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HE
106,4 Implementation and evaluation of
the modified feeling great
program for oncology children
294
C. Nadeane McCaffrey
University of Western Australia, Perth, Australia
Received September 2004
Accepted December 2005

Abstract
Purpose – Designed to reduce anxiety and boost self-concept, The Modified Feeling Great Program
(MFGP) consisted of a series of mental training exercises used to improve the quality of life for 6-17 year
old children (N ¼ 20) with cancer. More specifically, the children were taught how to relax, look for
highlights (good things that happen to them), and turn-off negative thoughts that came into their heads.
This paper aims to assess the program’s effectiveness.
Design/methodology/approach – A pre-/post-test design was used to determine the effectiveness of
the MFGP. To participate, children had to be of school age and diagnosed with cancer during the past five
years. Six questionnaires/scripts were administered to obtain pre and post information on the dependent
variables: highlights, relaxation, stress control, heart rate imagery/excitement and heart rate
imagery/relaxation, self concept, and anxiety. Heart rate monitors (DT1000, Polar, New York)
measured the physiological effects of the MFGP relaxation component. The 37-item Revised Children’s
Manifest Anxiety Scale (RCMAS) and Song and Hattie’s 15-item self-concept scale were also used in this
investigation to measure the dependent variables. All instruments had established validity and reliability.
Findings – An examination of pre- versus post-test results showed that the MFGP program
produced significant (0.05 level) reduction in (RCMAS) worry/over-sensitivity, (RCMAS) social
concerns/concentration, e.g. physical anxiety, highlights, exciting heart rate/imagery, and relaxation
heart rate/imagery. Further statistical analysis revealed that the MFGP was equally effective for boys
and girls.
Research limitations/implications – Six children were unable to do the mental training exercises
on a regular basis due to ill health from chemotherapy treatments. There was no control group and
sample size was small (N ¼ 20). A more robust research design should be used during future
investigations.
Practical implications – To date, most of the treatment for children with cancer is concerned with
the physical aspects of the problem, i.e. the use of chemotherapy to kill cancer cells. The results of the
present investigation demonstrate that greater attention needs to be given to psychological factors, e.g.
anxiety, poor self-concept and problematic interpersonal relations with parents, teachers and medical
personnel. These results suggest that positive effects can be obtained by using the MFGP.
Originality/value – These results are useful for hospital personnel, parents, teachers, and other
persons who provide services to children with cancer.
Keywords Children, Cancer, Stress, Relaxation theory
Paper type Research paper

