Posttraumatic stress disorder in mothers of pediatric cancer survivors

Psychological Experiences of Parents of Pediatric Cancer Patients during and after COVID-19 Pandemic

BACKGROUND

Family members dealing with the devastating impact of a cancer diagnosis are now facing even greater vulnerability due to the COVID-19 pandemic. Alongside the already overwhelming trauma, they must also bear the distressing burden of the infection risks. The purpose of this study was to examine and explore the effects in parents of pediatric cancer patients two years after the start of the COVID-19 pandemic to compare these data with the previous data.

METHODS

We conducted a single-center prospective observational study, enrolling 75 parents of 42 pediatric oncology patients. Four questionnaires (IES-R; PSS; STAI-Y and PedsQL) were given to the parents 2 years after the first evaluation.

RESULTS

The bivariate matrix of correlation found a strong significant positive correlation between IES-R and PSS scores (r = 0.526, p < 0.001) as in T1. Stress symptoms (t = 0.00, p < 0.001) and levels of anxiety (trait) (t = 0.32, p < 0.001) remained unchanged; anxiety state levels appeared to have increased (t = 0.425, p < 0.001); there was a significant decrease in the PedsQL tot (t = 5.25, p < 0.001).

CONCLUSIONS

The COVID-19 pandemic has influenced the levels of stress and anxiety of parents and the quality of life of patients, also correlating with the traumatic impact of the diagnosis.

Navigating The Cancer Journey Using Online Information: A Grounded Theory Emerging From The Lived Experience of Cancer Patients and Informal Caregivers With Implications for Online Content Design (Preprint)

BACKGROUND

The internet is an important source of information for many informal caregivers and patients living with cancer. A better understanding of how individuals use the internet to meet their informational needs is important for guiding intervention development.

OBJECTIVE

The objectives of this study were to develop a theory describing why individuals living with cancer use the internet to find information, characterize the challenges faced with existing web-based content, and provide recommendations for web-based content design.

METHODS

Adults (≥18 years) with a history of being patients with cancer or informal caregivers were recruited from Alberta, Canada. After providing informed consent, participants were engaged through digitally recorded one-on-one semistructured interviews, focus groups, a web-based discussion board, and emails. Classic grounded theory guided the study procedures.

RESULTS

A total of 21 participants took part in 23 one-on-one interviews and 5 focus groups. The mean age was 53 (SD 15.3) years. Breast, gynecological, and hematological cancers were the most common cancer types (4/21, 19% each). In total, 67% (14/21) of patients, 29% (6/21) of informal caregivers, and 5% (1/21) of individuals reporting both roles participated. Participants experienced many new challenges in their cancer journey and used the internet to become better oriented to them. For each challenge, internet searching attempted to address one or more of 3 key orientation questions: why the challenge was happening, what to expect, and options for managing it. Better orientation resulted in improved physical and psychosocial well-being. Content that was well laid out, concise, free of distractions, and that addressed the key orientation questions was identified as the most helpful in assisting with orientation. Creators of web-based content are encouraged to 1) clearly identify the cancer challenge and population the content is addressing, as well as the presence of any potentially distressing information; 2) provide versions of the content in different formats, including printer-friendly, audio, video, and alternative languages; 3) state who created the content, including the individuals, organizations, and processes involved; 4) place hyperlinks after the key orientation questions have been addressed; and 5) ensure that the content is optimized for discovery by search engines (ie, Google).

CONCLUSIONS

Web-based content plays an essential role for many living with cancer. Clinicians are encouraged to take active steps to help patients and informal caregivers find web-based content that meets their informational needs. Content creators also have a responsibility to ensure that the content they create assists and does not hinder those navigating the cancer journey. Research is needed to better understand the many challenges that individuals living with cancer face, including how they are temporally related. In addition, how to optimize web-based content for specific cancer challenges and populations should be considered an important area for future research.

Psychological Needs and Resources of the Staff in a Pediatric Neurosurgery Ward: A Phenomenological-Hermeneutic Study

Brain tumors are a common form of solid tumors in children and, unfortunately, they are characterized by a very uncertain prognosis. The treatment of this pathology often includes one or more very invasive surgical procedures, quite often in the very first steps of the treatment. Cases of brain tumors in children represent one of the greatest challenges for health care professionals in the domain of pediatric neurosurgery. This is clearly due to the complexity of the therapeutic plan, but also to the nature of the bond that is established between the child, the parents, and the members of the staff during the often-dramatic initial phase of the illness. In this phenomenological-hermeneutic study, we explore both the emotional and organizational needs, as well as the available professional and personal resources of the staff in the Neurosurgery ward of the Meyer Children’s Hospital in Florence (Italy). The ward staff, composed of 7 surgeons, a pediatric neuro-oncologist, 12 nurses, and 4 auxiliary health care professionals, underwent in-depth interviews that were recorded (with the consensus of the participants). The recordings were then transcribed and submitted to content analysis according to COREQ standards. A complex picture of emotional as well as organizational demands emerged from the data. Shared experiences were pointed out, together with more specific and idiosyncratic contents characteristic of different professional roles. The focus of the present paper was twofold, first, we considered the needs that are overtly expressed by the staff, and then we discussed the main sources of their motivational drives. We found that the latter is mainly found in the quality of the therapeutic bond that is established with the children and the family members, together with the deep interest in one’s own professional activity and the effective complementarity and integration of the personal and professional qualities of the staff members within the multidisciplinary caring group.

A cross-sectional examination of caregiver mental health and childhood cancer survivors' tobacco, alcohol, and marijuana use

PURPOSE

As childhood cancer survivors (CCS) age, they face numerous long-term consequences, or late effects, from their cancer treatments. Late effects may be mitigated by health-promoting behaviors, including the avoidance of substance use. CCS with greater depression symptomology have reported greater substance use, but whether their habits are associated with the mental health of their caregivers is unknown. The aim of this study was to examine caregiver psychosocial correlates of CCS substance use.

