Developing a conceptual model for fatigue in children

Developing a conceptual model for fatigue in children Marilyn Hockenberry-Eaton, Pamela Hinds, Jill Brace O'Neill, Pat Alcoser, Sarah Bottomley, Nancy E Kline, Kerri Euell, Vanessa Howard, Jami Gattuso

The purpose of this research study was to define fatigue experienced by children with cancer and to begin development of a conceptual model.Two major Paediatric Cancer Centers in the Southern U S A participated in this study. Children who participated in this study were in the out-patient clinic or in the hospital. Five focus groups with a total of 14 children between 7 and 12 years-of-age were held over a 2-month period of time. Focus groups were used to first assess the contextual understanding and essential attributes of fatigue in 7 to 12-year-old children. Each focus group session lasted 30 to 45 minutes, was audiotaped and transcribed verbatim.A team of four researchers used content analysis to evaluate the transcripts. Codes and definitions were developed for the characteristics of fatigue, causes of fatigue and what alleviates fatigue. Concept analysis was completed as a basis for developing the conceptual framework. Eight codes emerged to define fatigue. Seven codes were used to describe the causes of fatigue.An additional three codes were used to describe what alleviated fatigue.A conceptual definition for fatigue experienced by children with cancer emerged from the data, and a conceptual model was developed to demonstrate relationships between fatigue and contributory and alleviating factors.The conceptual work for model development contributes to understanding fatigue in children with cancer and serves as a basis for establishing operational definitions

Entwicklung eines konzeptuellen Modells Ober Ersch6pfung bei I~ndern Marilyn HockenberryEaton PhD,RN CS, PNP, FAAN,AssociateProfessor, Department of Pediatrics, Pediatric Hematology Oncology Division, Baylor College of Medicine, Houston,Texas 77030, USA Pamela Hinds PhD, RN, CS, Coordinator of Nursing Research,Associate Director of Research For Behavior Medicine,St.Jude Children's Research Hospital, Memphis, Tennessee,USA Jill Brace O'Neill MS, RN, CPNR Pat Alcoser MSN, RN, CPNR Sarah Bottomley MN, RN, CPNP, Nancy E. Kline MS, RN, CPNP,Kerri Euell RN, Texas Children's Cancer Center,Texas Children's Hospital, Houston,Texas, USA Vanessa Howard MSN, RN, CPON, Jami Gattuso MSN, RN, CPON, St.JudeChildren's Research Hospital, Memphis,Tennessee,USA

Correspondence and offprint requeststo: Marilyn Hockenberry-Eaton

Der Sinn dieser Forschungsstudie war es, Ersch~pfung bei krebskranken Kindern zu definieren und die Entwicklung eines konzeptuellen Modells anzusto~en. Zwel gro~e onko-p~diatrische Zentren im S0den Amerikas nehmen an tier Studie teil. Die teilnehmenden Kinder kaman aus dem Krankenhaus oder der angeschlossenen Ambulanz. F0nf Zielgruppen mit insgesamt 14 Kindern zwischen 7 und 12 Jehren wurden in einem Zeitraum yon 2 Monaten untersucht. Diese Zielgruppen wurden gebitdet, um zuerst alas kontextuelle Verst~ndnis und die wesentlichen Eigenschaften von Ersch~pfung, wie Kinder im Alter yon 7 bis 12 sie wahrnehmen, zu ermitteln. Jede Zlelgruppensitzung dauerte 30 bis 45 Minuten, wurde auf Tonband aufgezeichnet und anschlie~end wSrtlich transkribiert. EIn Team yon vier Forschern f0hrte eine inhaltsanalyse dutch, um die Transkripte auszuwerten. Schl~isselw6rter und Definitionen for die Charakteristika, Ursachen und Erliechterungsm6glichkeiten von Ersch6pfung wurden entwickelt. Die Begriffsanalyse wurde als Basis for einen konzeptuellen Rahmen fertiggestellt. Acht SchlCisselw6rter zur Definition yon Erschbpfung kristallisierten sich heraus. Sieben Schl0sselw6rter dienten der Definition der Ursachen von Ersch6pfung. Weitere drei wurden genutzt, um zu definieren, was Ersch6pfung erleichtert. Eine begriffliche Definition for yon krebskranken Kindern erlebte Ersch6pfung wurde aus den Ergebnissen abgeleitet. Au~erdem wurde ein konzeptuelles Modell entwickelt, das die Bezlehungen zwischen Ersch6pfung, sowie den ersch6pfungesteigernden und-mildernden Faktoren aufzeigt. Die konzeptuelle Arbeit der Modellentwicklung tr~gt zum Verst~ndnis von Ersch6pfung bel krebskranken Kindern bei und dient als Basis zur Bitdung von Arbeitsdefinitionen.