A special thank you, to Dr William Straub for his encouragement and guidance in the writing of
this article. An indebtedness and recognition go to the oncology children, their parents, families,
Health Education
Vol. 106 No. 4, 2006 and staff at the Princess Margaret Children’s Hospital, for their continual cooperation during this
pp. 294-308 study. Appreciation is also extended to my advisors, Professor Houghton, and Dr Douglas, at the
q Emerald Group Publishing Limited
0965-4283
University of Western Australia, for their assistance and attention to detail throughout this
DOI 10.1108/09654280610673472 investigation.
Mental training for children with cancer Program for
Approximately 130 children out of one million, aged 0-14 years, will develop cancer oncology
annually (Keene, 1999). In the USA, approximately 8,600 children were diagnosed with
cancer and about 1,500 children died from the disease in 2001 (National Cancer children
Institute, 2002). The diagnosis of cancer in a child is generally viewed as a source of
severe stress not only for the child him/herself, but also for the family. Immediately
following the diagnosis of childhood cancer, tremendous upheavals in the emotional 295
and practical aspects of each family member’s life occurs (Hinds et al., 1996). At the
hospital, a continuous procession of unknown people enters the child’s life. The child
receives needles, LPs (lumbar punctures), bone marrow aspirations and other painful
procedures. Therefore, there is a need to develop strategies, which reduce stress and
enhance the quality of life (QOL) for the child, her/his parents and family. The results
of the present study are important since life skills training resulted in a reduction in
anxiety and positive increments in self-esteem.
There are numerous studies supporting the benefits of relaxation training with
children, including increases in secretory immunoglobulin A (slgA) which prevents
infection (Lowe et al., 2001). In addition, rapid heart rate has been linked to problems
with immunity, while a lower heart rate creates a less negative affect (Farag, 2002).
Research also shows that teaching children positive life skills at an early age helps to
off set potential life adjustment problems (Cox and Orlick, 1996; Gilbert and Orlick,
1996; Denis et al., 1996; Orlick and McCaffrey, 1991).
Research by Barrera et al. (2005), Macner-Licht et al. (1998) and Woodgate and
McClement (1998), suggest that teaching oncology children life skills and coping
strategies is beneficial, and that interventions should focus on self-worth from the
initial diagnosis to ensure that late effects are controlled. According to Schwartz and
Gredler (1998), children with high self-esteem strive to overcome challenges, are
determined in the face of failure and strive to attain personal goals. Conversely, those
with low self-esteem give up in the face of difficulties, set only achievable goals and
suffer increased anxiety and stress. The intervention approach is recognized in the
literature as simple, inexpensive and beneficial, when offered to patients to improve
QOL during primary chemotherapy (Curtis, 2001; Walker et al., 1999).
Brissette et al. (2002) suggest that an optimistic and positive attitude is beneficial,
and that a pessimist might benefit by adopting an optimist’s techniques for effective
coping. Other recent literature also supports an optimistic outlook for better health and
well-being (Brenes et al., 2002; Levy et al., 2002). Speca et al. (2000) emphasized that
to be in control of stress, a person should write about it, talk it out, and look at
the situation in a new and more positive way to effect change. Conversely, negative
emotions may inhibit the healing process (Cole-King and Harding, 2001) while the
fostering of a happy frame of mind may bring symptom relief (Van Oyen Witvliet et al.,
2001). In the present investigation, children were asked to describe “Highlights”, i.e. the
positive aspects of their lives. They enjoyed and profited from sharing these events
with their peers. Thinking positively is an integral part of the Feeling Great mental
training program that was used in this investigation.
It is well documented that selecting positive words to repeat to oneself, and
progressing to better thoughts is favourable (Linney, 2001). Self-talk is also used in the
FGP CD relaxation activities and exercises to bring about reductions in elevated levels
of anxiety. Without these skills there are links with higher rates of negative self-talk,
HE and higher incidences of anxiety and depression (Hardy et al., 2001; Lodge et al., 1998;
106,4 Prins and Hanewald, 1999; Ronan and Kendall, 1997). The Modified Feeling Great
Program (MFGP) thus attempts to address many of the personal issues associated with
a person’s cognitive functioning during illness.
According to Kazak et al. (1997), psychological interventions are needed during and
after cancer treatments, as the emphasis of care focuses more and more on the QOL for
296 both child and family. Recent research (Barrera et al., 2005) accentuates fostering
higher self-esteem, as then the children’s outcomes are better. Woodman (2002),
demonstrates that for children diagnosed with cancer, discomfort lies in the acute
distress, pain, joint aches, headaches, fatigue, fever, nausea, and taste aversions related
to treatments, e.g. chemotherapy. The motivation for MFGP came from the realization
the children with cancer not only experience great physical pain but also debilitating
psychological problems, e.g. high anxiety, worry and disrupted interpersonal
relationships with peer, sibling and parents.
As a result of recurrent painful medical procedures, such as bone marrow
aspirations, lumbar and vein punctures, children with cancer frequently experience
conditioned anxiety. Consequently, more than half of all cancer patients (children and
adults alike) are using alternative therapies to cope with such discomforts and the side
effects of chemotherapy (Woodman, 2002). Although the chances of long-term survival
for some children with cancer have improved, in many cases the emotional impact of
the diagnosis and experience of cancer on the child, family, and community, is extreme
and enduring (Hinds et al., 1996).
Eiser et al. (2004), when applying Regulatory Focus Theory (RFT), predicted that
among survivors of childhood cancer, QOL may be compromised by
prevention-focused parenting. Eiser interviewed the parents of 64 survivors of acute
lymphoblastic leukemia (ALL) or central nervous system (CNS) tumours. Overall,
parents expressed more promotion than prevention focus, especially in relation to
general rather than illness-related contexts. In the present study, the parents of
children who participated in MFGP were asked to manage their thought processes so
that they served as models for their children to emulate.
Irrespective of the medical outcome, families facing these predictable crises require
skilled supportive care. Hence, the continuing consideration of psychosocial needs is a
major component of effective multi-modal treatment (Eapen et al., 1999; Kazak, 1999;
Kazak et al., 1997).

