Journal of Pediatric Psychology Advance Access published online on May 17, 2008
Journal of Pediatric Psychology, doi:10.1093/jpepsy/jsn050
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Commentary: Life Threat, Risk, and Resilience in Pediatric Medical Traumatic Stress
1The Children's Hospital of Philadelphia and 2University of Pennsylvania
All correspondence concerning this article should be addressed to Dr Branlyn Werba, 3535 Market Street, 14th Floor, Philadelphia, PA, 19102, USA. E-mail: werba{at}email.chop.edu
Since the initial descriptive studies in the 1980s, the medical traumatic stress field has grown substantially, with an estimated 8-fold increase in papers about children and their families from 2000 to 2007 compared to the 1990s (Kazak, Schneider & Kassam-Adams, in press). Pediatric conditions can be traumatic experiences across family members and a traumatic stress framework can help explain short- and long-term responses to illnesses and injuries. Traumatic stress is compelling, in part, because it maps on to a competency based framework for understanding the trajectory of adjustment, from acute stress through potential long-term effects.
The two reports in this issue related to cancer (Jurbergs, Long, Ticono, & Phipps, 2007
) and burns (Landolt, Buehlmann, Maag, & Schiestl, 2007) are largely consistent with the existing literature and help to advance our understanding of posttraumatic stress symptoms (PTSS) in pediatrics. In this commentary, we link these papers to three concepts key to PTSS—life threat, risk, and resiliency. Both papers highlight the importance of considering what circumstances place children and families at risk for developing PTSS (e.g., history of traumatic experiences and recurrent) or are associated with resiliency (e.g., maternal presence when the injury is occurring) and potentially growth enhancing aspects of traumatic events. Although Jurbergs et al. (2007) present some data that is somewhat discrepant from others (including some from our laboratory), we offer comments in terms of how we may understand variability across studies.
In both investigations, the perception of life threat appears to be a key element that contributes to PTSS across developmental stage and type of medical condition. That is, for young children with burns, maternal presence at the time of the trauma may minimize the potential for children to perceive their burn as life-threatening (they may feel safer with their parents). This is consistent with evidence that separation anxiety may help explain traumatic stress responses for young children with burns (Stoddard et al., 2006). For parents of children with cancer, relapse could introduce or reintroduce child life-threat. Although relapse has not been studied as a discrete event, their finding is consistent with other evidence that parental perceptions of life-threat are related to PTSS (Kazak et al., 2001). Thus, a child's severe burn or cancer diagnosis may be examples of actual or threatened harm to self or others, but yet not necessarily include the subjective experience of life-threat that is important for not only the diagnosis of posttraumatic stress disorder (PTSD), but the development of PTSS.
It is important to understand circumstances that may place children and parents at greater risk for developing PTSS after potentially traumatic events (PTE; Kazak et al., 2006) that occur as part of pediatric illness and injury. Jurbergs and colleagues (2007) highlight that increased exposure to traumatic events may result in greater PTSS. In parents of children who had relapsed, this traumatization was associated with substantively more PTSS, compared to parents of children with cancer who had not relapsed. The framing of relapse as a "second hit" for parents after the initial "first hit" of child cancer diagnosis seems useful. Indeed, parents may have more extensive trauma histories; cancer could realistically be the third, fourth, or fifth "hit." Alternatively, if parents believe that their child's chances of cure were high during initial treatment, relapse could mark the first time they perceive their child's life as truly threatened.
Both articles highlight resiliency in families of children. Acute short-term stress responses are "normal" and understandable in the face of potentially traumatic events. Landolt and colleagues (2007) show that interpersonal circumstances at the time can be associated with PTSS for childhood burn survivors. Maternal presence at the accident, during the peritrauma phase of trauma (Kazak et al., 2006), was associated with fewer PTSD symptoms, more adaptive physical and cognitive functioning, and better quality of life. Maternal presence when a child is severely injured is one of many potential protective factors. Resiliency is also exemplified by Jurbergs and colleagues’ assertion that "simply having a child with cancer does not lead to increased PTSS." More generally, exposure to a PTE neither automatically result in interpretation of the event as traumatic (horrific or life-threatening) nor does it necessarily lead to PTSS (Balluffi et al., 2004; Stuber et al., 1997). To the contrary, some resilient individuals and families will adapt to cancer or other pediatric illness or injury without PTSS, with mild or more circumscribed symptoms, or experience growth enhancing aspects traumatic events (Barakat, Alderfer, & Kazak, 2006).