Desarrollando un modelo conceptual de fatiga en los ni~os El objetivo de este proyecto de investigaci6n fue definir le fatiga experimentada por ni~os con cancer y empezar a desarrollar un modelo conceptual. Los dos Centros Pedi~tricos de Cancer m~s importantes del sur de Los Estados Unidos de America (USA) participaron en este estudio. Los ni~os que participaron en este estudio se encontraban hospitalizados o en ~mbito extrahospitatario (consultas externas). Se enfoc6 el ~studio en 5

EuropeanJournal of Ontology Nursing 3(I) 5-L I © HarcourtBrace& Co. Ltd 1999

Developing a conceptual model for fatigue in children

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grupos con un total de 14 nifios con edades comprendidas entre 7 y 12 afios en un periodo de un mes. Estos grupos fueron utilizados para hacer una valoraci6n inicial sobre el entendimiento contextual y sobre los sintomas e implicaciones m~s importantes de la fatiga entre los nifios de 7 a 12 afios. Carla sesi6n con el grupo duraba entre 30 a 45 minutos, estas sesiones eran grabadas y transcritas en diskettes. Un equipo de 4 investigadores evaluaban estas transcripciones. Se obtuvieron deflniciones y se desarrollaron los puntos m~s importantes sobre tas caracteffsticas de la fatiga, las causas y los factores que la mejoran. Un an~lisis conceptual rue completado como base para desarrollar unas directrices. Se utilizaron oche puntos para describir las causas de la fatiga. Otros tres puntos adicionales fueron tambi6n utilizados para describir que factores aliviaban la fatiga. Se obtuvo una definici6n conceptual de fatiga experimentada por los nifios con c~ncer con estos datos y se desarroll6 un modeto conceptual que demuestra la relaci6n entre la fatiga y las causas que la producen y los factores que pueden aliviar y / o mejorar este problema. Este trabaio conceptual sirve para desarrollar un modelo que contribuya a un mejor entendimiento de Io que es la fatiga experimentada p o r los nifos con cancer y sirve c o m o base para establecer una definici6n operativa.

INTRODUCTION Numerous authors have defined fatigue in the adult cancer patient. Definitions include lack of energy (Winningham et al 1994), decreased ability to function (Pickard-Holley 1991), subjective feelings of tiredness influenced by circadian rhythms (Aistars 1987) and impaired functional status (Pickard-Holley 1991). Fatigue has been shown to be a distressing symptom, associated with many other side-effects caused by cancer and its treatment. The prevalence of fatigue ranges from 60-100% in the adult cancer literature (Irvine et al 1994, King et al 1985, Meyerowitz et al 1983, Pickard-Holley 1991, Robinson & Posner 1992). Fatigue has been shown to be a common symptom associated with chemotherapy (Winningham et al 1994, Meyerowitz et al 1983, Cassileth et al 1985, Adams et al 1984, Blesch et al 1991), radiation therapy (Eardley 1986, King et al 1985, Kubricht 1984, Piper et al 1989) and biologic response modifiers (Robinson & Posner 1992). Adult cancer studies over the past 18 years have revealed numerous symptoms associated with fatigue including insomnia (Knoff 1986, McCorkle & Young 1978), changes in taste or appetite (Cassileth et al 1985), mood disturbances, nervousness or depression (Bresch et al 1991, Cassileth et al 1985, Kubricht 1984, Piper et al 1989), alteration in self-care activities (Winningham et al 1994), changes in attention capacity (Cimprich 1990) and decreased participation in leisure activities (Bloom et al 1990). McCorkle and Young (1978), in one of the earliest nursing studies evaluating fatigue in adult patients with cancer, described fatigue as the most distressing side-effect associated with the disease. While previous studies revealed fatigue as a common symptom in adults with cancer, they provide limited insight into factors associated with the onset and duration of fatigue, the effect on dally activity and performance, and modulating factors associated with the symptom (Irvine et al 1991). Design and methodological inadequacies in the adult oncology fatigue research literature may contribute to conflicting findings. Many of these studies had no control groups, lacked reliable fatigue

