Posttraumatic stress disorder and family functioning in adolescent cancer

The relationship between family functioning and non-suicidal self-injury in adolescents: A structural equation modeling analysis

BACKGROUND

Previous research has suggested that depressive symptoms, emotional competence, and posttraumatic stress symptoms (PTSS) may mediate the association between family functioning and non-suicidal self-injury (NSSI). Therefore, this study aimed to evaluate the mediation effects of depressive symptoms, emotional competence, and COVID-related PTSS on the relationship between family functioning and NSSI in adolescents.

METHOD

A sample of 5854 adolescents was recruited from June 16 to July 8, 2020. The data for family functioning, depressive symptoms, emotional competence, COVID-related PTSS, and NSSI behavior of adolescents were collected via self-reported questionnaires. A structural equation model was constructed to examine the relationship, and a bootstrap analysis was conducted to evaluate the mediation effects.

RESULTS

The reporting rate of adolescent NSSI was 30.2%. The poor family functioning was positively associated with adolescent NSSI (β = 0.130, 95% CI = 0.093-0.182), which was mediated by depression with effect size of 0.231 (95% CI = 0.201-0.257). The pathway coefficients between emotional competence and NSSI, and depression, COVID-related PTSS and NSSI, though statistically significant were unlikely to be clinically meaning with values of 0.057 and 0.015. There was no mediating effect by COVID-related PTSS. The pathways initially constructed between family functioning and COVID-related PTSS, emotional capacity and COVID-related PTSS were not been verified.

LIMITATIONS

It was unclear whether this mediational effect would be supported in a longitudinal design. The application and extension of this model toward other regions and countries, and different ages need to be further explored.

CONCLUSION

The interventions of adolescent NSSI should focus on both the family level and individual levels. Improving family environment, screening depressive symptoms, enhancing emotional competence and lessening COVID-related PTSS may reduce NSSI.

Psychological and Psychiatric Comorbidities in Youth with Serious Physical Illness

An estimated one in six children in the United States suffers from a mental disorder, including mood, anxiety, or behavioral disorders. This rate is even higher in children with chronic medical illness. This manuscript provides a concise review of the symptoms that comprise mental conditions often observed in children with chronic illness or at the end of life. It further provides some guidance to help clinicians distinguish normative from pathological presentations. Evidence-based psychotherapy interventions, potentially applicable to the acute inpatient setting, are briefly summarized. Broad recommendations are made regarding both psychotherapeutic as well as pharmacotherapeutic interventions, with a review of common or serious medication side effects. Finally, delirium recognition and management are summarized.

Psychiatric Symptoms, Posttraumatic Growth, and Life Satisfaction Among Parents of Seriously Ill Infants: A Prospective Case-Controlled Study

We evaluated psychiatric symptoms, posttraumatic growth, and life satisfaction among the parents (n = 34) of newborns (n = 17) requiring therapeutic hypothermia or urgent surgery (interest group). Our control group included 60 parents of healthy newborns (n = 30). The first surveys were completed soon after diagnosis or delivery and the follow-up surveys 1 year later (participation rate 88% in the interest group and 70% in the control group). General stress was common in both groups but was more prevalent in the interest group as were depressive symptoms, too. Anxiety was more common in the interest group, although it showed a decrease from the baseline in both groups. Life satisfaction had an inverse correlation with all measures of psychiatric symptoms, and it was lower in the interest group in the early stage, but similar at 12 months due to the slight decline in the control group. Mothers in the interest group had more anxiety and depressive symptoms than fathers in the early stage. Mothers had more traumatic distress than fathers at both time points. Half of the parents experienced substantial posttraumatic growth at 12 months. In conclusion, the serious illness of an infant substantially affects the well-being of the parents in the early stages of illness and one year after the illness.

In the name of the family? Against parents' refusal to disclose prognostic information to children

Parents frequently attempt to shield their children from distressing prognostic information. Pediatric oncology providers sometimes follow parental request for non-disclosure of prognostic information to children, invoking what we call the stability of the family argument. They believe that if they inform the child about terminal prognosis despite parental wishes, cohesion and family structure will be severely hampered. In this paper, we argue against parental request for non-disclosure. Firstly, we present the stability of the family argument in more detail. We, then, set out the (conceptual, legal, systemic) entitativity of the family and the kind of value the stability of the family argument assumes, before we set on to critically evaluate the argument. Our analysis shows that disclosure of prognostic information to children does not necessarily destabilize the family to a greater extent than non-disclosure. In fact, a systemic perspective suggests that mediated disclosure is more likely to result in a (long-term) stability of the family than non-disclosure. It is in the interest of the family to resist the initial aversive reaction to delivering bad news. In the final part, we draw a set of recommendations on how to facilitate decision-making in face of parental request for non-disclosure.