The feeling great program

The Feeling Great Program (FGP) (Orlick and McCaffrey, 1995a, b, c, d) was developed
as a specialized curriculum for children in the elementary public schools of Ottawa,
Canada. Over a period of three years approximately 3,000 children from eight schools
participated in the development of this program. The purpose of the FGP was to teach
children life skills and stress control strategies to enable them to learn more effectively,
live a happy more fulfilling life and excel on a daily basis. Experienced mental trainers
taught relaxation, concentration, imagery, goal setting, and cognitive restructuring
(getting rid of negative thoughts). These specific life skills were taught for 20-30
minutes three times each week for 12 weeks.
Research has repeatedly demonstrated that the FGP is effective in enhancing the lives
of elementary school children. Orlick and McCaffrey’s (1995a, b, c, d) investigations
show that children who participated in the FGP of stress control interventions enjoyed Program for
the activities, learned to relax “at will” and successfully implemented stress control oncology
strategies in a wide variety of real world situation. Additionally, these children reported
more “highlights” (good things that happen to them) and increased positive feelings children
about themselves (Orlick, 1996).
Additional support for the use of the FGP comes from recent research by Lutgendorf
et al. (2002) and Burns et al. (2002). Lutgendorf and his associates established the link 297
between stress and the immune response. Burns et al., used stress reduction techniques,
such as deep breathing exercises and positive imagery, to promote calm feelings.
According to Dhabhar et al. (1996), during diagnosis and treatment it is important for
children with cancer to remain calm since stress has been shown to inhibit healing.
Research by Woodgate and McClement (1998) indicate that children who experience
frequent cancer stressors exhibit higher levels of anxiety and lower self-esteem.
Observational evidence from the present study supports the above generalization.

The modified feeling great program

The program consisted of activities to teach, highlights (events or happenings that
make you feel good, happy), relaxation, stress control, positive thinking/positive
perspectives, imagery, and goal setting. For the purposes of this research, it was
modified for children or adolescents (6-17 years) with cancer. The FGP was structured
for elementary school children (5-12 years). All participants in the original phone
interviews, child, parent or teacher, made reference to the need for confidence building
activities and stress control techniques. “Wording” such as hospital, procedures,
treatment, was also included in the program to encompass the ongoing check-up visits
or regular treatment sessions. Monthly meetings held with the participants (during the
implementation time frame of the program), also aided in shaping individual
modifications, e.g. sport related, animal stories, relaxation scripts, etc.
In summary, as demonstrated above, there exists considerable empirical evidence to
support the value of mental training for children with cancer. In the present
investigation, although sample size was small (N ¼ 20) and a control group was not
utilized, the MFGP produced significant reductions in anxiety, improved self-worth
and a more stable and positive perspective of life events.
Practitioners should pay careful attention to the findings of the present investigation
because MFGP has the potential to significantly enhance the QOL for children cancer.

Methodology
Using a pretest-posttest design, this exploratory investigation tested the effectiveness
of a MFGP (McCaffrey, 2003) on 20 children with cancer at a children’s hospital in
Western Australia.