measures, were unable to examine the onset and duration of fatigue, had small sample sizes and often used only one criterion to measure fatigue (St. Pierre et al 1992). The limited approach to examining fatigue is a concern in the majority of the adult studies. There is limited information available on fatigue in children. Chronic fatigue in children is a rare problem, but several articles on its occurrence which have been published provide some insight into the concept of fatigue in children. Chronic fatigue syndrome (CFS) in children is defined as a severe and disabling fatigue that affects both mental and physical functioning and lasts for at least 6 months (Carter et al 1995). Carter et al (1996) examined symptoms of chronic fatigue in 20 children and found that these children experienced concentration changes, muscle weakness, depressed mood, decreased appetite, sleep disturbances and a need for excessive sleep. An article published in 1996 by Carter et al evaluated certain psychological factors that discriminated chronic fatigue from depressive symptomatology in matched groups of 20 healthy, depressed and chronic fatigue subjects. Characteristics of paediatric patients with chronic fatigue included multiple somatic complaints, excessive sleepiness, low energy, decreased appetite, loss of interest or pleasure in usual activities, loneliness, social isolation and feelings of unhappiness. Depressed subjects reported more symptoms of affective disturbances, were more likely to have suicidal ideation, pronounced social isolation and demonstrated behaviours such as irritability, restlessness, difficulty concentrating, anger and aggressive behavior. Depressed subjects were significantly affected by feelings of tiredness, fatigue and an excessive need for sleep. While the review of the adult oncology fatigue and paediatric chronic fatigue literature provides important information regarding this symptom, it provides limited insight into the changes cancer and its treatment cause in the lives of children. No studies are found evaluating fatigue in the childhood cancer literature. A study by the Principal Investigator EuropeanJournal of Ontology Nursing 3(I), 5 - I I

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I. 2. 3. 4. 5. 6. 7. 8. 9.

How would you describe fatigue or being tired? Are there different kinds of feeling tired? Like being tired in your body or in your mind? Please describe the things that you can't do when you feel tired. How long does feeling tired last? Have your school activities changed? If so, how? Do you ever have trouble falling asleep at night? Why do you thing that happens? Does sleep make you feel less tired? How tired are you feeling today? W h y do you think you are feeling this way? When you are tired, or have low energy, what kind of things help you feel better?

Codes

Descriptions

Examples

Hard to move or run

Child describes that they are not as active as they used to be. Child describes needs to lie down and wanting to do nothing.

'For me it's really hard to run and my legs feel like they're 100 pounds.' 'Like you're weak and all that kind of stuff. Like just going and laying down and going to bed.' 'Well, back before my surgery and I was kind of really active, but not very tired usually. And now I'm very tired.' 'Sad, sad and hurt. Because when you don't get to go home, it feels bad because when you don't get to go home you don't get to see your family and your friends.' '1 sleep a long time in the morning.'

Feel like laying around Tired

Child describes feelings of being tired. They watch -IV and aren't able to do much.

Makes you sad/mad

Child discusses feeling upset when they are emotionally tired. It occurs most often in the morning, in school days and following treatment.

