Journal of Pediatric Psychology, 45(9), 2020, 1063–1073
doi: 10.1093/jpepsy/jsaa070
Original Research Article
Downloaded from https://academic.oup.com/jpepsy/article/45/9/1063/5910717 by Bar Ilan University user on 30 September 2020
Child and Family Factors Associated With
Posttraumatic Stress Responses Following a
Traumatic Medical Event: The Role of Medical
Team Support
Yaara Sadeh,1,2 MA, Rachel Dekel,1 PHD, Amichai Brezner,2 MD,
Jana Landa,2,4 MD, and Tamar Silberg,2,3,5 PHD
1
The Louis and Gabi Weisfeld School of Social Work, Bar-Ilan University, 2Department of Pediatric Rehabilitation,
The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, 3Holland Bloorview Kids Rehabilitation
Hospital, 4Sackler Faculty of Medicine, Tel-Aviv University, and 5Department of Psychology, Bar-Ilan University
All correspondence concerning this article should be addressed to Yaara Sadeh, MA, The Louis and Gabi
Weisfeld School of Social Work, Bar-Ilan University, Ramat Gan 5290002, Israel. E-mail: yaarakraus@gmail.com.
Received 7 March 2020; revisions received 13 June 2020; accepted 23 July 2020
Abstract
Objectives This study examined the contribution of pretrauma psychosocial factors (child emotional functioning, family resources, family functioning, and social support) and environmental factors (mother’s posttraumatic stress symptoms [PTSSs], medical team support [MTS]) to PTSSs of
injured or seriously ill children within a pediatric rehabilitation setting. It was hypothesized that
psychosocial variables would be strongly associated with child’s PTSS; that mother’s PTSS and
MTS would mediate the association between psychosocial factors and child’s PTSS; that mother’s
report on child’s PTSS would mediate the association between mother’s PTSS and child’s PTSS.
Methods Participants were 196 children hospitalized following an injury/illness and assessed
M ¼ 47.7 days postevent. Children completed measures of PTSS, mothers completed measures of
their own PTSS, child’s PTSS, and pretrauma psychosocial factors. Family’s therapist completed a
MTS measure. Structural equation modeling was employed to evaluate the study hypotheses.
Results Pretrauma family structure and resources were associated with child’s self-reported
PTSS; each pretrauma variable and mother’s report of child’s PTSS was significantly associated.
Although mother’s PTSS was not directly associated with child’s PTSS, this relationship was mediated by mother’s report of child’s PTSS. MTS mediated the relationship between pretrauma social
support and mother’s PTSS. Conclusion This study further explicates the utility of a biopsychosocial framework in predicting childhood PTSS. Findings confirm the role of pretrauma factors and
environmental factors at the peritrauma period in the development of PTSS following a pediatric
injury/illness. Mother’s PTSS and MTS may be appropriate targets for prevention and early
intervention.
Key words: accidents and injuries; chronic illness; parent stress; parenting; posttraumatic stress.
Pediatric illnesses and injuries affect many children,
adolescents, and families; 30 million children are injured each year in the United States alone (Centers for
Disease Control & Prevention, 2014). In Israel,
202,000 children visit emergency rooms annually
(Nir et al., 2017). These traumatic medical events
C The Author(s) 2020. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
V
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
1063
1064
Child’s Biological Factors
During the pretrauma period, biological factors such
as child’s gender and age were found to have small to
medium-effect sizes, with female gender and younger
age as risk factors for PTSS among various types of
traumatic events in general (Trickey et al., 2012), and
following accidental trauma specifically (Cox et al.,
2008). During the peritrauma period biological
markers have the potential to serve as screeners for the
development and maintenance of PTSS (Marsac et al.,
2014). However, during rehabilitation, due to children’s complex medical and functional conditions, they
are often highly medicated; addressing biological variables such as heart rate, as indicators of the body’s response to stress, is therefore problematic.