Participants
The initial sample of oncology children (N ¼ 22) (Table I) consisted of 12 girls and 10
boys who ranged in age from 6 to 17 years. Not long after pre-testing, participant #21
chose not to continue and participant 22 passed away, (N ¼ 20). Medical diagnoses of
participants ranged from ALL (n ¼ 9), Hodgkin’s Lymphoma (n ¼ 3), Non-Hodgkin’s
Lymphoma (n ¼ 3), Sarcomas (n ¼ 3), Wilm’s Tumour and other cancer related
disorders (n ¼ 4).
HE Child Age/sex Diagnosis/medical status
106,4
1 11/Girl Acute lymphocytic leukemia (ALL) – maintenance
2 14/Boy ALL – maintenance, relapsed, passed away, 11/01
3 7/Girl ALL – off treatment
4 12/Girl Osteogenic sarcoma – off treatment
298 5 8/Girl Non-Hodgkin’s lymphoma – off treatment
6 14/Boy Hodgkin’s disease – off treatment
7 11/Girl ALL – off treatment
8 14/Boy Ewing’s sarcoma – treatment ongoing
9 9/Boy Neuro-lymphocytic leukemia – maintenance treatment
10 11/Boy ALL – off treatment
11 12/Boy ALL – off treatment, 98; 2002 relapsed
12 11/Girl Sickle cell anaemia – treatment ongoing every 5 weeks
13 6/Boy Non-Hodgkin’s lymphoma – maintenance treatment
14 9/Boy Hodgkin’s disease – off treatment
15 13/Boy Hodgkin’s disease – off treatment
16 13/Girl Rhabdomyosarcoma paremeningeal – ongoing treatment to jaw and mouth
17 15/Girl Osteogenic sarcoma – off treatment
18 16/Girl ALL – off treatment
19 12/Girl Wilm’s tumour – off treatment
20 11/Boy ALL – off treatment
Table I. 21 15/Girl Non-Hodgkin’s lymphoma – off treatment
Participants of the FGP 22 14/Girl ALL – on maintenance, relapsed, passed away, 11/00

Specific criteria were adopted for sample selection. To participate in the research, individuals
needed to be; school age, and have been diagnosed with cancer within the last five years, or
be presently on treatment, or completely off treatment, or in maintenance, within the five
year period. No specific cancer was singled out as part of the exclusion criteria.

Materials
Instrumentation. Participants completed six questionnaires/scripts to obtain pre-test
and post-test information on the 11 dependent variables:
(1) highlights;
(2) relaxation;
(3) stress;
(4) heart rate imagery/excitement;
(5) heart rate imagery/relaxation, Self concept;
(6) social;
(7) physical;
(8) peer, and Revised Children’s Manifest Anxiety Scale (RCMAS);
(9) physiological;
(10) worry/oversensitivity; and
(11) social concerns/concentration.

Testing took approximately 30-60 minutes.