When fatigue occurs

Child discusses when fatigue occurs and how long it lasts. Child discusses not being able to participate in sports such as baseball or physical education. Child discusses when tired their eyes are hard to keep open. They notice their eyes are tired, and they have a dull face. Child discusses falling asleep easily and needing to sleep more when they are tired.

Not able to play

Physical Signs

Falls asleep easily

(Bottomley et al 1995) evaluating an instrument developed to measure childhood cancer stressors found that over 50% of a group of 75 school-age children reported being tired, not sleeping well and being unable to do the things they wanted to do. More than half of these children were not as active as before the illness, and reported playing less. Children with cancer experience numerous side-effects from treatment including nausea and vomiting, which may cause weight loss, nutritional deficits, electrolyte imbalances, weakness and lethargy. Infection and fever are common occurrences during treatment. These symptoms are experienced differently by the child with cancer when compared to the adult oncology patient. For this reason, it is important to undertake a comprehensive evaluation of fatigue as a symptom in children with cancer to characterize its presentation, frequency, severity and natural history. This study is part of a larger fatigue research programme developed to evaluate the occurrence, causes, conceptual and operational definitions, and effective interventions for children with cancer. In this paper, the perceptions of fatigue reported by a group of children with cancer are discussed. The specific objectives of this research study were to: European Journal of Oncology Nursing 3 ( I ), 5- I I

• •

•

'If you're really tired you can't ride our bike.'

'1 can see tired in my eyes.' 'In the afternoon, I'llgo take a nap and before I was diagnosedwith cancer I never did that.'

Develop a conceptual definition of fatigue in 7-12-year-old children with cancer Complete a formal concept analysis of fatigue by using data collected from children's focus groups Develop a conceptual model that would describe contributing and alleviating factors for fatigue in children receiving treatment for cancer.

METHODS

Setting and sample Children receiving treatment for cancer at two major Children's Cancer Centers in the Southern USA were invited to participate in the study. Parents and the child were informed about the study and informed consent was obtained from both the parent and child before participating in the study. Inclusion criteria consisted of children who were: •

•

12 years-of-age, to ensure that children of the same developmental level were obtained Presently receiving treatment for cancer 7 to

Developing a conceptual model for fatigue in children

Codes

Descriptions

Examples

Treatment

Child discusses that chemotherapy, radiation and surgery can cause fatigue, often associated with feeling sick. Child discusses being tired after play and activities.

'1 feel tired right after radiation.'

Being active

Pain

Child discusses being tired when they experience discomfort such as pain.

Sleep changes

Child's sleeping patterns change making it hard to sleep all night or get to sleep. Schedule changes may influence this. Child discusses feeling tired when experiencing myelosuppression. Child discusses noises, frequent interruptions, location of their hospital room as causing fatigue because of lack of sleep. Sometimes they have trouble fallingasleep in the hospital.

Low counts Hospital environment

'1 had to quit playing baseball, my counts were too low.' 'When I am in the hospital, I am just so drained when I get home.'

Descriptions

Examples

Naps/sleep

Child describes resting during the day and at night sometimes helps. Child describes having someone come and visit as helping he/she feel less tired. Child describes activities such as going to the movies, reading a book or listening to music make him/her less tired.

'1 usually take two naps every day and that makes me feel better.' 'Having someone come visit you.'

Fun/activities

* •

'At Camp Periwinkle, running around, going from place to place and the activities we did there [that made me really tired].' 'There's different kinds of tired because one for me is when your feet hurt and they hurt very much and you have to lay down for a second or when you just feel sleepy, or when you have both. That's the worse thing I can think.' 'Me, usually sometimes at night I get a little restless and it's a while for me to go to sleep.'

Codes

Visitors

Not terminally ill at the time of the study Able to communicate in English.

