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Step 1 Read the article in Appendix D “Example of a Correlational Study” (Turner et al., 2016). 
Step 2 Discuss the following questions related to the article found on ~ p. 177 under Critical Appraisal Criteria:
1. What quasi-experimental design is used in the study, and is it appropriate?
2. What does the author say about the limitations of the study?
3. What are the most common threats to internal and external validity?
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Psychological Functioning, Post-Traumatic Growth,
and Coping in Parents and Siblings of Adolescent
Cancer Survivors

Andrea M. Turner-Sack, PhD, Rosanne Menna, PhD, Sarah R. Setchell, PhD, Cathy Maan, PhD,
and Danielle Cataudella, PsyD


ince the 1980s, the incidence rates of childhood and adolescent cancer
have increased and the mortality rates have decreased in the United
States and Canada (National Cancer Institute, n.d.; National Cancer
Institute of Canada, 2008). This has resulted in a growing population
of young cancer survivors with a unique set of psychological issues.

Researchers have explored some of these issues, including survivors’ moods,
anxieties, and coping strategies (Dejong & Fombonne, 2006; Schultz et al., 2007;
Turner-Sack, Menna, Setchell, Mann, & Cataudella, 2012). However, the focus
is often on the negative aspects of childhood cancer, such as depression, with
fewer studies addressing a more positive aspect, such as positive changes in
perspectives, life priorities, and interpersonal relationships (Kamibeppu et al.,
2010; Seitz, Besier, & Goldbeck, 2009). In addition, the experiences of young
cancer survivors’ families often are ignored.

The diagnosis and treatment of cancer in childhood or adolescence can be
exceptionally stressful not only for the young patients with cancer, but also
for members of their family. Several studies suggest that parents of children
and adolescents with cancer experience psychological distress, post-traumatic

Purpose/Objectives: To examine psychological functioning, post-traumatic growth (PTG),
coping, and cancer-related characteristics of adolescent cancer survivors’ parents and

Design: Descriptive, correlational.

Setting: Children’s Hospital of Western Ontario in London, Ontario, Canada.

Sample: Adolescents who finished cancer treatment 2–10 years prior (n = 31), as well as
their parents (n = 30) and siblings (n = 18).

Methods: Participants completed self-report measures of psychological distress, PTG, life
satisfaction, coping, and cancer-related characteristics.

Main Research Variables: Psychological functioning, PTG, and coping.

Findings: Parents’ and siblings’ PTG levels were similar to survivors’ PTG levels; however,
parents reported higher PTG than siblings. Parents who used less avoidant coping, were
younger, and had higher life satisfaction experienced less psychological distress. Parents
whose survivor children used more active coping reported less psychological distress. Sib-
lings who were older used more active coping, and the longer it had been since their brother
or sister was diagnosed, the less avoidant coping they used.

Conclusions: Childhood and adolescent cancer affects survivors’ siblings and parents in
unique ways.

Implications for Nursing: Relationship to the survivor, use of coping strategies, life satisfac-
tion, and time since diagnosis affect family members’ postcancer experiences.

Turner-Sack is a psychologist at JVS
Toronto; Menna is a professor in the De-
partment of Psychology at the University
of Windsor; Setchell is a psychologist in
supervised practice at the York Region
District School Board; and Maan and
Cataudella are both psychologists at the
Children’s Hospital London Health Science
Center, all in Ontario, Canada.

This research was supported by a Cana-
dian Institute for Health and Research
Professional Student Training Award.

Turner-Sack and Menna contributed to the
conceptualization and design, statistical
support, and analysis. Turner-Sack, Maan,
and Cataudella completed the data collec-
tion. All of the authors contributed to the
manuscript preparation.

Turner-Sack can be reached at andrea
[email protected], with copy to edi-
tor at [email protected]

Submitted January 2015. Accepted for
publication May 12, 2015.

Key words: leukemia; hematology; post-
traumatic growth; adolescence; coping;
family caregivers

ONF, 43(1), 48–56.

doi: 10.1188/16.ONF.48-56


stress, and poor quality of life (Brown, Madan-Swain,
& Lambert, 2003; Kazak et al., 1997, 2004; Witt et al.,
2010). Other studies indicate that parents of cancer
survivors appear to function just as well as parents of
healthy controls or in accordance with standardized
norms (Dahlquist, Czyzewski, & Jones, 1996; Green-
berg, Kazak, & Meadows, 1989; Radcliffe, Bennett,
Kazak, Foley, & Phillips, 1996).