 Highlights pertain to events or happenings that made the children smile, feel good, Program for
and/or happy. Participants wrote down all the highlights/positive experiences on that oncology
day. A frequency count was recorded. For example, child #5 had one highlight in the
pre-test (I saw my friend Chloe at the clinic today) and three highlights in the post-test children
(The teacher gave me a star for my story; I was allowed a sleep over on the weekend;
and My Mum put my favourite snack in my lunch today). The highlight difference
scores between the pre- and post-tests were used to assess the level of change when 299
looking for positive experiences over the course of the intervention.
Self-rating scales. Relaxation and stress control. The pre- and post-test measures
comprised two questions with five point scales which asked: How good are you at relaxing
yourself? How good are you at making yourself less worried? Both questions were
anchored with response options, no good at all (score of 1), good (3), up to great (score of 5).
Heart rate. Heart rate monitors (DT1000, Polar, New York) (clipped to the participant’s
ear lobe) were used to measure the physiological effects of the MFGP relaxation
component. Cox and Orlick (1996) and Reed (1993) demonstrated that this instrument has
a test-retest reliability of r ¼ 0.97. The researcher asked the child, “In your mind I would
like you to imagine or pretend that you are doing something that would be really exciting
to do. Close your eyes and try to imagine it.” The heart rate was then recorded as it
occurred at its highest level after a 30-60 second period. Following a two minute break the
researcher asked, “Now try and imagine or pretend that you are doing something really
relaxing, restful, calm or quiet. Close your eyes and try to be it, imagine it.” The heart rate
was then recorded at its lowest level after a 30-60 second period.
The About Myself Test of Self-concept (Hattie, 1992): An abbreviated 15 item
version of the Song and Hattie Test of Self-concept which has excellent validity and
reliability was used to collect data pertaining to self-concept. Three of the seven
subscales of the test of self-concept were used to assess the self-concept levels of the
oncology patients and a five-point Likert response option was used with 4 as “strongly
agree” to 0 as “strongly disagree”. The three subscales each comprising five questions
were; peer/friends, physical, and social/confidence in self-concept.
The RCMAS, subtitled “what I think and feel” is a 37 item, self-report instrument
designed to assess the level of anxiety in children and adolescents from 6-19 years old
(Reynolds and Richmond, 1986); of the 37 Items, nine are discounted as the Lie factor,
leaving 28 Items. The RCMAS consists of three subscales namely; physiological
anxiety (10 items); worry/over-sensitivity (11 items); and social concerns/concentration
(seven items). Participants are required to respond “Yes” or “No” to each statement.
“Yes” responses are counted to determine a total anxiety score (28 items).
Individual Feeling Great Logbooks (Orlick and McCaffrey, 1995b, d) were used to
provide qualitative information relating to ongoing feelings and experiences of
children with cancer. Substantiation for the use of logbooks comes from Gardner and
Cole (1988) and Garbarino and Stott (1989). According to Gardner and Cole, recording
procedures should be kept simple when children are asked to describe certain emotions
or behaviours. Garbarino and Stott indicated that children are most likely to share
information that is reliable when they are reporting events relating to their own
interests and everyday experiences. As a result, the Logbooks in the FGP are fun,
cartoon illustrated (Figure 1), and simply worded for reporting information (by drawing
or words). They provided information about relaxation, stress control activities,
positive thinking, highlights, goal setting and positive imagery experiences.
HE
106,4

300

Figure 1.
Heart rate relaxation
(FGP logbook)

Feeling Great Program materials (Table II, Figure 1) consisted of the Modified Manual
(McCaffrey, 2003), Logbook (Orlick and McCaffrey, 1995b, d), and FGP CD series 1 and 2
(Orlick and McCaffrey, 1993a, b).

Procedure
Permission to participate in this investigation was initially obtained from the Human
Research Ethics Committee at the University of Western Australia and the relevant
Hospital Ethics Committee. A letter of consent and an information sheet explaining the
research was sent to 100 oncology patients at the children’s hospital. Twenty-five
Date:
Program for
Questions: Did you use special place relaxation or the peaceful sea on your own oncology
yesterday or today? children
Teaching point: One of the best ways to relax your whole body and mind is to focus on
relaxing different muscles in your body
Activity 1: 1. Logbook – heart rate relaxation (page 3). Children take their own pulse
for 30 seconds, before the relaxation exercise (on your instruction), and 301
again after relaxation (on your instruction). Children record their heart
rate in their logbook
2. CD2 – Act.3 – muscle relaxation (TEENS as well)
Post-activity questions: Were you able to focus on relaxing the different muscles in your body? Did
you feel relaxed? When could you use muscle relaxation?
Reminders:
Child: Practice muscle relaxation on your own before you go to sleep tonight.
Practising will make you great at these skills
Teacher: Muscle relaxation is an excellent activity to become competent at, so try it Table II.
when sitting, standing or lying down. With some nice deep breaths it is DAY 4 Activities in the
very effective FGP

parents/children responded and of these, 22 children were pre-tested for inclusion in

