{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T15:20:38Z","timestamp":1790090438284,"version":"4.0.1"},"reference-count":53,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2020,6,18]],"date-time":"2020-06-18T00:00:00Z","timestamp":1592438400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Children with chronic illnesses are called to undertake complicated processes of adjustment and re-organization in their daily lives; as a result, they could experience several internalizing problems. Symbolic play could be a useful way to cope with these difficulties. The main aim of this paper is to assess pretend play, coping, and psychological symptoms in three groups of school-aged children with pediatric chronic diseases. The study involved 44 Italian school-aged, chronically ill children: 16 with type 1 diabetes mellitus (T1DM), 12 with cystic fibrosis (CF), and 15 with Leukemia. All patients were assessed by the Affect in Play Scale\u2013Brief version (APS-Br), and the Children\u2019s Coping Strategies Checklist\u2013Revision1 (CCSC-R1). Children with T1DM and CF also completed the Separation Anxiety Symptom Inventory for Children (SASI-C) and the Strengths and Difficulties Questionnaire (SDQ)\u2013children\u2019s version. Cohen\u2019s d (effect size) was applied between clinical and normative samples, and it showed a more organized play (APS-BR), but a more negative affect tone, comfort, and frequency of affect expression. Comparing APS-BR and CCSC-R1 rates between the three groups, significant differences were found for all the APS-BR dimensions, except for tone, and for CCSC-R1 seeking understanding. Comparing SASI-C score between T1DM and CF, higher scores were found for children with CF. In the end, correlations between all dimensions highlighted several relationships between play, coping, and adjustment problems for children with T1DM, and relationship between affect play and all variables for children with CF. Symbolic play helps chronically ill children to express emotions; helping them, as well as clinicians, to understand the difficulties caused by chronic conditions, and to cope with them.<\/jats:p>","DOI":"10.3390\/ijerph17124364","type":"journal-article","created":{"date-parts":[[2020,6,18]],"date-time":"2020-06-18T11:00:56Z","timestamp":1592478056000},"page":"4364","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Associations between Pretend Play, Psychological Functioning and Coping Strategies in Pediatric Chronic Diseases: A Cross-Illness Study"],"prefix":"10.3390","volume":"17","author":[{"given":"Daniela","family":"Di Riso","sequence":"first","affiliation":[{"name":"Department of Developmental Psychology and Socialization, University of Padova, 35121 Padova, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elena","family":"Cambrisi","sequence":"additional","affiliation":[{"name":"Department of Developmental Psychology and Socialization, University of Padova, 35121 Padova, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Simone","family":"Bertini","sequence":"additional","affiliation":[{"name":"Department of Developmental Psychology and Socialization, University of Padova, 35121 Padova, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4218-1068","authenticated-orcid":false,"given":"Marina","family":"Miscioscia","sequence":"additional","affiliation":[{"name":"Department of Developmental Psychology and Socialization, University of Padova, 35121 Padova, Italy"},{"name":"Department of Women\u2019s and Children\u2019s Health, Hospital-University of Padua, 35128 Padova, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,6,18]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1441","DOI":"10.1007\/s00431-008-0697-y","article-title":"Defining chronic diseases and health conditions in childhood (0\u201318 years of age): National consensus in The Netherlands","volume":"767","author":"Mokkink","year":"2008","journal-title":"Eur. J. Pediatr."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"623","DOI":"10.1001\/jama.2010.104","article-title":"Dynamics of obesity and chronic health conditions among children and youth","volume":"303","author":"Gortmaker","year":"2010","journal-title":"JAMA"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1111\/j.1752-9824.2010.01047.x","article-title":"The experience of parenting children with chronic health conditions: A new reality","volume":"2","author":"Kepreotes","year":"2010","journal-title":"J. Nurs. Healthc. Chronic Illn."