Although Jurbergs et al. interpret their lack of significant differences between cancer and control groups as contradictory to existing data, there are some methodological points to consider. Their sample may not have been "less sick" than other samples with regard to the child's medical diagnoses; however, other indicators of child illness severity would enhance comparisons between studies, such as objective and subjective data on treatment intensity, complications, and ongoing health problems. Further, medical advances since the early 1990s have resulted in improved prognoses and more intensive treatments. Historical effects can influence perception of life threat and PTSS, and complicate comparison among studies from different treatment eras. Furthermore, selecting a control group is complicated and none are ideal. Control parents in the Jurbergs study may report higher PTSS than those in other studies because parents were reporting PTSS reactions to their own (it happened directly to them) most significant trauma. In Barakat et al. (1997) and Kazak et al. (2004), control group parents identified a child stressor, in order to control for the child trauma of cancer. The majority of the parents in the Jurbergs study reported events that could meet the A Criterion for PTSD, such as death of a loved one, diagnosis of a major illness, or an emergency. Ongoing consideration to the advantages and disadvantages of design and recruitment strategies in this field will further help investigators compare study outcomes.
In sum, the papers in this issue advance our understanding of PTSS in pediatric illness and injury by highlighting ways to identify and understand factors associated with the development and persistence of trauma symptoms. Future research exploring these ideas more fully is critical, particularly when linked to assessment of PTSS and intervention, which may ultimately span the range of time from diagnosis or acute trauma through survivorship.
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Preparation of this commentary was supported, in part by the Center for Pediatric Traumatic Stress (CPTS; SM058139). We thank Lisa Schwartz, PhD, for her thoughtful input on this commentary.
Conflicts of interest: None declared.
Received January 29, 2008; revision received April 22, 2008; accepted April 25, 2008
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Balluffi A, Kassam-Adams N, Kazak A, Tucker M, Dominguez T, Helfaer M. Traumatic stess in parents of children admitted to the pediatric intensive care unit. Pediatric Critical Care Medicine (2004) 5:547–553.[CrossRef][Medline]
Barakat L, Alderfer M, Kazak A. Posttraumatic growth in adolescent survivors of cancer and their families. Journal of Pediatric Psychology (2006) 31:413–419.
Barakat L, Kazak A, Meadows A, Casey R, Meeske K, Stuber M. Families surviving childhood cancer: A comparison of posttraumatic stress symptoms with families of healthy children. Journal of Pediatric Psychology (1997) 22:843–859.
Jurbergs N, Long A, Ticona L. Symptoms of posttraumatic stress in parents of children with cancer: Are they elevated relative to parents of controls? In: Journal of Pediatric Psychology (2007) December 11. doi:10.1093/jpepsy/jsm119.
Kazak A, Alderfer M, Rourke M, Simms S, Streisand R. Posttraumatic stress symptoms (PTSS) and posttraumatic stress disorder (PTSD) in families of adolescent childhood cancer survivors. Journal of Pediatric Psychology, 29 (2004) 211–219.
Kazak A, Barakat L, Alderfer M, Rourke M, Meeske K, Gallagher P, et al. Posttraumatic stress in survivors of childhood cancer and mothers: Development and validation of the impact of traumatic stressors interview schedule (ITSIS). Journal of Clinical Psychology in Medical Settings (2001) 8:307–323.[CrossRef][Web of Science]
Kazak A, Kassam-Adams N, Schneider S, Zelikovsky N, Alderfer M. An integrative model of pediatric medical traumatic stress. Journal of Pediatric Psychology, 31 (2006) 343–355.
Kazak A, Schneider S, Kassam-Adams N. Pediatric medical traumatic stress. In: Handbook of pediatric psychology—Roberts M, Steele R, eds. 4th. New York: Guilford. (in press).
Landolt M, Buehlmann C, Maag T. Brief Report: Quality of life is impaired in pediatric burn survivors with posttraumatic stress disorder. In: Journal of Pediatric Psychology (2007) September 21. doi:10.1093/jpepsy/jsm088.
Stoddard FJ, Ronfeldt H, Kagan J, Drake JE, Snidman N, Murphy JM, et al. Young burned children: The course of acute stress and physiological and behavioral responses. American Journal of Psychiatry (2006) 163:1084–1090.
Stuber M, Kazak A, Meeske K, Brarakat L, Guthrie D, Garnier H, et al. Predictors of posttraumatic stress symptoms in childhood cancer survivors. Pediatrics (1997) 100:958–964.
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