Body Image 6 (2009) 247–256

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Body Image
journal homepage: www.elsevier.com/locate/bodyimage

Review article

Body image of children and adolescents with cancer: A systematic review

Sheng-Yu Fan *, Christine Eiser
Department of Psychology, University of Sheffield, Western Bank, Sheffield S10 2TP, UK

A R T I C L E I N F O A B S T R A C T

Article history: We report a systematic literature review to identify (1) differences in body image (BI) between children
Received 17 December 2008 and adolescents with cancer and healthy controls; (2) relationships between BI and demographic or
Received in revised form 19 June 2009 medical variables; (3) implications of BI for psychological adjustment; and (4) relationship between BI
Accepted 19 June 2009
and social support. Thirty-two studies were identified from computerized databases including BNI
(1985-March, 2008), CINAHL (1982-March, 2008), MEDLINE (1950-March, 2008), PsychInfo (1806-
Keywords: March, 2008), and PubMed (1950-March, 2008). There was no consistent evidence regarding BI
Body image
differences between children and adolescents with cancer and healthy controls. Relations between BI
Paediatric cancer
Children
and gender, disease characteristics, and psychological adjustment were found. Changes in BI have
Adolescents adverse implications for self-esteem and adjustment, but can be moderated by social support. Future
Systematic review research should also adopt broader definitions of BI, and cancer-specific age-appropriate BI measures are
needed to increase sensitivity of this work.
ß 2009 Elsevier Ltd. All rights reserved.

Introduction BI is a complex and multidimensional psychological construct

Cancer is a rare condition in children and adolescents, with an
age-adjusted incidence rate in the U.S. of 165.92 per million among
those 0–19 years of age (Li, Thompson, Miller, Pollack, & Stewart,
2008). Advances in medical treatment have resulted in improved
survival rates for both children and adolescents (Smith & Gloeckler
Ries, 2002). As survival rates improve, there has been increased
focus on ‘late effects’ and long-term adjustment (Evan & Zeltzer,
2006). Adverse physical and psychosocial consequences have been
described (Gray et al., 1992; Wallace & Green, 2004). Cancer is
more frequently diagnosed among preschoolers and adolescents,
with important implications for adjustment, health-related quality
of life (HRQOL) and body image (BI) (Eiser & Jenney, 1996).
BI is an important issue for young people with cancer (Roberts,
Turney, & Knowles, 1998). Development of BI is one of the key tasks
of childhood and adolescence with implications for self-identity
and intimate relationships (Erikson, 1959). However, cancer and its
treatment are associated with aggressive side-effects that affect
physical appearance (Larouche & Chin-Peuckert, 2006). These
include hair loss, compromised linear growth, changes in body
weight (both weight gain and loss), muscle wastage or amputation,
and all of which threaten body integrity and functioning.
* Corresponding author.
E-mail address: dibe1011@yahoo.com.tw (S.-Y. Fan).
that encompasses body-related self-perceptions and self-attitudes,
including thoughts, beliefs, feelings, and behaviors (Cash, 2004;
Pruzinsky & Cash, 2002b). Two components are integral to BI
attitudes. These include BI evaluation; which refers to satisfaction/
dissatisfaction with one’s body, including associated evaluative
beliefs and emotions; and BI investment referring to the cognitive-
behavioral importance of one’s body for self-evaluation (Cash,
2002a). It is influenced by a variety of historical, cultural, social,
individual and biological factors, which operate over varying time-
spans (Slade, 1994). The impact of cancer and its treatment on BI is
likely to depend on characteristics of the disease and treatment as
well as chronological age and development. Adaptation to BI
change is a dynamic psychosocial process (White, 2000).
Disease and treatment-related changes in appearance influence
physical integrity, but for children and adolescents, objective
visible physical impairment does not correlate with BI (O’Malley,
Foster, Koocher, & Slavin, 1980). Critical, however, for satisfaction
with BI, is the individual’s subjective interpretation of these
changes in appearance and physical integrity (Cash, 2004).
Although cancer and treatment would be expected to have
adverse consequences for BI, empirical evidence is inconsistent
(White, 2000). We therefore conducted a systematic review to
determine (1) differences in BI between children and adolescents
with cancer and healthy controls, siblings, or other disease groups;
(2) relationships between BI and demographic or medical
variables; (3) implications of BI for psychological adjustment;
and (4) relationship between BI and social support.