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.

Parenting in the face of serious illness: Childhood cancer survivors remember different rearing behavior than the general population

OBJECTIVE

A child's cancer diagnosis and treatment affect the whole family. While it has been recognized that parents are an important resource for their children, little is known about the specifics of parenting in the face of serious illness.

METHODS

We used the Recalled Parental Rearing Behavior Questionnaire in a register-based cohort of adult childhood cancer survivors (CCS) (N = 951) and a representative population sample of the same age range (N = 2042). The questionnaire assesses behavior of mothers and fathers with three scales (emotional warmth, rejection/punishment, and control/overprotection) by querying the (former) child. We compared the two groups using general linear models. With a hierarchical linear regression analysis, we tested associations of recalled rearing behavior with disease- and treatment-related factors.

RESULTS

Compared with the general population, CCS remembered both parents as emotionally warmer, more overprotective, and less punishing/rejecting and less ambitious. The regression analysis showed that having received radiotherapy (β = 0.092; P = .009) and chemotherapy (β = 0.077; P = .027) was positively related to memories of maternal emotional warmth.

CONCLUSIONS

CCS remembered parenting styles which are generally deemed more positive. The extent of recalled control and overprotection deviated from the population in different directions, suggesting that parenting in childhood cancer entails more complex adaptations than being affectionate and giving comfort. The results suggest an adaptation of parental behavior to particularly challenging treatments. They highlight potential vulnerability and resilience factors, some of which were sex-dependent.

The Effects of Family Functioning on the Development of Posttraumatic Stress in Children and Their Parents Following Admission to the PICU

OBJECTIVES

To report the rate of acute stress and posttraumatic stress among children and parents following PICU admission and the relation between family function and posttraumatic stress.

DESIGN

Prospective, longitudinal, multi-informant observational study. Pediatric patients (n = 69) and parents were recruited in the ICU. They completed measures evaluating acute stress and posttraumatic stress during their hospitalization and at 3-month follow-up. Parents completed measures of family functioning during the hospitalization. Pearson correlations and multiple regression models were used to examine the relations between family functioning and acute stress and posttraumatic stress.

SETTING

An academic, urban, pediatric hospital in California.

PATIENTS

Children, 8-17 years old, admitted to the PICU for greater than 24 hours and their English- or Spanish-speaking parents.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All children endorsed acute stress during their PICU admission, with 51% meeting criteria for acute stress disorder. At 3-month follow-up, 53% of the children continued to endorse posttraumatic stress with 13% meeting criteria for posttraumatic stress disorder. Among parents, 78% endorsed acute stress during admission with 30% meeting criteria for acute stress disorder, and at follow-up, 35% endorsed posttraumatic stress with 10% meeting criteria for posttraumatic stress disorder. In multiple linear regression modeling, child acute stress significantly predicted child posttraumatic stress (β = 0.36; p < 0.01). In the parent model, parent acute stress (β = 0.29; p < 0.01) and parent education (β = 0.59; p < 0.00) positively predicted parent's posttraumatic stress. Family function was not a predictor of either's posttraumatic stress.

CONCLUSIONS

Both children and parents have alarmingly high rates of acute stress and posttraumatic stress following the child's PICU admission. Although family function did not emerge as a predictor in this study, further understanding of the influence of the family and the interplay between child and parent posttraumatic stress is needed to improve our understanding of the model of development of posttraumatic stress in this population to inform the intervention strategies.

Posttraumatic stress symptoms in young people with cancer and their siblings: results from a UK sample

PURPOSE

This study investigated levels of posttraumatic stress symptoms (PTSS) in children with cancer and their siblings from a British sample. It also examined aspects of the Ehlers and Clark ¹ model of posttraumatic stress disorder in the current population.

METHODS

Sixty participants (34 children with cancer and 26 siblings) aged between 8 and 18 years completed measures of PTSS, maladaptive appraisals, trauma-centered identity, perceived social support and family functioning.

RESULTS

Over a quarter of the sample scored above the clinical cutoff on the Impact of Events Scale-Revised. No differences were observed between patients and siblings with respect to levels of PTSS. Maladaptive appraisals and age were found to account for unique variance in levels of PTSS for the overall sample.

CONCLUSIONS

Rates of PTSS in the sample were relatively high. Support was found for aspects of the Ehlers and Clark ¹ model in explaining PTSS for the current population.

