Psychology and Health, 2002, Vol. 17, No. 4, pp. 501–511

POSTTRAUMATIC STRESS SYMPTOMATOLOGY IN MOTHERS OF PEDIATRIC CANCER SURVIVORS BARBARA GOLDENBERG LIBOVa,*, JEFFREY S. NEVIDb, DAVID PELCOVITZc and THOMAS M. CARMONYb a

Center for Psychiatric Legal Services at Long Island Jewish Medical Center; b St. John’s University; cNorth Shore University Hospital (Received 29 February 2000; In final form 2 August 2001)

Forty-nine mothers of pediatric cancer survivors were administered structured interviews to assess the presence of posttraumatic stress disorder (PTSD) and self-report questionnaires to measure degree of PTSD symptomatology. Twenty percent of the mothers met diagnostic criteria for current PTSD and 27% met criteria for lifetime PTSD. The number of low magnitude stressors experienced in the past year, current perceptions of cancer threat, and family income were shown to contribute to the prediction of PTSD symptomatology. Keywords: Posttraumatic stress disorder (PTSD); Mothers; Pediatric cancer; Oncology

The DSM-IV modified the gatekeeper criterion for posttraumatic stress disorder (PTSD) to include as qualifying traumatic events a diagnosis of a life-threatening illness in oneself or one’s child (American Psychiatric Association, 1994). Consequently, researchers have turned their attention to the prevalence of PTSD in populations consisting of individuals facing such life-threatening physical conditions or illnesses as myocardial infarction (Doerfler et al., 1994), severe burn (Powers et al., 1994), chronic asthma (Yellowlees et al., 1988), and breast cancer (Andrykowski et al., 1998). A DSM-IV diagnosis of PTSD is based on six primary criteria. The gatekeeper criterion, criterion A, is met when a person is exposed to a traumatic event and experiences an intense fear response. Previous editions of the DSM allowed this criterion to be met only by traumas directly experienced by the individual, rather than by others. Thus, parents of pediatric cancer survivors could not meet diagnostic criteria for PTSD until the introduction of DSM-IV. Criterion B targets symptoms related to reexperiencing the traumatic event. Criterion C targets an ongoing avoidance

*Corresponding author. Center for Psychiatric Legal Services at Long Island Jewish Medical Center, 410 Lakeville Road, Suite 207, New Hyde Park, NY 11042. E-mail: [email protected] ISSN 0887-0446 print: ISSN 1476-8321 online ß 2002 Taylor & Francis Ltd DOI: 10.1080/0887044022000004975

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of stimuli related to the trauma, while criterion D targets increased physiological arousal. Finally, criteria E and F deal with the duration and level of impairment, respectively. PTSD in Pediatric Cancer Survivors and Family Members Recent work on the prevalence of PTSD and posttraumatic symptomatology in response to a life-threatening illness has expanded to include family members as well as the affected patient. A study conducted as part of the DSM-IV field trials investigated the presence of PTSD symptomatology in a sample of adolescent cancer survivors and their mothers. Results indicated that 35% of adolescent cancer survivors fulfilled criteria for a lifetime diagnosis of PTSD, while 15% met criteria for current PTSD (Alter et al., 1992). The mother study for the field trials investigated 24 mothers of adolescent cancer survivors compared to a control group of 23 mothers of healthy adolescents (Pelcovitz et al., 1996). A significantly greater percentage of mothers of cancer survivors (54%) met criteria for lifetime PTSD as compared to mothers of healthy adolescents (4%). Twenty-five percent of mothers of cancer survivors also met diagnostic criteria for current PTSD, as compared to none of the mothers in the control group. In addition, a current PTSD diagnosis was associated with a history of high magnitude trauma earlier in life, but was not associated with current life stressors. Stuber et al. (1996) examined PTSD symptomatology in 64 pediatric leukemia survivors and their parents (63 mothers and 42 fathers). Findings showed that 12.5% of the leukemia survivors reported severe levels of PTSD symptomatology, while 39.7% of the mothers and 33.3% of the fathers reported similar levels. Kazak and colleagues expanded upon these findings by comparing 130 pediatric leukemia survivors and their parents with a comparison group of 155 healthy children and their parents (Kazak et al., 1997). Significantly more PTSD symptomatology was reported by parents of cancer survivors as compared to control group parents. Of particular interest was the fact that no significant differences were found in rates of PTSD symptomatology between leukemia survivors and their comparison group peers. Such findings may reflect a pattern in which parents of pediatric cancer patients view the illness as more threatening than the children themselves do (Kazak et al., 1997). Manne et al. (1998) also examined the prevalence of PTSD, as well as subclinical PTSD symptomatology, in 65 mothers of childhood cancer survivors. Results indicated that 6.2% of the sample was diagnosed with current PTSD, while an additional 20% showed subclinical levels of PTSD. No diagnoses of lifetime PTSD were made. Correlates of PTSD Symptomatology Relationships between PTSD and other variables have been investigated in pediatric cancer survivors and their parents. In their study of mothers of pediatric cancer survivors, Pelcovitz et al. (1996) found that the number of high magnitude events experienced (e.g., crime victimization, exposure to combat, physical abuse, etc.) was significantly greater among mothers diagnosed with PTSD than those not diagnosed.