1740-1445/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.bodyim.2009.06.002
248 S.-Y. Fan, C. Eiser / Body Image 6 (2009) 247–256
Method
The systematic review was conducted according to the
recommendations of CRD (Center for Reviews and Dissemination)
(NHS, 2001). We searched the following computerized databases:
BNI (British Nursing Index, 1985-March, 2008), CINAHL (Cumu-
lative Index to Nursing and Allied Health Literature, 1982-March,
2008), MEDLINE (1950-March, 2008), PsychInfo (1806-March,
2008), and PubMed (U.S. Library of Medicine and National Institute
of Health, 1950-March, 2008). Text word and Thesaurus terms
were used to maximize identification of relevant articles. The
following keywords were searched using Boolean logic: (1) child,
children, childhood, adolescent, paediatric, paediatric; (2) body
image, short, short stature, appearance, self-image; (3) cancer,
leukaemia, leukemia, brain tumor, brain tumour, CNS tumor, CNS
tumour, malignancy, pediatric oncology, paediatric oncology; (4)
quality of life, health-related quality of life, QOL, HRQOL.
Additional references cited in retrieved articles or relevant review
articles were also obtained.
Inclusion and exclusion criteria
Articles were included which were: (1) published in English in a
peer reviewed journal; (2) included children and adolescents with
cancer; (3) focused on assessment of BI or relationships between BI
and psychological variables; (4) included qualitative, quantitative
methodology or both.
Exclusion criteria were: (1) literature review or case study
article; (2) adult participants only; (3) studies reporting findings
not directly relevant to the core concepts of BI, appearance or self-
image.
Review procedure
Abstracts were evaluated for relevance and full articles
obtained where appropriate. A summary sheet was developed
for extracting data. This included (1) aims; (2) methodology:
qualitative or quantitative; longitudinal or cross-sectional or
mixed; and comparison group; (3) participants: age, gender; (4)
medical data: time since diagnosis, cancer type, receiving or
completed treatment; (5) measure of BI and psychological
variables; (6) results.
The first author was primarily responsible for extracting data,
and the authors worked together to integrate all data. In the
process of data synthesis, qualitative and quantitative evidence
were first analyzed separately. Quantitative evidence focused on BI
differences between children and adolescents with cancer and
healthy controls, and the relationships between BI and other
psychological variables. Qualitative evidence was tabulated for
important information including themes, subcategories, meanings,
and quotations. Concept construction that focused on consistency
and peculiarity of data was emphasized in the evaluation process.
After that, the two kinds of data were synthesized together
(Goldsmith, Bankhead, & Austoker, 2007).
Results
Description of studies included in the review
Two hundred and fifty-nine articles were identified and
abstracts obtained. Based on the defined eligibility criteria,
32 articles were selected for review and are summarized in
Table 1.
Demographic characteristics. Most studies recruited male and
female participants, but three focused on females only (Puukko,
Hirvonen, Aalberg, Hovi, Rautonen, & Siimes, 1997; Puukko,
Sammallahti, Siimes, & Aalberg, 1997; Wallace, Harcourt, Rumsey,
& Foot, 2007). Seven studies focused on children (<12 years old),
19 on adolescents (13–19 years old), 2 on children and adolescents
(Beardslee & Neff, 1982; Kyritsi, Matziou, Papadatou, Evagellou,
Koutelekos, & Polikandrioti, 2007), and 3 on adolescents and young
adults (>20 years old) (Langeveld, Grootenhuis, Voute, de Haan, &
van den Bos, 2004; Maggiolini et al., 2000; Zebrack & Chesler,
2001). One study recruited mothers of children and adolescents
aged 0–14 years (Earle & Eiser, 2007).
Medical characteristics. Six studies recruited children with Acute
Lymphoblastic Leukemia or Acute Myeloid Leukemia (Earle &
Eiser, 2007; Maggiolini et al., 2000; Moore, Challinor, Pasvogel,
Matthay, Hutter, & Kaemingk, 2003; Mullis, Mullis, & Kerchoff,
1992; Puukko, Hirvonen, et al., 1997; Puukko, Sammallahti, et al.,
1997), and other studies included a number of cancer diagnoses.
Twenty-two studies included participants who had completed
treatment, eight included participants who were currently under-
going treatment, and two included both kinds of participants.
Thirteen studies included participants within 5 years of diagnosis,
seven studies included those 6–10 years, three studies included
more than 10 years, but nine studies did not provide relevant
information.
Research design. Thirty studies were cross-sectional in design.
Eighteen used quantitative methods, seven used qualitative and
seven used both quantitative and qualitative methods. Thirty-one
studies included child report, and one (Earle & Eiser, 2007)
included mothers only. In addition, five studies included proxy
reporting from parents and two others included reports from
health professionals. Fourteen studies included a comparison
group of healthy controls, two included siblings (Freeman, O’Dell,
& Meola, 2003; Woodgate, 2005) and two included other diseases
(Beardslee & Neff, 1982; Kyritsi et al., 2007).
Measurement of BI. The most commonly used measures were
the Offer Self-Image Questionnaire (Offer, Ostrov, & Howard, 1982)
used in four studies; Piers-Harris Self-Concept Scale (Piers, 1984)
in three studies; Body Image Instrument (BII) (Kopel, Eiser, Cool,
Grimer, & Carter, 1998) in two studies; physical impairment rating
scale (O’Malley et al., 1980) in two studies, and Self-Perception
Profile for Children (Harter, 1985) in two studies and Adolescents
(Harter, 1988) in two studies. These measures are all designed for
children or adolescents. The BII was the only measure specifically
developed for young people treated for cancer. Measures and
domains are summarized in Table 1.
Differences in BI between children and adolescents with cancer and
healthy controls, siblings, or other disease groups
Fourteen quantitative studies used standardized measures
and made comparisons with a healthy comparison group. Nine
studies found no statistical differences between children and
adolescents with cancer and healthy controls (Anholt, Fritz, &
Keener, 1993; Beardslee & Neff, 1982; Calaminus, Weinspach,
Teske, & Gobel, 2007; Jamison, Lewis, & Burish, 1986; Langeveld
et al., 2004; Mullis et al., 1992; Pendley, Dahlquist, & Dreyer,
1997; Puukko, Hirvonen, et al., 1997; Stern, Norman, & Zevon,
1993). Three concluded children and adolescents with cancer
had worse BI (Kyritsi et al., 2007; Madan-Swain, Brown, Sexson,
Baldwin, Pais, & Ragab, 1994; Puukko, Sammallahti, et al., 1997),
and two showed that they had better BI than healthy controls
(Maggiolini et al., 2000; Weigers, Chesler, Zebrack, & Goldman,
1998).
There were no differences in BI between children with cancer
and those treated for orthopedic surgery (Beardslee & Neff, 1982),
or thalassaemia (Kyritsi et al., 2007). The studies which included
siblings were qualitative studies and did not make any statistical
comparisons (Freeman et al., 2003; Woodgate, 2005).
Table 1
Summary of studies included in the review.

Study Aims Research design: Measure Sample (N) Age Time since Receiving Results
1. Quantitative (SD, range) diagnosis treatment
vs. qualitative (years) (years) (on) or
vs. mixed. completed
2. Cross- treatment
sectional vs. (off)
longitudinal

Anholt et al. To compare self- 1. Quantitative, Piers-Harris Self-Concept Scalea (Piers, N = 62; 13.5, 1.7 (since Off Survivors rated behavior, intellectual and school,
(1993) concept between 2. Cross- 1984). Physical and visible impairment N = 120, 11.0 the end of happiness and satisfaction more positively than
Canada children with cancer sectional rating scaleb (O’Malley et al., 1980) healthy treatment) controls. Physical appearance was lower but non-
and healthy children control significant. Visible physical impairment and time since
end of treatment were predictors of physical self-
concept. Visible physical impairment had long-term
negative effects on self-concept
Beardslee To explore body- 1. Quantitative, Sentence completion test: perceived N = 15; 8–13 On There was no significant difference between cancer
et al. (1982) related concerns of 2. Longitudinal threats to body integrity. Modified index ofN = 15, children and healthy controls on BI. Children with a fatal
USA children with fatal at first entry to body knowledge (Gellert, 1962): children with illness did not feel more vulnerable or have greater
illness, orthopedic study and 3–4 knowledge of body parts and body orthopedic concerns about threat to body integrity and normal body
problems and healthy months after the functioning. Free-hand drawing of house: surgery, functioning than children with a nonfatal illness

S.-Y. Fan, C. Eiser / Body Image 6 (2009) 247–256

initial interview strength or weakness of body boundaries N = 30,
healthy
control
Calaminus To evaluate the 1. Quantitative, Quality of Life Questionnaire for Children N = 36; 12.4 5 Off There were no differences in BI between survivors and
et al. (2007) physical long-term 2. Cross- and Adolescents with Cancer, the German N = 319, (3.1, 8–18), controls, but patients with long-term effects had lower
Germany effects of childhood sectional instrument (PEDQOL) (Calaminus, healthy age-matched BI than those without long-term effects. Impairment of
cancer survivors Weinspach, Teske, & Gobel, 2000): physical control BI was more often in solid tumors than leukemia or
function, emotion, cognition, autonomy, lymphoma
social function, BI
Eapen To examine cancer 1. Quantitative, Self-Perception Profile for Childrenc N = 20; 9.6 (8–14) 0.5–1.5 On Males had better BI than females. There were significant
et al. (1999) children’s self- 2. Cross- (Harter, 1985) N = 16, differences between children’s rating of self-perceptions
USA perceptions about sectional parents and parents’ rating of perceptions. Poor agreement on
competence, behavior, physical appearance (the effects of chemotherapy) and
and self-worth social acceptance between parents and children
Earle et al. To describe behavior 1. Qualitative, Semi-structured interview: focus on child’s N = 32, Three aged On T1: mothers of 5–9 years group mentioned BI and
(2007) UK and coping of children 2. Longitudinal behavior in relation to school, friendships, mothers of groups: 0–4, appearance, more often than the 0–4 years group. T2:
with ALL over the 2- or at 3–4 months appearance and understanding the illness children with 5–9, 10–14 better adjustment than T1, but 5–9 and 10–14 years
3-year-course of following ALL groups worry other people’s concerns that they do not
treatment diagnosis (T1), want to be stared and be treated as normal. T3: mothers
at 15 months of 5–9 and 10–14 years groups reported social
(T2) and at 27 difficulties following from BI disturbances
months (T3)
Eiser et al. To compare illness 1. Mixed, 2. Body Image Instrument (BII)d (Kopel et al., N = 63; 18.8 (4.2, 9.5 Off Moderate correlations in BI ratings between children
(2000) UK experience and the Cross-sectional 1998). Semi-structured interview: recall of N = 63, 9.8–26) and mother (r = .45, p < .002)
impacts on lives diagnosis, impact on schooling, work, and mothers of
between survivors of mobility and competence survivors
childhood cancer and with
their mothers childhood
cancer
Enskar To identify experiences 1. Mixed, Problem list (Enskar, Carlsson, Hamrin, & N = 10 17.9 (15–20) 5.3 Off Major appearance changes due to treatment or the
et al. (1997) of life situations 2. Cross- Kreuger, 1996): physical problems, disease was very hard to live with, especially for girls.
Sweden affected by the disease sectional psychological problems, social problems, Changes in appearance include hair loss, short stature,
and problems related to existential problems, interview, problems weight gain, or amputation. Changes in appearance were
it due to the disease and areas of life that had correlated with psychological symptoms, such as
been affected by the disease depression and decreased self-esteem

