Impact of Prior Traumatic Life Events on Parental Early Stage Reactions following a Child's Cancer

Background

In pediatric oncology, effective clinic–based management of acute and long–term distress in families calls for investigation of determinants of parents'' psychological response to the child''s cancer. We examined the relationship between parents'' prior exposure to traumatic life events (TLE) and the occurrence of posttraumatic stress symptoms (PTSS) following their child''s cancer diagnosis. Factors mediating the TLE–PTSS relationship were analyzed.

Methodology

The study comprised 169 parents (97 mothers, 72 fathers) of 103 cancer diagnosed children (median age: 5,9 years; range 0.1–19.7 years). Thirty five parents were of immigrant origin (20.7%). Prior TLE were collated using a standardized questionnaire, PTSS was assessed using the Impact of Events–Revised (IES–R) questionnaire covering intrusion, avoidance and hyperarousal symptoms. The predictive significance of prior TLE on PTSS was tested in adjusted regression models.

Results

Mothers demonstrated more severe PTSS across all symptom dimensions. TLE were associated with significantly increased hyperarousal symptoms. Parents'' gender, age and immigrant status did not significantly influence the TLE–PTSS relationship.

Conclusions

Prior traumatic life–events aggravate posttraumatic hyperarousal symptoms. In clinic–based psychological care of parents of high–risk pediatric patients, attention needs to be paid to life history, and to heightened vulnerability to PTSS associated with female gender.     

Cultural Identity and Internationally Adopted Children: Qualitative Approach to Parental Representations

Approximately 30 000 children are adopted across national borders each year. A review of the literature on the cultural belonging of these internationally adopted children shows substantial differences between the literature from English-speaking countries and that from France and Europe in general. The objective of this study is to start from the discourse of French adoptive parents to explore their representations of their child''s cultural belonging and their positions (their thoughts and representations) concerning connections with the child''s country of birth and its culture. The study includes 51 French parents who adopted one or more children internationally. Each parent participated in a semi-structured interview, focused on the adoption procedure and their current associations with the child''s birth country. The interviews were analyzed according to a qualitative phenomenological method, Interpretative Phenomenological Analysis. The principal themes that emerged from our analysis of the interviews made it possible to classify the parents into three different groups. The first group maintained no association with the child''s country of birth and refused any multiplicity of cultural identities. The second group actively maintained regular associations with the child''s country of birth and culture and affirmed that their family was multicultural. Finally, the third group adapted their associations with the child''s birth country and its culture according to the child''s questions and interests. Exploring parental representations of the adopted child enables professionals involved in adoption to provide better support to these families and to do preventive work at the level of family interactions.     

Viewing the Body after Bereavement Due to Suicide: A Population-Based Survey in Sweden

Background

Research on the assumed, positive and negative, psychological effects of viewing the body after a suicide loss is sparse. We hypothesized that suicide-bereaved parents that viewed their childs body in a formal setting seldom regretted the experience, and that viewing the body was associated with lower levels of psychological morbidity two to five years after the loss.

Methods and Findings

We identified 915 suicide-bereaved parents by linkage of nationwide population-based registries and collected data by a questionnaire. The outcome measures included the Patient Health Questionnaire (PHQ-9). In total, 666 (73%) parents participated. Of the 460 parents (69%) that viewed the body, 96% answered that they did not regret the experience. The viewing was associated with a higher risk of reliving the child''s death through nightmares (RR 1.61, 95% CI 1.13 to 2.32) and intrusive memories (RR 1.20, 95% CI 1.04 to 1.38), but not with anxiety (RR 1.02, 95% CI 0.74 to 1.40) and depression (RR 1.25, 95% CI 0.85 to 1.83). One limitation of our study is that we lack data on the informants'' personality and coping strategies.