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Additional variables of interest, including severity of illness and levels of perceived family and extrafamilial social support, did not differ significantly between the PTSD and non-PTSD groups. While some evidence suggests a relationship between PTSD and the presence of high magnitude stressors, additional research has also shown low magnitude stressors to be related to PTSD symptomatology. A study of male and female combat veterans showed that exposure to low magnitude stressors (living in a harsh, stressful, unpleasant environment) more strongly predicted the later development of PTSD symptomatology than high magnitude stressors (exposure to combat and abusive violence) (King et al., 1995). The presence of low magnitude stressors may be of particular interest in families facing pediatric cancer. While the initial diagnosis introduces a high magnitude stressor, the events and stressors that follow (e.g., commencement of treatment, financial strain on the family, etc.) may exact an even greater toll on family members. Other correlates of PTSD symptomatology in cancer populations include sociodemographic variables, such as income and age. These factors, as well as perceived quality of life, were found to be significantly related to levels of PTSD symptoms in a sample of breast cancer survivors (Cordova et al., 1995). Conversely, time since treatment, type of treatment, and stage of disease were unrelated to PTSD symptomatology. Other investigators found that low socioeconomic status similarly predicted increased psychological sequelae in parents of pediatric cancer survivors (Van Dongen-Melmen et al., 1995). Heiney et al. (1994) reported characteristics associated with a child’s bone marrow transplant that were linked to the presence of PTSD in the parents. Factors associated with an increased risk of PTSD included degree of life threat, duration of trauma, degree of bereavement or loss of significant others, displacement from the home community, potential for recurrence, roles of the parents in the trauma, and exposure to death and disturbing treatments. Kazak et al. (1997) found that a number of factors related to family functioning significantly predicted increased levels of PTSD symptomatology in parents of pediatric leukemia survivors. Parents with greater PTSD symptomatology reported poorer general family functioning and communication styles, as well as lower satisfaction within the family. Other hypothesized factors, including the child’s age, age at cancer diagnosis, and months off treatment, failed to predict the presence of PTSD symptomatology in either children or their parents. Gender differences in rates of PTSD have also been identified. Although PTSD has often been associated with males with a history of combat experiences, recent findings point to a higher prevalence of the disorder in women. The National Comorbidity Survey (NCS) found that women were twice as likely as men (10.4% versus 5.0%, respectively) to have developed PTSD during their lifetimes (Kessler et al., 1995). A lifetime PTSD prevalence of 12.3% has also been reported in a sample of 4008 U.S. adult women (Resnick et al., 1993). With respect to a cancer survivor population, Stuber et al. (1996) also reported a greater prevalence of PTSD symptomatology in mothers (39.7%) than fathers (33.3%). The present study was intended to expand prior research by examining prevalences of PTSD diagnosis and symptomatology in mothers of pediatric cancer survivors, as well as possible predictive factors such as high and low magnitude stressors, perceived threat at diagnosis, current perceived threat, and family income.