249
 250
Table 1 (Continued )
Study Aims Research design: Measure Sample (N) Age Time since Receiving Results
1. Quantitative (SD, range) diagnosis treatment
vs. qualitative (years) (years) (on) or
vs. mixed. completed
2. Cross- treatment
sectional vs. (off)
longitudinal

Freeman et al. To identify commonly 1. Quantitative, Survey instrument (Freeman, O’Dell, & N = 25; 15 (4.1, 9–23), 4.5 Off 40% children were concerned about changes in their
(2003) USA reported problems and 2. Cross- Meola, 2000): interactions with health care N = 32, their 17 (5.5, 9–30) physical abilities and appearance. After diagnosis,
helpful resources sectional providers, medical information and siblings changes in personality or moods, appearance, and
important to children education, health care delivery/utilization, activity levels were reported as important problems.
with brain or spinal psychosocial issues Support from family and friends were reported as
tumor and their helpful and important by both groups
siblings
Fritz et al. To assess the 1. Mixed, Piers-Harris Self-Concept Scalea (Piers, N = 41 17.3 (3.6) 6.3 Off 75% survivors scored their self-image in the upper third
(1988) USA adjustment of 2. Cross- 1984). Structured interview: the issues on the instrument’s normative scale. 29% of survivors
adolescent survivors sectional relating to developmental tasks of had low or negative BI that could be a consequence of

S.-Y. Fan, C. Eiser / Body Image 6 (2009) 247–256

adolescents both medical and psychodynamic factors
Hedstrom To explore distressing 1. Qualitative, Semi-structured interview: distressing/ N = 23; 13-19 <1 year:13, 11 on, Adolescents had different BI concerns depending on
et al. (2004) and positive 2. Cross- positive about being told the diagnosis, N = 21, 1–3 years:7, 12 off disease stage. Diagnosis: fears about losing hair or
Sweden experiences for sectional receiving chemotherapy, being admitted to nurses 3–5 years:3 having to amputate a leg. Chemotherapy: altered self-
adolescents with the ward, important aspects of care image including hair-loss, dejection, fatigue, loss of
cancer appetite, and loss of weight
Jamison To explore self-image, 1. Quantitative, Offer Self-Image Questionnaire for N = 31; 15.2 (12–18), 2.7 Off Female survivors reported better self-image and BI than
et al. (1986) locus of control, 2. Cross- Adolescents (OSIQ)e (Offer et al., 1982) N = 203, 15.4 (13–18) male survivors. There was no significant difference
USA perception of illness sectional healthy between survivors and healthy controls on BI. Positive
and knowledge of control relationship between the patients’ knowledge of their
cancer of adolescent matched disease and self-image, but not significant relation with
cancer patients Social BI
Economic
Status (SES)
Kopel To explore the 1. Quantitative, BIId (Kopel et al., 1998) N = 67 19.7 (3.9, 10.3 Off Measures five components of BI for adolescents and
et al. (1998) relationships between 2. Cross- 12.5–29) young people with cancer: general appearance, body
UK BI and HRQOL, sectional competence, others’ reaction to appearance, value of
perceived illness appearance, and body parts. No significant sex
experience differences in BI emerged, nor was age at diagnosis or
time since diagnosis significantly correlated with BI. The
BI subscales concerned with respondents’ own
appearance correlated significantly positively with
HRQOL subscales tapping social and emotional domains
but not with subscales tapping physical functioning
Kyritsi To compare the self- 1. Quantitative, Piers-Harris Self-Concept Scalea (Piers, N = 165; 8–19 On Children with cancer had worse BI than healthy controls,
et al. (2007) concept of children 2. Cross- 1984) N = 417, and evaluated themselves negatively in appearance,
Greece with cancer in sectional healthy behavior, intellectual and academic level, and happiness
comparison with control; and satisfaction. 95 children (57.6%) had undergone
healthy children and N = 212, changes in their BI. Among healthy controls, younger
children with children with children and adolescents (8–13 years old) had better BI
thalassaemia thalassaemia and happiness than older adolescents (17–19 years old).
Langeveld To assess HRQOL, self- 1. Quantitative, Medical Outcome Study Scale (MOS-24) N = 400; 24 (4.9, 16–49); 16 Off No significant difference between survivors and healthy
et al. (2004) esteem and degree of 2. Cross- (Stewart, Hays, & Ware, 1988): physical N = 560, 26 (5.3, 16–53) on BI, but survivors had worse physical functioning. No
Netherland worry in young adult sectional functioning, role functioning, social healthy difference between survivors and controls in self-
survivors of childhood functioning, mental health, bodily pain, control esteem, but male survivors had better self-esteem than
cancer general health perceptions. Rosenberg Self- females. Lower self-esteem associated with poorer
Esteem Scale (Rosenberg, 1965): the self- HRQOL scores and more concerns
acceptance aspect of self-esteem or the
overall sense of being capable, worthwhile,
and competent. Worries questionnaire
(Weigers et al., 1998): cancer-specific
concerns, general health concerns, present
and future concerns
Larouche To explore adolescents’ 1. Qualitative, Semi-structured interview: perceived N=5 15.6 (14–17) 0.3–1 On Negative perceptions of BI: ‘‘I don’t look normal’’ (hair
et al. (2006) perceptions of their BI. 2. Cross- change in BI and impact on daily life loss and CVC: I look ugly and I look sick), ‘‘people look at
Canada sectional me’’. Impact of BI perception on their life included:
avoiding social situations, maintaining normality, peer-
shield, testing the safety of environment. Peer friendship
and secure environments act as a protector and facilitate
re-entry to social situations
Madan-Swain To examine the late 1. Quantitative, Self-Perception Profile for Adolescentf N = 25; 15.6 (1.1); 10 Off Compared with controls, survivors report body comfort
et al. (1994) effects of surviving 2. Cross- (Harter, 1988). Millon Adolescent N = 16, 15.4 (1.4) as more problematic and unresolved and as a major
USA cancer on adolescents, sectional Personality Inventory (MAPI) (Millon, healthy concern. Survivors did not have psychopathology