Childhood Cancer and Brain Tumor Late Effects: Relationships with Family Burden and Survivor Psychological Outcomes

This study examines illness-specific family burden as a mediator of the association between late effects of childhood cancer and survivors' emotional and behavioral outcomes. Childhood cancer survivors (n = 65; ages 10-17) two or more years off-treatment completed measures assessing internalizing and PTSD symptoms. Parents reported on illness-specific family burden, late effects severity, and survivor internalizing/externalizing problems. Providers documented the number of late effects. Illness-specific family burden was correlated with provider-reported late effects (r = .29, p < .05) and parent report of severe late effects (r = .56, p < .01). Results supported an indirect effect of illness-specific family burden on number of late effects and parent-reported survivor internalizing problems, p < .05. Indirect effects were not found in models predicting PTSD and externalizing problems. Illness-specific family burden is an important intervention target for reducing internalizing problems in childhood cancer survivors with late effects.

Child symptoms, parent behaviors, and family strain in long-term survivors of childhood acute lymphoblastic leukemia

OBJECTIVE

How family environment and parental factors affect health status and symptoms in childhood cancer survivors is understudied. We examined the influence of family cohesion, parent distress, and overprotection on child symptom burden and health-related quality of life (HRQOL) and family strain in survivors of childhood acute lymphoblastic leukemia.

METHODS

Parents of 213 children treated with chemotherapy only completed a survey when survivors were at least 5-year postdiagnosis. Family Environment Scale, Brief Symptom Inventory-18, Parent Protection Scale, Pediatric Quality of Life Inventory, and Impact on Family were used to assess family cohesion, parental distress, overprotection, child symptom burden and HRQOL, and family strain, respectively. Path analysis was conducted to quantify effects of family cohesion on family strain through parental distress, overprotection, child symptoms, and HRQOL.

RESULTS

Lower family cohesion (β = 0.06, 95% CI, 0.01-0.13), higher parental distress (β = 0.35, 95% CI, 0.20-0.45), and overprotection (β = 0.17, 95% CI, 0.01-0.32) were associated with more child symptom burden. More symptom burden were associated with poorer child HRQOL (β = 0.66, 95% CI, 0.57-0.75), which in turn was associated with more family strain (β = 0.11, 95% CI, 0.01-0.22). Lower maternal education was associated with overprotection (β = -0.23, 95% CI, -0.33 to -0.12), more child symptoms (β = -0.30, 95% CI, -0.41 to -0.16), poorer child HRQOL (β = -0.36, 95% CI, -0.46 to -0.21), and more family strain (β = -0.15, 95% CI, -0.23 to -0.08).

CONCLUSIONS

Family and parental factors contributed to health outcomes of childhood acute lymphoblastic leukemia survivors. Interventions to enhance family cohesion, decrease parental distress and overprotection, and ameliorate child symptoms may improve family functioning.

Family Functioning and Depressive Symptoms in Adolescent and Young Adult Cancer Survivors and Their Families: A Dyadic Analytic Approach

Background

To examine dyadic relationships between depressive symptoms and family functioning in families of pediatric cancer survivors. Methods Sixty-four adolescent and young adult (AYA) cancer survivors and their caregivers self-reported on depressive symptoms and family functioning. Multilevel modeling analyses were used to test actor–partner interdependence models.

Results

Significant actor effects of depressive symptoms on domains of family functioning were found for AYAs and their caregivers. Only caregivers’ depressive symptoms exerted a significant effect on AYAs’ report of family cohesion, indicating the presence of significant partner effects for AYAs.

Conclusions

AYAs’ and caregivers’ depressive symptoms are related to poorer family functioning. Caregivers’ perceptions of depressive symptoms relate not only to their own perceptions of family functioning but also to that of their children. These findings begin to map the complex relationships that exist between AYAs and their caregivers and elucidate some of the mechanisms through which caregiver-related variables affect AYA outcomes.

Understanding the Impact of Paediatric Asthma on Families: Development of a Theoretical Model

The experience of paediatric asthma is associated with increased stress and emotional difficulties for both the child and family. The current study aimed to qualitatively explore parents’ views of their child's asthma experience, from initial diagnosis onwards, to enhance our understanding of how families emotionally adjust and adapt to the diagnosis and management of asthma. Semi-structured interviews were conducted with 17 parents of children (<18 years) with physician-diagnosed asthma. Questionnaires were used to capture demographic information and anxiety symptom status of parents (State Trait Anxiety Inventory — Form Y [STAI-Y1/Y2]) and children (Spence Children's Anxiety Scale — Parent reported [SCAS-P]). Grounded theory was used to analyse the results. Analysis saw three themes emerge as important in understanding the impact of asthma on the family: (1) the experience of obtaining an asthma diagnosis, (2) parents’ belief in their competence to manage asthma, and (3) parents’ behaviour in response to the asthma. A model was developed that posits adaptive parental adjustment to asthma is determined in part by the circumstances around the time of diagnosis, the level of knowledge and skills, and the controllability of the asthma. This model can guide medical and allied health professionals to specific areas where intervention may reduce stress and emotional difficulties associated with asthma and its management for affected families.