Heterogeneity of diagnoses and time since diagnoses were specifically chosen to provide a broad perspective of the fatigue definition since this was the first study to evaluate the concept in children with cancer. Children returning to the out-patient clinic or who were admitted to the hospital were approached to determine their interest in participating in a focus group to discuss their perceptions of fatigue during treatment for cancer. Fourteen children participated in one of five focus groups, 43% (6) were female and 57% (8) were male. In this study, focus groups were defined as sessions containing two or more children. Focus groups had from two to five children participating in the session 86% (12) were Caucasian and 14% (2) were African-American. 57% of these (8) were diagnosed with leukemia/lymphoma and 43% (6) had a solid tumor, with the time since diagnosis ranging from 1 to 95 months, with a mean of 16 month~. The mean age of the participants was 10 years.

Procedure Prior to implementation of the focus groups, research teams from both Cancer Centers participated in a

8

'Reading a book.' 'Listening to music.'

session on how to lead focus groups. Researchers at both study sites developed focus groups questions based on the experience of paediatric oncology nurses and the literature. The same questions were used for all five focus group sessions. Nine focus groups questions were used and are found in Table 1. Children and their parents were approached by one of the nurse researchers and asked to participate in an audiotaped focus group discussion without their parents. Once interest was elicited, children and parents signed an informed consent. Focus groups were held in a clinic or hospital conference r o o m and were led by one of the nurse researchers who had attended the focus group training session. Five focus groups with 14 children between 7 to 12 years-of-age were held over a 2-month period. Focus groups lasted 30 to 45 minutes and were audiotaped and transcribed verbatim.

D a t a analysis Transcripts from each of the five focus groups were coded independently by four researchers, and the computer software program E T H N O G R A P H was used to assist with data management and to generate summaries of the frequencies for each code. The researchers met as a group to review the codes and European Journal of Oncology Nursing 3(I ), S-I I

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to evaluate the inter-rater reliability of the coding, which ranged from .80 to .95. To verify interpretations of the data, researchers used peer debriefing through frequent sessions to review each coded transcript and examine its contextual meaning, and by member-checking with participants to ensure accurate assessment of the data.

ing the 'model case'. This case is based entirely on the collected data and represents the true example of the concept being studied, the one that the researchers describe with absolute certainty as best conveying the essence of the concept. A subsequent step in the method is developing the 'contrary case', or that which represents the opposite instance of the concept being studied and thus one that lacks the essential characteristics. An additional step is to develop the 'related case' of a concept that is similar and may even occur in the same or similar context but which differs in some critical way from the concept of interest. A conceptual definition was developed, and cases that included a model, contrary and related case were written. A conceptual model with relationships specified between fatigue and contributory and alleviating factors emerged from the data.

FINDINGS Codes and definitions were developed for the characteristics of fatigue, causes of fatigue and what helps. Eight codes emerged to define fatigue: hard to move or run, feel like laying around, being tired, makes you sad/mad, not able to play, physical signs, and falling asleep easily (Table 2). Children described both physical and mental symptoms of fatigue, expressing their perception of fatigue in relation to changes that occurred in the ability to participate in physical activities they did prior to having cancer. Six codes were used to describe the causes of fatigue: treatment, being active, pain, sleep changes, low counts and hospital environment (Table 3). Children discussed normal childhood activities causing fatigue at the end of the day. In addition, these children expressed that treatment such as chemotherapy, radiation therapy and surgery causes tiredness. Children as young as 7 were able to discuss the impact of the hospital environment on their ability to rest. Children agreed that they were more tired when in the hospital because of frequent interruptions, interactions with numerous personnel and noise heard outside the room. The children identified sleep changes as a cause of fatigue. Difficulty going to sleep at night was discussed as a cause of fatigue in the morning. Three codes were used to describe what helps: naps/sleep, visitors and fun/activities (Table 4). A good night's sleep was described as something that helped the children when they were tired. Children discussed quiet activities such as reading, listening to music or watching a video as helpful when they experienced fatigue. When hospitalized, having visitors was reported as helping to decrease fatigue. In addition to the content analysis, researchers completed a concept analysis by using a modified version of the Wilson method (Walker & Avant 1995). The intent of the method is to identify the essential elements of the concept that remain the same over situations. Determining the essential elements of the concept relies heavily on develop-

Definition of fatigue The following definition emerged from the data obtained in the focus group sessions. Fatigue is a profound sense of being tired, or having difficulty with movement such as using arms and legs, or opening eyes which is influenced by environmental, personal/social and treatment-related factors and can result in difficulties with play, concentration and negative emotions (most typically anger and sadness). The profound sense of tiredness can be acute, episodic or chronic, and is relieved by rest and distraction.