S.-Y. Fan, C. Eiser / Body Image 6 (2009) 247–256

and also compared Green, & Meagher, 1982): sexual control problems, but some have adjustment difficulties and BI
with healthy controls adjustment, body comfort disturbances
Maggiolini To evaluate the attitude 1. Quantitative, OSIQe (Offer et al., 1982) N = 70; 12–20 10 Off Survivors showed a more positive and mature self-image
et al. (2000) to face the life cycle and 2. Cross- N = 70, relative to the comparison group. The older girls
Italy the impact that the sectional healthy demonstrated a significantly more positive self-image in
experience of control who emotion level, command of the outside world, attitudes
childhood ALL and AML matched age, toward the family, aspirations, self-image and BI
gender, SES,
and
residence
area
Mattsson To explore negative and 1. Qualitative, Telephone interview: identify good or bad N = 38 18 (1.7, 2 Off Negative: 25 adolescents reported physical and
et al. (2007) positive consequences 2. Cross- things due to cancer 15–21) appearance problems and negative consequences.
Sweden of cancer during sectional Positive: 16 adolescents reported an inner change with
adolescence 2 years regard to maturity and development into a responsible
after diagnosis person with good self-esteem, including BI attitudes
McCaffrey To explore the major 1. Qualitative, Semi-structured interviews and focus N = 6; 11.3 (5–15) 3 on, Compromised BI is major stressor, and compromises
(2006) stressors of children 2. Cross- groups: major daily stressors; the effects N = 6, 3 off children’s self-esteem. Children with cancer view
Australia diagnosed with cancer sectional on well-being, family, school, and hospital; parents; themselves as a burden to others and wish to change
and the effect on their the consequences of these major stressors N = 23, their physical appearance
physical and on the child’s physical and emotional well- hospital
psychological well- being; effective coping mechanisms professional
being
Moore To describe behavioral 1. Quantitative, Behavioral Assessment System for Children N = 47, 9.9 (5.2-16) 3.4 Off 23% children reported at risk level of self-esteem. A ‘‘yes’’
et al. (2003) adjustment in children 2. Cross- (BASC) (Reynolds & Kamphaus, 1992): children with response to BI alterations during treatment was
USA and adolescents with sectional adaptability, anxiety, attention problems, ALL, parents correlated significantly with child and adolescent self-
acute ALL attitude to school, attitude to teachers, and teachers ratings on somatization, social stress, depression,
depression, leadership, learning problems, interpersonal relations, clinical maladjustment
self-esteem, sense of inadequacy, social composite, and emotional symptoms index. BI
skills, social stress, somatization, study alterations may increase the risk for behavioral
skills, withdrawal adjustment problems in children and adolescents with
ALL
Mullis To investigate the 1. Quantitative, Kinetic Family Drawing-Revised (KFD-R) N = 13; 7.6 (6–11); On Males with leukemia had better self-image than females.
et al. (1992) self-esteem of school- 2. Cross- (Spinetta, McLaren, Fox, & Sparta, 1981): N = 50, 8.5 Females reported less open communication than males.
USA age children with ALL sectional communication, self-image, emotional healthy There was no difference in overall self-mage between
tone. Coopersmith Self-Esteem Inventory control ALL children and healthy controls, but healthy had better
(Coopersmith, 1981): self-esteem about adaptive emotional state. There was no difference in
competence, successful, significant, and overall self-esteem, and healthy had better school

251
worthy achievement
 252
Table 1 (Continued )
Study Aims Research design: Measure Sample (N) Age Time since Receiving Results
1. Quantitative (SD, range) diagnosis treatment
vs. qualitative (years) (years) (on) or
vs. mixed. completed
2. Cross- treatment
sectional vs. (off)
longitudinal

O’Malley To explore the 1. Quantitative, Physical and visible impairment rating N = 116 18 (5.8-36) 12.4 Off Five levels of physical and visible impairment from none
et al. (1980) relationship between 2. Cross- scaleb (O’Malley et al., 1980). The to severe based on obviousness of physical residua,
USA the degree of visible sectional psychological adjustment rating scale: self- interference with activities of daily living, medical
physical impairment esteem, social adjustment, anxiety, attention or equipment, employability or ability to
and psychological depression, death anxiety, personality attend school identified. The degree of impairment
adjustment dynamics occurring as a result of cancer treatment was not
significantly related to current psychological adjustment
Pendley To explore 1. Mixed, Self-Image Questionnaire for Young N = 21; 15.2 (11-21) 3 Off No significant differences were found between cancer
et al. (1997) psychological 2. Cross- Adolescents (SIQYA) (Petersen, N = 21, children and healthy controls on four kinds of
USA difficulties and BI of sectional Schulenberg, Abramowitz, Offer, & Jarcho, healthy attractiveness (overall, face, body and mobility), but
adolescent cancer 1984): positive and negative feelings control there was significant differences between objective
patients toward general aspects of his/her body. matched for versus self-perceptions of attractiveness. BI correlated
Body Cathexis Scale (BCS) (Secord & age, gender, negatively with social anxiety and loneliness, and

S.-Y. Fan, C. Eiser / Body Image 6 (2009) 247–256

Jourard, 1953): degree of satisfaction with and ethnicity positively with global self-worth. Psychosocial
different body parts and functions. Self- adjustment significantly related to adolescents’
report Likert rating of BI: subjects’ feelings subjective rating of their overall appearance instead of
about their overall appearance, facial objective rating. Within cancer group, adolescents who
appearance, body appearance, and had been off treatment longer had more negative BI
mobility. Self-Perception Profile for perception
Adolescentsf (Harter, 1988). Body Image
Avoidant Questionnaire (BIAQ) (Rosen,
Srebnik, Saltzberg, & Wendt, 1991):
behaviors that often occur with BI
disturbances. Situational Inventory of Body
Image Distress (SIBID) (Cash, 2002c): How
often they experienced negative thoughts
or feelings about their physical appearance
in different situations. Objective ratings of
attractiveness: attractiveness of overall
appearance, facial appearance, body
appearance, and mobility.
Interview: psychological adjustment
Puukko, To assess the BI of 1. Mixed, Subject’s self-assessment of BI: importance N = 42, 18.6 (3.9); 7.4 Off Less than 30% of survivors had appropriate BI, and 76%
Hirvonen, young female 2. Cross- of physical appearance; evaluation of female had impaired BI. There were no correlations between BI
et al. (1997) survivors of ALL sectional appearance; favorable features of survivors; 18.9 (4.1) and age, age at diagnosis, duration of active treatment,
Finland appearance. Psychiatric evaluation: N = 69, follow-up time, height, and weight. The BI of bone
perceptions of BI, ability to perceive BI and healthy marrow transplantation survivors was more impaired
the significance of the leukemia to BI. females than that of the other survivors
Rorschach test: the BI data from the clinical matched age
Rorschach evaluation. Semi-structured
interview: school and work, puberty, BI and
self-image, sexuality, object relationship,
ego ideals, disease history
Puukko, To explore the BI as 1. Mixed, 2. OSIQe (Offer et al., 1982). N = 28, 16.5 (2.1); 10 Off No significant difference in perceived BI between
Sammallahti, perceived by ALL Cross-sectional Semi-structured interview: How do you female; survivors and controls. However, in qualitative
et al. (1997) survivors, focusing on find your own physical appearance? What N = 34, 15.9 (1.1) interview, 36% of survivors were rated as having
Finland whether the chosen are positive and negative features of your healthy impaired BI and 36% a diffuse BI, which survivors cannot
methodology affects own appearance? females express a clear opinion of their appearances. The
the results matched age interview reveals aspects that remain undetected in the
questionnaire responses, and the majority of the
leukemia survivors had impaired or diffuses BI
Stern To explore self-image 1. Quantitative, OSIQe (Offer et al., 1982) N = 48; 17.5 (2.8, 14–23); 3.64 Off No age or gender effects were found on self-image.
et al. (1993) and perceived social 2. Cross- N = 40, 17.6 (1.8, 16–22) Survivors were relatively well-adjusted, but had less
USA support of adolescents sectional healthy positive self-image in terms of their social and sexual self
with cancer control than healthy control
Varni To investigate the 1. Quantitative, Self-Perception Profile for Childrenc N = 30 10.7 (1.7, 8–13) On Age, gender and cancer diagnosis were not significantly
et al. (1995) conceptual model that 2. Cross- (Harter, 1985) correlated with perceived physical appearance. Higher
USA perceived physical sectional perceived physical appearance was significantly related
appearance has direct to higher general self-esteem, lower depressive
and indirect effects on symptoms, and lower social anxiety. The effect of
depressive symptoms perceived physical appearance on psychological distress
and social anxiety with is mediated by general self-esteem
the indirect effects
mediated by general
self-esteem
Wallace To explore 1. Qualitative, Semi-structured interview: general life N = 6, 16.5 (14–19) 2.5 Off Appearance changes impacted on behavior by restricting
et al. (2007) appearance-related 2. Cross- style, cancer and its treatment, appearance females social activity, mediated by changes in self-esteem and
UK concerns and ascertain sectional and the impact of appearance changes perceptions and expectations of others’ responses to
their psychosocial their appearance. Altered appearance made being
impact perceived as normal and unchanged more difficult. Some
positive changes after cancer including value of the
important of life and increased appreciation and
enjoyment of life. Aspects of healthcare provision: They