Parental Factors Associated with Child Post-traumatic Stress Following Injury: A Consideration of Intervention Targets

Post-traumatic stress disorder (PTSD) symptoms are relatively common following pediatric traumatic injury and are related to poor long-term child outcomes. However, due to concerns regarding the efficacy of early child preventive interventions, and difficulty intervening with injured and medicated children soon after the event, it is not feasible to provide early psychological interventions to children exposed to traumatic injury. Parental PTSD symptoms and reactions to the child’s traumatic injury impact child outcomes and provide potential targets for early intervention to reduce child symptom development without involving the child. The authors conducted a review of the literature using Psycinfo and Pubmed research databases (publication years = 1990–2017) and identified 65 published studies relevant to the topic of the review. The present review considers parent factors [parenting styles, parental post-traumatic pathology (PTS), adaptive and maladaptive coping strategies, and communication regarding the traumatic injury] and their impact on child PTS. We focus specifically on factors amenable to intervention. We further review moderators of these relationships (e.g., child age and gender, parent gender) and conclude that it is unlikely that a one-size-fits-all approach to treatment will be successful. Rather, it is necessary to consider the age and gender of parent child dyads in designing and providing targeted interventions to families following the traumatic injury of a child.

Predictors of Posttraumatic Stress and Posttraumatic Growth in Childhood Cancer Survivors

This longitudinal study aims to analyze predictors of posttraumatic stress symptoms (PTSS) and posttraumatic growth (PTG) among gender, age, objective factors of the disease and its treatment, family environment factors and negative emotionality. The sample consisted of 97 childhood cancer survivors (50 girls and 47 boys) aged 11-25 years who were in remission 1.7 to seven years at T1 and four to 12.5 years at T2. Survivors completed a set of questionnaires including the Benefit Finding Scale for Children and the University of California at Los Angeles Posttraumatic Stress Disorder Index. Regression and correlation analyses were performed. The relation between PTSS and PTG was not proven. A higher level of PTSS (T2) was associated with higher levels of negative emotionality (T1). A higher level of PTG (T2) was connected to a higher level of warmth in parenting (T1), female gender and older age at assessment. Medical variables such as the severity of late effects and the time from treatment completion did not play a significant role in the prediction of PTSS and PTG. PTG and PTSS are more influenced by factors of parenting and emotional well-being of childhood cancer survivors than by objective medical data.

Posttraumatic Stress Disorder Symptoms and Family Functioning in Adult Children Facing Parental Cancer: A Comparison Study

This study analyzed posttraumatic stress disorder (PTSD) symptoms and family functioning in a sample of adult children caregivers of cancer patients and in a group of adult children of nonchronically ill parents. Participants completed measures of family functioning and PTSD symptoms. The parental cancer group was subdivided into PTSD subgroups, and significant differences, on family functioning, were found. In the parental cancer group, the predictors of PTSD symptoms were being a woman and having an enmeshed or chaotic family functioning. Chaotic functioning mediated the relationship between family communication/satisfaction and PTSD symptoms, in the parental cancer group. Finally, there was a higher prevalence of PTSD symptoms in the parental cancer group, and participants with a probable PTSD diagnosis showed higher levels of family imbalance. This study shows that adult children facing parental cancer, who have a poorer family balance, may benefit from interventions that target family functioning.

Maternal Factors as Moderators or Mediators of PTSD Symptoms in Very Young Children: A Two-Year Prospective Study

Research has suggested that parenting behaviors and other parental factors impact the long-term outcome of children's posttraumatic stress disorder (PTSD) symptoms. In a sample of 62 children between the ages of one and six who experienced life-threatening traumas, PTSD was measured prospectively two years apart. Seven maternal factors were measured in a multi-method, multi-informant design. Both moderation and mediation models, with different theoretical and mechanism implications, were tested. Moderation models were not significant. Mediation models were significant when the mediator variable was maternal symptoms of PTSD or depression (measured at Time 1), self-report of maternal escape/avoidance coping (measured at Time 2), or self-report emotional sensitivity (measured at Time 2). Greater maternal emotional sensitivity was associated with greater Time 2 PTSD symptoms among children. Observational measures of emotional sensitivity as the mediator were not supported. Correlation of parents' and children's symptoms is a robust finding, however caution is warranted in attributing children's PTSD symptoms to insensitive parenting.

Association of Genetic Factors and Gene-Environment Interactions With Risk of Developing Posttraumatic Stress Disorder in a Case-Control Study

BACKGROUND

The dopamine receptor D2 (DRD2) and serotonin transporter (5-HTT) genes are associated with posttraumatic stress disorder (PTSD). However, it remains largely unknown whether these genes interact with environmental factors to affect the development of PTSD.

PURPOSE

The purpose of this study was to examine the associations of gene polymorphisms and gene-environment interactions with the risk of developing PTSD among adolescent earthquake survivors.