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METHOD Participants Mothers of pediatric cancer survivors were recruited from a list of consecutively diagnosed cases of childhood cancer from the pediatric oncology division of a university hospital in Long Island, New York. To be eligible for participation, the child’s cancer had to be diagnosed before age 18 and the child must have previously completed treatment. Forty-nine mothers of qualifying children responded to mailed requests for participation, from an initial pool of 127 eligible cases. Participating mothers ranged in age from 27 to 60 years (M ¼ 42.55, SD ¼ 7.33). The majority of the participants were Caucasian (92%), with 6% African-American and 2% Hispanic. Eighty-four percent were married; 16% were either divorced or separated. Eight percent reported annual family incomes of less than $29,999; 31% between $30,000 and $59,999; 35% between $60,000 and $89,999; and 25%, over $90,000. No demographic information was available for individuals who declined or did not respond to requests for participation. The ages at which the children received a cancer diagnosis ranged from birth to 17 years (M ¼ 6.88, SD ¼ 5.30). The amount of time in treatment ranged from 4 months to 4 years (M ¼ 1.53, SD ¼ 1.03). At the time of the interviews, the mean age of the children was 13.58 years (SD ¼ 6.27, range, 1–27 years). A number of different forms of cancer were represented in the children, including leukemia (43%), lymphomas (20.5%), central nervous system and brain cancers (20.5%), Wilm’s tumor (6%), and others (10%). The type of treatment most often consisted of chemotherapy (41%) or chemotherapy combined with radiation (55%). Two children (4%), both of whom were diagnosed at birth, received no treatment. Of the 49 children represented in the present study, 3 (6%) experienced a relapse at some time following the completion of treatment. All mothers of intact families were asked at the time of interview if their husbands would be interested in participating in the study. Unfortunately, very often husbands were either unavailable due to difficult work schedules or disinterested due to the distressful nature of the topic. Due to the low response rate of fathers (less than 20%), the present sample was restricted to mothers of pediatric cancer survivors. Measures Demographics Interview A brief structured interview was administered to each participant to obtain basic demographic information, including marital status, ethnicity, number of children, family income, as well as parents’ educational and occupational levels. Structured Clinical Interview for Axis I DSM-IV Disorders – PTSD Module (SCIDPTSD; First et al., 1994) The PTSD module of the SCID is a structured interview designed to assess the presence of PTSD symptomatology, based upon DSM-IV criteria. Interviewers rate individuals’ responses to items on a four-choice scale: inadequate information, absent or false, subthreshold, threshold or true. The SCID-PTSD is one of the most widely used measures of PTSD symptomatology and is frequently used as the criterion against which other measures are validated (Foa et al., 1997).

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Potential Stressful Events Interview (PSEI; Kilpatrick et al., 1991) The PSEI is a structured interview that assesses the participant’s exposure to traumatic incidents (high magnitude stressors) meeting DSM-IV Criterion A for PTSD, such as natural disasters or sexual abuse. The measure also assesses other stressful events within the past year (low magnitude stressors) that fail to meet Criterion A, such as marital distress or economic hardship. The PSEI has been employed in DSM-IV field trials for PTSD (Kilpatrick et al., 1998), as well as in a large-scale prevalence study of PTSD in women (Resnick et al., 1993).