S.-Y. Fan, C. Eiser / Body Image 6 (2009) 247–256

needed to hear ‘success stories’ and speak to someone
who they felt could understand what they were going
through
Weigers To explore self- 1. Mixed, Self-developed questionnaire (Chesler & N = 322; 18 (14–21); Off Cancer survivors worried less about ‘how my body looks’
et al. (1998) reported worries of 2. Cross- Barbarin, 1987): experiences, attitudes, N = 257, 17 than the comparison group. Long-term survivors
USA long-term survivors of sectional needs and worries of survivors. healthy worried significantly less than healthy peers about
childhood cancer Interview: worried concerns control common health concerns including how their body
looked, and positive psychological outcomes could help
them cope with their concerns effectively
Woodgate To explore the impact 1. Qualitative, Individual interview, focus group, and N = 15; 14 (12–18) Off The changing sense of self in adolescents was tied closely
(2005) of cancer and its 2. Cross- participant observation: the daily life and N = 16, 2 to their changing body. Physical and mental bodily
Canada symptoms on sectional different things, feelings and emotions, parents and changes affected adolescent’s self-perception. It was
adolescents’ sense of good things, and any changes 14 siblings important that friends treated adolescents with cancer
self as the same persons
Wu et al. (2003) To explore factors 1. Quantitative, Self-developed questionnaire: subject’s N = 118 10.8 (6–18) 2.3 On BI was significantly related to gender, level of education
Taiwan related to satisfaction 2. Cross- satisfaction with physical characteristics, and appearance side effects of chemotherapy (female,
with BI in children sectional feelings about BI during chemotherapy high level of education, more frequent changes with
undergoing lower satisfaction). Social support was not related to BI
chemotherapy
Zebrack To explore childhood 1. Quantitative, Self-developed questionnaire (Chesler & N = 303 20 (3.4, 11.3 (1–25) Off Age at diagnosis was significantly related to self-image.
et al. (2001) cancer survivors’ 2. Cross- Barbarin, 1987): cancer-specific worries, 14–29) Self-image has positive correlations with physical
USA worries, self-image sectional general health worries, self-image, life condition and perception of themselves as cured. Extent
and life outlook outlook to which physical after-effects interfere with life was not
related to self-image and life outlook

The domains of measures.

a
Piers-Harris Self-Concept Scale: behavior, intellectual and school status, physical appearance, anxiety, popularity, happiness and satisfaction.
b
Physical and visible impairment rating scale: obviousness of physical residua, interference with activities of daily living, medical attention or equipment, employability or ability to attend school.
c
Self-Perception Profile for Children: scholastic competence, social acceptance, athletic competence, physical appearance, behavioral conduct, global self-worth.
d
Body Image Instrument (BII): general appearance, body competence, others’ reaction to appearance, value of appearance, body parts.
e
Offer Self-Image Questionnaire for Adolescents (OSIQ): impulse control, mood, BI, social relations, morals, vocational and educational goal, sexual attitudes and behavior, family relations, mastery of the external world,
psychopathology, idealism, superior adjustment.
f
Self-Perception Profile for Adolescents: global self-worth, scholastic competence, social acceptance, athletic competence, physical appearance, behavioral conduct, romantic appeal, close friendships, job competence.