Psychological Factors
Child’s Psychological Factors
Child’s pretrauma emotional functioning serves as a
significant predictor for the development of PTSS
(Brosbe et al., 2011; Cox et al., 2008; Trickey et al.,
2012). Results from longitudinal studies show that
pretrauma internalizing difficulties (i.e., depression
and anxiety problems; Storr et al., 2007) and disruptions in emotion regulation (i.e., greater rumination,
high levels of catastrophizing, and low levels of positive reappraisal) predict PTSS among youth exposed
to a traumatic event (Jenness et al., 2016; McLaughlin
& Lambert, 2017). Among children following a pediatric traumatic injury specifically, preinjury child behavior problems were predictive of higher PTSS (i.e.,
belonging to the recovery and high-chronic trajectory
groups; Le Brocque et al., 2010).
Parental Psychological Factors
A large evidence base suggests that parental acute
PTSS increases the risk for, and maintenance of the
child’s PTSS during the peritrauma period (Brosbe
et al., 2011; Landolt et al., 2012). In addition, several
studies have shown that following a child’s TME,
parents with more stress symptoms report higher
symptoms in their child, suggesting that they might be
more prone to overestimating the child’s stress symptoms (Dame et al., 2014; Shemesh et al., 2005). For
example, Ostrowski et al. (2011) evaluated 118 children admitted to the hospital for an injury and found
that while caregiver’s PTSS did not predict child’s
PTSS, the interaction between child’s and parent’s
PTSS at 2 weeks predicted child’s 6-week PTSS. Thus,
examining the complex relationship between parent’s
and child’s PTSS is important for understanding shortand long-term outcomes.
Environmental Factors
Family Structure and Resources
There is inconsistency in the literature regarding the
relationship between socioeconomic status and PTSS
among children and families following TMEs.
Whereas some studies showed a low–moderate relationship (Trickey et al., 2012), others found that lower
parental income (Delahanty et al., 2005) and lower
parental education (Vanderbilt et al., 2009) were associated with stress responses among families.
Family Functioning
Environmental and social pretrauma factors of the
family (for instance, substance abuse, marital conflicts, or histories of mental health or legal problems),
as well as the family’s social support, have been found
to impact the family’s functioning and determine
whether and how symptoms are expressed within the
child and the parent (Brosbe et al., 2011; Muscara
et al., 2017). The literature on childhood TMEs indicates that family, and parents in particular, are usually
the main source of support for their child following a
traumatic event (Brown et al., 2018; Price et al.,
2016). Attachment theory (Bowlby, 1981; Fonagy &
Target, 2013) makes it abundantly clear that the physical presence of parents during hospitalization, and
the protection they provide, is not enough to ensure
that a child will receive the emotional support needed
during confusing and stressful times. Following
TMEs, children need their parents’ help and support
in making sense of their traumatic experience and integrating it into their existing schemas; in general, they
need their parents’ support for their overall physical
and emotional recovery (Cohen, 2009).
Downloaded from https://academic.oup.com/jpepsy/article/45/9/1063/5910717 by Bar Ilan University user on 30 September 2020
(TMEs) are associated with impaired physical functioning, emotional distress, and substantial health
services utilization (Hilliard et al., 2015). Of particular concern, 16–19% of children and youth with
TMEs develop significant posttraumatic stress disorder (PTSD) or elevated levels of posttraumatic stress
symptoms (PTSSs; Price et al., 2016). Whether or not
a child meets the full diagnostic criteria for PTSD,
PTSS might impair day-to-day interpersonal and academic functioning (Kassam-Adams et al., 2013) and is
often linked to negative outcomes in children and
youth.
The biopsychosocial theoretical model of PTSS following TMEs (Marsac et al., 2014) suggests that biological, psychological, and social factors in the pre
and peritrauma periods contribute directly or through
interactional relationships to the development and
maintenance of PTSS over time. This study wished to
examine a mediation model in which the relationship
between child’s factors and PTSS symptoms is mediated by various factors within the child, the family
(e.g., parental PTSS), and the environment (e.g., medical team support [MTS]).