},{"key":"ref_4","unstructured":"Bonora, E., and Sesti, G. (2016). Epidemiologia del diabete. Il Diabete in Italia, Bononia University Press."},{"key":"ref_5","first-page":"1","article-title":"Gruppo di lavoro RIFC. Italian Cystic Fibrosis Registry (ICFR). Report 2015-2016","volume":"43","author":"Giordani","year":"2019","journal-title":"Epidemiol. Prev."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2444","DOI":"10.1002\/ijc.30665","article-title":"AIRTUM Working Group. An estimate of the number of people in Italy living after a childhood cancer","volume":"140","author":"Francisci","year":"2017","journal-title":"Int. J. Cancer"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1016\/j.pedn.2019.12.013","article-title":"The lived experiences of children and adolescents with non-communicable disease: A systematic review of qualitative studies","volume":"51","author":"Shorey","year":"2020","journal-title":"J. Pediatr. Nurs."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1155\/2012\/134132","article-title":"Management issues for adolescents with cystic fibrosis","volume":"2012","author":"Withers","year":"2012","journal-title":"Pulm. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"586","DOI":"10.1016\/j.jaac.2020.01.007","article-title":"Editorial: Anxiety in Pediatric Chronic Illness: The Elephant in the Exam Room","volume":"59","author":"Tarbell","year":"2020","journal-title":"J. Am. Acad. Child Psy."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1045","DOI":"10.1007\/s00787-016-0834-5","article-title":"Psychological treatments for depression in pre-adolescent children (12 years and younger): Systematic review and meta-analysis of randomised controlled trials","volume":"25","author":"Saikia","year":"2016","journal-title":"Eur. Child Adolesc. Psychiatry"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1186\/1477-7525-5-43","article-title":"Impaired health-related quality of life in children and adolescents with chronic conditions: A comparative analysis of 10 disease clusters and 33 disease categories\/severities utilizing the PedsQL\u2122 4.0 Generic Core Scales","volume":"5","author":"Varni","year":"2007","journal-title":"Health Qual. Life Outcomes"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"146","DOI":"10.1097\/01.XME.0000430426.13729.3d","article-title":"Anxiety and depression among children with chronic diseases","volume":"20","author":"Amer","year":"2013","journal-title":"Middle East Curr. Psychiatry"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1016\/j.ijdevneu.2017.02.002","article-title":"Type 1 diabetes, cognition and the neurologist: Exploring Go\/No-Go and Maze tasks in the search for a practical screening tool","volume":"60","author":"Shinosaki","year":"2017","journal-title":"Int. J. Dev. Neurosci."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1016\/j.jcf.2017.11.020","article-title":"Attention deficit hyperactivity disorder symptoms in patients with cystic fibrosis","volume":"17","author":"Tanny","year":"2018","journal-title":"J. Cyst. Fibros."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Sakhr, H.M., Hassan, M.H., and Desoky, T. (2020). Possible Associations of Disturbed Neurometals and Ammonia with Glycaemic Control in Type 1 Diabetic Children with Attention Deficit Hyperactivity Disorder. Biol. Trace Elem. Res., 1\u20139.","DOI":"10.1007\/s12011-020-02063-5"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"435","DOI":"10.1016\/j.jcf.2011.06.012","article-title":"Anxiety and depression in adolescents with CF and their caregivers","volume":"10","author":"Besier","year":"2011","journal-title":"J. Cyst. Fibros."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1927","DOI":"10.1002\/ppul.24492","article-title":"Major depression and psychiatric comorbidity in Turkish children and adolescents with cystic fibrosis","volume":"54","author":"Gundogdu","year":"2019","journal-title":"Pediatr. Pulmonol."},{"key":"ref_18","first-page":"158","article-title":"Type 1 diabetes mellitus: Psychosocial factors and adjustment of pediatric patient and his\/her family. Review","volume":"113","year":"2015","journal-title":"Arch. Argent. Pediatr."