253
254 S.-Y. Fan, C. Eiser / Body Image 6 (2009) 247–256
Relationships between BI and demographic or medical variables
Age. Of nine studies that assessed relationships between BI
and age, no relationships were found in seven (Kopel et al.,
1998; Kyritsi et al., 2007; Pendley et al., 1997; Puukko,
Hirvonen, et al., 1997; Puukko, Sammallahti, et al., 1997; Stern
et al., 1993; Varni, Katz, Colegrove, & Dolgin, 1995). Maggiolini
et al. (2000) found females aged >16 years had better BI than
healthy controls matched for age, gender, social economic
status, and residence area. Mothers reported that 5–9 years old
children had more concerns about BI than 0–4 years old
children, and 10–14 year olds concerned about BI were more
likely to show social withdrawal than those who were not
concerned (Earle & Eiser, 2007).
Gender. Twelve studies addressed gender differences. Five
showed males rated their BI better than females (Eapen, Revesz,
Mpofu, & Daradkeh, 1999; Enskar, Carlsson, Golsater, & Hamrin,
1997; Langeveld et al., 2004; Mullis et al., 1992; Wu & Chin, 2003),
but six found no differences (Kopel et al., 1998; Kyritsi et al., 2007;
Pendley et al., 1997; Stern et al., 1993; Varni et al., 1995; Zebrack &
Chesler, 2001). Only one study found that females rated their BI
better than males (Jamison et al., 1986).
Medical variables. Survivors of leukemia rated their BI better
than survivors of solid tumors (Calaminus et al., 2007), and
survivors who underwent bone marrow transplantation had worse
BI than those not undergoing bone marrow transplantation
(Puukko, Hirvonen, et al., 1997). Beardslee and Neff (1982) found
children rated their BI better when their response to treatment was
good, but poorer when they perceived their cancer could not be
cured.
Adolescents with cancer had different BI concerns at different
stages of treatment, including more fears about altered appearance
when undergoing chemotherapy than when first diagnosed
(Hedstrom, Skolin, & von Essen, 2004). After discharge from
hospital, changes in appearance became more important (Freeman
et al., 2003). Adolescents who recently completed treatment rated
BI better than those who completed treatment more than 1 year
previously (Pendley et al., 1997). However long-term survivors had
significantly less BI worries than healthy controls (Weigers et al.,
1998).
Other factors such as frequency and length of hospitalization,
multiple relapses, and frequent and severe side effects had
negative effects on BI of survivors (Enskar et al., 1997). Visible
physical impairment (Anholt et al., 1993) and changes in physical
functioning and appearance (Calaminus et al., 2007) were
associated with negative effects on BI. Satisfaction with BI was
negatively related to appearance-related side effects but not
cancer status or chemotherapy protocol (Wu & Chin, 2003).
Implications of BI for psychological adjustment
BI and self-esteem. Five qualitative, one quantitative and two
mixed-methods studies assessed the relationship between BI and
self-esteem among children with cancer. Self-esteem was
adversely affected compared with healthy peers (Woodgate,
2005). Both Enskar et al. (1997), and Varni et al. (1995) showed
that self-esteem was negatively related to changes in physical
appearance. Three qualitative studies showed that decreased self-
esteem was associated with BI disturbance (Enskar et al., 1997;
McCaffrey, 2006; Wallace et al., 2007). Physical appearance
changes contributed to a sense of being special and different from
healthy peers, for example a feeling of ‘I look ugly or sick’ (Larouche
& Chin-Peuckert, 2006). However, some adolescents had positive
feelings and felt more confident about their own BI. For example,
they reported stronger or better BI following treatment (Mattsson,
Ringner, Ljungman, & von Essen, 2007).
BI and anxiety, depression, behavioral adjustment, HRQOL. Three
quantitative and three mixed-methods studies explored the
relationships between BI and indicators of psychological adjust-
ment including anxiety, depression, behavioral adjustment, and
HRQOL. Changes in appearance were correlated with psychological
symptoms, such as depression (Enskar et al., 1997), and poor BI
during treatment was significantly related to behavioral malad-
justment such as depression, somatization, withdrawal, and social
stress (Moore et al., 2003). Among survivors, better BI was
associated with lower anxiety and loneliness, and greater self-
worth (Pendley et al., 1997). There were significant relationships
between BI and social and emotional dimensions of HRQOL but not
physical functioning (Kopel et al., 1998). There was no association
between BI and adolescents’ global adjustment that assessed based
on interviews, process notes, and medical comments (Fritz &
Williams, 1988). The degree of visible physical impairment was not
significantly associated with psychological adjustment (based on a
battery of measures including self-esteem, social adjustment,
anxiety, depression, death anxiety; projective test and mental
status examination) (O’Malley et al., 1980).
Relationship between BI and social support
Four qualitative and three quantitative studies explored
relationships between BI and social support. Social support was
not significantly related to BI (Stern et al., 1993; Wu & Chin, 2003),
but was an important resource to facilitate adjustment to physical
appearance changes (Freeman et al., 2003). Qualitative research
showed that children and adolescents with cancer worried about
how other people judged them, and their perception of body
changes affected their desires to interact with others and establish
intimate relationships (Earle & Eiser, 2007; Larouche & Chin-
Peuckert, 2006; McCaffrey, 2006). This led to withdrawal, feeling
different or rejected, losing touch with peers, feeling lost at school
and behind with schoolwork (Larouche & Chin-Peuckert, 2006;
McCaffrey, 2006). They wanted to be treated the same as others
instead of as patients or abnormal persons (Wallace et al., 2007).
Discussion
The effects of cancer and treatment on BI
Nine of 14 studies found no differences in BI between children
and adolescents with cancer and healthy peers. Thus, there is
currently insufficient evidence to support the hypothesis that
children and adolescents with cancer have worse BI than healthy
peers. However, demographic and medical variables may con-
tribute to compromised BI following childhood cancer. Males seem
better able to cope with appearance changes than females, while,
as might be expected, adolescents have more concerns about
appearance and BI than younger children. The stage of cancer and
the effects of treatment are also important. During the initial stages
of disease, children and adolescents may focus on treatment and
not notice appearance changes. In the remission stage or on
discharge, implications of appearance changes for social interac-
tion arise (Evans, 1997).
BI is also associated with children’s self-esteem, and significant
correlations also were observed between BI and psychosocial
adjustment. Children and adolescents with cancer who have
compromised BI have higher levels of anxiety, depression, and
more behavioral problems. They also have worse emotional and
social HRQOL. However, adverse effects of cancer and treatment on
BI can be moderated by social support. This can come from family
and friends as well as medical staff (Maggiolini et al., 2000). It is
important that family and friends treat children and adolescents as
normal and the same person (Woodgate, 2005). Interaction with
 S.-Y. Fan, C. Eiser / Body Image 6 (2009) 247–256
friends provides survivors with an opportunity to test out the
reaction of others, reintegrate their experiences and regain
confidence (Larouche & Chin-Peuckert, 2006). The implication is
that social support can moderate the impact of cancer and
treatment on BI changes and enhance adjustment.
Although objective visible physical impairment would be
expected to affect the BI of children and adolescents with cancer
(O’Malley et al., 1980), subjective perceptions of physical
appearance are important, in that cognitive appraisal of physical
characteristics was found to predict adaptational outcome
(Pendley et al., 1997; Varni et al., 1995). Varni et al. (1995)
suggest that BI should be conceptualized not only as an outcome
variable but also as a potentially important predictor of long-term
psychological adjustment. Medical staff can contribute to improve
BI by providing accurate information about cancer and treatment
to facilitate self-assurance and cooperation (Kyritsi et al., 2007). In
addition, processes of cognitive reconstruction (Maggiolini et al.,