METHOD

A total of 183 adolescent survivors from an earthquake-stricken area participated in this study. Measures included a questionnaire about demographic characteristics and earthquake exposure, the PTSD Checklist-Civilian Version and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition disorders. Genotypes were analyzed by using the polymerase chain reaction-based restriction fragment length polymorphism.

RESULTS

The 5-HTTLPR and 5-HTTVNTR polymorphisms and earthquake exposure had statistically significant positive effects on PTSD. The interaction effects of 5-HTTLPR × Earthquake Exposure and 5-HTTVNTR × Earthquake Exposure were statistically significant.

CONCLUSION

The development of PTSD is the result not only of a genetic effect and environmental factors but also of the interactive effect between gene and environment.

Child perceptions of parental care and overprotection in children with cancer and healthy children

The primary aims of this study were to: (a) examine child perceptions of overprotection; and (b) explore how these perceptions relate to child health and adjustment. Children with a prior diagnosis of cancer (n = 205) and children without a history of serious illness (n = 76) reported on parental overprotective and caring behaviors. Children with cancer were recruited from one of four strata based on the elapsed time since their cancer diagnosis (1-6 months; 6-24 months; 2-5 years; >5 years) Children also reported on symptoms of depression, anxiety, and posttraumatic stress. Children with cancer did not differ from healthy children in their perceptions of parental care or overprotection. Child distress was more strongly related to perceptions of care and overprotection than child's health status. Children with cancer do not report their parents approach to care and protection differently than children without a cancer history. These findings mirror prior research examining parental perceptions of overprotection and suggest that, despite the challenges of parenting a child with serious illness, parental protection is not significantly altered.

Posttraumatic stress disorder and its risk factors among adolescent survivors three years after an 8.0 magnitude earthquake in China

BACKGROUND

Serious and long-lasting psychiatric consequences can be found in children and adolescents following earthquake, including the development of posttraumatic stress disorder (PTSD). Although researchers have been focused on PTSD recently, its prevalence and risk factors after a huge natural disaster are still unclear because of limited sample size. The purpose of this study is to explore the prevalence of posttraumatic stress disorder (PTSD) in adolescent survivors three years after the Wenchuan earthquake, describe PTSD symptoms, and to find out risk factors of PTSD.

METHODS

A total of 4,604 adolescents from three middle schools which located in earthquake-stricken areas were recruited in this study. Instruments included the demographic questionnaire, questionnaire about earthquake exposure, the Social Support Appraisal Scale (SSA), the Posttraumatic stress disorder Checklist-Civilian Version (PCL-C), and the structured clinical interview for DSM-IV Disorders (SCID).

RESULTS

The prevalence rate of PTSD was 5.7% (frequency: n = 261), and the most commonly occurring symptoms of PTSD were distress at reminders (64.5%), difficulty concentration (59.1%), and being easily startled (58.6%). Loss of houses and property, being injured, deaths of family members, and witness of death are positive risk factors of PTSD, and physical exercise and social support are negative risk factors of PTSD.

CONCLUSIONS

Professional and effective interventions are needed to reduce the development of PTSD among adolescents after the Wenchuan earthquake, especially for these who lost their houses or property and lost their family members, witnessed death, and lacked of social support in the earthquake. Moreover, injured adolescents and adolescents who lacked of physical exercise also need intervention due to high risk.

Pharmacological modulation of acute trauma memories to prevent PTSD: considerations from a developmental perspective

Estimates of the lifetime prevalence of posttraumatic stress disorder (PTSD) in American adults range from 6.4% to 6.8%. PTSD is associated with increased risk for comorbid major depression, substance use disorder, suicide, and a variety of other mental and physical health conditions. Given the negative sequelae of trauma/PTSD, research has focused on identifying efficacious interventions that could be administered soon after a traumatic event to prevent or reduce the subsequent incidence of PTSD. While early psychosocial interventions have been shown to be relatively ineffective, early (secondary) pharmacological interventions have shown promise. These pharmacological approaches are largely based on the hypothesis that disruption of altered stress hormone levels and the consequent formation of trauma memories could protect against the development of PTSD. The present manuscript reviews the literature regarding the role of peri-traumatic stress hormones as risk factors for the development of PTSD and reviews evidence for the efficacy of exogenously modulating stress hormone levels to prevent/buffer the development of PTSD symptoms. Whereas prior literature has focused primarily on either child or adult studies, the present review incorporates both child and adult studies in a developmental approach to understanding risk for PTSD and how pharmacological modulation of acute memories may buffer the development of PTSD symptoms.