Sadeh, Dekel, Brezner, Landa, and Silberg
1065
Medical Team Support
The support given by the medical team during the
acute peritrauma period is a unique and important
variable which, to the best of our knowledge, has not
received sufficient attention in past research in the
field. When a family is coping with a child’s TME, the
child’s health-care providers are an essential part of
the child’s system of care. Being present in the medical
setting allows the medical team to provide support to
families as they begin to cope with the traumatic
event. In rehabilitation settings, the medical team aims
to engage the parents by using a collaborative approach to help explore the family’s knowledge and understanding of their child’s abilities as a result of the
illness/injury, including symptoms, etiology, and impact on behavioral and emotional functioning
(Williams et al., 2014). During prolonged hospitalizations, providing support to the family may allow the
team to differentiate between symptoms explained by
trauma and those associated with the illness/injury. As
such, MTS has the potential of increasing parental
presence and support as well as the parent’s ability to
make meaning of the child’s experiences and behaviors in the medical setting (Williams et al., 2014).
Thus, if the medical teams support the parents and address parental symptoms, the parents themselves may
be better able to support their child (Marsac et al.,
2014).
Families differ in their willingness and ability to use
the medical team’s support during hospitalization.
Past experiences of social support may be related to
the relationship that develops between the family and
the medical staff. More specifically, during times of
stress, pretrauma history of close relationships can be
used as a protective factor facilitating family’s engagement and positive relationships with the medical team.
Examining the relationship between social support
and the use of MTS may help us understand important
factors that help families buffer the negative effects of
stress and enable recovery and resilience (Cohen,
2004).
from families with reduced resources and poorer family functioning, and a child with more pre-TME emotional difficulties, would demonstrate more PTSS as
reported by child and by mother. Furthermore, we hypothesized that child’s pre-TME emotional difficulties,
poorer family functioning, and less social support,
would contribute to mother’s PTSS. Second, we
wished to examine the mediational role of mother’s
PTSS and MTS in the association between pretrauma
factors and child’s PTSS. Specifically, we hypothesized
that mother’s PTSS would serve as a mediator between
pretrauma factors and child’s PTSS, and that MTS
during hospitalization would serve as a mediator between pretrauma social support and mother’s PTSS.
Our third goal was to examine the contribution of
mother’s PTSS to child’s PTSS according to both the
mother’s report and the child’s self-report. We hypothesized that mother’s PTSS during the peritrauma period would contribute to child’s PTSS during
peritrauma, and that the mother’s report of the child’s
PTSS would contribute to the child’s PTSS. We also
hypothesized that the mother’s report of the child’s
PTSS would serve as a mediator between mother’s
PTSS and the child’s PTSS.
This study
This study used an accepted biopsychosocial approach
to examine the contribution of selected biological factors (i.e., child’s gender, child’s age), psychological
factors (i.e., child’s pre-TME emotional functioning),
and environmental factors (i.e., parent’s PTSS, family
structure and resources, family functioning, social support, MTS) at the pre and peritrauma period, to
child’s PTSS (Figure 1). The study had three specific
goals. First, we wished to examine pretrauma factors
that contribute to child’s and mother’s PTSS during
the peritrauma period. We hypothesized that child’s
female gender and younger age would be risk factors
for PTSS. Additionally, we hypothesized that children
Materials and Methods
Participants
Posthospitalization archival clinical data (consisting of
questionnaires for the children and their mothers, described in the Procedure section) were extracted from
the medical records of 196 children (120 males),
7–18 years of age (M ¼ 12.8, SD ¼ 3.1), who were
admitted to the Pediatric Rehabilitation Department
between the years 2013–2018 (see Table I for a
detailed description of the demographic and injury/
illnesses characteristics of study participants).