Procedure Appointments were scheduled via telephone to interview and administer the questionnaires to participants in their homes. After obtaining informed consent, a brief structured interview was conducted to obtain basic demographic information. The participants were then administered the SCID-PTSD and the PSEI. The procedure required approximately 1–2 h to complete. In addition, mothers responded to a brief series of questions addressing their perceptions of threat posed by the cancer at both diagnosis and at the time of the interview. All interviews were conducted by the lead experimenter (B.G.L.), a doctoral student in clinical psychology who had substantial experience conducting SCID-PTSD interviews for DSM-IV field trials. Information regarding the child’s illness, including diagnosis, age at diagnosis, type of treatment, and occurrence of relapse, was obtained from the pediatric oncologist’s records. The oncologist also provided ratings of perceived severity of both the children’s cancer and the forms of treatment employed.

Reliability Check As a reliability check, all interviews were audiotaped and the tapes of 10 cases were randomly selected and submitted to two independent raters who independently scored the SCID-PTSD. The two raters were trained in the scoring of the SCIDPTSD by the lead experimenter. Both raters were trained to 90% criteria before conducting the reliability assessment. Raters were unaware of any identifying data or clinical records related to the mother or child. Coefficient kappa and percentages of agreement were used as measures of interrater reliability. Percent agreement, determined by comparing the scores from the lead experimenter with each of the independent raters, ranged from 70 to 100% for the 17 PTSD symptoms, with the majority (12 of 17 symptoms) showing 90–100% agreement. The mean kappa coefficient was 0.75, with values ranging from 0.29 to 1.0. The few low kappas appear to have been a result of the relatively small sample size (N ¼ 49), rather than a lack of interviewer reliability (given the high percent agreement values).

RESULTS Ten mothers (20%) met DSM-IV diagnostic criteria for current PTSD, while 13 (27%) met diagnostic criteria for lifetime PTSD. The number of PTSD symptoms reported by participants ranged from 0 to 14 (M ¼ 5.02, SD ¼ 3.45). Table I provides lifetime

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B.G. LIBOV et al. TABLE I Frequencies and percentages of each of the PTSD symptoms for criteria B, C, and D from the SCID-PTSD (N ¼ 49) Variable

Frequency

Percentage %

Meet criteria for current PTSD Meet criteria for lifetime PTSD

10 13

20 27

Criterion B – Reexperiencing Recurrent and intrusive recollections Recurrent distressing dreams Reliving the event (e.g., flashbacks) Distress at symbolization of trauma Physiological Reactivity

44 30 7 1 39 19

90 61 14 2 80 39

Criterion C – Avoidance Efforts to avoid thoughts and feelings Efforts to avoid places, people, etc. Inability to recall the trauma Diminished interest in activities Feelings of detachment Restricted range of affect Sense of a foreshortened future

16 14 12 4 13 19 10 17

33 29 24 8 27 39 20 35

Criterion D – Arousal Difficulty sleeping Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response

19 12 13 9 20 6

39 25 27 18 41 12

frequencies and percentages of PTSD symptoms, as well as the frequencies and percentages of each symptom cluster (Criterion B, Criterion C, and Criterion D).1 Although mothers were much more likely to meet diagnostic criteria for the reexperiencing cluster (90%) than either the avoidance (29%) or arousal (25%) clusters, only one individual (2%) reported having experienced an actual flashback. Mothers most frequently reported reexperiencing the trauma either in the presence of traumarelated cues (80%) or through recurrent recollections (61%). Table II presents the bivariate correlation coefficients for the study variables. Current degree of perceived threat relating to the cancer and number of low magnitude stressors experienced in the past year were most strongly related to the criterion variable (reported number of PTSD symptoms). Mothers’ perceptions of threat at diagnosis and family income were also significantly related to the criterion variable. Time since the conclusion of treatment, number of high magnitude stressors experienced, child’s age at diagnosis, and mother’s age and educational level were not significantly related to PTSD symptomatology. A hierarchical multiple regression analysis was performed to examine predictors of symptomatology. The results are presented in Table III. Sociodemographic and treatment-related variables (mother’s current age, child’s age at diagnosis, mother’s educational level, family income, time since treatment termination) were entered in 1 The first two items of the SCID-PTSD assess the occurrence of a traumatic event (Criterion A). These items were scored positively for all participants based on the trauma of having a child diagnosed with cancer, which meets Criterion A in DSM-IV. There was also a single item assessing Criterion E (symptom duration for at least one month), which was required for any diagnosis of PTSD.