METHODS

This study utilizes data from the Project Forward pilot study, which collected data from 129 CCS-caregiver dyads (CCS mean age = 19.43, SD = 2.78; years since diagnosis = 7.62, SD = 2.06) from two large hospitals in Los Angeles County. CCS provided self-reported information on substance use, while caregivers self-reported on posttraumatic stress symptomatology (PTSS) associated with their child's cancer and current depressive symptoms.

RESULTS

Among CCS, prior 30-day tobacco, marijuana, binge drinking, and polysubstance use were 12.50%, 14.17%, 13.18%, and 12.40%. In multivariable logistic regression models, caregiver PTSS was independently positively associated with CCS tobacco use. No other significant relationships between caregiver mental health (PTSS or depressive symptoms) and CCS substance use were observed.

CONCLUSION

These findings suggest that caregiver PTSS is partially associated with CCS behavioral health. Survivorship care may improve tobacco use prevention efforts by incorporating family or caregiver mental health needs. Future research should examine the potential mediating effect of CCS mental health, including depressive symptoms, on this relationship.

Post-Traumatic Stress Reactions in Caregivers of Children and Adolescents/Young Adults with Severe Diseases: A Systematic Review of Risk and Protective Factors

Severe illnesses in children and adolescents/young adults (AYAs) may represent a complex burden for patients and their caregivers, including a wide range of mental disorders, particularly post-traumatic stress disorder (PTSD). Few events are as potentially traumatizing as having a son or a daughter diagnosed with a severe, life-threatening, or disabling disease. The presence of PTSD symptoms in caregivers may compromise their efficacy as caregivers and negatively affect the child’s well-being. This systematic review aims at outlining potential risk and protective factors for the development of PTSD symptoms in caregivers of children and AYAs affected by severe acute or chronic illnesses. Thirty-one studies on caregivers of children and AYAs affected by severe, acute, or chronic diseases were included. Socio-demographic and socio-economic characteristics, illness-related distress, psychiatric symptoms, support, and coping styles were found as potential risk/protective factors across studies. It is crucial to consider risk factors affecting caregivers of severely ill young patients, in order to plan focused interventions aimed at preventing an adverse clinical outcome in caregivers and at enhancing caregivers’ coping skills, in order to ultimately improve their quality of life.

Stress and Growth in Cancer: Mechanisms and Psychotherapeutic Interventions to Facilitate a Constructive Balance

Post-traumatic stress and growth are common responses to adverse life events such as cancer. In this article, we establish how cancer becomes a "fertile land" for the emergence of stress and growth responses and analyze the main mechanisms involved. Stress-growth responses on adjusting to cancer is potentially determined by factors like the phase of the illness (e.g., initial phases vs. period of survivorship), patient's coping strategies, meaning-making, and relationships with significant others. We also review the mechanisms of constructive and adaptative stress-growth balances in cancer to study the predictors, interrelated associations, triggering mechanisms, long-term results, and specific trajectories of these two responses to cancer. Finally, we update the evidence on the role of these stress-growth associations in psychologically adjusting to cancer. Together with this evidence, we summarize preliminary results regarding the efficacy of psychotherapeutic interventions that aim to facilitate a constructive psychological balance between stress and growth in cancer patients. Recommendations for future research and gaps in knowledge on stress-growth processes in this illness are also highlighted. Researchers are encouraged to design and use psychotherapeutic interventions according to the dynamic and changeable patients' sources of stress and growth along the illness. Relevant insights are proposed to understand the inconsistency of stress-growth literature and to promote psychotherapeutic interventions to facilitate a constructive balance between these key responses in cancer.

Damocles' syndrome revisited: Update on the fear of cancer recurrence in the complex world of today's treatments and survivorship

OBJECTIVE/BACKGROUND

Improvements in curative treatments for many types of cancer have emerged over the past several decades, resulting in a growing population of long-term cancer survivors - of both adult and childhood cancers. Despite this incredible medical achievement, long-term survivors of cancer face a unique fear: the fear of relapse.

METHODS

We conducted a review of the literature for data on fear of relapse among cancer survivors.

RESULTS

The fear of cancer recurrence is present in survivors of childhood and adult cancers as well as family members and often leads to psychological sequelae.

CONCLUSION

Literature on the fear of cancer recurrence has begun to emerge. However, herein we provide a unique approach through the use of a metaphor: Cicero's story of Damocles' sword. We aim to outline the many fear-related and emotional challenges faced by cancer survivors with an extensive review of studies demonstrating such challenges.

Granting wishes of seriously ill children: Effects on parents’ well-being

We investigated whether a positive intervention (i.e. granting a wish) in children with a chronic illness could promote positive psychological responses in their parents. Hospitalized children were randomly assigned to either the wish group or to a waiting-list control group. Mothers and fathers’ responses ( N = 86 and 38, respectively) were studied. Parents from the wish group showed higher levels of positive emotions and beliefs in a benevolent world than the control group. Mothers from the wish group reported higher benefit finding, gratitude, and love than those in the control group. Given that the child’s illness inevitably affects their parents, it is important to promote studies that include parents’ well-being dimensions.

Emotional distress in parents of long-term survivors of childhood acute lymphoblastic leukemia

OBJECTIVE

The current study investigated the occurrence of emotional distress in parents of long-term survivors of childhood acute lymphoblastic leukemia (ALL) and identified factors associated with parent emotional distress symptoms.