Participants were eligible for inclusion if they:
(a) agreed to fill out the questionnaires; (b) experienced a TME within a 3-month period prior to their
hospitalization in the rehabilitation department; and
(c) had sufficient mastery of Hebrew to complete the
questionnaires. Potential participants were excluded
if: (a) their medical conditions or cognitive limitations
did not allow for completion of the clinical data; (b)
their injuries were due to family violence or suspected
child abuse; and (c) the child or parent was subject to
legal proceedings related to the injury, the child or
parent was the perpetrator of violence related to the
injury, or the child or parent declined to complete the
questionnaires.
Among the 405 children who were eligible for the
study, the reasons for exclusion were: family declined
to participate (N ¼ 104), the parent or the child did
not have sufficient mastery of Hebrew (N ¼ 41), the
family was intended to be discharged from the
Downloaded from https://academic.oup.com/jpepsy/article/45/9/1063/5910717 by Bar Ilan University user on 30 September 2020
Child and Family Factors Associated With Posttraumatic Stress
Sadeh, Dekel, Brezner, Landa, and Silberg
1066
Table I. Demographics and Injury/Illness Characteristics
Variable
a
12.8 (3.1), 7–18
120 (61.2)
172 (88.2)
23 (11.8)
26 (14.2)
62 (33.9)
71 (38.8)
24 (13.1)
8 (4.3)
76.9 (80.2)
28 (15)
1 (0.5)
83 (46.6)
59 (33.1)
20 (11.2)
16 (9)
92 (46.9)
16 (8.1)
5 (2.6)
21 (10.7)
32 (16.3)
12 (6.2)
18 (9.2)
ABI ¼ acquired brain injury.
pediatric ward within a short time (<3 weeks), not
sufficient for completing the psychosocial protocol
when needed (N ¼ 64). There were no significant differences in child’s gender or age between those who
participated in the study and those who were
ineligible.
All baseline assessments occurred within 90 days
(and at least 30 days from the TME, according to
DSM-IV and DSM-V diagnostic criteria; American
Psychiatric Association, 1994, 2013; T1; M ¼
47.7 days postinjury, SD ¼ 18.3 days postinjury).
Pre- and Peri-TME Psychological and Environmental
Variables
The PAT2.0 (Pai et al., 2008) comprises seven subscales; however, for the purpose of this study, only 4
subscales were utilized. We assessed child’s pretrauma
emotional functioning using the child’s problems subscale (eight items), and pretrauma environmental variables were assessed using the family structure and
resources subscale (eight items), the social support
subscale (eight items), and the family problems subscale (eight items). Subscale total scores were calculated by dividing the number of endorsed high-risk
items by the total number of items in each subscale.
Adjusted subscale scores ranged from 0 to 1, with
higher scores indicating higher psychosocial risk. In a
recent study by Kazak et al. (2018) the PAT subscales
have shown good internal consistency using the
Kuder–Richardson 20 coefficient (child problems
KR20 > 0.80; family structure/resources, social support, and family problems were adequate, ranging
from .59 to .64). The PAT has shown excellent convergent validity with standardized measures of family
resources, family functioning, child functioning, and
sibling functioning, in a range of pediatric conditions
(McCarthy et al., 2016; Pai et al., 2012; Reader et al.,
2020; Sint Nicolaas et al., 2016).
Procedure
As part of the admission process in the Pediatric
Rehabilitation Department, each family was asked by
their psychologist/social worker to complete the questionnaires in order to screen for psychosocial risk and
for child’s and mother’s PTSS. All study procedures
were approved by the Institutional Review Board at
The Sheba Medical Center.
Child’s PTSSs
Child’s PTSS was evaluated using the Child PTSD
Symptom Scale (CPSS; Foa et al., 2001). The CPSS is a
17-item self-report instrument that can yield an overall PTSS severity score corresponding to the DSM-IV
edition of PTSD symptom categories. In our study all
17 items were summed to create a total score, with a
higher score indicating greater PTSS severity (0–51).
The CPSS has shown excellent internal consistency,
test–retest reliability, and convergent validity with
structured clinical interview measures of PTSD (Foa
et al., 2001; Nixon et al., 2013). Rachamim et al.