FGP. The initial data pertaining to demographics and illness/treatment regime were
gathered through home telephone interviews. Information included: child’s name, date
of birth, parent’s names, number of brothers and/or sisters, and year in school.
Additional information was obtained about the duration of hospital stay, type of
cancer, date of diagnosis, type(s) of treatment(s), ongoing effects of cancer, special
interests, special needs and pets. Parents were also asked about where they would
prefer the MFGP to be implemented, i.e. at home, school or hospital. Prior to
pre-testing, parent information sessions were arranged at the hospital to provide
an overview of the program and to answer questions. Immediately following the
information sessions the researcher contacted schools to arrange meetings with school
principals and teachers to determine how they might accommodate the program.
There were two methods of program delivery: In school and at home. The beginning
organization and pre-course information/education was conducted at the child’s home,
school or hospital, whichever was chosen. To arrange meetings, the researcher made
contact with participants by telephone or e-mail. School principals were contacted to
obtain permission for the oncology child’s teacher or school counselor/special needs
teacher to implement the program in class or individually, respectively. The children
who had elected to begin the program at home were visited at their homes, pre-tested,
given the materials by the researcher with the parents present, and taught how to
implement the program. Five schools (three elementary, two secondary) started the
FGP but only three elementary schools continued through the nine months of the
investigation. Teacher changes, adjustments of the curriculum, timetable issues, and
lack of time to commit to the program were the major reasons for discontinuation.
Parents taught participants whose schools ceased delivering the program. The
schools/classes delivering the program were e-mailed and visited on a regular basis by
the researcher, while children receiving the program at home were met regularly by the
researcher at the hospital during checkups or treatment. Fifteen children had access to
e-mail and were contacted monthly for progress reports.
HE Pre-program education consisted of three meetings per school and an information
106,4 session arranged for the class teacher/counsellor on how to deliver the MFGP. Fifteen
schools (three high schools and 12 primary schools) were initially contacted, whereas only
five schools started the program and three finished it. Although all school principals
recognized the benefits of the FGP, the majority of schools would not commit to the
10-15 minutes/day due to time, curriculum programming and other timetable issues.
302 The CD’s in the FGP were designed to help facilitate the delivery of the program
through activities, e.g. relaxation, highlights, listening, focusing, laughing, diaphragm
breathing, imagining positive outcomes, and other psychological skills. The children
listened and followed the instructions.

Analysis
Following data collection, the information was coded and prepared for data analyses.
Descriptive and inferential statistical procedures were used to determine the program’s
effectiveness. A two-way repeated measures, analysis of covariance was used to
analyze the data obtained from the 11 dependent variables. The two factors in the
repeated measures were a between persons factor of gender and a within factor of the
pre- versus post-measures. With age in months serving as the covariate, ANCOVA was
used to determine the overall effectiveness of the MFGP. An 11 £ 11 correlation
matrix determined the interrelationship of the dependent variables. Overall, an
analysis of responses from the oncology children indicated high internal consistency
reliability (RCMAS - coefficient a ¼ 0.87, test of self-concept 2 coefficient a ¼ 0.92.
The positive correlation (RCMAS and test of self-concept) found between participants’
scores provided evidence of concurrent validity.