METHODS

Parents of 127 long-term survivors of childhood ALL treated on a chemotherapy-only protocol at St. Jude Children's Research Hospital participated in the study. Parents completed standard ratings of emotional distress, caregiver strain, and child physical, emotional, and psychosocial functioning. Multivariable hierarchical linear regression analyses were used to examine associations between symptoms of caregiver strain, survivor functioning, and parent emotional distress. Covariates included parent education, survivor age, survivor sex, and time since childhood cancer diagnosis.

RESULTS

On average, few parents reported significant symptoms of emotional distress. Clinically significant levels of anxiety and depression were reported by 7.1% and 3.1% of parents, respectively. Only 3.9% of parents endorsed significant symptoms of posttraumatic stress. Perceived caregiver strain was significantly associated with symptoms of parent anxiety, depression, and posttraumatic stress. Parent-report of child emotional functioning was significantly associated with symptoms of parent anxiety.

CONCLUSIONS

Most parents of long-term survivors of ALL exhibit low levels of emotional distress in the context of rates observed in the general population. Perceived caregiver strain was significantly associated with parent emotional distress. Further research is required to examine specific sources of caregiver strain, as well as other risk and protective factors associated with parent emotional distress symptoms.

Children's positive dispositional attributes, parents' empathic responses, and children's responses to painful pediatric oncology treatment procedures

Pain/distress during pediatric cancer treatments has substantial psychosocial consequences for children and families. The authors examined relationships between children's positive dispositional attributes, parents' empathic responses, and children's pain/distress responses to treatment procedures. Participants were 41 pediatric cancer patients and parents. Several weeks before treatment, parents rated children's resilience and positive dimensions of temperament. Parents' pretreatment empathic affective responses to their children were assessed. Children's pain/distress during treatments was rated by multiple independent raters. Children's resilience was significantly and positively associated with parents' empathic affective responses and negatively associated with children's pain/distress. Children's adaptability and attention focusing also showed positive relationships (p < 0.10) with parents' empathic responses. Parents' empathic responses mediated effects of children's resilience on children's pain/distress. Children's positive dispositional attributes influence their pain/distress during cancer treatments; however, these effects may be mediated by parents' empathic responses. These relationships provide critical understanding of the influence of parent-child relationships on coping with treatment.

Endocrine response and perceived stress test during an experimental challenge task in adult survivors of a childhood cancer

BACKGROUND

Although long-term implications of cancer in childhood or adolescence with regard to medical conditions are well documented, the impact on mental health and on response to stress, which may be an indicator of psychological vulnerability, is not yet well understood. In this study, psychological and physiological responses to stress were examined.

PROCEDURE

Fifty-three participants aged 18-39 years (n = 25 survivors of childhood or adolescence cancer, n = 28 controls) underwent an experimental stress test, the Trier Social Stress Test (TSST). Participants were asked to provide repeated evaluations of perceived stress on visual-analogical scales and blood samples were collected before and after the TSST to measure plasma cortisol.

RESULTS

The psychological perception of stress was not different between the two groups. However, the cancer survivors group showed a higher global plasma cortisol level as well as higher amplitude in the response to the TSST. The global cortisol level in cancer survivors was increased when depression symptoms were present. The subjective perception of stress and the plasma cortisol levels were only marginally correlated in both groups.

CONCLUSIONS

It is suggested that the exposure to a life-threatening experience in childhood/adolescence increases the endocrine response to stress, and that the presence of depressive symptoms is associated with an elevation of plasma cortisol levels. A better knowledge of these mechanisms is important given that the dysregulations of the stress responses may cause psychological vulnerability.

Objective and subjective factors as predictors of post-traumatic stress symptoms in parents of children with cancer--a longitudinal study

BACKGROUND

Parents of children with cancer report post-traumatic stress symptoms (PTSS) years after the child's successful treatment is completed. The aim of the present study was to analyze a number of objective and subjective childhood cancer-related factors as predictors of parental PTSS.

METHODS

Data were collected from 224 parents during and after their child's cancer treatment. Data sources include self-report questionnaires and medical records.

RESULTS

In a multivariate hierarchical model death of the child, parent's perception of child psychological distress and total symptom burden predicted higher levels of PTSS. In addition, immigrants and unemployed parents reported higher levels of PTSS. The following factors did not predict PTSS: parent gender, family income, previous trauma, child's prognosis, treatment intensity, non-fatal relapse, and parent's satisfaction with the child's care.

CONCLUSIONS

Although medical complications can be temporarily stressful, a parent's perception of the child's distress is a more powerful predictor of parental PTSS. The vulnerability of unemployed parents and immigrants should be acknowledged. In addition, findings highlight that the death of a child is as traumatic as could be expected.

Posttraumatic stress disorder in children and their parents following admission to the pediatric intensive care unit: a review

OBJECTIVE

To evaluate posttraumatic stress disorder in children who have been admitted to the pediatric intensive care unit and their families.

DATA SOURCES

Studies were identified through PubMed, MEDLINE, and Ovid.

STUDY SELECTION

All descriptive, observational, and controlled studies with a focus on posttraumatic stress disorder and the pediatric intensive care unit were included.

DATA EXTRACTION AND DATA SYNTHESIS

Posttraumatic stress disorder rates in children following admission to the pediatric intensive care unit were between 5% and 28%, while rates of posttraumatic stress disorder symptoms were significantly higher, 35% to 62%. There have been inconsistencies noted across risk factors. Objective and subjective measurements of disease severity were intermittently positively associated with development of posttraumatic stress disorder. There was a positive relationship identified between the child's symptoms of posttraumatic stress disorder and their parents' symptoms.The biological mechanisms associated with the development of posttraumatic stress disorder in children admitted to the pediatric intensive care unit have yet to be explored. Studies in children following burn or other unintentional injury demonstrate potential relationships between adrenergic hormone levels and a diagnosis of posttraumatic stress disorder. Likewise genetic studies suggest the importance of the adrenergic system in this pathway.The rates of posttraumatic stress disorder in parents following their child's admission to the pediatric intensive care unit ranged between 10.5% and 21%, with symptom rates approaching 84%. It has been suggested that mothers are at increased risk for the development of posttraumatic stress disorder compared to fathers. Objective and subjective measures of disease severity yielded mixed findings with regard to the development of posttraumatic stress disorder. Protective parental factors may include education or the opportunity to discuss the parents' feelings during the admission.