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1995","DOI":"10.1002\/pon.5179","article-title":"Pediatric bone marrow transplantation: Psychopathologic features in recipients along with siblings","volume":"28","author":"Erden","year":"2019","journal-title":"Psychooncology"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1002\/da.20727","article-title":"Anxiety in medically ill children\/adolescents","volume":"28","author":"Pao","year":"2011","journal-title":"Depress. Anxiety"},{"key":"ref_21","unstructured":"Moen, P., Elder, G.H., and Lu\u0308scher, K. (1995). Social structure and personality through time and space. Examining lives in context: Perspectives on the ecology of human development, American Psychological Association Press."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Shaw, R.J., and DeMaso, D.R. (2010). Adaptation and coping in chronic childhood physical illness. Textbook of Pediatric Psychosomatic Medicine, American Psychiatric Pub, Inc.","DOI":"10.1176\/appi.books.9781585629305"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1146\/annurev-clinpsy-032511-143108","article-title":"Coping with chronic illness in childhood and adolescence","volume":"8","author":"Compas","year":"2012","journal-title":"Annu. Rev. Clin. Psychol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1243","DOI":"10.1080\/13548506.2019.1619789","article-title":"The role of psychological and medical variables in the process of adaptation to life with chronic illness in a group of COPD outpatients","volume":"24","author":"Wytrychiewicz","year":"2019","journal-title":"Psychol. Health Med."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Rohan, J.M., and Verma, T. (2020). Psychological Considerations in Pediatric Chronic Illness: Case Examples. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17051644"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e035261","DOI":"10.1136\/bmjopen-2019-035261","article-title":"Barriers and facilitators to physical activity among children, adolescents, and young adults with cystic fibrosis: A systematic review and thematic synthesis of qualitative research","volume":"10","author":"Denford","year":"2020","journal-title":"BMJ Open"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1111\/j.1365-2214.2010.01184.x","article-title":"Coping and resilience in adolescents with type 1 diabetes","volume":"37","author":"Jaser","year":"2011","journal-title":"Child Care Health Dev."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"330","DOI":"10.1111\/j.1365-2214.2009.00937.x","article-title":"Daily stressors and coping responses of children and adolescents with type 1 diabetes","volume":"35","author":"Hema","year":"2009","journal-title":"Child Care Health Dev."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1348\/135910710X506895","article-title":"Understanding needle-related distress in children with cystic fibrosis","volume":"16","author":"Ayers","year":"2011","journal-title":"Br. J. Health. Psychol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1016\/j.ejon.2017.08.002","article-title":"Coping strategies of children treated for leukemia in China","volume":"30","author":"Han","year":"2017","journal-title":"Eur. J. Oncol. Nurs."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1177\/1367493517749326","article-title":"Coping strategies and emotional well-being in children with disease-related pain","volume":"22","author":"Failo","year":"2018","journal-title":"J. Child Health Care"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"935","DOI":"10.1007\/s00431-018-3146-6","article-title":"The impact of coping patterns and chronic health conditions on health-related quality of life among children and adolescents","volume":"177","author":"Oppenheimer","year":"2018","journal-title":"Eur. J. Pediatr."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Whitebread, D., Grau, V., Kumpulainen, K., McClelland, M., Perry, N., and Pino-Pasternak, D. (2019). The role of pretend play in supporting young children\u2019s emotional development. The SAGE Handbook of Developmental Psychology and Early Childhood Education, SAGE Publications Limited.","DOI":"10.4135\/9781526470393"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Reddy, L.A., Files-Hall, T.M., and Schaefer, C.E. (2016). Play interventions for hospitalized children. Empirically Based Play Interventions for Children, American Psychological Association.","DOI":"10.1037\/14730-000"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1097\/00004703-200606000-00011","article-title":"Pretend play as a resource for children: Implications for pediatricians and health professionals","volume":"27","author":"Moore","year":"2006","journal-title":"J. Dev. Behav. Pediatr."