Conclusions

In this Swedish population-based survey of suicide-bereaved parents, we found that by and large everyone that had viewed their deceased child in a formal setting did not report regretting the viewing when asked two to five years after the loss. Our findings suggest that most bereaved parents are capable of deciding if they want to view the body or not. Officials may assist by giving careful information about the child''s appearance and other details concerning the viewing, thus facilitating mental preparation for the bereaved person. This is the first large-scale study on the effects of viewing the body after a suicide and additional studies are needed before clinical recommendations can be made.     

Effects of childhood cancer on long-term survivors and their families.

Problems experienced by families of long-term survivors of acute lymphatic leukaemia and Wilms''s tumour were investigated to find out the best way of using limited resources to improve management of such patients. All patients had received treatment at Alder Hey Children''s Hospital, and all had completed treatment at least two years before the study. A social worker interviewed the parents of each child. The results showed that various aspects of management needed improvement, including: information given to parents at diagnosis of their child''s illness and during subsequent treatment; continuity of care and multidisciplinary teamwork among those caring for the child; greater understanding by school teachers that such children have the same educational needs as others; wider communication by hospital staff with the child''s other relatives, particularly grandparents; financial help for parents; and marital counselling. To help implement these proposals full-time social workers were attached to the hospital. Preliminary results were encouraging, though it is too early to evaluate the long-term effects of the changes.     

Parental attitudes toward pediatric organ donation: a survey.

We conducted a telephone survey of parents in the National Capital Region to assess their intention to donate their child''s organs and to provide physicians with information that could help alleviate their concerns about approaching parents for consent. Of 339 parents who agreed to answer questions after being given details of their child''s "death" 288 (85%) said that they would be willing to donate their child''s organs. The degree of willingness was associated with the certainty of death, altruism and empathy toward children in need of an organ, previous discussion of organ donation with a family member and knowledge of an adolescent or adult child''s attitude toward donation. Factors that inhibited the intention to donate included uncertainty of death, insufficient information from medical professionals and fear of multilation. The child''s age was not significantly associated with intention to donate. Concordance between the results and actual donation rates in Canada and the United States supports the generalizability of the survey findings.     

Effects of interpersonal violence-related post-traumatic stress disorder (PTSD) on mother and child diurnal cortisol rhythm and cortisol reactivity to a laboratory stressor involving separation

Women who have experienced interpersonal violence (IPV) are at a higher risk to develop posttraumatic stress disorder (PTSD), with dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis and impaired social behavior. Previously, we had reported impaired maternal sensitivity and increased difficulty in identifying emotions (i.e. alexithymia) among IPV-PTSD mothers. One of the aims of the present study was to examine maternal IPV-PTSD salivary cortisol levels diurnally and reactive to their child's distress in relation to maternal alexithymia. Given that mother-child interaction during infancy and early childhood has important long-term consequences on the stress response system, toddlers' cortisol levels were assessed during the day and in response to a laboratory stressor. Mothers collected their own and their 12–48 month-old toddlers' salivary samples at home three times: 30 min after waking up, between 2–3 pm and at bedtime. Moreover, mother-child dyads participated in a 120-min laboratory session, consisting of 3 phases: baseline, stress situation (involving mother-child separation and exposure to novelty) and a 60-min regulation phase. Compared to non-PTSD controls, IPV-PTSD mothers — but not their toddlers, had lower morning cortisol and higher bedtime cortisol levels. As expected, IPV-PTSD mothers and their children showed blunted cortisol reactivity to the laboratory stressor. Maternal cortisol levels were negatively correlated to difficulty in identifying emotions. Our data highlights PTSD-IPV-related alterations in the HPA system and its relevance to maternal behavior. Toddlers of IPV-PTSD mothers also showed an altered pattern of cortisol reactivity to stress that potentially may predispose them to later psychological disorders.     