Similar to research on parents of young cancer sur-
vivors, studies of the psychological impact on siblings
within these families are scarce. Several studies have
found that siblings of young cancer survivors have
more negative emotional reactions (e.g., fear, worry,
anger), more post-traumatic stress, and poorer quality
of life than controls (Alderfer et al., 2010; Alderfer, La-
bay, & Kazak, 2003). Other studies found that siblings
of survivors function similarly to their peers whose
siblings are healthy (Dolgin et al., 1997; Kamibeppu et
al., 2010). Together, these findings suggest that fam-
ily members of young cancer survivors experience a
range of psychological responses to cancer and that
additional research could provide some clarification.

Although understanding how survivors’ cancer af-
fects their parents and siblings is important, equally
important is understanding the associations among
family members’ psychological functioning. In accor-
dance with a family systems perspective, a person’s
well-being is related to other family members’ well-
being (Nichols & Schwartz, 2001). In support of this
perspective, research generally has found that most
young cancer survivors’ psychological functioning
is related to their parents’ psychological functioning
(Barakat et al., 1997; Brown et al., 2003; Phipps, Long,
Hudson, & Rai, 2005). Few studies have examined the
relations between young cancer survivors’ psycholog-
ical distress and their siblings’ psychological distress.

Although coping with a traumatic experience, such
as cancer, tends to be distressing, it also may provide
individuals with the opportunity to achieve positive
change, such as post-traumatic growth (PTG). PTG
is defined as mastering a previously experienced
trauma, perceiving benefits from it, and developing
beyond the original level of psychological function-
ing (Tedeschi, Park, & Calhoun, 1998). Similar to the
literature concerning young cancer survivors, PTG in
parents of young survivors has received little atten-
tion. The few studies that exist suggest that parents
of young survivors may experience at least some de-
gree of PTG (Best, Streisand, Catania, & Kazak, 2001;
Yaskowich, 2003). Research of PTG in other family
members of patients with cancer also is limited. Ka-
mibeppu et al. (2010) found that young adult sisters
of young adult childhood cancer survivors reported
experiencing greater PTG than female controls. Other
studies identified some positive changes that siblings

experienced (e.g., feeling more mature, independent,
and empathic; valuing life more) (Barbarin et al., 1995;
Chesler, Allswede, & Barbarin, 1992; Havermans &
Eiser, 1994), but the researchers did not determine
whether the siblings perceived as much benefit from
the trauma or developed beyond their original level
of functioning enough to be consistent with PTG.
In keeping with the familial model of illness-related
stress and growth, the current study examined PTG in
parents and siblings of adolescent cancer survivors.

The lack of research examining the relations among
family members’ levels of PTG is not surprising given
the limited research examining PTG in parents and
siblings of young cancer survivors. Two studies have
found that parents’ PTG was not correlated with ado-
lescent cancer survivors’ overall PTG (Michel, Taylor,
Absolom, & Eiser, 2010; Yaskowich, 2003). However,
parents’ PTG accounted for as much as 10% of the
variance in two aspects of survivors’ PTG: improved
relationships and appreciation for life (Yaskowich,
2003). These results suggest that the association
between survivor PTG and PTG among other family
members warrants further investigation. The current
study fills a notable gap in the literature by examining
the associations between adolescent cancer survivors’
PTG and PTG in parents and siblings of survivors.

An additional goal of the current study was to
examine whether coping strategies were related to
psychological functioning and PTG in parents and
siblings of adolescent cancer survivors. Available
studies suggest that parents of young patients with
cancer and survivors who use more self-directed and
active coping report lower levels of psychological dis-
tress, and those who use more emotion-focused and
avoidant coping report higher levels of psychological
distress (Fuemmeler, Mullins, & Marx, 2001; Norberg,
Lindblad, & Boman, 2005). Other studies indicate that
siblings of adolescent cancer survivors who have high
emotional social support tend to be less depressed, be
less anxious, and have fewer behavioral problems than
siblings with low emotional social support (Barrera,
Fleming, & Khan, 2004). To the researchers’ knowledge,
no studies have examined the associations between
parents’ and siblings’ coping strategies and their levels
of PTG, but Calhoun and Tedeschi’s (1998) model of
PTG suggests that active social support and accep-
tance coping are most closely associated with PTG.