CONCLUSIONS

Following admission to the pediatric intensive care unit, both children and their parents have high rates of trauma exposure, both personally and secondary exposure via other children and their families, and subsequently are reporting significant rates of posttraumatic stress disorder. To effectively treat our patients, we must recognize the signs of posttraumatic stress disorder and strive to mitigate the negative effects.

The role of cortisol in PTSD among women exposed to a trauma-related stressor

Research linking post-traumatic stress disorder (PTSD) to hypercortisolism in laboratory experiments was extended to a natural clinical setting. Mothers of children diagnosed with a life-threatening illness (N = 92) completed standardized measures of PTSD and provided a salivary cortisol sample during their child's medical check-up (Time 1) and again 24h later, after the threat of possible negative medical reports was removed (Time 2). Women who met diagnostic criteria for PTSD exhibited significantly higher cortisol levels at Time 1 compared to women who did not meet criteria for a diagnosis. No significant differences were observed for cortisol levels at Time 2 between the women with and without PTSD. These findings extend current laboratory findings linking hypercortisolism and PTSD to a natural, stressful situation. Implications for understanding the etiology of PTSD as well as for possible prevention and intervention options are discussed.

The factor structure of traumatic stress in parents of children with cancer: a longitudinal analysis*

OBJECTIVES

To determine the factor structure of posttraumatic stress symptoms (PTSS) and assess its stability over time among parents of children diagnosed with cancer.

METHODS

Parents of children with cancer included in a longitudinal study completed the posttraumatic stress disorder (PTSD) Checklist-Civilian Version 2 weeks (n = 249) and 2 (n = 234) and 4 (n = 203) months after their child's diagnosis. Confirmatory factor analysis (CFA) was used to assess 3 models of the underlying dimensions of PTSD and invariance tests were used to assess stability over time.

RESULTS

A longitudinal CFA with the factors reexperiencing, avoidance, dysphoria, and hyperarousal provided best fit to the data. Invariance testing suggested that the pattern and size of loadings were equivalent across the three assessments. Discussions Findings tentatively suggest that PTSS among parents of children with cancer consist of four factors. Implications for research and clinical practice are discussed.

Physical and psychological outcome in long-term survivors of childhood malignant solid tumor in Japan

PURPOSE

Few studies have assessed physical and psychological status in long-term survivors of childhood solid tumors in Japan. For children with such diseases diagnosed and treated in our hospital, our purpose was to clarify the physical and psychological status of long-term survivors and their parents.

METHODS

Subjects were 56 patients who were diagnosed at our institution as having a childhood malignant solid tumor between 1982 and 2005 and had been alive for at least 5 years after treatment. Surveys were sent and returned by mail.

RESULTS

Of the 56 patients surveyed, 32 responded. The current health condition and psychosocial status of survivors were evaluated as good by their parents. However, psychological tests revealed psychosocial problems in 28.1% of the children. Severe posttraumatic stress associated with the child's disease and its treatment was present in 15.6% of the parents.

CONCLUSION

Physical status of long-term survivors of childhood malignant solid tumors was good in general. However, psychological tests revealed psychosocial problems in some of the children and posttraumatic stress in the parents. Considering the diversity of both the diseases and their clinical course, a qualitative study is warranted for further analysis.

Post-traumatic stress symptoms in childhood brain tumour survivors and their parents

OBJECTIVES

This study aimed to investigate post-traumatic stress symptoms (PTSS) in childhood brain tumour survivors and their parents. A further aim was to explore the relationship between objective illness parameters, parent-child interactions, coping styles and PTSS.

METHODS

A cross-sectional correlational design was employed. Fifty-two childhood brain tumour survivors, aged 8-16, and 52 parents completed a battery of questionnaires designed to assess quality of parent-child interactions, monitoring and blunting attentional coping styles and PTSS.

RESULTS

Over one-third (35%) of survivors and 29% of their parents reported severe levels of PTSS (suggestive of post-traumatic stress disorder 'caseness'). Increased parent-child conflict resolution for survivors and number of tumour recurrences for parents independently predicted the variance in PTSS.

CONCLUSIONS

For a substantial proportion of brain tumour survivors and their parents the process of survivorship is a considerably distressing experience.

Hematopoietic stem cell transplantation in children with cancer and the risk of long-term psychological morbidity in the bereaved parents

We have investigated whether hematopoietic stem cell transplantation (HSCT) before the death of children with cancer has a long-term effect on the physical and psychological well-being of the parents. A nationwide questionnaire was sent out to all bereaved parents in Sweden who had lost a child due to a malignancy from 1992 to 1997. Self-reported levels of anxiety, depression and quality of life as well as overall psychological and physical well-being in bereaved parents of children who underwent HSCT were compared with bereaved parents whose children did not receive a transplant. Bereaved parents whose children underwent HSCT had, according to a visual digital scale, an increased relative risk (RR) of long-term anxiety (RR 1.5; 95% confidence interval (CI) 1.0-2.1), poor psychological well-being (RR1.3; 95% CI 1.1-1.5), low quality of life (RR 1.4; 95% CI 1.2-1.7) and poor physical health (RR 1.3; 95% CI 1.1-1.5), whereas the State-Trait Anxiety Inventory and 'The Göteborg Quality of Life Instrument' were non-significantly increased (RR 1.3; 95% CI 0.8-2.3 and RR 1.7; 95% CI 0.9-3.3, respectively). The risks of these consequences were further augmented in case of multiple HSCT. We suggest that bereaved parents of children undergoing HSCT may be at greater risk of decreased psychological well-being than other bereaved parents of children with cancer.