Defining attributes The following descriptions were used by the children participating in the focus groups and are the defining attributes of the concept of fatigue: difficult to move or run, being tired, mad or sad feelings, not able to play, physical signs and a change in sleep/rest patterns.

Model case A model case was developed to describe fatigue in the child receiving treatment for cancer. PB, an 8year-old boy with T-cell lymphoma, describes how active and playful he was prior to being diagnosed. Since he has started treatment with chemotherapy, this patient has become less active, frequently complaining of feeling tired, and only wants to lay around (i.e. watch TV). PB is no longer able to participate in sports like baseball because he finds it hard to run like he used to. He is unable to attend

C o n t r i b u t i n g Factors

Alleviati

P

Environmental Personal/Behavioural Treatment/Treatment-Related

Fig. I

Conceptual model for fatigue in children with cancer.

EuropeanJournal of OncologyNursing 3(I), 5-1 I

FATIGUE

Personal/Be Fami

Developing a conceptual model for fatigue in children school because he needs so much assistance (i.e. cannot carry books) and is frequently too tired. This young boy reports that resting during the day sometimes can relieve the tiredness he feels so often. PB goes on to state that sometimes this tiredness can make him mad and/or sad.

Contrary case To examine the difference in a child experiencing fatigue compared to a child without the symptom, a contrary case was developed. SW is an 8-year-old girl with good risk acute lymphocytic leukemia who will complete therapy in months. She made the cheerleading team for the Fall, and finished her first week of pre-season practice today. At dinner she is nearly ecstatic as she tells her parents that she had no problems with most of the routines and finally mastered the most difficult routine today. She boasts that she's in better shape than she thought and does not complain half as much about sore muscles as her best friend does. Her mother reminds her how important a good night's sleep is, and states how pleased she is that SW has been making an effort to get to bed early each night. SW agrees and adds that she sleeps like a rock these days and it feels great.

Related case A related case describes similar symptoms that may occur during treatment for childhood cancer but which are distinctly different in their presentation. Related cases may have some of the defining attributes, but not all are found. JD is a 6-year-old with acute lymphocytic leukemia, admitted for high dose Cytosine Arabinoside during his consolidation stage of therapy for high-risk leukemia. During his admission, he and his mother are walking in the hall and JD complains that his legs feel like they weigh 100 pounds each. JD begs his mother to carry him back to his room so he can take a nap. His mother encourages him to pick out a video on the way back to the room. He becomes angry and whines that his eyes are too tired to watch a movie. His mother gives in, rationalizing that neither of them slept well last night with all the noise at the nurse's station.

Conceptual model development Content and concept analysis led to the development of a conceptual model to describe fatigue in 7 to 12-year-old children with cancer. Assumptions underlying this model are that: • • *

Fatigue is a symptom that occurs in children receiving treatment for cancer Fatigue is associated with physical and mental limitations for children Fatigue, although a subjective experience, can be more clearly defined in this population, lead-

*

I0

ing to more accurate and comprehensive nursing assessments Understanding fatigue in children requires knowledge of growth and development in relation to the diagnosis of cancer.