Examining demographic and cancer-related vari-
ables, such as age of parents and siblings, survivors’
age at diagnosis, time since diagnosis, and time since
treatment completion, can provide insight into the
experiences of young cancer survivors and their
families. Little is known about the relations between
age and psychological functioning, PTG, and coping
in siblings of cancer survivors (Alderfer et al., 2003).


Several studies have found that adolescent cancer
survivors’ age at diagnosis was unrelated to parents’
post-traumatic stress symptoms (Brown et al., 2003;
Kazak et al., 1997) and PTG (Barakat, Alderfer, & Ka-
zak, 2006). In terms of PTG, theorists have suggested
that, although positive consequences of life crises can
happen shortly after the crisis, they are more likely
to occur after a long process of crisis resolution and
personal recovery (Schaefer & Moos, 1992). However,
the only known study to examine the relation between
time since cancer treatment and parental PTG found
that a shorter time since the end of young cancer
survivors’ treatment was associated with more PTG in
fathers but not mothers (Barakat et al., 2006).

The goals of the current study were to (a) examine
psychological functioning (defined as level of distress
and life dissatisfaction), PTG, and coping in parents
and siblings of adolescent cancer survivors; (b) com-

pare adolescent cancer survivors,
parents, and siblings on those
same variables; and (c) examine
psychological functioning, PTG,
and coping in parents and siblings
in relation to age, time, and cancer-
related variables.


English-speaking Canadian fami-
lies with an adolescent (aged
13–20 years) who completed treat-
ment for a solid tumor, leukemia,
or lymphoma 2–10 years earlier at
a children’s hospital were eligible
to participate in the study (see
Table 1). They were not eligible
if they had a cancer relapse, an
organ transplantation, a brain tu-
mor that required only surgery, or
significant cognitive or neurologic
impairments. All siblings reported
living with the survivor while he
or she was receiving treatment.

Following institutional ethics

approvals from the University of
Windsor in Ontario, Canada and
the University of Western Ontario
in London, Ontario, Canada, data
were collected from the pediatric
oncology population at Children’s
Hospital of Western Ontario in
London, Ontario, Canada. Ques-

tionnaires were mailed to 89 families that met criteria
for the study. They were informed that participants’
names would be entered into a drawing for a $50 gift
certificate from a local store. Thirty-one adolescents,
30 parents, and 18 siblings returned completed pack-
ages. In total, 35 families had at least one member
participate in the study. Fourteen families had an ado-
lescent, parent, and sibling participate. The remain-
ing 21 families had various combinations of family
member participation, and, as such, the adolescent,
parent, and sibling groups represent different sets of
families in the current study.

Demographics and cancer variables: Participants

completed a background questionnaire that asked
about age, gender, ethnicity, education, type of
cancer, age at diagnosis, time since diagnosis, time

TABLE 1. Characteristics of Study Participants


(N = 31)

(N = 30)

(N = 18)





Age (years) 15.74 02.25 45.07 5.64 15.67 2.74
Age at diagnosis (years) 07.45 04.75 – – 06.83 3.97
Time since diagnosis (years) 08.28 03.02 – – – –
Time since treatment comple-

tion (years)
06.47 02.67 – – – –

Treatment duration (months) 21.31 12.10 – – – –

Characteristic n n n

Female 20 29 09
Male 11 01 09
European/Canadian 27 27 16
Not reported 04 03 02
Graduated college or university – 20 –
Graduated high school – 07 –
Not reported – 03 –
Acute lymphoblastic leukemia 18 – –
Hodgkin lymphoma 04 – –
Acute myelogenous leukemia 03 – –
Ewing’s sarcoma 02 – –
Osteosarcoma 02 – –
Non-Hodgkin lymphoma 01 – –
Wilms’ tumor 1 – –
Chemotherapy 31 – –
Radiation 04 – –
Surgery 03 – –

a Several respondents had multiple types of treatment.


since treatment completion, and length and type of

Psychological distress: The Brief Symptom Inven-
tory (BSI) (Derogatis & Melisaratos, 1983) was used to
assess psychological distress. Participants used this
53-item questionnaire to self-report to what extent
they experienced psychological symptoms. Partici-
pants rated their symptoms in a number of areas (e.g.,
somatization, depression, anxiety) on a five-point
scale ranging from 0–4, with 0 indicating not at all
and 4 indicating extremely. The BSI generates scores
on three overall indices of distress: General Severity
Index (GSI), Positive Symptom Distress Index, and
Positive Symptom Total. Analyses used GSI t scores,
with low scores indicating low psychological distress.
The internal consistency in the current study was 0.97
for survivors and siblings and 0.98 for parents.

