therapy According Levy Approach in Reduction of Anxiety in Children with Diagnosed Cancer. Holist Nurs Midwifery J 2015;22(75):54-62. (Persian).
5.   Rahimi S, Fadakar Soghe R, Tabri R, Kazemnezhad Leili E. Related Factors with Quality of Life among Preschool Children with Cancer. Holist Nurs Midwifery J 2014;24(71):30-9. (Persian).
6.   Parandeh Motlagh Z. The Effect of Storytelling on Anxiety 7-10 years old Children Hospitalization. (Thesis MSc Nursing), Tehran School of Nursing and Midwifery; 2013. (Persian).
7.   Banki Y, Abedin A, Monirpour N. Investigating Role of Cognitive Variables in Depression of Children and Adolescents with Cancer. Q J Health & Psychol 2011;1(1):111-34. (Persian).
8.   Dantzera C, Swendsenb J, Maurice-Tisonc S, Salamon R. Anxiety and depression in juvenile diabetes: A critical review. Clin Psychol Rev 2003;23(7):787-800.
9.   Pourmovahed Z, Dehghani Kh, Yassini Ardakani M. Evaluation of Hopelessness and Anxiety in Young Patients with Thalassemia Major. J Med Res 2003;2(1):45-52. (Persian).
10. Hamidiyeh M, Shahidi S, editors. Principles of Mental Health. Tehran: SAMT; 2010. (Persian).
11. Zare M, Ahmadi S. The Effectiveness of Cognitive Behavior Play Therapy on Decreasing Behavior Problems of Children. Applied Psychol 2007;1(3):18-28. (Persian).
12. Mohammad Ismail E, editor. Play Therapy: Theories, Methods and Clinical Applications. Tehran: danjeh pub; 2010. (Persian).
13. Kaduson H, Schaefer C. 101 more Favorite Play Therapy Technique. Translated by Saberi S, Vakili P. Tehran: Agah & Arjmand pub; 1997. (Persian).
14. Ashwill J, Droske S. Nursing Care of Children: principles and practice. Philadelphia: Saunders; 1997.
15. Shen YJ. Short-Term Group Play Therapy with Chinese Earthquake Victims: Effects on Anxiety, Depression, and Adjustment. Int J Play Ther 2002;11(1):43-63.
16. Baggerly J, Parker M. Child-centered group play therapy with African American Boys at the Elementary School Level. J Couns Dev 2005;83(4):387-96.
17. Chilamakuri S, Nuvvula S, Sunkara N. Play Therapy in Pediatric Dentistry. J Paediatr Dent 2014;2(1):28.
18. Chari  U, Hirisave U, Appaji L. Exploring Play Therapy in Pediatric Oncology: A Preliminary Endeavour. Indian J Pediatr2013;80(4):303-8.
19. Athanassiadoua E, Giannakopoulosa G, Kolaitisa G, Tsiantisa J, Christogiorgosa S. Preparing the Child Facing Surgery: The Use of Play Therapy. Psychoanal Soc Work 2012;19(1):91-100.
20. Constantinou M. The Effect of Gestalt Play Therapy on Feelings of Anxiety Experienced by the Hospitalized Oncology Child.  (Thesis M.Diac Play Therapy),South Africa University; 2007.
21. Hamre H, Witt C, Glockmann A, Ziegler R, Willich S, Kiene H. Anthroposophic Art Therapy in Chronic Disease: A Four-Year Prospective Cohort Study. J Sci Healing 2007;3(4):365-71.
22. Carrol J, editor. Play Thrapy: The Children Views. Child and Family Social Work. New York: W.W. Norton & Company; 2002.
23. Farshbaf Manisefat F. The effect of Play Therapy on Reduction of Anxiety and Depression in Children With Cancer. (Thesis MSc Psychology), Tabriz University of Faculty Educational and Psychology; 2012. (Persian).
24. Hamedtavasoli S, Alhani F, Hajizadeh E. Investigating of The Effect of Familiarzation Play on the Iinjective Procedural Anxiety in B-Thalassemic Preschool Children. Iranian J Nurs Res7(26):42-9. (Persian).
25. Kariminasab A. Investigating The Effect of Narrative Therapy on Reducing Depressive Symptoms of Children with Cancer. (Thesis MSc  Clinical Psychology), Ferdowsi University of Mashhad; 2010. (Persian).
26. Zareapour A, Falahi Khoshknab M, Kashaninia Z, Biglarian A, Babashahabi R. Effect of Group Play Therapy on Depression in Children with Cancer. Sci J Kurdistan University Med Sci 2009;14(3):64-72. (Persian).
27. Nersi M. The Effect of Play Therapy's Techniques on Reduction of Anxiety and Increasing of Positive Feeling as well as General Adjustment Level in Children Suffering Blood Cancer in Tehran City. (Thesis MSc Clinical Psychology), Rodehen Azad  University; 2004. (Persian).
28. Kaviani H, Seyfourian H, Sharifi V, Ebrahimkhani N. Reliability and Validity of Anxiety and Depression Hospital Scales (HADS): Iranian Patients with Anxiety and Depression Disorders. Tehran Univ Med J 2009;67(5):379-85. (Persian).
29. Zigmond A, Snaith R. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67(6):361-70.
30. Drayer R, Piraino B, Reynolds S, Houck P, Mazumdar S, Bernardini J, et al. Charactristics Depression Hemodialysis Patient. Psych Med J 2006;4(24):306-12.
31. Montazeri A, Vahdaninia M, Ebrahimi M, Jarvandi S. The Hospital Anxiety and Depression Scale (HADS): Translation and Validation Study of the Iranian Version. Health Qual Life Outcomes. 2003;1(1):14. (Persian).
32. Liebmann M. Art therapy for groups: a handbook of themes and exercises. Translated by ZadehMohamad M, Tavakoli H.Tehran: Ghatreh pub; 1986. (Persian).
33. Geldard K, Geldard D. Counselling children: a practical introduction. Translated by Parniani M.Tehran: Roshd pub; 2009. (Persian).
34. Drewes A, editor.Blending play therapy with cognitive behavioral therapy : evidence-based and other effective treatments and techniques. Translated by Ramezani Gh.Tehran: Vania pub; 2002.
35. Mamyyanlo H, Alhani F, Ghofranipour F. Evaluation of the Effects of a Play Program on the Anxiety of Hospitalized School-Age Children in Tehran Medical Center of Children in 1999-2000. Modares Medical Sciences Journal 2001;4(1):55-62. (Persian).
36. Shafie SM. The Effect of Storytelling on Anxiety 7-10 years old Children Hospitalization. (Thesis MSc Nursing), Jundishapur University of Medical Sciences; 2012. (Persian).
37. Beebe A, Gelfand E, Bender B. A Randomized Trial to Test the Effectiveness of Art Therapy for Children with Asthma. J Allergy Clin Immunol 2010;126(2):263-6.
38. Bar-Sela G, Antid L, Danos S, Gabay N, Epelbaum R. Art Therapy Improved Depression And Influenced Fatigue Level In Cancer Patients on Chemotherapy. PsychoOncol 2007;16(11):980-4.
39. Li WH, Chung OK. Enhancing the efficacy of psychoeducational interventions for paediatric patients in a randomised controlled trial: methodological considerations. J Clin Nurs2009;18(21):3013-21.
40. Li WH, Chung JO, Ho EK. The effectiveness of therapeutic play, using virtual reality computer games, in promoting the psychological well-being of children hospitalised with cancer. J Clin Nurs 2011;20(15-16):2135-43.