Mental Health of Parents as Caregivers of Children with Disabilities: Based on Japanese Nationwide Survey

The number of children with disability is increasing gradually in Japan. Previous researches in other countries have reported that parents as caregivers (CGs) of children with disability have mental health problems, but the actual situation has not been examined nationwide in Japan so far. The aim of this study was to evaluate the association between mental health of CGs who had children with disability and characteristics of children, CGs, and household based on the nation-wide survey. This study utilized data from 2010 Comprehensive Survey of the Living Conditions, and defined children with disability aged 6 to 17. Individual data of children and CGs were linked, and 549 pairs of them were extracted. The Japanese version of Kessler 6 (K6) was used to assess mental health status of caregiver, scored 5 and over represented to general psychological distress. Logistic regression was used to evaluate the associations of interest. The almost half (44.4%) of CGs had psychological distress (k6 score; 5 +) in nationwide, and 8.9% of CGs might have serious mental illness (K6 score; 13+). After adjusting covariates of child, CG, and household factors, CG having a current symptom (OR, 95% CI: 3.26, 1.97–5.39), CG''s activity restriction (OR, 95% CI: 2.95, 1.38–6.32), low social support (OR, 95%CI: 9.31, 1.85–46.8), three generation family (OR, 95% CI: 0.49, 0.26–0.92), and lower 25% tile group of monthly household expenditure (OR, 95% CI:1.92, 1.05–3.54), were significantly associated with psychological distress of CGs. This study encourages health care providers to pay more attentions toward parent''s mental health, especially for in case of having low social support, and lower income family. Further research should examine the detailed information of child''s disease and disability, medical service use, and quality and quantity of social support in nationwide to straighten the system for supporting services of both children with disabilities and their CGs.     

Psychological Implications of Cystic Fibrosis

A psychological and psychiatric study of 11 children with cystic fibrosis revealed major psychological problems in all of them. Among the parents of the majority of these children, marked psychopathology and gross marital discord were noted. Popular literature concerning cystic fibrosis had a negative effect on the child''s attitude toward the disease. Virtually all of these patients showed a preoccupation with death. In this study, the necessity of psychiatric consultation as an integral part of current intensive treatment programs in cystic fibrosis clinics was demonstrated.     

Knowledge, perceptions and information about hormone therapy (HT) among menopausal women: a systematic review and meta-synthesis

Background

The use of hormone therapy (HT) by menopausal women has declined since the Women''s Health Initiative randomized trial (WHI) in 2002 demonstrated important harms associated with long-term use. However, how this information has influenced women''s knowledge and attitudes is uncertain. We aimed to evaluate the attitudes and perceptions towards HT use, as well as specific concerns and information sources on HT since the WHI trial.

Method/Results

We did a systematic review to assess the attitudes and knowledge towards HT in women, and estimate the magnitude of the issue by pooling across the studies. Using meta-synthesis methods, we reviewed qualitative studies and surveys and performed content analysis on the study reports. We pooled quantitative studies using a random-effects meta-analysis. We analyzed 11 qualitative studies (n = 566) and 27 quantitative studies (n = 39251). Positive views on HT included climacteric symptom control, prevention of osteoporosis and a perceived improvement in quality of life. Negative factors reported included concerns about potential harmful effects, particularly cancer risks. Sources of information included health providers, media, and social contact. By applying a meta-synthesis approach we demonstrate that these findings are broadly applicable across large groups of patients.

Conclusions

Although there are clear hazards associated with long-term HT use, many women view HT favorably for climacteric symptom relief. Media, as a source of information, is often valued as equivalent to health providers.     

Impact of whooping cough on patients and their families.

The effects of whooping cough were studied in 21 children admitted to hospital with the disease and in their families. The illness caused considerable distress to both child and family. Parents suffered especially from fears for the life and health of their child and from serious loss of sleep. Two months after admission the child''s behaviour was still disturbed, but in most cases the rest of the family had returned to normal. There was much misunderstanding and misinformation about whooping cough among both parents and doctors.     

Attention,self-regulation and consciousness.