Life satisfaction: Survivors and siblings completed
the Students’ Life Satisfaction Scale (SLSS) (Huebner,
1991), a self-report questionnaire that assesses global
life satisfaction in children and adolescents. Partici-
pants used a six-point scale ranging from 1 (strongly
disagree) to 6 (strongly agree) to respond to seven
statements about their lives. The average score per
SLSS item was used in the analyses, with high scores in-
dicating more life satisfaction. The internal consistency
in the current study was 0.87 for survivors and siblings.

Parents completed the Satisfaction With Life Scale
(SWLS) (Diener, Emmons, Larsen, & Griffin, 1985), a
self-report questionnaire that assesses adult global
life satisfaction. Parents used a seven-point scale
ranging from 1 (strongly disagree) to 7 (strongly
agree) to respond to five statements about their life.
The average score
per SWLS item was
u s e d i n t h e a n a l y –
ses, with high scores
indicating more life
satisfaction. In the
current study, the in-
ternal consistency
was 0.91 for parents.

P o s t – t r a u m a t i c
growth: The PTG In-
ventory (PTGI) (Te-
deschi & Calhoun,
1996) assesses the
experience of posi-
t i v e c h a n g e s f o l –
lowing a traumatic
event. Participants
used the 21-item self-
report questionnaire
to indicate the extent
to which they expe-

rienced various positive changes. Participants used
a six-point scale ranging from 0–5, with 0 indicating
“I did not experience this change as a result of my
crisis,” and 5 indicating “I experienced this change
to a very great degree as a result of my crisis.” The
PTGI wording was modified to refer specifically to
changes resulting from having had a family member
with cancer. In addition, the language used in the
PTGI given to siblings was modified to better suit a
younger population (similar to modifications used by
Yaskowich [2003]). The average score per PTGI item
was used in the analyses, with high scores indicating
more PTG. Tedeschi and Calhoun (1996) reported an
internal consistency coefficient of 0.9 for the full scale
and a test-retest reliability of 0.71 after two months.
Yaskowich (2003) reported an internal consistency of
0.94 for the full scale of the modified PTGI in a sample
of 35 adolescent cancer survivors. The internal con-
sistency of the modified PTGI was 0.94 for survivors
and siblings and 0.96 for parents in the current study.

Coping strategies: The COPE (Carver, Scheier, &
Weintraub, 1989) assesses coping strategies in ado-
lescents and adults. Participants used this 60-item
self-report questionnaire to rate the way they respond
to stressful events. Participants used a four-point
scale ranging from 1–4, with 1 indicating “I usually do
not do this at all,” and 4 indicating “I usually do this
a lot.” The COPE yields scores on 15 different scales.
Factor analyses have revealed slightly different fac-
tor structures for adolescents and adults. Phelps
and Jarvis (1994) proposed a four-factor structure
for adolescents: active coping, emotion-focused
coping, avoidant coping, and acceptance coping.

TABLE 2. Scores on Measures of Psychological Distress, Coping, Post-Traumatic
Growth, and Life Satisfaction for Adolescent Cancer Survivors and Siblings

Adolescent Cancer
Survivors (N = 31) Siblings (N = 18)


X SD Range

X SD Range

Brief Symptom Inventorya 47.31 13.59 25–79 48.94 10.83 27–72
• Acceptance coping 02.58 00.42 1.63–3.53 02.53 00.46 1.81–3.19
• Active coping 02.23 00.58 1.38–3.38 02.17 00.49 1.38–3.13
• Avoidant coping 01.33 00.30 1–2.05 01.41 00.30 1.08–2.15
• Emotion-focused coping 02.08 00.77 1.13–3.63 01.99 00.73 1–3.5
• Religious coping 02.24 01.00 1–4 01.88 01.13 1–4
Post-Traumatic Growth Inventoryc 02.15 01.01 0–3.62 01.84 01.14 0–3.33
Students’ Life Satisfaction Scale d 04.77 00.86 2.3–5.9 04.43 00.79 2.4–5.3

a Possible scores range from 1 (low psychological distress) to 100 (high psychological distress).
b Possible scores range from 1 (lesser use of the coping strategy) to 4 (greater use of the coping
c Possible scores range from 0 (low post-traumatic growth) to 5 (high post-traumatic growth).
d Possible scores range from 1 (low life satisfaction) to 6 (high life satisfaction).