Offspring psychological and biological correlates of parental posttraumatic stress: review of the literature and research agenda

Millions of individuals with posttraumatic stress disorder (PTSD) are parents. A burgeoning literature suggests that offspring of parents with this condition may be at increased risk for psychological problems. The current paper provides an integrative and comprehensive review of the diverse research literature examining the sequelae of parental posttraumatic stress among offspring. Over 100 studies that evaluated psychological and/or biological variables among children of parents with PTSD are reviewed. Findings suggest parental symptoms of posttraumatic stress are uniquely related to an array of offspring outcomes, including internalizing-type problems, general behavioral problems, and altered hypothalamic-pituitary-adrenal axis functioning. Although very little work has directly evaluated mechanisms of transmission, there is increasing support for genetic and epigenetic effects as well as parenting behaviors. These and other mechanisms are discussed; drawing upon findings from other literatures to consider how parental PTSD may impart psychobiological vulnerability upon offspring. We conclude with a detailed discussion of the methodological strengths and challenges of the extant research, along with a recommended agenda for future research in this important area of study.

Cancer-related traumatic stress reactions in siblings of children with cancer

The purpose of this study was to explore cancer-related posttraumatic stress (PTS) reactions in siblings of children with cancer including prevalence, common symptoms, comorbidity with anxiety and depression, and gender- and age-related patterns. A total of 125 children (63 girls) between the ages of 8 and 17 (M = 12.4; SD = 2.9 years) with a brother or sister with cancer, diagnosed 4 to 38 months prior to the study (M = 1.3 years; SD = 6.7 months), completed the Child PTSD Symptom Scale (CPSS), Revised Children's Manifest Anxiety Scale, and Child Depression Inventory-Short Form. Over half of the sample (60%) scored in the moderate to severe range for PTS and 22% fulfilled full criteria for PTSD based upon CPSS responses. Nearly 75% reported "Feeling upset when you think about or hear about the cancer," and "Trying not to think about, talk about, or have feelings about the cancer." Over 60% reported arousal symptoms. PTS symptoms reportedly interfered with functioning for 75% of the sample and co-occurred with anxiety and depressive symptoms. Gender and age-related patterns were not found. Siblings of children with cancer experience cancer-related PTS reactions and greater attention should be paid to ameliorating their cancer-related distress with empirically based treatments.

Concordance of parent proxy report and child self-report of posttraumatic stress in children with cancer and healthy children: influence of parental posttraumatic stress

OBJECTIVE

This study examined the relationships between parental posttraumatic stress symptoms (PTSS), child PTSS, and parent-child concordance for child PTSS.

METHOD

Participants were children with cancer (n = 199), and healthy children (n = 108) and their parents. Children self-reported on PTSS and parents completed measures of child and parent PTSS.

RESULTS

In the cancer group, child and parent reports of child PTSS were significantly correlated with no mean differences between reporters. In contrast, correlations were non-significant in the control group, and parents reported significantly lower levels of child PTSS than children. Increased parental PTSS was associated with better concordance in the cancer group but not in the control group. In fact, in the cancer group, parent-child concordance was strongest at the highest level of parental PTSS.

CONCLUSIONS

Parents of children with cancer were found to be accurate reporters of their children's distress, even with high levels of reported personal distress. In contrast, parents of healthy children appear primarily influenced by personal distress when reporting child PTSS. Although multiple informant assessments are always desirable, it appears that utilization of a single informant may be reasonable in the cancer setting when access to informants is limited.

Impact of a parent-based interdisciplinary intervention for mothers on adjustment in children newly diagnosed with cancer

OBJECTIVE

To determine if maternal distress predicts child adjustment outcomes or if child adjustment outcomes predict maternal distress among children newly diagnosed with cancer, and if a parent-focused intervention has downstream effects on child adjustment.

METHODS

Mothers (n = 52) were randomly assigned to a clinic-based, interdisciplinary intervention for parents of children newly diagnosed with cancer. Measures of maternal distress and child adjustment were collected at baseline, posttreatment, and follow-up.

RESULTS

A lagged relationship was identified between maternal distress and child internalizing symptoms, but not externalizing symptoms. The parent intervention reduced child internalizing and externalizing symptoms at follow-up. Only the child internalizing symptoms effect was mediated by reduced maternal distress. The child externalizing symptoms effect was mediated by unobserved parent factors.

CONCLUSIONS

This study provides support for illness adjustment and coping models that emphasize the role of parent factors in driving child adjustment outcomes and is encouraging for future parent-focused intervention research.

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.

Prevalence and predictors of post-traumatic stress symptoms in adolescent and young adult cancer survivors: a 1-year follow-up study

OBJECTIVES

Post-traumatic stress symptoms (PTSS) have been identified as a meaningful indicator of distress in cancer survivors. Distinct from young adult survivors of childhood cancer, young people diagnosed with cancer as adolescents and young adults (AYAs) face unique psychosocial issues; however, there is little published research of PTSS in the AYA population. This study examines prevalence and predictors of PTSS among AYAs with cancer.