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Russ, W.S. (2004). Play in Child Development and Psychotherapy: Toward Empirically Supported Practice, Lawrence Erlbaum Associates.","DOI":"10.4324\/9781410609397"},{"key":"ref_37","first-page":"81","article-title":"Pretend play, coping, and subjective well-being in children a follow-up study","volume":"5","author":"Fiorelli","year":"2012","journal-title":"Am. J. Play."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"250","DOI":"10.3389\/fpubh.2019.00250","article-title":"Hospitalized Children: Anxiety, Coping Strategies, and Pretend Play","volume":"7","author":"Delvecchio","year":"2019","journal-title":"Front. Public Health"},{"key":"ref_39","unstructured":"Clark, C.D. (2003). In Sickness and in Play: Children Coping with Chronic Illness, Rutgers University Press."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"523","DOI":"10.1046\/j.1365-2214.2003.00372.x","article-title":"The therapeutic power of play: Examining the play of young children with leukaemia","volume":"29","author":"Howe","year":"2003","journal-title":"Child Care Health Dev."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1681","DOI":"10.1007\/s10826-017-0688-6","article-title":"Perceptions of hospitalization by children with chronic illnesses and siblings","volume":"26","author":"Nabors","year":"2017","journal-title":"J. Child Fam. Stud."},{"key":"ref_42","unstructured":"Hollingshead, A.B. (1975). Four Factor Index of Social Status, Yale University."},{"key":"ref_43","unstructured":"American Psychological Association (2010). Pubblication Manual of the American Psychological Association, American Psychological Association. [6th ed.]."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"350","DOI":"10.1080\/00223891.2013.838171","article-title":"Assessment of pretend play in preschool-aged children: Validation and factor analysis of the affect in play scale\u2013preschool version","volume":"96","author":"Fehr","year":"2014","journal-title":"J. Pers. Assess."},{"key":"ref_45","first-page":"1","article-title":"From research to clinical settings: Validation of the affect in play scale\u2013preschool brief version in a sample of preschool and school aged Italian children","volume":"8","author":"Salcuni","year":"2017","journal-title":"Front. Psychol."},{"key":"ref_46","unstructured":"Ayers, T.S., and Sandler, I.N. (1999). Manual for the Children\u2019s Coping Strategies Checklist & the How I Coped under Pressure Scale, Arizona State University."},{"key":"ref_47","first-page":"197","article-title":"The Children\u2019s Coping Strategies Checklist-Revision1: A validation study in the Italian population","volume":"19","author":"Camisasca","year":"2012","journal-title":"TPM Test Psychom. Methodol. Appl. Psychol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1337","DOI":"10.1097\/00004583-200111000-00015","article-title":"Psychometric properties of the strengths and difficulties questionnaire","volume":"40","author":"Goodman","year":"2001","journal-title":"J. Am. Acad. Child Adolesc. Psychiatry"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"570","DOI":"10.1016\/j.paid.2010.05.005","article-title":"The Strengths and Difficulties Questionnaire (SDQ). Early evidence of its reliability and validity in a community sample of Italian children","volume":"49","author":"Salcuni","year":"2010","journal-title":"Pers. Individ. Dif."},{"key":"ref_50","first-page":"29","article-title":"A preliminary examination of the psychometric properties of the Separation Anxiety Symptom Inventory in Italian children","volume":"59","author":"Chessa","year":"2013","journal-title":"BP A Appl. Psychol. Bull."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"477","DOI":"10.3109\/00048679309075806","article-title":"The development of the separation anxiety symptom inventory (SASI)","volume":"27","author":"Silove","year":"1993","journal-title":"Aust. N. Z. J. Psychiatry"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"724","DOI":"10.2466\/10.02.09.PR0.111.6.724-738","article-title":"Early evidence for factorial structure of the separation anxiety symptom inventory in Italian children","volume":"111","author":"Delvecchio","year":"2012","journal-title":"Psychol. Rep."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1037\/0033-2909.112.1.155","article-title":"A power primer","volume":"112","author":"Cohen","year":"1992","journal-title":"Psychol. 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