(2011) reported high-internal consistency (a ¼ .91)
and excellent test–retest reliability (r ¼ .81) for the total scale in the Hebrew version. In this study, internal
reliability was high (Cronbach’s a ¼ .85). A PTSD risk
cutoff score of 15 was decided based on previous
recommendations (Kassam-Adams et al., 2015).
Measures
Throughout the screening phase, children completed
PTSS measures; mothers completed a psychosocial assessment tool (PAT; e.g., family structure and resources, child’s pre-TME emotional functioning, family
pre-TME functioning, social support), mother’s PTSS,
Child’s PTSSs: parent report
Mother’s report of her child’s level of symptoms was
evaluated using the CPSS-parent’s report (Foa et al.,
2001; for the full description, see the measurement
above). In this study, internal reliability was high for
mother’s report on child’s PTSD symptoms
Downloaded from https://academic.oup.com/jpepsy/article/45/9/1063/5910717 by Bar Ilan University user on 30 September 2020
Child age in years M (SD), range
Child gender, male N (%)
Child ethnicity N (%)
Jews
Arabs
Highest parental education N (%)
Less than high school education
High school education
Some college/vocational school
Graduated from 4-year college or higher
Relationship status N (%)
Single
Married/partnered
Separated/divorced
Widow
Financial status N (%)
No financial problems
Some financial problems
Many financial problems
Hard to meet basic needs
Child injury/illness type N (%)
ABIa
Spinal Cord
Burns
Developmental after surgery
Orthopedic
Guillain Barre syndrome
Others
N ¼ 196
and child’s PTSS. Child and injury-related factors
were abstracted from medical records.
1067
(Cronbach’s a ¼.92). Cutoff score of 15 was applied
(Kassam-Adams et al., 2015).
In accordance with the Marsac et al. (2014, 2017)
biopsychosocial model, we specified SEM for PTSS, in
which pretrauma variables contributed to peritrauma
PTSS, controlling for child’s gender, age, parental education, ethnic group, and financial status. We included
pretrauma variables as concurrent predictors of child’s
self-reported PTSS. Then, we separately added MTS,
mother’s PTSS, and mother’s report of child’s PTSS,
respectively. Finally, in Figure 1, we included all variables in a combined model. In addition, we tested
whether mother’s report of child’s PTSS was a mediator between mother’s PTSS and child’s PTSS, and
whether MTS was a mediator between pretrauma social support and mother’s PTSS. In order to examine
mother’s report of child’s PTSS as a mediator, we entered child’s PTSS scores into the model as a manifest
variable and not as a latent variable (as usually required in multi-method assessment strategies involving
data collected from multiple reporters). Next, we examined the model fit and ensured that we did not inaccurately specify the model.
Missing data were managed by SPSS Version 22, using multiple imputation (Enders, 2010). We used
Little’s missing completely at random test (Little &
Rubin, 1987), which did not reach significance, suggesting that the data were missing completely at random.
Data analyses were conducted using SPSS Version 22
(for descriptive and bivariate analyses) and AMOS (for
SEM analyses). To examine the hypotheses, each type
of child’s PTSS factor (i.e., mother’s report on the child,
child’s self-report) was first examined in a separate
model, followed by a final model including both
informants’ reports. In the combined models, the residuals of each informant type were allowed to correlate.
Overall model fit was evaluated using three indices: the
v2 statistic, the comparative fit index (CFI), and the
root mean square error of approximation (RMSEA).
Hypotheses regarding mediation were tested using
bootstrapping procedures; confidence intervals (CIs) of
indirect effects were calculated using the bias-corrected
bootstrap (MacKinnon, 2008).