METHODS

As part of a longitudinal study of AYAs with cancer, 151 patients aged 15-39 years completed mailed surveys at 6 and 12 months post-diagnosis. Severity of PTSS was estimated at 6 and 12 months post-diagnosis. Multiple regression analyses were conducted to investigate the predictive effects of socio-demographic and clinical characteristics on changes in PTSS over time.

RESULTS

At 6 and 12 months, respectively, 39% and 44% of participants reported moderate to severe levels of PTSS; 29% had PTSS levels suggestive of post-traumatic stress disorder. No significant differences in severity of PTSS between 6 and 12 months were observed. Regression analyses suggested that a greater number of side effects were associated with higher levels of PTSS at 6 months. Currently receiving treatment, having surgical treatment, diagnosis of a cancer type with a 90-100% survival rate, remaining unemployed/not in school, and greater PTSS at 6 months were associated with higher levels of PTSS at 12 months.

CONCLUSIONS

Post-traumatic stress symptoms were observed as early as 6 months following diagnosis and remained stable at 12-month follow-up. The development of early interventions for reducing distress among AYA patients in treatment is recommended.

The association between parent PTSD/depression symptoms and child PTSD symptoms: a meta-analysis

OBJECTIVE

The present article presents a meta-analysis of studies examining the association between parent posttraumatic stress disorder (PTSD)/depression symptoms and child PTSD symptoms (PTSS) after a child's exposure to a traumatic event while considering multiple moderating factors to explain heterogeneity of effect sizes.

METHODS

35 studies were included: 32 involving the association between parent and child PTSS and 9 involving the association between parent depression and child PTSS.

RESULTS

Across existing studies, both parent and child PTSS (r = 0.31) and parent depression and child PTSS (r = 0.32) yielded significant effect sizes. Parent gender, assessment type (interview vs. questionnaire), differences in assessment type for parents and children, and study design (cross-sectional vs. longitudinal) moderated the relationship between parent and child PTSS.

CONCLUSIONS

The current findings confirm the associations between parental posttraumatic responses and child PTSS and highlight important moderating factors to include in future studies of child PTSS.

The role of beliefs in the relationship between health problems and posttraumatic stress in adolescent and young adult cancer survivors

In addition to the potential for ongoing health concerns, adolescent and young adult (AYA) childhood cancer survivors frequently report posttraumatic stress symptoms (PTSS). The current study examines whether beliefs about health moderate the relationship between the number of health problems and PTSS 2 months later in 140 survivors. Beliefs, as measured by scales of the Health Competence Beliefs Inventory (HCBI), negatively related to PTSS while health problems positively related to PTSS. Three scales of the HCBI-health perceptions, satisfaction with healthcare and cognitive competence--were significant moderators. The relationship between health problems and PTSS was stronger in the presence of less adaptive beliefs. These beliefs represent potentially malleable intervention targets for reducing PTSS in childhood cancer survivors.

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.

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.

Cognitive adaptation theory as a means to PTSD reduction among cancer pain patients

Eighty-nine cancer pain patients participated in a study evaluating components of the Cognitive Adaptation Index on symptoms of posttraumatic stress disorder (PTSD). Positive correlations were found between optimism, mastery, and self-esteem. Inverse relationships with a PTSD symptom scale were also established. Multiple regression analyses for aggregate PTSD scores, avoidance/numbing, and arousal symptoms were each significant at p < 0.0001, intrusive symptoms at p < 0.020. Except for intrusive symptoms, self-esteem played a statistically significant mediating role for the influence of other variables. These results are discussed regarding their impact on PTSD, intervention strategies, and mental health of individuals experiencing stress.

Family adjustment to childhood cancer: a systematic review

This systematic review integrates qualitative and quantitative research findings regarding family changes in the context of childhood cancer. Twenty-eight quantitative, 42 qualitative, and one mixed-method studies were reviewed. Included studies focused on family functioning, marital quality, and/or parenting in the context of pediatric cancer, were written in English, and were published between 1996 and 2009. Overall, qualitative findings show that families alter roles, responsibilities, and day-to-day functioning to accommodate the needs of children with cancer. Although some degree of family reorganization is normative, the extent and impact of these changes varies. Quantitative work shows that mean levels of family functioning (e.g., cohesion, flexibility) are similar between families facing cancer and normative or comparison samples. However, families follow different trajectories of improvement, decline, or stability in family closeness and marital quality. Parenting has received limited quantitative research attention, but qualitative work suggests that parents perceive deeper bonds with ill children and may spoil or overprotect them. Conclusions support future work examining the influence of family-level variables on the adjustment of individual family members.

