Introduction
eukemia is the most common type of cancer in children. Both genetic and environmental factors may play a role in the development of leukemia, but the causative agents have remained unknown in most children [1]. The primary treatment for most childhood cancers is chemotherapy. Other treatments such as immunotherapy, radiation therapy, and surgery may be used in certain conditions [2]. The treatment of leukemia in children has improved dramatically in the last 50 years [3]. However, the incidence of leukemia in children has sadly been increasing worldwide since 1980 [4, 5, 6]. In the United States, it has increased about 0.7% per year since 1975 [7]. Unfortunately, accurate statistics on the prevalence of cancer in children are not available in Iran, but one of the most common disorders leading to the death of children in Iran is cancer [8]. Despite many advances in the treatment of leukemia, acceptance of the disease is still very difficult for family members of the child and causes major changes in their lives [9]. Changes in the children’s condition and the effects of medications and illness on their physical condition can cause severe depression in parents, especially in the first months after diagnosis [10]. At this time, the child needs attention and support more than ever, and on the other hand, parents are confused and vulnerable [11]. Having a child with cancer restricts parental involvement in recreational, occupational, and educational activities, which can further jeopardize their mental health [12, 13]. Akhtar et al. showed that depression is prevalent among mothers of children with leukemia, and they suffer from depression more than fathers [14]. 
Participation is defined as involvement in meaningful life activities and is a vital part of human existence. It creates life satisfaction and competence in people and expands their social skills [15]. Diagnosis and treatment of cancer and long-term hospitalizations negatively affect the participation of children with cancer in activities of daily living. Thus most children with leukemia have daily challenges in life [16, 17, 18]. The speed of change and the urgency of starting treatment after diagnosis, the need to observe hygienic principles, side effects of drugs, etc., make the child dependent on parents in many life activities [11]. Children with cancer may experience various problems, including growth retardation, cognitive dysfunction, reduced neurological function, cardiopulmonary problems, musculoskeletal disorders, and so on. Each of which can somehow affect their daily activities [19]. No research has so far examined the effect of parents’ psychological conditions on the participation level of children with leukemia. Besides, the mother, as the primary caregiver of the child, is exposed to psychological problems which can affect the child’s condition [11]. Thus, we aimed to examine whether the mother’s depression can affect the participation of children with leukemia in various life activities.
Materials and Methods
This research is a descriptive-analytical study with a cross-sectional design. The study population consists of children aged 13-15 years with leukemia (n=79) and their mothers. The children were referred to Seyed Al-Shohada Hospital in Isfahan City, Iran. Of these, 72 children were selected using a convenience sampling method for 6 months from January to June 2019. The inclusion criteria for the children were age 5-13 years, more than 2 months elapsed from the leukemia diagnosis, and accessibility of their mothers. The inclusion criteria for the mothers were not receiving treatment for depression and other mental disorders and not taking drugs with psychological side effects. The exclusion criteria were failure to complete the questionnaire or unwillingness of the mother or child to continue participation. In this regard, 62 children and their mothers finally entered the study.
After explaining the study objectives and methods to the mothers and receiving their consent to cooperate, a demographic form, the Beck Depression Inventory II (BDI-II), and the short form of assessment of Life Habits (LIFE-H) questionnaire were completed by them. The BDI-II is a self-report tool for measuring depression [20]. Gasemzadeh et al. prepared and validated the Persian version of BDI in 2005 [21]. They reported its acceptable reliability (The Cronbach α=0.87). Mortazavi et al. prepared and validated the Persian version of LIFE-H [22]. They obtained ICC values of more than 0.60 for all subscales and 0.87 for the whole questionnaire, indicating its good validity and reliability. The collected data were analyzed using descriptive statistics (mean, standard deviation, and frequency) and the Pearson correlation test, the Spearman test, ANOVA, and the independent t test in SPSS v. 20. The significance level was set at 0.05.
Results
The Mean±SD age of the mothers was 36.98±5.8 years. More than 85% of mothers showed some degree of depression, with 24.4% suffering from major depression. Of 62 children, 20(32.3%) were girls, and 42(67.7%) were boys. Other characteristics of the subjects are presented in Table 1.


The descriptive findings are presented in Table 2.


There was no significant relationship between the social participation of children with leukemia and their disease duration, mothers’ education, family economic status, and mothers’ age. Moreover, there were no significant relationships between mothers’ depression and their economic status, education, child’s disease duration, and age (Table 3).


There were significant negative relationships between maternal depression and child participation in education and social life. In other domains of participation (nutrition, physical fitness, personal care, communication, housing, mobility, responsibility, interpersonal relationships, and recreation), the relationships were not significant (Table 4).