A Narrative Review Summarizing the State of the Evidence on the Health-Related Quality of Life Among Childhood Cancer Survivors

This narrative review summarizes the state of the evidence about the phenomenon of health-related quality of life (HRQOL) among survivors of childhood cancer. A major strength of the state of the evidence on the HRQOL among survivors of childhood cancer is the availability and quality of the data generated from the Childhood Cancer Survivor Study (CCSS). Findings from most studies find comparable levels of HRQOL among survivors and constructed cohort samples; however, a poorer level of HRQOL exists among female survivors. Factors that predict a lower or poorer level of HRQOL among survivors include age at diagnosis, age attained, time since diagnosis, socioeconomic status (education level, household income, and employment status), physical role functioning, and health insurance. Those survivors who received cranial radiation, especially survivors of central nervous system tumors, are at an increased risk for poorer HRQOL and long-term negative effects.

Stressful life events and posttraumatic stress symptoms in children with cancer

This study examined the contribution of stressful life events in posttraumatic stress symptoms (PTSS) stemming from childhood cancer among 121 patients. When controlling for demographic characteristics (age, gender, ethnicity, and socioeconomic status), cancer factors (treatment status, time since diagnosis, and cancer type), and intensity of parental PTSS, history of stressful life events in the child's life emerged as a salient correlate of PTSS across the different measures and reporting methods used in the study. Overall, children who had experienced more frequent and severe life stressors endorsed greater PTSS in relation to the cancer experience. Clinical work and future research on children with cancer should focus accordingly on the potential cumulative impact of stressful life events on PTSS.

Application of the DSM-IV Criteria to the Experience of Living with AIDS

A diagnosis with HIV is often considered traumatic. According to the DSM-IV-TR's criteria for PTSD, a traumatic event precipitates a set of reactions in an individual that includes avoidant behaviour, intrusive thoughts, and physiologic hyperarousal. However, persons diagnosed with HIV are typically concerned with events that will occur in the future such as physical decline and death, access to treatment, the welfare of dependants, and stigma and discrimination. Their concerns are thus future-oriented rather than anchored to a past traumatic event, which is the requirement of PTSD. This article argues that an HIV diagnosis may be inappropriately regarded as traumatic.

Posttraumatic stress disorder in mothers of children who have undergone surgery for congenital disease at a pediatric surgery department

PURPOSE

The aim of the study was to investigate posttraumatic stress disorder (PTSD) in mothers of children who have undergone surgery for congenital disease at a pediatric surgery department.

METHODS

A questionnaire survey was carried out in 145 mothers of children who had undergone surgery and were still alive. For comparison, the mothers were categorized into 3 groups according to the severity of their child's disease.

RESULTS

Of the 145 mothers, 29 (20%) were likely to be diagnosed as having developed PTSD at the time of the survey. Posttraumatic stress disorder symptoms correlated with factors such as anxiety and condition of the child. In terms of the disease severity of the child, factors such as anxiety tended to be observed more frequently in the higher disease severity group, whereas the proportion of mothers likely to be diagnosed as having developed PTSD was smallest in the moderate-severity group.

CONCLUSIONS

Twenty percent of the mothers of children had probably developed PTSD. In the moderate-severity group, there seemed to be a factor that alleviated PTSD symptoms. Because mothers provided effective care for the symptoms of children in the moderate-severity group, this observation suggests that participation of the mother in their child's treatment might prevent them from developing PTSD symptoms.

Parent distress in childhood cancer: a comparative evaluation of posttraumatic stress symptoms, depression and anxiety

The aim was to assess symptoms consistent with posttraumatic stress (PTS; cognitive intrusions, avoidance, arousal) related to the child's illness, and generic distress (anxiety, depression) in parents of childhood cancer patients. Outcomes were compared to normative and relevant reference data, and analysed for their dependence on time passed since diagnosis. Swedish parents (266 mothers, 208 fathers) were recruited at two centres. Data from a clinical sample of posttraumatic stress disorder (PTSD) patients and parents of healthy children were used for comparison. The Impact of Events Scale (IES-R) was used for assessing PTS symptoms, and self-report scales for anxiety and depression. Elevated stress and generic distress varied as a function of time from diagnosis. Up to 12% of parents for whom >5 years had passed since diagnosis still reported equally, or more intrusive thoughts, avoidance and arousal when contrasted to patients suffering from PTSD. Parents of recently diagnosed children had more cancer-related intrusive thoughts than those of long-term survivors. Heightened anxiety and depression was most prominent in mothers and fathers up to 2.5 years after diagnosis. In conclusion, severe generic distress characterises the first years after diagnosis, and initially common PTS symptoms are found in a considerable portion of parents years after diagnosis. Clinically, attention should be paid to continuous parent support needs. Individual variation vis-à-vis distress vulnerability should be acknowledged, and presupposed gender differences avoided. When treatment situation asks the most of parents' collaboration, many are under pressure of severe stress.

Assessment of parental psychological stress in pediatric cancer: a review

OBJECTIVES

We present an overview of the literature between 1997 and 2007 on parental stress reactions following the diagnosis of childhood cancer and we evaluate methodological strengths and weaknesses of the studies.

METHODS

PubMed, PsychInfo, and Cinahl databases were used. Sixty-seven were included in the review.