Similarly, Carver et al. (1989) proposed a four-factor
structure for adults: active coping, social support
and emotion-focused coping, avoidant coping, and
acceptance coping. The current study used the four
factors proposed by Phelps and Jarvis (1994) for the
survivors and siblings and the four factors proposed
by Carver et al. (1989) for the parents. The religious
coping scale was not associated with any of the fac-
tors but was included for all groups. High scores on a
particular factor or scale reflect a greater use of that
type of coping strategy. In the current study, internal
consistency ranged from 0.74 (acceptance coping) to
0.94 (religious coping) for survivors and siblings, and
from 0.52 (avoidant coping) to 0.94 (religious coping)
for parents.

Data Analyses
All tests of significance were two-tailed with an

alpha level of 0.01 to correct for the number of analy-
ses performed and type I errors. Analyses were com-
pleted separately for parents and siblings. Pearson
product-moment correlations and standard regres-
sions with forward entry were conducted to examine
parents’ and siblings’ reports of demographic and
cancer-related variables in relation to their reported
levels of psychological distress, life satisfaction, PTG,
and coping strategies. Independent sample t tests
were conducted to compare the survivors, parents,
and siblings on measures of psychological distress,

life satisfaction, PTG, and coping strategies. To ex-
amine the associations between survivors’ coping,
psychological distress, and PTG and that of their
matched parents, Pearson product-moment correla-
tions were used.

The focus of this article is family members of ado-

lescent cancer survivors, particularly their parents
and siblings. Detailed information on the psychologi-
cal functioning, PTG, and coping of adolescent cancer
survivors in the current study are provided in Turner-
Sack et al. (2012).