Consciousness has many aspects. These include awareness of the world, feelings of control over one''s behaviour and mental state (volition), and the notion of continuing self. Focal (executive) attention is used to control details of our awareness and is thus closely related to volition. Experiments suggest an integrated network of neural areas involved in executive attention. This network is associated with our voluntary ability to select among competing items, to correct error and to regulate our emotions. Recent neuroimaging studies suggest that these various functions involve separate areas of the anterior cingulate. We have adopted a strategy of using marker tasks, shown to activate the brain area by imaging studies, as a means of tracing the development of attentional networks. Executive attention appears to develop first to regulate distress during the first year of life. During later childhood the ability to regulate conflict among competing stimuli builds upon the earlier cingulate anatomy to provide a means of cognitive control. During childhood the activation of cingulate structures relates both to the child''s success on laboratory tasks involving conflict and to parental reports of self-regulation and emotional control. These studies indicate a start in understanding the anatomy, circuitry and development of executive attention networks that serve to regulate both cognition and emotion.     

Bioethics for clinicians: 9. Involving children in medical decisions

Medical decisions involving children raise particular ethical issues for physicians and other members of the health care team. Although parents and physicians have traditionally made most medical decisions on behalf of children, the developing autonomy of children is increasingly being recognized in medical decision-making. This poses a challenge for physicians, who must work with the child''s family and with other health care practitioners to determine the child''s role in decision-making. A family-centred approach respects the complex nature of parent-child relationships, the dependence and vulnerability of the child and the child''s developing capacity for decision-making.     

Psychological effects of false-positive results in expanded newborn screening in China

Objectives

As more families participate expanded newborn screening for metabolic disorders in China, the overall number of false positives increases. Our goal was to assess the potential impact on parental stress, perceptions of the child''s health, and family relationships.

Methods

Parents of 49 infants with false-positive screening results for metabolic disorders in the expanded newborn screening panel were compared with parents of 42 children with normal screening results. Parents first completed structured interview using likert scales, closed and open questions. Parents also completed the parenting stress index.

Results

A total of 88 mothers and 41 fathers were interviewed. More mothers in the false-positive group reported that their children required extra parental care (21%), compared with 5% of mothers in the normal-screened group (P<0.001). 39% of mothers in the false-positive group reported that they worry about their child''s future development, compared with 10% of mothers in the normal-screened group (P<0.001). Fathers in the false-positive group did not differ from fathers in the normal-screened group in reporting worry about their child''s extra care requirements, and their child''s future development. Children with false-positive results compared with children with normal results were triple as likely to experience hospitalization (27%vs 9%, respectively; P<0.001).

Conclusions

The results showing false-positive screening results may affect parental stress and the parent-child relationship. Parental stress and anxiety can be reduced with improved education and communication to parents about false-positive results.     

EMOTIONAL FACTORS IN PHYSICALLY HANDICAPPED CHILDREN

The staff of the Reiss-Davis Clinic for Child Guidance has been concerned with the emotional factors in physically handicapped or chronically ill children. It is felt by the staff that work with these children must include not only the known procedures to improve or correct their physical condition, but also efforts directed toward preventing or removing any evidence of emotional or psychological crippling.The symbolic or unconscious meaning of the disability is of great importance in this work. Attitudes of the parents may seriously interfere with the handicapped child''s ability to develop his maximum level of functioning and adjustment. Individual and group psychotherapy was found of value in helping these parents.     

Habilitation of Patients with Congenital Malformations Associated with Thalidomide: Psychiatric and Psychological Aspects

Nearly 100 cases of congenital malformations associated with thalidomide ingestion by the mother have been reported in Canada to the Department of National Health and Welfare. Depression and selfcastigation have been the specific psychiatric reactions noted, particularly in the mother. In most cases it is preferable psychologically for the parents and the child if the child is kept at home rather than placed in an institution. Parents should be fully informed concerning the child''s prognosis for future development. Most of the children followed up for about two years showed no intelligence defects. A prosthesis, if required, should be applied early (at three to six months) so that it may become a part of the child''s body-image, but it should not interfere with play activities. Assessment by a psychiatrist and a psychologist is indicated at about six months.     