RESULTS

The conceptualization of parental stress and timing of assessment varies considerably between the studies, which makes comparison difficult. Most emotional stress reactions are seen around the time of diagnosis, with mothers reporting more symptoms than fathers. As a group, parents seem relatively resilient, although a subset of parents reports continuing stress even up to 5 years or more postdiagnosis.

CONCLUSIONS

The authors recommend clear definitions of parental stress, fixed points in time to assess parental stress, and an approach that highlights both parental strengths and weaknesses. Improved assessment can contribute to tailoring psychological care to those parents most in need.

Posttraumatic stress disorder and risk factors in parents of children with a cancer diagnosis

The purpose of this study was to determine the prevalence of posttraumatic stress disorder (PTSD) in parents of children with cancer. Five questionnaires were administered to 104 parents, including a sociodemographic questionnaire, a traumatic events check list, the Structured Clinical Interview for DSM-IV PTSD and Major Depressive Disorder modules, and the self-rating instrument General Health Questionnaire-12. The prevalence of PTSD was 34.6%. The statistically significant tendency to develop PTSD were found in the female gender, better educational status, death of a loved one, previous history of psychiatric disorder, having a child with poorer prognosis, and the presence of radiotherapy in child's treatment. The vulnerable parents must receive psychosocial support.

Symptoms of posttraumatic stress in parents of children with cancer: are they elevated relative to parents of healthy children?

OBJECTIVE

To examine posttraumatic stress symptoms (PTSS) in parents of children with cancer as a function of time since diagnosis, treatment status, and relapse history, and as compared to parents of healthy children.

METHOD

Participants included parents of 199 children with cancer, comprising a cross-sectional sample of diagnoses and treatment phases, ranging from currently on therapy to long-term survivors, and 108 parents of healthy children obtained via acquaintance control methods. Parents completed a standardized self-report measure of PTSS.

RESULTS

Within the cancer group, parental report of PTSS differed as a function of treatment status and time since diagnosis. Parents of children on active treatment endorsed similar levels of PTSS as control parents, whereas parents of children off treatment reported significantly lower levels of PTSS than did controls. Similarly, parents of long-term survivors reported significantly lower levels of PTSS than did controls, while parents of recently diagnosed children did not differ from controls on PTSS. In contrast, parents of children who had suffered a relapse reported significantly higher levels of PTSS, and were much more likely to be identified as a posttraumatic stress disorder (PTSD) case.

CONCLUSIONS

As a group, parents of children with cancer did not demonstrate any evidence of increased PTSS relative to parents of healthy children. Time since diagnosis, child treatment status, and relapse history are significant determinants of parent PTSS. Only parents of children who experienced a relapse appear to be at increased risk of PTSD. The current results appear discrepant from the existing literature, and possible explanations for these discrepancies are examined.

Symptoms of posttraumatic stress in parents of children with cancer: are they elevated relative to parents of healthy children?

OBJECTIVE

To examine posttraumatic stress symptoms (PTSS) in parents of children with cancer as a function of time since diagnosis, treatment status, and relapse history, and as compared to parents of healthy children.

METHOD

Participants included parents of 199 children with cancer, comprising a cross-sectional sample of diagnoses and treatment phases, ranging from currently on therapy to long-term survivors, and 108 parents of healthy children obtained via acquaintance control methods. Parents completed a standardized self-report measure of PTSS.

RESULTS

Within the cancer group, parental report of PTSS differed as a function of treatment status and time since diagnosis. Parents of children on active treatment endorsed similar levels of PTSS as control parents, whereas parents of children off treatment reported significantly lower levels of PTSS than did controls. Similarly, parents of long-term survivors reported significantly lower levels of PTSS than did controls, while parents of recently diagnosed children did not differ from controls on PTSS. In contrast, parents of children who had suffered a relapse reported significantly higher levels of PTSS, and were much more likely to be identified as a posttraumatic stress disorder (PTSD) case.

CONCLUSIONS

As a group, parents of children with cancer did not demonstrate any evidence of increased PTSS relative to parents of healthy children. Time since diagnosis, child treatment status, and relapse history are significant determinants of parent PTSS. Only parents of children who experienced a relapse appear to be at increased risk of PTSD. The current results appear discrepant from the existing literature, and possible explanations for these discrepancies are examined.

Anxiety, depressive, and posttraumatic stress symptoms in mothers of children with type 1 diabetes

This study investigated the prevalence of mothers' anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms triggered by their child's type 1 diabetes and identified individual diabetes-related traumatic stressors. Sixty mothers of children who had been diagnosed with diabetes within the past 5 years were interviewed using the Structured Clinical Interview (SCID) DSM-IV-PTSD module, and completed the Posttraumatic Stress Diagnostic Scale (PDS) and the Hospital Anxiety and Depression Scale (HADS). Fifteen percent of participants met criteria for partial and 10% for full PTSD. Fifty-five percent of participants identified hearing about their child's diagnosis as the traumatic stressor. Forty percent of participants reported moderate to severe symptoms of state-anxiety and 17% moderate to severe symptoms of depression. This study highlights the significant emotional impact this diagnosis in children can have on mothers, and identifies a population with clinical needs.

Posttraumatic stress disorder among parents of children on cancer treatment: a longitudinal study

The main aim of this study was to investigate the occurrence of cancer-related posttraumatic stress disorder (PTSD) among parents of children on cancer treatment. A longitudinal design with assessments at one week (T1), two (T2), and four (T3) months after the child's diagnosis was used. Two hundred and fourteen parents (107 mothers, 107 fathers) participated at T1-T3. The PTSD Checklist Civilian (PCL-C), a self-report screening instrument for PTSD, was answered by parents over the telephone. According to the PCL-C symptom criteria method 33%, more mothers than fathers, score as potential cases of acute stress disorder (ASD) at T1, whereas 28% as potential cases of PTSD at T2 and 22% at T3. The levels of acute- and posttraumatic stress symptoms show a linear, descending pattern, and mothers report higher levels than fathers. Half of the parents who score as potential cases of ASD a week after the child's diagnosis score as potential cases of PTSD four months later. The findings illustrate that a group of parents of children with cancer experience serious psychological distress related to their child's disease. A traumatic stress perspective on childhood cancer should be applied to paediatric oncology care and appropriate psychosocial interventions should be offered to parents when needed.