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TABLE II Intercorrelations of study variables (N ¼ 49) 1

Variable 1. Number of symptoms 2. Mother’s current age 3. Child’s age at diagnosis 4. Mother’s education 5. Family income 6. Time since treatment 7. Low magnitude stressors 8. High magnitude stressors 9. Threat at diagnosis 10. Threat today

2

– 0.16 – 0.7 0.61*** 0.03 0.04 0.32* 0.10 0.11 0.44** 0.46*** 0.03 0.11 0.41** 0.36** 0.06 0.46*** 0.26*

3

4

5

6

– 0.11 – 0.04 0.29* – 0.08 0.02 0.13 – 0.05 0.05 0.13 0.13 0.03 0.17 0.09 0.37** 0.08 0.17 0.03 0.15 0.14 0.20 0.01 0.08

7

8

9

– 0.21 – 0.18 0.02 – 0.13 0.19 0.22

10

–

* p<0.05; ** p<0.01; *** p<0.001.

TABLE III Hierarchical multiple regression analyses examining sociodemographic, illness-related, and PTSD-related variables as predictors of PTSD symptomatology (N ¼ 49) Variable

Adj R2

Step 1 Mother’s current age Child’s age at diagnosis Mother’s education Family Income Time since treatment

0.11

Step 2 Low magnitude stressors High magnitude stressors Threat at diagnosis Threat today

0.49***

R2 0.20

F for R2

Beta

2.13 0.10 0.06 0.03 0.39** 0.20

0.38

8.96*** 0.44*** 0.14 0.16 0.32**

Note. Betas are standardized partial regression coefficients as found in the last step of the regression equation. * p<0.05; ** p<0.01; *** p<0.001.

Step 1. PTSD-related variables (frequency of low magnitude stressors, frequency of high magnitude stressors, mother’s perception of threat at diagnosis, mother’s perception of current threat) were entered in step 2. Only family income emerged as a significant predictor among the group of sociodemographic and illness-related variables, with more affluent mothers surprisingly reporting greater PTSD symptomatology. The addition of PTSD-related variables added incrementally to prediction, with number of low magnitude stressors experienced in the past year and mother’s present perceived threat to the child contributing significantly to prediction of PTSD symptomatology. These two variables were associated with higher levels of PTSD symptomatology.

DISCUSSION The present study investigated prevalences of current and lifetime PTSD among a sample of 49 mothers of pediatric cancer survivors and predictors of PTSD symptomatology. Results showed high levels of both current and lifetime PTSD (20% and 27% of the sample, respectively).