Mother’s PTSSs
Mother’s PTSS was evaluated using the Posttraumatic
Diagnostic Scale (PDS; Foa et al., 1997). The PDS is a
widely used 17-item self-report questionnaire for
assessing PTSS based on DSM-IV criteria for PTSD
(American Psychiatric Association, 1994). All 17 items
are summed to create a total score, with a higher score
indicating greater PTSS severity (0–51). Psychometric
evaluation has demonstrated acceptable to excellent
internal consistency, good test–retest reliability, and
acceptable convergent and concurrent validity (Foa
et al., 1997; Powers et al., 2012). To obtain an indication of whether mothers’ reported PTSD symptoms
were related specifically to their child’s medical event,
mothers were asked to complete the questions related
to their own PTSD symptoms with respect to their
child’s medical event, rather than the traumatic event
“that bothered them the most,” as in the original version. In this study, internal reliability was high for
mother’s self-report (Cronbach’s a ¼.92). A PTSD risk
cutoff score of 23 was decided based on previous
recommendations (Sheeran & Zimmerman, 2002).
Medical Team Support
A MTS measure was created for this study and was derived from the Staff PAT questionnaire (Pai et al.,
2008). The Staff PAT questionnaire is a 17-item
Likert-type rating scale that provides a parallel assessment of psychosocial risk from the perspective of the
patient’s medical team. The items correspond to the
PAT2.0 and seek to assess whether a particular risk
factor is an area of concern for the family (4-point
scale ranging from definitely no to definitely yes). The
MTS scale consisted of four items that captured the relationship between the family and the medical team
(e.g., “this family is connected to the medical team
and trusts the medical team”). A sum score of the four
items was conducted (0–16). Internal consistency for
the Staff PAT in the current sample was Cronbach’s
a ¼ .82.
Statistical Analysis
We first examined bivariate relationships (using
Pearson’s correlations and chi-square) among key
study variables. Bivariate analyses of demographic, injury/illness type, and pretrauma variables with child’s
and mother’s PTSS provided an initial examination of
the model. We then used structural equation modeling
(SEM) with maximum likelihood parameter estimation (Raykov & Marcoulides, 2006), to explore and
test the complex patterns of relationships between the
hypothesized pretrauma variables and child’s and
mother’s PTSS.
Results
Bivariate Analyses
Levels of Posttraumatic Symptoms in the Sample
Approximately 27% of the children in our sample selfreported significant levels of PTSS (i.e., > 15) and mothers’ reports of their child’s PTSS indicated that 38%
had significant levels of symptoms (i.e., > 15). Mothers’
self-reports of their own level of PTSS revealed that
21% had significant levels of symptoms (i.e., >23;).
Demographics and Injury/Illness Characteristics
Mothers were more likely to have above-clinical
cutoff scores if they had less than a high school education
Downloaded from https://academic.oup.com/jpepsy/article/45/9/1063/5910717 by Bar Ilan University user on 30 September 2020
Child and Family Factors Associated With Posttraumatic Stress
Sadeh, Dekel, Brezner, Landa, and Silberg
1068
Ethnic
group
-.135*
Child pre-TME
emotional functioning
Mother PTSS
0.20**
0.71**
Family
functioning
0.23**
0.59**
Child PTSS
Mother
report
0.38**
Social support
0.24*
0.23**
.128*
Family structure
& resources
Medical team
support
Financial
difficultie
Figure 1. Completed structural equation model including standardized estimates (N ¼ 196). Model Fit, X2 (196) ¼ 4.781,
p ¼ .311, comparative fit index ¼ 0.998, root mean square error of approximation ¼ 0.032, TLI ¼ 0.973, X2/df ¼ 1.19.
***p < .001, **p < .01, and *p < .05. Not pictured: covariates relationships (i.e., child age, gender, and parental education;
none had a direct effect on PTSS).
(v2 ¼ 10.33, p < .05), or had Arab ethnicity (v2 ¼ 7.62,
p < .05). They were more likely to have below the PTSS
clinical cutoff scores if they had some college/vocational
school education (v2 ¼ 9.51, p < .05). Children were
more likely to have below clinical PTSS cutoff scores if
their family had no financial difficulties (v2 ¼ 7.27,
p < .05). Accordingly, parental education, ethnic group,
and financial status were retained as a covariates in the
tested models (see Table II). Bivariate analyses suggested
that family social support was associated with child’s age
(r ¼ .170, p < .05), and less social support (higher score)
was associated with older age. Child’s gender and type of
medical event involved were not related to any of the
study variables. Accordingly, only child’s age was
retained as a covariate in the tested models.