Swedish mothers and fathers of children with cancer: perceptions of well-being, social life, and quality care

The overall aim was to describe and compare well-being, social life, and quality care among parents of children with cancer with respect to mothers versus fathers and whether the children were on versus. off treatment. The Life Situation Scale for Parents (LSS-P) was answered by 320 parents, comprising 85 mothers and 71 fathers of children on treatment, and 93 mothers and 71 fathers of children off treatment. The results show that the well-being of parents of children with cancer is affected by their child's situation, and that they experience such things as economic strain and a sense of being dependent on the care provided, especially during the child's treatment phase. Mothers whose children are receiving treatment see their life situation as less satisfying, and report being sadder and having lower self-esteem.

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.

The role of family phenomena in posttraumatic stress in youth

TOPIC

Youth face trauma that can cause posttraumatic stress (PTS).

PURPOSE

(1) To identify the family phenomena used in youth PTS research; and(2) to critically examine the research findings regarding the relationship between family phenomena and youth PTS.

SOURCES

Systematic literature review in PsycInfo, PILOTS, CINAHL, and MEDLINE. Twenty-six empirical articles met inclusion criteria.

CONCLUSION

Measurement of family phenomena included family functioning,support, environment, expressiveness, relationships, cohesion, communication, satisfaction, life events related to family, parental style of influence, and parental bonding. Few studies gave clear conceptualization of family or family phenomena. Empirical findings from the 26 studies indicate inconsistent empirical relationships between family phenomena and youth PTS, although a majority of the prospective studies support a relationship between family phenomena and youth PTS. Future directions for leadership by psychiatric nurses in this area of research and practice are recommended.

Anxiety in medically ill children/adolescents

Anxiety disorders are thought to be one of the most common psychiatric diagnoses in children/adolescents. Chronic medical illness is a significant risk factor for the development of an anxiety disorder, and the prevalence rate of anxiety disorders among youths with chronic medical illnesses is higher compared to their healthy counterparts. Anxiety disorders may develop secondary to predisposing biological mechanisms related to a child's specific medical illness, as a response to being ill or in the hospital, a threatening environment, as a result of other genetic and psychological factors, or as a combination of all these factors. Additionally, exposure to physical pain early in one's life and/or frequent painful medical procedures are correlated with fear and anxiety during subsequent procedures and treatments, and may lead to medical nonadherence and other comorbidities. Anxiety disorders can have serious consequences in children/adolescents with chronic and/or life-limiting medical illnesses. Therefore, proper identification and treatment of anxiety disorders is necessary and may improve not only psychiatric symptoms but also physical symptoms. Behavioral and cognitive methods as well as psychotropic medications are used to treat anxiety disorders in pediatric patients. We will review current treatments for anxiety in children/adolescents with medical illnesses and propose future research directions.

Parents' perceptions of their children's cancer-related symptoms during treatment: a prospective, longitudinal study

CONTEXT

This article describes a comprehensive assessment of treatment-related symptoms in children aged 0-18 years undergoing cancer treatment from the perspective of their parents.

OBJECTIVES

The aim was to describe which symptoms that, according to parents, cause most problems for children receiving cancer treatment and to explore whether there is a relationship between parents' ratings of their children's symptoms and their own post-traumatic stress at one week (T1), two months (T2), and four months (T3) after a child's cancer diagnosis.

METHODS

In total, 214 parents (107 mothers and 107 fathers) of 115 children answered a modified version of the Memorial Symptom Assessment Scale 10-18 and the PTSD Checklist Civilian Version over the telephone at T1-T3.

RESULTS

According to parents, the following symptom areas cause the most problems for children undergoing cancer treatment: emotional distress, fatigue, nutrition, and pain. Pain is the most problematic area. The prevalence of most symptoms and the symptom burden decreases over time. Parents' ratings of their children's symptom burden and their own emotional distress, and mothers' and fathers' ratings of their child's symptom burden, are associated. Parents of adolescents report a greater symptom burden for their child than the parents of the youngest children.

CONCLUSION

The opinions of both the patient and the parent are important in pediatrics. The results of this study can be used to guide health care professionals within pediatric oncology in their discussions of cancer treatment's adverse effects with patients and families. Not only the expectations and potential interventions but also the sources of worry should be discussed.

Children's enduring PTSD symptoms are related to their family's adaptability and cohesion

This study compared, 18-24 months after an industrial disaster, in two groups of children (those with clinically relevant PTSD symptoms versus those with low PTSD symptoms), the child's perception of family cohesion and adaptability, the child's experience of the explosion, and parental characteristics. Enmeshed family cohesion or rigid family adaptability were more frequently found in children with low PTSD symptoms. PTSD symptoms in the mother, living in a family of 3 or more children, and being female were significantly associated with PTSD symptoms in the children. The assessment of traumatized children should include assessment of family's adaptability and cohesion.