2000) and social comparison (Eiser & Eiser, 2000) can result in
improved BI.
The findings that children and adolescents with cancer have
comparable BI with healthy controls is not intuitive, but may be
explained by individual differences in resilience. ‘Resilience’
describes the strengths and abilities of those who can ‘bounce
back’ from stress and challenges, and eliminate, or minimize
negative outcomes (Patterson, 1995; Rutter, 1985). Resilient
children may learn strategies to minimize the effects of BI change,
for example wearing a hat to disguise hair loss; or long trousers to
hide an affected limb. They can also reinterpret their experiences of
BI change in order to hasten the process of ‘getting back to normal’
(Earvolino-Ramirez, 2007).
Methodological issues
A major problem experienced in conducting this review was the
heterogeneity in BI measures, sample characteristics, and research
methods. Lack of consistency across studies made it hard to
compare and synthesize data. These issues have important
consequences for future studies.
The reviewed studies used different measures of BI, including
subscales from broader measures of self-image, self-perception,
self-esteem, or perceived physical appearance. These measures are
often limited to the extent that they refer to the attitudinal
component of BI or body satisfaction (Smolak, 2004) and do not
encompass broader definitions including the emotional and
behavioral components (Cash, 2002b). In addition, these measures
are unlikely to be sensitive to the specific changes in BI associated
with cancer treatment. Social desirability may influence response
patterns so that children and adolescents may use denial or appear
to accept BI changes (Madan-Swain et al., 1994). Appropriate tools
for measuring BI of children and adolescents with cancer are
essential (Kopel et al., 1998).
Explicit information about sample characteristics needs to
include visible physical impairment, treatment and side effects,
stage of disease, and time since diagnosis and treatment.
Sensitivity to developmental stage is particularly important when
evaluating a child’s adaptation to BI changes (Pruzinsky & Cash,
2002a).
In research designs involving comparisons between children
with cancer and controls, the assumption is that ‘poor’ or ‘good’ BI
relates to scores lower or comparable with scores achieved by the
comparison group. Thus, it is important to specify characteristics of
the comparison groups, since scores obtained by healthy controls
or children with other physical conditions or impairment are likely
to be different.
Both quantitative and qualitative research methods can make
potentially interesting contributions to understanding BI changes
255
following childhood cancer. Qualitative methods can detect subtle
changes in BI beliefs that cannot detected by questionnaires,
especially questionnaires designed to assess BI generally, rather
than as related to cancer treatment specifically (Puukko, Hirvonen,
et al., 1997).
Future studies
It is importance to investigate the impact of cancer and
treatment on all components of BI schemas and attitudes (Cash,
2002a), as well as consider how children and adolescents adjust
and cope with negative thoughts, feelings, and situations (Cash,
2002a; Cash, Santos, & Williams, 2005). Given the methodological
limitations identified, future studies should include explicit
information about participants, including demographic and
medical information about children and adolescents with cancer
and appropriate demographic information about any comparison
group. Longitudinal follow-up may contribute important informa-
tion regarding the permanent nature of BI change following cancer
treatment. It is necessary to assess both objective physical
appearance changes and subjective BI. Qualitative methods such
as open-ended questions or semi-structured interviews can yield
important information over that obtained from standardized self-
report measures.
In summary, we conclude that there is insufficient evidence to
show that children and adolescents with cancer have worse BI than
healthy controls. However, demographic and medical variables can
affect BI and adjustment. It is possible to identify several ways in
which current methods can be improved: development of cancer-
specific BI measures that recognize more sophisticated and
multifaceted definitions of BI; explicit information about partici-
pants and disease characteristics; sensitive research methods,
including interview and standard measures; and longitudinal
follow-up. Further work also needs to place greater emphasis on
the processes of adjustment whereby many children show
considerable resilience in BI and adjustment following the
potentially adverse effects of cancer and its treatment.
References
References marked with an asterisk indicate studies included in the
review.
*Anholt, U. V., Fritz, G. K., & Keener, M. (1993). Self-concept in survivors of childhood
and adolescent cancer. Journal of Psychosocial Oncology, 11, 1–16.
*Beardslee, C., & Neff, E. J. (1982). Body related concerns of children with cancer as
compared with the concerns of other children. Maternal Child Nursing Journal, 11,
121–134.
Calaminus, G., Weinspach, S., Teske, C., & Gobel, U. (2000). Quality of life in children and
adolescents with cancer. First results of an evaluation of 49 patients with the
PEDQOL questionnaire. Klinische Padiatrie, 212, 211–215.
*Calaminus, G., Weinspach, S., Teske, C., & Gobel, U. (2007). Quality of survival in
children and adolescents after treatment for childhood cancer: The influence of
reported late effects on health related quality of life. Klinische Padiatrie, 219, 152–
157.
Cash, T. F. (2002a). Cognitive-behavioral perspectives on body image. In T. F. Cash & T.
Pruzinsky (Eds.), Body image: A handbook of theory, research and practice (pp. 38–
46). New York: Guilford.
Cash, T. F. (2002b). A negative body image: Evaluating epidemiological evidence. In T. F.
Cash & T. Pruzinsky (Eds.), Body image: A handbook of theory, research and practice
(pp. 269–276). New York: Guilford.
Cash, T. F. (2002c). The Situational Inventory of Body-Image Dysphoria: Psychometric
evidence and development of a short form. International Journal of Eating Disorders,
32, 362–366.
Cash, T. F. (2004). Body image: Past, present, and future. Body Image, 1, 1–5.
Cash, T. F., Santos, M. T., & Williams, E. F. (2005). Coping with body-image threats and
challenges: Validation of the Body Image Coping Strategies Inventory. Journal of
Psychosomatic Research, 58, 191–199.
Chesler, M., & Barbarin, O. (1987). Childhood cancer and the family. New York: Brunner/
Mazel.
Coopersmith, S. (1981). Self-esteem inventories. Palo Alto, CA: Consulting Psychologists
Press.
*Eapen, V., Revesz, T., Mpofu, C., & Daradkeh, T. (1999). Self-perception profile in
children with cancer: Self vs parent report. Psychological Reports, 84, 427–432.
256 S.-Y. Fan, C. Eiser / Body Image 6 (2009) 247–256
*Earle, E. A., & Eiser, C. (2007). Children’s behaviour following diagnosis of acute
lymphoblastic leukaemia: A qualitative longitudinal study. Clinical Child Psychol-
ogy and Psychiatry, 12, 281–293.
Earvolino-Ramirez, M. (2007). Resilience: A concept analysis. Nursing Forum, 42, 73–82.
*Eiser, C., & Eiser, J. R. (2000). Social comparisons and quality of life among survivors of
childhood cancer and their mothers. Psychology and Health, 15, 435–450.
Eiser, C., & Jenney, M. E. (1996). Measuring symptomatic benefit and quality of life in
paediatric oncology. British Journal of Cancer, 73, 1313–1316.
*Enskar, K., Carlsson, M., Golsater, M., & Hamrin, E. (1997). Symptom distress and life
situation in adolescents with cancer. Cancer Nursing, 20, 23–33.
Enskar, K., Carlsson, M., Hamrin, E., & Kreuger, A. (1996). Swedish Health care
personnel’s perceptions of disease and treatment-related problems experienced
by children with cancer and their families. Journal of Pediatric Oncology Nursing, 13,
61–70.
Erikson, E. H. (1959). Identity and the life-cycle. Psychological Issues, 1, 18–164.
Evan, E. E., & Zeltzer, L. K. (2006). Psychosocial dimensions of cancer in adolescents and
young adults. Cancer, 107, 1663–1671.
Evans, M. (1997). Altered body image in teenagers with cancer. Journal of Cancer
Nursing, 1, 177–182.
Freeman, K., O’Dell, C., & Meola, C. (2000). Issues in families of children with brain
tumors. Oncology Nursing Forum, 27, 843–848.
*Freeman, K., O’Dell, C., & Meola, C. (2003). Childhood brain tumors: Children’s and
siblings’ concerns regarding the diagnosis and phase of illness. Journal of Pediatric
Oncology Nursing, 20, 133–140.
*Fritz, G. K., & Williams, J. R. (1988). Issues of adolescent development for survivors of