Child’s self-reported PTSS score positively correlated with child’s pre-TME emotional functioning
(r ¼ .20 p < .001), family structure and resources
(r ¼ .32 p < .005), family functioning (r ¼ .26
p < .005), and mother’s PTSS (r ¼ .33 p < .005).
Positive associations were also found between each
pretrauma variable and mother’s report of child’s
PTSS. Child’s emotional functioning (r ¼ .30
p < .005), family structure and resources (r ¼ .30
p < .005), and family functioning (r ¼ .37 p < .005),
were significantly positively correlated with mother’s
own PTSS score.
Positive associations were found between MTS and
all pretrauma variables: child’s emotional functioning
(r ¼ .64 p < .005); family structure and resources
(r ¼ .16 p < .05); family functioning (r ¼ .30 p < .005);
and social support (r ¼ .33, p < .005). MTS was
positively related to mother’s report of child’s PTSS
(r ¼ .42 p < .05). Furthermore, positive associations
were found between child’s self-reported PTSS, mother’s report of child’s PTSS, and mother’s report of her
own PTSS (r ¼ .33–.74, p < .005).
Structural Models
The hypothesized model, which included mother’s
PTSS and MTS as mediators between pretrauma psychosocial factors and child’s PTSS fit the data well, X2
(196) ¼ 4.781, p ¼ .311, CFI ¼ 0.998, RMSEA ¼
0.032, and TLI ¼ 0.973 (see Figure 1 for the complete
model). As to our hypotheses, the results were as follows. Family’s pretrauma structure and resources, and
financial difficulties, were positively associated with
child’s self-reported PTSS (structure and resources
standardized b ¼ .243, p < .001, financial difficulties
standardized b¼.128, p < .05), with less family resources and more financial difficulties associated with
higher levels of PTSS. Family’s ethnic group, pretrauma structure and resources, child’s pretrauma
emotional functioning, and family’s pretrauma functioning were positively associated with mother’s PTSS
(ethnic group standardized b ¼ .135, p < .05, structure and resources standardized b ¼ .229, p < .001;
child’s emotional functioning standardized b ¼ .203,
p < .001; family’s functioning standardized b ¼ .256,
p < .001), with Arab ethnicity, less family resources,
higher levels of child’s emotional problems, and
poorer family functioning being associated with higher
maternal PTSS. Mother’s PTSS mediated the effects of
Downloaded from https://academic.oup.com/jpepsy/article/45/9/1063/5910717 by Bar Ilan University user on 30 September 2020
Child PTSS
Child report
-0.18*
Child and Family Factors Associated With Posttraumatic Stress
1069
Table II. Correlations Between Pretrauma Psychosocial Factors, Peritrauma Environmental Factors, and Child’s
Posttraumatic Stress Factors (N ¼ 196)
Variable
2
3
4
5
6
7
1
0.08
0.32**
0.12
0.30**
0.64**
0.20**
0.30**
1
0.27**
0.28**
0.30**
0.16*
0.32**
0.21**
1
0.17*
0.37**
0.30**
0.26**
0.30**
1
0.13
0.33**
0.03
0.17*
1
0.13
0.33**
0.74**
1
0.08
0.19**
1
0.42**
*p < .05 (two-tailed); **p < .01 (two-tailed).