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Previously published findings regarding the prevalence of current and lifetime PTSD in mothers of pediatric cancer survivors are wide ranging. Rates of diagnosis for current PTSD have ranged from 6.2% (Manne et al., 1998) to 25% (Pelcovitz et al., 1996). Pelcovitz et al. (1996) also found that 54% of the mothers sampled met criteria for lifetime PTSD. Others have examined prevalences of PTSD symptomatology, rather than diagnostic rates. Stuber et al. (1996) reported that 39.7% of mothers and 33.3% of fathers of childhood leukemia survivors reported severe PTSD symptoms. Another sample of parents of childhood leukemia survivors displayed significantly greater PTSD symptomatology than did parents of healthy children (Kazak et al., 1997). Despite variability in reported rates of diagnosed PTSD in parents of cancer survivors, it is clear that the disorder is more prevalent among parents of pediatric cancer survivors than in the general population. As a point of comparison, Kessler et al. (1995) reported general population rates of current and lifetime PTSD of 2.3% and 7.8%, respectively, based upon data drawn from the NCS survey. Although less than a third of the present sample met diagnostic criteria for lifetime PTSD, patterns of symptomatology were common among the mothers. Forty-four of 49 mothers (90%) met diagnostic criteria for the reexperiencing symptom cluster (Criterion B). This finding indicates that while most mothers did not develop fullfledged PTSD, virtually all reexperienced the trauma in some form, even years after treatment termination. Such reexperiencing of the event is one of the primary diagnostic criteria for PTSD (APA, 1994). It was typical for mothers in the present sample to report thinking about their child’s illness virtually every day, as well as often becoming distressed when exposed to trauma-related events, such as viewing a television program about childhood cancer. Only one mother described a true flashback experience, however. Such flashback experiences are common PTSD symptoms among survivors of combat or rape, but the prevalence of these experiences among parents of pediatric cancer survivors has not been reported. Similarly, relatively few mothers (14%) reported recurrent and distressing dreams or nightmares, another commonly reported PTSD-symptom pattern. The exaggerated startle response, another classic PTSD symptom, was uncommon, reported by only 12% of the sample. Only 8% of the mothers reported an inability to recall an important aspect of the trauma. In fact, mothers typically recalled the trauma with extreme accuracy and detail. Hypervigilance was the most common arousal symptom reported. Mothers tended to describe feeling overprotective toward each of their children since the cancer diagnosis, and wanting to be extra-cautious to prevent another trauma (e.g., relapse, another illness, a serious accident) from occurring. The present study expands upon prior research by examining possible predictors of PTSD symptomatology in mothers of pediatric cancer survivors. Drawing upon prior literature, the present study examined a set of predictors including high and low magnitude stressors, past and current perceptions of threat posed by the cancer, and income level. Of the sociodemographic and illness-related predictors, family income, the number of low magnitude stressors experienced in the past year, and mother’s current perception of threat contributed significantly to the prediction of PTSD symptomatology. More specifically, higher income, increased number of low magnitude stressors, and increased present perception of threat were associated with higher levels of PTSD symptomatology. The finding of higher income relating to increased symptomatology appears counterintuitive and is contrary to previous results reported from samples of mothers

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of cancer survivors (Van Dongen-Melmen et al., 1995) and breast cancer survivors (Cordova et al., 1995). One possibility is that higher income may reflect employment in more high-stress, high-pressure occupations, thus further contributing to the stresses introduced by the cancer diagnosis and treatment. Demographic information on the occupations of mothers (and fathers for intact families) was not available in the present data set. Further research is needed to duplicate these results and to investigate possible moderators which may account for this finding. Pelcovitz et al. (1996) found that mothers of pediatric cancer survivors reported experiencing a greater number of high magnitude stressors than did mothers of healthy children. Our findings failed to confirm this. While frequency of high magnitude stressors were not significantly related to reported PTSD symptomatology, the frequency of low magnitude stressors were. King et al. (1995) found a similar pattern of results in a sample of Vietnam veterans. However, since almost half of the sample (47%) did not report any high magnitude stressors in their lifetimes, there may have not been sufficient variability to demonstrate significant relationships involving this variable. The importance of low magnitude stressors has not been fully recognized in the literature, but is emerging as a general trend that needs further exploration. It is possible that the accumulation of current stressors in the mothers’ lives may overtax their coping resources or abilities, putting them at greater risk for experiencing more PTSD-related symptoms. Not surprisingly, both degree of threat at diagnosis and current threat posed by the cancer were related to increased PTSD symptomatology. However, only current threat added uniquely to prediction on the basis of a hierarchical regression. These results partially support those reported by Heiney et al. (1994), who found that perceived degree of life threat was related to an increased risk of PTSD. The remaining demographic and treatment-related variables, including mother’s age and educational level, child’s age at diagnosis, and time since the conclusion of treatment, were not significantly related to PTSD symptomatology. Time since treatment has been investigated as a possible predictor in a number of studies (e.g., Cordova et al., 1995; Kazak et al., 1997), none of which supported its utility in predicting PTSD symptoms. Such findings are in accord with other PTSD research. For example, among combat veterans, many individuals still meet diagnostic criteria for PTSD four or five decades after their combat experience (Falk et al., 1994). One related factor of interest for future research may be the length and course of treatment. In the present study, length of treatment ranged from four months to four years. Although not directly addressed in this study, the experiences of children and their families may differ greatly depending on the length and course a particular treatment takes. Given the findings of the present study, as well as the previously published literature, it appears quite clear that the presence of PTSD and PTSD symptomatology among mothers of pediatric cancer survivors is of legitimate concern. Physicians, therapists, and other healthcare professionals should be aware of this increased risk among mothers of cancer survivors and should be educated about the possible treatment options available for individuals suffering from PTSD. Moreover, the finding that many mothers experienced significant PTSD-related distress for years posttreatment suggests that early clinical interventions may be crucial. It may be beneficial to incorporate PTSD-prevention into the treatment planning of support groups for this population.