childhood cancer. Journal of the American Academy of Child & Adolescent Psychiatry,
27, 712–715.
Gellert, E. (1962). Children’s conceptions of the content and functions of the human
body. Genetic Psychology Monographs, 65, 293–411.
Goldsmith, M., Bankhead, C., & Austoker, J. (2007). Synthesis quantitative and quali-
tative research in evidence-based patient information. Journal of Epidemiology
Community Health, 61, 262–270.
Gray, R. E., Doan, B. D., Shermer, P., FitzGerald, A. V., Berry, M. P., Jenkin, D., et al. (1992).
Psychologic adaptation of survivors of childhood cancer. Cancer, 70, 2713–2721.
Harter, S. (1985). Manual of Self-Perception Profile for Children. Denver, CO: University of
Denver.
Harter, S. (1988). Manual of Self-Perception Profile for Adolescents. Denver, CO: Uni-
versity of Denver.
*Hedstrom, M., Skolin, I., & von Essen, L. (2004). Distressing and positive experiences
and important aspects of care for adolescents treated for cancer. Adolescent and
nurse perceptions. European Journal of Oncology Nursing, 8, 6–17.
*Jamison, R. N., Lewis, S., & Burish, T. G. (1986). Psychological impact of cancer on
adolescents: Self-image, locus of control, perception of illness and knowledge of
cancer. Journal of Chronic Diseases, 39, 609–617.
*Kopel, S. J., Eiser, C., Cool, P., Grimer, R. J., & Carter, S. R. (1998). Brief report:
Assessment of body image in survivors of childhood cancer. Journal of Pediatric
Psychology, 23, 141–147.
*Kyritsi, H., Matziou, V., Papadatou, D., Evagellou, E., Koutelekos, G., & Polikandrioti, M.
(2007). Self concept of children and adolescents with cancer. Health Science Journal,
11, 1–11.
*Langeveld, N. E., Grootenhuis, M. A., Voute, P. A., de Haan, R. J., & van den Bos, C. (2004).
Quality of life, self-esteem and worries in young adult survivors of childhood
cancer. Psycho-oncology, 13, 867–881.
*Larouche, S. S., & Chin-Peuckert, L. (2006). Changes in body image experienced by
adolescents with cancer. Journal of Pediatric Oncology Nursing, 23, 200–209.
Li, J., Thompson, T. D., Miller, J. W., Pollack, L. A., & Stewart, S. L. (2008). Cancer incidence
among children and adolescents in the United States 2001–2003. Pediatrics, 121,
e1470–1477.
*Madan-Swain, A., Brown, R. T., Sexson, S. B., Baldwin, K., Pais, R., & Ragab, A. (1994).
Adolescent cancer survivors. Psychosocial and familial adaptation. Psychosomatics,
35, 453–459.
*Maggiolini, A., Grassi, R., Adamoli, L., Corbetta, A., Charmet, G. P., Provantini, K., et al.
(2000). Self-image of adolescent survivors of long-term childhood leukemia.
Journal of Pediatric Hematology/Oncology, 22, 417–421.
*Mattsson, E., Ringner, A., Ljungman, G., & von Essen, L. (2007). Positive and negative
consequences with regard to cancer during adolescence. Experiences two years
after diagnosis. Psycho-oncology, 16, 1003–1009.
*McCaffrey, C. N. (2006). Major stressors and their effects on the well-being of children
with cancer. Journal of Pediatric Nursing, 21, 59–66.
Millon, T., Green, C. J., & Meagher, R. (1982). Millon Adolescent Personality Inventory.
Minneapolis, MN: National Computer Systems.
*Moore, I. M., Challinor, J., Pasvogel, A., Matthay, K., Hutter, J., & Kaemingk, K. (2003).
Behavioral adjustment of children and adolescents with cancer: Teacher, parent,
and self-report. Oncology Nursing Forum, 30, E84–91.
*Mullis, R. L., Mullis, A. K., & Kerchoff, N. F. (1992). The effect of leukemia and its
treatment on self-esteem of school-age children. Maternal Child Nursing Journal, 20,
155–165.
NHS. (2001). Center for Reviews and Dissemination Report No. 4. Retrieved March 25,
2008, from http://www.york.ac.uk/inst/crd/report4.html
*O’Malley, J., Foster, D., Koocher, G., & Slavin, L. (1980). Visible physical impairment and
psychological adjustment among pediatric cancer survivors. American Journal of
Psychiatry, 137, 94–96.
Offer, L. D., Ostrov, E., & Howard, K. I. (1982). The Offer Self-Image Questionnaire for
Adolescents: A manual (revised). Chicago: Michal Reese Hospital.
Patterson, J. M. (1995). Promoting resilience in families experiencing stress. Pediatric
Clinics of North America, 42, 47–63.
*Pendley, J. S., Dahlquist, L. M., & Dreyer, Z. (1997). Body image and psychosocial
adjustment in adolescent cancer survivors. Journal of Pediatric Psychology, 22, 29–
43.
Petersen, A. C., Schulenberg, J. E., Abramowitz, R. H., Offer, D., & Jarcho, H. D. (1984). A
Self-Image Questionnaire for Young Adolescents (SIQYA): Reliability and validity
studies. Journal of Youth and Adolescence, 13, 93–111.
Piers, E. V. (1984). Piers-Harris Children’s Self-Concept Scale: Revised manual. Los
Angeles: Western Psychological Services.
Pruzinsky, T., & Cash, T. F. (2002a). Assessing body image and quality of life in medical
settings. In T. F. Cash & T. Pruzinsky (Eds.), Body image: A handbook of theory,
research and practice (pp. 171–179). New York: Guilford.
Pruzinsky, T., & Cash, T. F. (2002b). Understanding boy images: Historical and con-
temporary perspectives. In T. F. Cash & T. Pruzinsky (Eds.), Body image: A handbook
of theory, research and clinical practice (pp. 3–12). New York: Guilford Press.
*Puukko, L. R., Hirvonen, E., Aalberg, V., Hovi, L., Rautonen, J., & Siimes, M. A. (1997a).
Impaired body image of young female survivors of childhood leukemia. Psychoso-
matics, 38, 54–62.
*Puukko, L. R., Sammallahti, P. R., Siimes, M. A., & Aalberg, V. A. (1997b). Childhood
leukemia and body image: Interview reveals impairment not found with a ques-
tionnaire. Journal of Clinical Psychology, 53, 133–137.
Reynolds, C. R., & Kamphaus, R. W. (1992). Behavioral assessment system for children.
Circles Pine, MN: American Guidance Services.
Roberts, C. S., Turney, M. E., & Knowles, A. M. (1998). Psychosocial issues of adolescents
with cancer. Social Work in Health Care, 27, 3–18.
Rosen, J. C., Srebnik, D., Saltzberg, E., & Wendt, S. (1991). Development of a body image
avoidance questionnaire. Psychological Assessment, 3, 32–37.
Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton
University Press.
Rutter, M. (1985). Resilience in the face of adversity. Protective factors and resistance to
psychiatric disorder. British Journal of Psychiatry, 147, 598–611.
Secord, P. F., & Jourard, S. M. (1953). The appraisal of body-cathexis: Body cathexis and
the self. Journal of Consulting Psychology, 17, 343–347.
Slade, P. D. (1994). What is body image? Behaviour Research and Theory, 32, 497–502.
Smith, M. A., & Gloeckler Ries, L. A. (2002). Childhood cancer: Incidence, survival, and
mortality. In P. A. Pizzo & D. Poplack (Eds.), Principles and practice of pediatric
oncology (4 ed., pp. 1–12). Philadelphia: Lippincott Williams & Wilkins.
Smolak, L. (2004). Body image in children and adolescents: Where do we go from here?
Body Image, 1, 15–28.
Spinetta, J. J., McLaren, H. H., Fox, R. W., & Sparta, S. N. (1981). The kinetic family
drawing in childhood cancer: A revised application of an age-dependent measure.
In J. J. Spinetta & P. Deasy-Spinetta (Eds.), Living with childhood cancer (pp. 86–120).
St Louis: Mosby.
*Stern, M., Norman, S. L., & Zevon, M. A. (1993). Adolescents with cancer self-image and
perceived social support as indexes of adaptation. Journal of Adolescent Research, 8,
124–142.
Stewart, A. L., Hays, R. D., & Ware, J. E., Jr. (1988). The MOS short-form general health
survey. Reliability and validity in a patient population. Medical Care, 26, 724–
735.
*Varni, J. W., Katz, E. R., Colegrove, R., Jr., & Dolgin, M. (1995). Perceived physical
appearance and adjustment of children with newly diagnosed cancer: A path
analytic model. Journal of Behavioral Medicine, 18, 261–278.
Wallace, H., & Green, D. M. (2004). Late effects of childhood cancer. London: Arnold.
*Wallace, M. L., Harcourt, D., Rumsey, N., & Foot, A. (2007). Managing appearance
changes resulting from cancer treatment: Resilience in adolescent females. Psycho-
oncology, 16, 1019–1027.
*Weigers, M. E., Chesler, M. A., Zebrack, B. J., & Goldman, S. (1998). Self-reported
worries among long-term survivors of childhood cancer and their peers. Journal of
Psychosocial Oncology, 16, 1–23.
White, C. A. (2000). Body image dimensions and cancer: A heuristic cognitive beha-
vioural model. Psycho-oncology, 9, 183–192.
*Woodgate, R. L. (2005). A different way of being: Adolescents’ experiences with
cancer. Cancer Nursing, 28, 8–15.
*Wu, L. M., & Chin, C. C. (2003). Factors related to satisfaction with body image in
children undergoing chemotherapy. Kaohsiung Journal of Medical Sciences, 19, 217–
224.
*Zebrack, B. J., & Chesler, M. (2001). Health-related worries, self-image, and life out-
looks of long-term survivors of childhood cancer. Health and Social Work, 26, 245–
256.