Discussion and Conclusion
The study results showed that more than 85% of mothers of children with leukemia had some degree of depression. Maternal depression did not show significant relationships with maternal age, duration of the child’s disease, and family economic status. These results are consistent with the results of Farhangi et al. on the depression and anxiety in parents of children with leukemia [31]. In Kholasezadeh et al. study [24], there was a significant relationship between income and maternal depression. This different result may be due to differences in economic criteria in the two studies. We evaluated the family’s economic status according to the mothers’ report and based on the Likert scale, while they measured monthly family income level. In the present study, there was no significant relationship between the education level of mothers of children with leukemia and their depression, which is consistent with the results of Kholezadeh et al. [24] but is against the results of Farhangi et al. [31]. This discrepancy in results may be because we only examined mothers’ educational level, while they examined the education level of both fathers and mothers [23]. 
Maternal depression had a significant impact on the participation of children with leukemia in education and social life, such that the more the mother’s depression, the lower the child’s participation in these areas. This result is consistent with the results of Shen et al., who reported that maternal depression had a significant adverse effect on the child’s performance in school [33], and the results of Augustine et al., who found that maternal depression reduces a child’s academic achievement [34]. Probably the mother’s depression hinders her efforts to provide educational services to the child [27]. Depressed mothers have a low sense of self-efficacy [28] which reduces their participation in their children’s educational process [29]. Furthermore, these children sometimes should be hospitalized for a long time that prevents them from attending classes.
Most importantly, due to the weakness of their immune system and their susceptibility to infectious diseases, they are often forbidden by the doctor to attend public places, especially school. Some parents make up for this gap with the training they provided for the child, and some use private tutors, but educational services are often not available. Previous studies have shown the vital role of parents in children’s participation and achievement in education [33, 34 ,35, 36, 37, 38, 39]. Pini et al. suggested that, despite the detachment from the school environment, individual involvement in educational activities can be increased with the participation of caregivers and health professionals [42]. Harris et al. stated that providing educational opportunities and programs for children can compensate for the problems posed by parents’ non-involvement in education [43]. The educational system of Iran has no program for hospitalized children and those who could not attend school for any reason, so it may be possible to increase their participation in education by providing virtual education or appropriate educational programs in the hospital environment. Our result regarding a significant negative relationship between maternal depression and child participation in social life is consistent with the findings of Apter-Levy et al. [44] and Feldman et al. [45]. Depressed mothers are less likely to make eye and verbal contact with their children, which can negatively affect the children’s social skills and participation [46]. The secretion of oxytocin, as a social hormone, is lower than normal in children whose mothers have been depressed for a long time [36, 38]. Depression also negatively affects mothers’ parenting behaviors and leads to child neglect, psychological aggression, and maternal non-involvement, thus limiting the child’s opportunities for social participation [39].
In the present study, no significant relationships were found between maternal depression and overall child participation (LIFE-H score), as well as participation in nutrition, physical fitness, personal care, communication, housing, mobility, responsibilities, interpersonal relationships, and recreation. This result is consistent with Yilmaz et al.’s study, where the relationship between maternal depression and functional dependence of children with disabilities was not significant in any daily activities [40]. However, the results of Smith et al. were different. They found a significant relationship between maternal depression and the level of disabilities in children [49]. This discrepancy may be due to differences in the type of disability. In the Smith et al. study, the subjects with motor and sensory disabilities were assessed. In Larson study on children with autism, those with mothers who were hypersensitive to their child care and suffering from depression and anxiety showed less participation in recreational, self-care, and social activities [50]. This difference in results is probably due to two factors of anxiety and sensitivity in maternal care.
Depression of mothers of children with leukemia, besides the destructive effects on their performance, can limit child participation in essential areas such as education and social life. Therefore, special attention to the mental condition of mothers can play a role in the prevention of further limitations in these children. Further studies are needed, especially in the areas of participation such as education, recreation, etc., and on the effect of other parental psychological conditions such as anxiety and stress on child participation. Moreover, more studies are recommended on the effect of other cancer-related factors that have not been studied in the present study. For example, there are side effects of specific treatments that can affect the social participation of children with leukemia.

Ethical Considerations
Compliance with ethical guidelines
All ethical principles are considered in this article. The participants were informed about the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them. Also, this study was approved by the ethics committee of Isfahan University of Medical Sciences (Code: 293295).

Funding
This research was supported by the research project (No. 293295), Funded by the Isfahan University of Medical Sciences.

Authors' contributions
Conceptualization and supervision: Khadije Khazaeli and Soraya Gharebaghy; Methodology: Khadije Khazaeli and Soraya Gharebaghy; Investigation, writing – original draft, and writing – review & editing: All authors; Data collection: Zahra Khazaeli and Khadije Khazaeli; Data analysis: Khadije Khazaeli and Nasrin Jalili; Funding acquisition and Resources: Khadije Khazaeli and Soraya Gharebaghy.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the participants and the personnel of the Pediatric Ward of Seyed Al-Shohada Hospital in Isfahan City, especially Ms Akbari, the Ward’s Head nurse, for their cooperation.


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