Parents’ psychological distress was positively asso-
ciated with age (r = 0.53, p < 0.01) and avoidant coping (e.g., denial, disengagement) (r = 0.52, p < 0.01), and it was negatively associated with life satisfaction (r = –0.62, p < 0.001) and active coping (e.g., focusing on, planning, and actively dealing with problems; seek- ing helpful social support) (r = –0.57, p < 0.001). Life satisfaction was also positively correlated with ac- tive coping (r = 0.56, p < 0.001). Time since treatment completion was positively associated with parents’ social support and emotion-focused coping (r = 0.5, p < 0.01). A standard regression analysis was performed to predict parents’ psychological distress using parent variables correlated with it: active coping, avoidant coping, life satisfaction, and age. The overall regres- sion model for psychological distress was significant (R2 = 0.51; F[3, 22] = 7.69, p < 0.001). Examination of the squared semipartial correlation coefficients indicated that avoidant coping (b = 0.37, t[25] = 2.42, p < 0.05; sr2 = 0.13), age (b = 0.35, t[25] = –2.26, p < 0.05; sr2 = 0.11), and life satisfaction (b = –0.33, t[25] = 2.14, p < 0.05; sr2 = 0.1) made significant unique contributions to the prediction of psychological distress. Therefore, parents who used less avoidant coping, were younger, and had higher life satisfaction were likely to experi- ence less psychological distress. Parents’ PTG was not significantly associated with any of the study variables. Siblings’ age was positively associated with active coping (r = 0.73, p < 0.001). Avoidant coping was negatively associated with time since diagnosis (r = –0.67, p < 0.01) and life satisfaction (r = –0.71, p < 0.001). None of the variables correlated with siblings’ psycho- logical distress or PTG at the 0.01 significance level. For each measure, the mean scores, standard devia- tions, and ranges of scores are presented for adoles- cent cancer survivors and siblings (see Table 2) and parents (see Table 3). Survivors, parents, and siblings reported similar levels of psychological distress but significantly different levels of PTG (F[2, 75] = 5.32, p < 0.01). Parents’ PTG was significantly higher than TABLE 3. Scores on Measures of Psychological Distress, Coping, Post-Traumatic Growth, and Life Satisfaction for Parents (N = 30) Measure — X SD Range Brief Symptom Inventorya 53.72 11.94 33–80 COPEb • Acceptance coping 03.01 00.42 1.98–3.75 • Active coping 02.81 00.54 1.58–3.91 • Avoidant coping 01.55 00.25 1.17–2.17 • Religious coping 02.64 01.01 1–4 • Social support and emotion-focused coping 02.61 00.52 1.58–3.55 Post-Traumatic Growth Inventoryc 02.83 01.13 0.05–4.67 Satisfaction With Life Scaled 05.21 01.20 1.8–7 a Possible scores range from 1 (low psychological distress) to 100 (high psychological distress). b Possible scores range from 1 (lesser use of the coping strategy) to 4 (greater use of the coping strategy). c Possible scores range from 0 (low post-traumatic growth) to 5 (high post-traumatic growth). d Possible scores range from 1 (low life satisfaction) to 6 (high life satisfaction). ONCOLOGY NURSING FORUM • VOL. 43, NO. 1, JANUARY 2016 53 that of siblings (t[46] = 2.91, p < 0.01), and survivors’ PTG was similar to that of parents (t[58] = –2.43, not significant [NS]) and siblings (t[47] = –0.98, NS). No significant differences were seen between survivors and siblings on their levels of life satisfaction (t[47] = 1.16, NS) or active (t[47] = 0.3, NS), avoidant (t[46] = –0.93, NS), emotion-focused (t[47] = 0.39, NS), ac- ceptance (t[47] = 0.38, NS), or religious (t[47] = 1.14, NS) coping strategies. Parents’ coping levels were not compared with survivor or sibling coping levels because the adult COPE factor structure differed from the adolescent COPE factor structure. In 28 of the 35 participating families, the survivor and one of his or her parents participated, resulting in 28 matched survivor–parent dyads. Correlations for matched dyads are presented in Table 4. Parents’ psychological distress was negatively correlated with their survivor child’s active coping (r = –0.53, p < 0.01). Discussion The current study revealed that younger age, higher life satisfaction, and less avoidant coping were strong predictors of lower psychological distress in parents of adolescent cancer survivors. As parents get older, they may have a greater awareness of the difficulties and possible limitations that their adolescent cancer survivors may face. Younger parents may pay less attention to these difficulties or be more naive about them and, as such, report experiencing less psycho- logical distress. Parents who are more satisfied with their lives (e.g., feel their lives are good, have what they want in life, would change little about their lives) may have fewer concerns and feel assured and grounded, which could contribute to lower levels of psychological distress. This finding is consistent with previous studies that found that parents’ reports of external attributions about cause, rather than self- blame and family satisfaction, are associated with better psy- chological adjustment (Kazak et al., 1997; Vrijmoet-Wiersma et al., 2008). Finally, parents who face their difficulties to a greater degree are likely less troubled or burdened by neglected ongoing difficulties and, therefore, experi- ence less psychological distress. Research on how family mem- bers of young cancer survivors cope is scarce. The current study found that the longer ago that the adolescent cancer survivors com- pleted treatment, the more social support and emotion-focused coping the parents used. As time passes after treat- ment is completed, parents may feel that they have more time in their daily lives to use the social support available to them and feel better able to face and deal with their emotions. The findings also suggest that older siblings were likely to use more active coping strategies. When a brother or sister was receiving cancer treatment, parents were occupied with the child with cancer, so older siblings likely had to attend to their own needs (Alderfer et al., 2010). In addition, during this period of time, siblings may have learned about the use of self-reliance, active coping, and prob- lem solving. Overall, siblings used similar coping strategies to survivors. Siblings whose brother or sister was diag- nosed longer ago tended to use less avoidant coping. Siblings may use avoidant coping to deal with the stressors they experience soon after their brother or sister is diagnosed. As time passes, they may experi- ence fewer cancer-related stressors, better adapt to such stressors, and find more effective ways of coping with them, using less avoidant coping strategies. The current study also found that siblings with greater life satisfaction used less avoidant coping. Those who are more satisfied with their lives may feel that they have fewer problems or difficult situations to avoid and, therefore, use less avoidant coping. The researchers’ results indicate that adolescent cancer survivors, parents, and siblings had aver- age levels of psychological distress compared to reported norms. This finding is consistent with previ- ous research that reported that most young cancer survivors have average or above-average levels of global adjustment (Fritz & Williams, 1988; …