Results
The original sample consisted of 22 children, 12 girls and 10 boys, ranging in age from
6 to 17 years. One child died and another decided not to continue with MFGP. All the
children were suffering from various forms of cancer, (Table I).
Prior to analysis, the pre-/post-test instruments were examined to determine if they
had established validity and reliability. The responses of the children were scored using
item-analysis, item-discrimination and other statistical procedures. Since, some of the
measures appeared to be similar, the 11 dependent variables were checked for
redundancy and overlap. The correlation of pre-test data indicated that self-concept,
social and peer variables produced an r ¼ 0.79, indicating that they were measuring
nearly the same quality. Additionally, an r ¼ 0.60 was found for self-concept and social
and physiological measures. For example, the relaxation question (How good are you at
relaxing yourself?) correlated r ¼ 0.67 with self-concept, and physiological variables. In
brief, these positive values indicated that some of the measures were highly correlated.
Of the 11 correlations with age, only one, worry/over-sensitivity was marginally
significant ( p , 0.046). Based on the above findings, it was concluded that there was
very little overlap among the measuring instruments. Post-test data were also
correlated with age and not a single r reached statistical significance at the 0.05 level.
The MFGP was equally effective for children, 6-17 years.
The overall effectiveness of the MFGP was determined by a two-way
(persons £ gender) repeated measures ANCOVA of the 11 dependent variables. Age
in months served as the covariate. A significant within subjects effect (pre versus post)
(F(11,8) ¼ 4.19, p , 0.03). Statistical significance was not found for gender or its Program for
interaction with pre- and post-test measures. Therefore, the MFGP was equally oncology
effective for boys and girls.
An examination of univariate effects (i.e. examination of one variable at a time) for children
the 11 dependent variables revealed significant differences for the RCMAS
worry/over-sensitivity measure (F(1,18) ¼ 6.30, p , 0.02), effect size 0.79; highlights
(F(1,18) ¼ 22.54, p , 0.001), and the exciting heart rate/imagery activity 303
(F(1,18) ¼ 4.82, p,0.04). Two other variables, relaxation heart rate/imagery,
RCMAS-social concerns/concentration also reached statistical significance at or
beyond the 0.05 level. In summary, of the 11 independent variables, five achieved
statistical significance.
The MFGP participants were asked to perform a relaxation exercise and an activity
from the logbook, 3-5 days a week, reinforcing any one or more of the program skills.
The stress control component of the program was therefore, encouraged on a daily
basis, and documented in the participant’s logbook. The efficacy of this approach is
typified by three participant’s comments such as: “I was asking the Principal
something and I was a little stressed and I breathed in and out slowly and felt a little
more relaxed” (12 year old boy); “I couldn’t sleep as I was a little stressed so I did
Muscle Relaxation and it made me very relaxed” (16 year old girl); “ My best ways of
dealing with worry or stress; Talking to Mum or Dad or a friend. Writing my problems
down. Exercising such as swimming” (16 year old girl).
To determine how the MFGP was received by teachers, participants and their
parents, 20 children were pre-tested and post-tested. And of those 20, 14 participants,
11 parents and three teachers provided qualitative evaluation feedback. The qualitative
evaluation instrument was designed by the researcher. Many reasons were cited to
explain why six children did not complete the MFGP over the period of nine months, e.g.
school class could not find the time, school counsellors would not give the time, home
environment was too hectic, child refused to participate, or the child relapsed, etc.
Twelve of the 14 participants liked the program, and all 14 said it helped them. The
exercises they liked best were generally the CD activities for relaxation. Eleven
participants used the activities in many different situations, i.e. for sleeping, at school,
with friends, for sports participation, treatments at the hospital, etc. The feedback was
positive, and the program was successful in teaching the participants’ useful life skills
that they were applying to every day situations. The parent/teacher feedback was also
positive and constructive. The teachers and parents outlined many changes in
themselves, e.g. being calmer and happier, looking for highlights, and relaxing with the
child, etc. and evidence that their child was using the program, e.g. relaxation and deep
breathing for pain control, the child using breathing to calm down, the child being better
at ignoring distractions, the child being better at listening, etc. One problem for the
teachers was finding time for the children’s daily logbook entry. Also all parents
reflected on how they would have liked to participate more regularly, as they recognized
the benefits, could see the progress in the child, but were unable to find the time on a
consistent basis. In summary, the children and parents/teachers liked the MFGP and
were able to share many examples of how it improved their overall well being.
Within the limitations of this exploratory investigation, analysis of data from
the participants (N ¼ 20) in the MFGP revealed significant changes in the overall well
being of children with cancer. More specifically, the children experienced a significant
HE reduction in anxiety, increasing frequency of positive events, and improving
106,4 physiological levels of relaxation.

Discussion
In this section of this paper the investigator will comment on the methodological
strengths and weaknesses of the study and point out import implications for
304 professionals who work with children with cancer. In addition, the investigator will
elaborate about the findings and how these results relate to the literature that was
presented in the beginning of the paper.