Psychosocial indicators of health-related quality of life in children with cancer 2 months after end of successful treatment

The purpose of the study was to identify psychosocial correlates of Health-Related Quality of Life (HRQoL) in pediatric cancer patients after completion of cancer treatment. Multiple regression analyses were performed to predict self-reported HRQoL of 52 patients aged 8 to 15 years, and parent-reported HRQoL of 54 patients aged 1 to 5 years. Cognitive coping, family functioning, parental emotional reactions, communication about the disease, and several medical variables were included in the regression models. Better HRQoL was especially associated with more positive expectations of the further course of the disease and less frequent parental asking after disease-related emotions of the child. Interventions should include "positive thinking" as a coping strategy. Several other psychosocial variables were indicative of better HRQoL but further research is needed to confirm and to understand the relationship between psychosocial variables and HRQoL.

Support-seeking, perceived support, and anxiety in mothers and fathers after children's cancer treatment

The objective was to examine the relationships between anxiety, the seeking of social support as a coping strategy, and perceived social support among mothers (n=103) and fathers (n=81) of children with successfully completed treatment for cancer. Assessments were done using self-report instruments. The mediating effect of perceived support on the relationship between social support-seeking and anxiety was evaluated through path analysis, and comparisons were done in order to evaluate effects of gender. For mothers and fathers alike, a positive relationship of moderate strength between support-seeking and perceived support was found. Anxiety was negatively related to support-seeking (mothers r=-0.22, p=0.025; fathers r=-0.21, p=0.063) as well as perceived support (mothers r=-0.55, p<0.001; fathers r=-0.41, p<0.001), although the relationship for support-seeking was weak. The path analysis showed that perceived support only to a minor extent could strengthen this association. The significance of support-seeking and perceived support was stronger for mothers than for fathers, as regards their association with anxiety. However, the patterns of interrelations were similar for mothers and fathers. In conclusion, parents' subjectively perceived support appears to be more important for anxiety regulation than their support-seeking coping. In clinical practice, individual variation should be acknowledged, and presumptions of general gender differences avoided.

Persistent psychological distress in long-term survivors of pediatric sarcoma: the experience at a single institution

BACKGROUND

The long-term psychological impact of pediatric sarcoma is largely unknown. As part of a cross-sectional study examining the late effects of pediatric sarcoma therapy, we examined whether psychological distress or posttraumatic stress symptoms are present in an adult cohort of pediatric sarcoma survivors.

METHOD

Thirty-four patients participated in the study, an average of 17 years after their treatment ended, each completing the SCID module for Posttraumatic Stress Disorder, Impact of Events Scale, Brief Symptom Inventory (BSI) and a questionnaire assessing sociodemographic variables and psychosocial issues.

RESULTS

Significant persistent psychological distress characterized this cohort of patients. Seventy-seven percent scored in the clinical range on the BSI. Twelve percent met diagnostic criteria for PTSD. Current psychological distress was associated with intrusive thoughts and avoidant behaviors, male gender, employment, difficulty readjusting to work/school after treatment, and enduring worries about health. No differences were found based on age, presence of metastatic disease or time since diagnosis.

CONCLUSIONS

This is the first report of a clinical evaluation of psychological distress in a cohort of pediatric sarcoma survivors treated with intensive multimodal cancer therapy. The results suggest that survivors of pediatric sarcoma might be at high risk for adverse psychological outcomes. Appropriate interventions are proposed.

Post-traumatic stress response to life-threatening illnesses in children and their parents

Symptoms of PTSD have been reported in response to a variety of life-threatening medical illnesses and injuries in adults and children. Emerging data suggest that children often experience medical treatment and hospitalization as traumatic, putting caregivers and medical personnel in the role of the unintended accomplice. Adequate pain control by pharmacologic and behavioral means; child and family psychological support using evidence-based CBT, dynamic psychotherapy, and other techniques; and meticulous attention to communication via a team-based approach are the cornerstones of pediatric palliative care in general and PTSD prevention and treatment in particular. Emerging evidence suggests that PTSD in life-limiting pediatric illness can be ameliorated, if not prevented, and treated when it occurs, contributing materially to the quality of life of a child and family. A landmark finding of PTSD research with medically ill children and their families is that parents are at least as symptomatic, or more, as their children, underlining the importance of a family-directed approach addressing every family mem-ber. Pediatric caregivers increasingly recognize their therapeutic role when curative therapy is no longer possible is as pivotal as in the setting of acute illness.

Brief report: the risk of posttraumatic stress disorder in mothers of children diagnosed with pediatric cancer and type I diabetes

OBJECTIVE

To evaluate the risk of and predictors of enduring and late-onset posttraumatic stress disorder (PTSD) among mothers of children diagnosed with type I diabetes and cancer.

METHOD

Mothers (N = 99) of children diagnosed with cancer or diabetes for at least 12 months completed a structured clinical interview for PTSD and self-report measures of PTSD, depression, anxiety, and stressful life events.

RESULTS

There was no significant difference in the rate of PTSD between the two groups. Overall, fewer mothers (7%) met criteria for PTSD on the structured clinical interview than those on a self-report measure of PTSD (17%). Mothers who reported more depressive symptoms, anxiety, and stressful life events tended to report significantly more PTSD symptoms.