Adaptation of children to a chronically ill or mentally handicapped sibling.

The presence of a chronically ill or mentally handicapped child in a family can be a stress for the child''s siblings, who often are ill informed about the nature and prognosis of the illness, may be uncertain what is expected of them in the caregiving role, may feel their own identities threatened, and may experience ostracism by their friends and misunderstanding at school. Although individual reactions vary widely, feelings of anger, guilt, resentment and shame are commonly reported. Excessive responsibility and concern about one''s identity may add to these feelings and culminate in psychologic problems in the sibling. The physician caring for the family must be alert for symptoms of emotional disturbance or social maladjustment among the siblings of chronically ill or mentally handicapped children and should be prepared to counsel the family or refer them to a counsellor experienced in this area. In general, the first step is to be sure that the sibling is fully informed about the condition and to encourage frank discussion between the parents and the handicapped child''s siblings.     

Respiratory Symptoms in Children and Parental Smoking and Phlegm Production

A study of respiratory symptoms in 2,426 schoolchildren aged 6-14 years was carried out in Aylesbury, Buckinghamshire, in 1971. The prevalence of cough in the children was associated with the parents'' smoking habits; prevalence was lowest where both parents were non-smokers, highest where both parents smoked, and lay between these two levels where only one parent smoked. A close association was found between parents'' and children''s respiratory symptoms that was independent of parents'' smoking habits. There was no suggestion that exposure to the cigarette smoke generated when parents smoked had any more than a small effect upon the child''s respiratory symptoms. While the sharing of genetic susceptibility between parents and children is a factor, therefore, cross infection, particularly in the families where parents smoke, is an important element in the association.     

Maternal and paternal controlling feeding practices: reliability and relationships with BMI

Objective: This study aimed to examine the interrelationships between mothers' and fathers' reports on the child‐feeding questionnaire (CFQ), the BMI of parents and their children, and observations of parents' controlling feeding practices at mealtimes. Methods and Procedures: Twenty‐three mothers and twenty‐three fathers of children aged between 18 and 67 months reported on their child‐feeding practices, on their child's height and weight, and were observed during a normal family mealtime at home. Results: No associations were found between mothers' reported and observed feeding practices. Fathers' reported pressure to eat and restriction were associated with more controlling observed mealtime feeding practices. Mothers and fathers did not significantly differ in their reported or observed child‐feeding practices. Children's BMI was not related to maternal or paternal reported or observed feeding practices. More mealtime pressure was observed in parents with a higher BMI. Discussion: Fathers' self‐reports of their mealtime practices are reliable. Mothers' feeding practices may differ when fathers are present and further work should examine mothers at mealtimes with and without fathers. Although children's BMI was not related to parents' use of reported or observed control, parents with a higher BMI were more controlling, highlighting the importance of considering parents' own weight in future studies.     

Use of automobile seat restraints by children in two Canadian cities.

A telephone survey was conducted in Montreal and Calgary to determine the extent to which parents use safety restraints for their children in cars, the types of restraints used and the factors associated with such use. Of the combined sample 39% reported that their child regularly used a restraint, and 47% of the children in Montreal and 55% of those in Calgary wore an age-appropriate safety device. Birth order and the child''s and the respondent''s ages were significantly related to the use of restraints. However, the respondent''s use of seatbelts was the factor most likely to affect the rate of use of restraints for children. Although a large proportion of the parents with younger children owned a carseat, one in four did not use it regularly. Parents who did not use carseats believed they were useless or dangerous; many preferred to hold the child in their laps or arms. The seatbelt law in Quebec and the existence of a carseat rental program in Calgary appear to have had some influence on the rate of the use of restraints for children.