Methodological strengths and weaknesses

The major strengths of the present investigation were:
.
the empirical testing of a MFGP in a real world setting, i.e. with children with
cancer;
.
the training procedures that were used to educate the children and their parents
about life skills education; and
.
the follow-up procedures to ensure that the program was being administered
according to the procedures in the MFGP training manual.

The cooperation of teachers, school administrators, parents, and the children

themselves was clearly evident.
The major methodological weaknesses of this study were:
.
absence of a control group;
.
inability of some school administrators to participate because of time restraints;
and
.
lack of compliance of some children because they were suffering from
chemotherapy treatments.

The constant reminders about the program through e-mail, telephone and personal
meetings on a regular basis either at hospital or home, may have motivated
individuals. Daily writing in journals or logbooks of one or more good events or
happenings for that day, also meant a continued emphasis on the positive. Brissette
et al. (2002) research support the value of this approach.
A positive constructive attitude to build confidence was one of the primary goals of
the MFGP which encouraged participants to adopt a positive perspective and to report
on this through the use of writing in the logbooks. As cited previously, Barrera et al.
(2005), Cole-King and Harding (2001) and Van Oyen Witvliet et al. (2001) support
positive approaches to care for children with cancer.

Implications
One of the most important lessons learned from this study is the need to individualize
mental training procedures for each child who is suffering from cancer. Designing the
mental training program to meet the specific needs of each child is one of the most
important aspects of MFGP. For example, some children need to learn how to relax
more effectively while others need to learn how to use self-talk and coping procedures
to enhance the quality of their lives.
 The findings of this investigation demonstrate that children with cancer can learn to Program for
relax and to understand what stress is, and its negative effects on the body and the oncology
healing process. Further, these data provide support for learning the relaxation
response and progressive muscle relaxation, which has also been shown to children
significantly improve an individual’s level of immunity (Lowe et al., 2001). As cited
previously, Farag (2002) and Lowe et al. (2001) also support the value of relaxation for
children with cancer. Investigations by Macner-Licht et al. (1998), Woodgate and 305
McClement (1998) and Schwartz and Gredler (1998) also support the findings of the
present study.
The MFGP enabled oncology children in the present study to regain their
composure, and to maintain active participation, rather than being helpless, passive
victims of the procedures surrounding their cancer. The activities in the MFGP better
prepared participants, and gave them some control over the procedures (i.e. to alleviate
pain, lessen pain, deal with procedural distress, nausea and vomiting). Moreover, it
taught them to tolerate procedures as positively as possible.
The outcomes of this research have important theoretical and practical relevance.
The findings will assist children with cancer to develop effective management
strategies to deal with the daily adversities they encounter. Oncology children will
develop a more positive perspective to their problems, relax more effectively, find
uplifting experiences each day, feel better about themselves, and use their imaginations
and goal setting in constructive positive ways. The active role engendered in the
children during their treatment ultimately provides a sense of control.
The findings of the present study should be interpreted within the limitations of this
investigation. First, this was an exploratory study that was limited to a very small
sample of oncology children. Second, since there was no control group, withholding an
intervention that was successful with healthy children did not seem to be appropriate
for children suffering from cancer. Therefore, the MFGP needs to be tested using
rigorous experimental procedures as some of the underlying tenants of multivariate
statistics were not met, and tighter controls need to be developed to make sure that the
MFGP is being applied consistently and effectively. Third, sampling procedures may
also have influenced the results since 100 cancer children were invited but only
25 volunteered to participate. Finally, sample size was small (N ¼ 20) and the inclusion
of children with different types of cancer may have been problematic since MFGP may
have been more effective for children with a particular type of cancer.
The development of an intervention that can be introduced as a standard protocol
within oncology units/hospitals, schools, and homes, that is “hands on” and can be
applied simply and effectively to benefit the children’s daily lives is of major practical
significance. Given the increased emphasis placed on the overall well being of the child
during the diagnosis and treatment process, the long-term pro-active survival
strategies taught in this program, offers a promising holistic approach.

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Corresponding author
C. Nadeane McCaffrey can be contacted at: sunshine@magma.ca

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