CONCLUSIONS

The findings extend prior research regarding the prevalence rate and predictors of PTSD and PTSD symptoms in pediatric populations. It is recommended that clinicians exercise caution when interpreting prevalence rates for PTSD that are derived from self-report measures.

Posttraumatic stress disorder in medically ill patients: what is known, what needs to be determined, and why is it important?

Can a medical illness or its treatment qualify as an emotionally traumatic event and can it cause posttraumatic stress disorder symptoms? If so, can the view of a medical illness as a traumatic experience enhance our ability to understand patients' adjustment to illness and their emotional reactions to it? Is it important to identify posttraumatic symptoms and try to address them in medically ill patients? These questions form the backbone for this review. Because many questions remain unanswered (or the answers are not definitive yet), we concisely summarize the issues and present our own view of the most pressing questions for further research.

A systematic and conceptual review of posttraumatic stress in childhood cancer survivors and their parents

Recent years have witnessed a rapid acceleration in the recognition and documentation of posttraumatic stress disorder (PTSD) and posttraumatic stress symptomatology (PTSS) in childhood cancer survivors and their parents. However, applicability of PTSD both diagnostically and conceptually to cancer-related traumatic responses remains poorly articulated within the current literature. Following an outline of childhood cancer and PTSD, this paper critically examines the applicability of such a diagnosis to this clinical population. It then systematically reviews the current evidence base (24 studies) on PTSD and PTSS in childhood cancer survivors and their parents. Prevalence of PTSD and PTSS, as well as associated predictors, in this clinical population varies widely. Findings are considered in the light of a number of contemporary theories of PTSD. Limitations within current conceptualizations of PTSD are highlighted with respect to the nature of cancer as a traumatic event and the specific features of traumatic stress manifestations in childhood cancer survivors and their parents. Finally, a number of pertinent research areas are elucidated which are argued to warrant further investigation.

ALLOSTATIC LOAD IN WOMEN WITH AND WITHOUT PTSD SYMPTOMS

Allostatic load (AL) is the term used to describe cumulative physiological wear and tear that results from repeated efforts to adapt to stressors over time. Operationalized as a composite index of biological risk factors (e.g., blood pressure, cholesterol, glycosylated hemoglobin, and cortisol, norepinephrine, and epinephrine), AL has been shown to increase with age, predict long-term morbidity and mortality among the elderly, and be associated with low parent education in a large adolescent sample. However, AL has not yet been studied in samples with putative "high stress" or posttraumatic stress disorder (PTSD). Accordingly, AL was measured in women with high acute and chronic stress: mothers of pediatric cancer survivors with and without PTSD and control mothers of healthy children. AL emerged in a "dose-dependent" ranking from high to low: cancer mothers meeting all criteria for PTSD, cancer mothers with no or low symptoms, and control mothers, respectively (p < .001). Effects were not altered by self-reported sleep quality or substance use (tobacco, caffeine, alcohol, or drugs) and remained significant when analyzing AL without cortisol or catecholamines. Results indicate elevated AL can be detected in relatively young women with high stress histories and particularly those with PTSD. Future prospective studies must evaluate whether this pattern represents an accelerated aging process and increased risk of disease.

Women's posttraumatic stress responses to maternal breast cancer

Levels of posttraumatic stress disorder (PTSD) symptoms and their relationships to demographic and psychosocial variables and maternal medical history were examined among 31 women with maternal histories of breast cancer. The results indicate that 19.4% of these women were likely to merit a PTSD diagnosis related to maternal breast cancer, particularly those who reported greater negative affect. In addition, PTSD symptom severity was positively associated with the mother's cancer stage at diagnosis and was inversely associated with participant age. These results suggest that maternal breast cancer is an emotionally traumatic event for many women and point to the potential influence of psychological factors and stressor characteristics on daughters' PTSD responses.

Parental traumatic stress during and after paediatric cancer treatment

The objective was to cross-sectionally compare parents of children during (n = 175) and after (n = 238) cancer treatment regarding traumatic stress (intrusion, avoidance, arousal). In both groups, time since child's diagnosis ranged from one month to six years. Intrusion and arousal were more frequent in parents during ongoing treatment, although also reported by many parents after treatment. Stress was evaluated in relation to situational and demographic factors: Parents who had experienced a relapse did not differ from parents of non-relapsed children. Time since diagnosis was only weakly associated with stress. In the stage of completed treatment the risk for severe stress was elevated in parents with lower education and immigrant parents. Mothers reported somewhat higher levels of stress than fathers, although the findings were ambiguous. To conclude, many parents experience high levels of disease-related stress, even after successful treatment. The pattern of stress symptoms may vary according to educational level, ethnicity, and gender.

Psychological Distress and the Impact of Social Support on Fathers and Mothers of Pediatric Cancer Patients: Long-Term Prospective Results

OBJECTIVE

To explore the effects of social support on psychological distress of parents of pediatric cancer patients using a prospective design over a 5-year period.

METHODS

Parents of children diagnosed with cancer participated at diagnosis (T1), 6 months (T2), 12 months (T3), and 5 years later (T4). Instruments The General Health Questionnaire and the Social Support List (SSL) measuring amount of support, (dis)satisfaction with support, and negative interactions were administered.

RESULTS

Psychological distress and amount of support received decreased significantly from diagnosis to T4. No significant change in (dis)satisfaction with support and negative interactions was found. Social support variables did not show any concurrent or prospective significant effect on mothers' distress at T4. Dissatisfaction with support showed a significant unique concurrent effect on fathers' distress at T4 and negative interactions had a prospective unique effect.

CONCLUSIONS

Dissatisfaction with support and negative interactions that fathers experienced significantly affected their levels of psychological distress. No such effect was found for mothers.