The development of the conceptual model demonstrated relationships between fatigue and contributory and alleviating factors. Contributing factors include environmental, personal/behavioural and treatment/treatment-related indicators. Alleviating factors include personal/behavioral and family/social indicators (Fig. 1). Environmental factors have direct impact on the child's level of fatigue and were most commonly associated with activities in the hospital that interrupt the child's sleep/rest patterns. Personal/ behavioural influences on fatigue reflected the child's concrete cognitive development level. Examples of personal/behavioural contributing factors were the effects of the child's efforts to continue normal daily activities as well as changes in sleep patterns, such as sleeping in a different location at night. Treatment/ treatment-related contributing factors were defined as side-effects of treatment such as pain or low counts. Alleviating factors included personal/behavioural indicators such as the ability to take a nap during the day and uninterrupted sleep at night. For the school-age child, family and friends were important influences on fatigue. Alleviating factors involved interaction with visitors and friends and participating in fun activities. In the hospital, friends and family visits that provided the child with opportunities to play with others reduced fatigue.

DISCUSSION The development of a conceptual definition of fatigue from the perspective of the child receiving treatment for cancer confirms the symptom as a debilitating, functionally limiting symptom for this age group. The defining attributes identified during content analysis reflect the perceptions of fatigue as being both physical and mental limitations. The development of a conceptual framework from the concept analysis provides further insight into the concept of fatigue in children. The content analysis revealed the environment as a cause of fatigue in young children. The effects of hospitalization on the cancer patient has not been previously explored in the adult oncology fatigue literature. Personal/ behavioural influences reflected the school-age child's concrete level of development. Children this age are able to solve problems in a systematic fashion based on what they perceive. Recognized causes of fatigue being related to treatment and treatment-related side-effects were similar to findings in the adult research studies. Findings in this group of children with cancer are EuropeanJournal of OncologyNursinE 3 (I), 5-1 I

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similar to the symptoms expressed in studies of children with CFS as well as adults with cancer. Similar descriptions include limitations in daily activities, lack of energy and feelings of extreme tiredness. Children described both physical and mental symptoms of fatigue and expressed their perception of fatigue in relation to changes that have occurred in their ability to perform activities they did prior to having cancer. Children with cancer were able to more distinctly identify the cause of fatigue in comparison to children with CFS, while children with CFS more readily identified fatigue in relation to somatic symptoms such as abdominal pain, headaches and myalgia. The fact that children with cancer could describe the causes of fatigue m a y demonstrate that this group found fatigue more tolerable than children with CFS. The children with cancer discussed peaks and valleys associated with fatigue, as if knowing the time limitations of fatigue made it easier to tolerate.

NURSING IMPLICATIONS Recognition of the presence of a mental and physical component related to fatigue in young children has specific nursing implications. Nursing interventions must address fatigue in relation to changes in physical activities as well as mental function. Acknowledgment that developmental differences exist is an important finding from this study. Young children were able to recognize several causes of fatigue, but were able to identify only three interventions that they perceived as helpful in decreasing the symptom. From a developmental perspective, this represents the concrete thought process of young children in being able to identify a source for concern, but unable to consider a solution to the problem. Recognition of the causes of fatigue in young children can assist the nurse with the development of interventions that will protect rest time, provide a quieter hospital environment and prevent boredom and inactivity in the hospital and at home.

REFERENCES

Adams F, Quesada LR, Gntterman JU (1984) Neuropsychiatric manifestations of human leukocyte interferon therapy in patients with cancer. Journal American Medical Association 151(7): 938-941 Aistars J (1987) Fatigue in the cancer patient A conceptual approach to a clinical problem. Oncology Nursing Forum 14(6): 25-30 Blesch KS, Paice JA, Wickham R, Harte N, Schnoor DK, Purl S, Rehwalt M, Kopp PL, Manson S, Coveny SB, McHale M, Cahill M (1991) Correlates of fatigue in people with breast or lung cancer. Oncology Nursing Forum 18(1): 81-87 Bloom JR, Gorsky RD, Fobair P, Hoppe R, Cox RS, Varghese A, Spiegel D (1990) Physical performance at work and at leisure: Validation of a measure of biological energy in survivors of Hodgkins Disease. Journal Psychosocial Oncology 8(1): 49-63 European Journal of Oncology Nursing 3(I), 5- ] I