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A number of methodological concerns of the present study need to be addressed. In particular, the relatively small sample size (N ¼ 49) may have limited power to the extent of attenuating the ability to identify potential significant predictors of PTSD symptomatology. Similar studies of PTSD prevalence in families facing pediatric cancer typically employed samples of 100–150 participants (e.g., Kazak et al., 1997). The prevalence of PTSD among mothers of pediatric cancer survivors may also have been underestimated due to the limitations of the volunteer sample and the relatively low response rate. Nonparticipants who would have met diagnostic criteria for PTSD may have wanted to avoid additional discussion of the trauma (a behavior pattern characteristic of Criterion C). Conversely, it is also conceivable that PTSD prevalence may have been overestimated due to mothers experiencing greater stress or symptoms and wanting to address them by participating in the study. An additional methodological concern is the lack of a comparison group. Although it is not unusual for similar studies of PTSD among cancer survivors and their families to forego the inclusion of comparison samples (e.g., Stuber et al., 1996; Manne et al., 1998), other studies have attempted to utilize comparison groups of healthy children and their parents (e.g., Pelcovitz et al., 1996; Kazak et al., 1997). Given the data available concerning the prevalence rates for PTSD among the general population, it can be argued that comparisons within samples of targeted groups can be made without the inclusion of a healthy comparison group (Cella et al., 1987). In conclusion, the present study has attempted to further investigate the prevalence of PTSD among mothers of pediatric cancer survivors, as well as to identify possible predictors of symptoms. These are only initial steps in understanding the factors that put individuals facing this trauma at an increased risk of development of the disorder. Future research should focus on the clarification of predictive factors, as well as identification of potential moderating and mediating variables. Moreover, further research on PTSD in pediatric cancer survivor families needs to focus on minority families, single mothers, and fathers in order to further generalize the results. Finally, longitudinal studies of PTSD may serve to clarify the time-course development of symptom patterns, as well as the interaction of other life stressors with the initial trauma.

References Alter, C.L., Pelcovitz, D., Axelrod, A., Goldenberg, B., Septimus, A. and Harris, H. (October, 1992). The identification of PTSD in cancer survivors. Paper presented at the annual meeting of the Academy of Psychosomatic Medicine, San Diego, CA. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th Edn. Washington, DC. Andrykowski, M.A., Cordova, M.J., Studts, J.L. and Miller, T.W. (1998). Posttraumatic stress disorder after treatment for breast cancer: Prevalence of diagnosis and use of the PTSD Checklist-Civilian Version (PCL-C) as a screening instrument. Journal of Consulting and Clinical Psychology, 66, 586–590. Cella, D.F., Tan, C., Sullivan, M., Weinstock, L., Alter, R. and Jow, D. (1987). Identifying survivors of pediatric Hodgkin’s disease who need psychological interventions. Journal of Psychosocial Oncology, 5(4), 83–96. Cordova, M.J. Andrykowski, M.A., Kenady, D.E., McGrath, P.C., Sloan, D.A. and Redd, W.H. (1995). Frequency and correlates of posttraumatic-stress-disorder-like symptoms after treatment for breast cancer. Journal of Consulting and Clinical Psychology, 63, 981–986. Doerfler, L.A., Pbert, L. and DeCosimo, D. (1994). Symptoms of posttraumatic stress disorder following myocardial infarction and coronary bypass surgery. General Hospital Psychiatry, 16, 193–199.

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Falk, B., Hersen, M. and Van Hasselt, V.B. (1994). Assessment of post-traumatic stress disorder in older adults: A critical review. Clinical Psychology Review, 14, 383–415. First, M.B., Spitzer, R.L., Gibbon, M. and Williams, J.B. (1994). Structured Clinical Interview for Axis I DSM-IV Disorders – Patient Edition (SCID-I/P Version 2.0). Biometrics Research Department, New York State Psychiatric Institute. Foa, E.B., Cashman, L., Jaycox, L. and Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale. Psychological Assessment, 9, 445–451. Heiney, S.P., Neuberg, R.W., Myers, D. and Bergman, L.H. (1994). The aftermath of bone marrow transplant for parents of pediatric patients: A post-traumatic stress disorder. Oncology Nursing Forum, 21, 843–847. Kazak, A.E., Barakat, L.P., Meeske, K., Christakis, D., Meadows, A.T., Casey, R., Penati, B. and Stuber, M.L. (1997). Posttraumatic stress, family functioning, and social support in survivors of childhood leukemia and their mothers and fathers. Journal of Consulting and Clinical Psychology, 65, 120–129. Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M. and Nelson, C.B. (1995). Posstraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060. Kilpatrick, D.G., Resnick, H.S. and Freedy, J.R. (1991). Potential Stressful Events Interview. Unpublished manual, Medical University of South Carolina, Crime Victims Research and Treatment Center, Charleston. Kilpatrick, D.G., Resnick, H.S., Freedy, J.R., Pelcovitz, D., Resick, P., Roth, S. and van der Kolk, B. (1998). Posttraumatic stress disorder field trial: Evaluation of the PTSD construct: Criteria A through E. DSMIV Sourcebook. American Psychiatric Association, Washington, DC. King, D.W., King, L.A., Gudanowski, D.M. and Verven, D.L. (1995). Alternative representations of war zone stressors: Relationships to posttraumatic stress disorder in male and female Vietnam veterans. Journal of Abnormal Psychology, 104, 184–196. Manne, S.L., Du Hamel, K., Gallelli, K., Sorgen, K. and Redd, W.H. (1998). Posttraumatic stress disorder among mothers of pediatric cancer survivors: Diagnosis, comorbidity, and utility of the PTSD Checklist as a screening instrument. Journal of Pediatric Psychology, 23, 357–366. Pelcovitz, D., Goldenberg, B., Kaplan, S., Weinblatt, M., Mandel, F. and Vinciguerra, V. (1996). Posttraumatic stress disorder in mothers of pediatric cancer survivors. Psychosomatics 37, 116–126. Powers, P.S., Cruse, C.W., Daniels, S. and Stevens, B. (1994). Posttraumatic stress disorder in patients with burns. Journal of Burn Care Rehabilitation, 15, 147–153. Resnick, H.S., Kilpatrick, D.G., Dansky, B.S., Saunders, B.E. and Best, C.L. (1993). Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. Journal of Consulting and Clinical Psychology, 61, 984–991. Stuber, M., Christakis, D., Houskamp, B. and Kazak, A.E. (1996). Posttraumatic symptoms in childhood leukemia survivors and their parents. Psychosomatics, 37, 254–261. Van Dongen-Melman, J.E., Pruyn, J.F., De Groot, A., Koot, H.M., Hahlen, K. and Verhulst, F.C. (1995). Late psychosocial consequences for parents of children who survive cancer. Journal of Pediatric Psychology, 20, 567–586. Yellowlees, P.M., Haynes, S., Potts, N. and Ruffin, R.E. (1988). Psychiatric morbidity in patients with lifethreatening asthma: Initial report of a controlled study. Medical Journal of Australia, 149, 246–249.