Bottomley S, Teegarden C, Hockenberry-Eaton M (1995) Fatigue in children with cancer: Clinical considerations for nursing [Abstract]. Association of Pediatric Oncology Nurses, National Conference, Dallas, Texas. Journal of Pediatric Oncology Nursing 13(3): 178 Carter BD, Edwards JF, Kronenberger WG, Michalczyk BA, Marshall GS (1995) Case control study of chronic fatigue in pediatric patients. Pediatrics 95(2): 179-186 Carter BD, Kronenberger WG, Edwards JF, Michalczyk BA, Marshall GS (1996) Differential diagnosis of chronic fatigue in children: Behavioral and emotional dimensions. Developmental and Behavioral Pediatrics 17(1): 16-21 Cassileth BP, Lusk EJ, Bodenheimer BJ (1985) Chemotherapeutic toxicity: The relationship between patients' pretreatment expectations and post-treatment results. American Journal Clinical Oncology 8:419-425 Cimprich B (1990) Attentional fatigue in the cancer patient. Oncology Nursing Forum 17(Suppl.2): 218 Eardley A (1986) Patients and radiotherapy patients' experiences after discharge. Radiography 52(601): 17-19 Irvine DM, Vincent L, Bubela N, Thompson L, Graydon J (1991 ) A critical appraisal of the research literature investigating fatigue in the individual with cancer. Cancer Nursing 14(4): 188-199 Irvine DM, Vincent L, Graydon JE, Bubela N, Thompson L (1994) The prevalence and correlates of fatigue in patients receiving treatment with chemotherapy and radiotherapy. Cancer Nursing 17(5): 367-378 King KG, Nail LM, Kreamer K, Strohl RA, Johnson JE (1985) Patients' descriptions of the experience of receiving radiation therapy. Oncology Nursing Forum 12(4): 55-61 Knoff M (1986) Physical and psychological distress associated with adjuvant chemotherapy in women with breast cancer. Journal Clinical Oncology 4(5): 678-84 Kubricht D (1984) Therapeutic self-care demands expressed by outpatients receiving external radiation therapy. Cancer Nursing 7(1): 43-52 McCorkle R, Young K (1978) Development of a symptom distress scale. Cancer Nursing 1:373-378 Meyerowitz BE, Watkings IK, Sparks FC (1983) Quality of life for breast cancer patients receiving adjuvant chemotherapy. American Journal of Nursing 83(2): 232-235 Pickard-Holley S (1991) Fatigue in cancer patients. Cancer Nursing 14(1): 13-19 Piper BE Lindsey AM, Dodd MJ (1987) Fatigue mechanisms in cancer patients: developing nursing theory. Oncology Nursing Forum 14(6): 17-23 Piper BG, Lindsey AM, Dodd MJ, Ferketich S, Paul SM, Waller S (1989) Development of an instrument to measure the subjective dimension of fatigue. In: S Funk & E Tournquist (Eds): Key Aspects Of Comfort: Management of Pain and Nausea. Springer, Philadelphia: Robinson K, Posner J (1992) Patterns of self-care needs and interventions related to biologic modifier therapy fatigue as a model. Seminars in Oncology Nursing 3(4, Suppll): 17-22 St. Pierre B, Kasper C, Lindsey A (1992) Fatigue mechanisms in patients with cancer: Effects of tumor necrosis factor and exercise on skeletal muscle. Oncology Nursing Forum 19(3): 419-425 Walker LO, Avant KC (1995) Strategies for Theory Construction in Nursing (3rd edn). Appleton & Lange, Norwalk, CT Winningham ML, Nail LM, Burke MB, Brophy L, Cimprich B, Jones LS, Pickard-Holley S, Rhodes V, St. Pierre B, Beck S, Glass EC, Mock VL, Mooney KH, Piper B (1994) Fatigue and the cancer experience: The state of the knowledge. Oncology Nursing Forum 21(1): 23-35