the following: family’s pretrauma functioning on
mother’s report of child’s PTSS (bootstrap estimate of
the indirect effect was 12.07 p < .05, 95% CI [4.12,
21.8]), child’s pretrauma emotional functioning on
mother’s report of child’s PTSS (bootstrap estimate of
the indirect effect was 11.22 p < .05, 95% CI [6.25,
19.33]), and family’s pretrauma structure and resources on mother’s report of child’s PTSS (bootstrap estimate of the indirect effect was 0.16 p < .05, 95% CI
[0.04, 0.28]). MTS mediated the effect of family’s pretrauma social support on mother’s PTSS (bootstrapped estimate of the indirect effect was .026, p <
.05, 95% CI [12.01, .83]). Mother’s PTSS was not
significantly associated with child’s self-reported
PTSS, a finding that did not support our hypothesis;
however, mother’s PTSS was strongly associated with
mother’s report of child’s symptoms (mother’s PTSS
standardized b ¼ .72, p < .001). Mother’s report of
child’s PTSS significantly contributed to child’s PTSS.
Finally, mother’s report of child’s PTSS mediated the
effect of mother’s PTSS on child’s PTSS (see Figure 1).
Bootstrapped estimate of the indirect effect was .056,
p < .05, 95% CI [0.12, 0.32].
Discussion
The aim of this study was to expand the current understanding of the development of PTSS following
TMEs in children, focusing on the pre and peritrauma
periods. This research supports the integration of selected variables from the biopsychosocial theoretical
model of PTSS (Marsac et al., 2014), after TMEs, for
an understanding of children’s PTSS.
In our study, 27% of the children self-reported significant symptoms of PTS. Parents’ reports on child’s
PTSS indicated that 38% of the children and youth
had significant symptoms. In addition, parents’ selfreports of their own level of PTS symptoms revealed
21% with significant symptoms, and similar rates
have been reported for parents following TMEs
(Landolt et al., 2012; Price et al., 2016). Our results
regarding child’s symptoms are in accordance with
previous reports suggesting that approximately 30%
of ill and injured children experience significant PTSS
(Price et al., 2016). Furthermore, the observed discrepancy in our study between child’s self-reports and
parents’ proxy reports of child’s symptoms, has been
demonstrated in various trauma populations (Egberts
et al., 2018; Shemesh et al., 2005). We elaborate on
the possible explanation for such a discrepancy below.
This study extends past work by revealing that
among the various psychosocial risk factors that were
examined, the family’s pretrauma structure and
resources had unique, independent relationships with
the child’s self-reported PTSS. These findings are consistent with earlier findings showing that lower parental income (Delahanty et al., 2005), and lower
parental education (Vanderbilt et al., 2009) are associated with higher stress responses among families. It
may be that people who grow up in lower-class environments (as may be reflected in a family with fewer
resources and an unstable family structure) are objectively characterized by having heightened vigilance to
threat (Manstead, 2018). Thus, in light of our findings, family’s pretrauma structure and resources are
important pre- and peri-TME factors associated with
the development of child’s PTSS following TMEs.
Child’s pretrauma emotional functioning and
family’s pretrauma functioning did not have an independent relationship with child’s self-reported PTSS
or with mother’s report on child’s PTSS. Early studies of traumatic events among children found similar
findings (Udwin et al., 2000), whereas a metaanalysis found a significant contribution of child’s
pretrauma emotional functioning to child’s PTSS
(Cox et al., 2008; Trickey et al., 2012). These mixed
findings might be understood in light of our results
indicating that child’s pretrauma emotional functioning and family’s pretrauma functioning were
both strongly associated with mothers’ PTSS at the
peritrauma period. Similarly, among the psychosocial variables in the aftermath of a serious illness or
injury, child’s behavioral problems within the family
context and parent’s mental health factors play a
major role in the parent’s own stress reactions
(Muscara et al., 2017).
Downloaded from https://academic.oup.com/jpepsy/article/45/9/1063/5910717 by Bar Ilan University user on 30 September 2020
1. Child function
2.Family structure and resources
3.Family function
4. Social support
5. Mother’s PTSS
6. MTS
7. Child’s PTS-child’s report
8. Child’s PTSS-mother’s report
1
1070
Our third main goal was to examine the effect of
mother’s PTSS and mother’s report of child’s PTSS on
child’s self-reported PTSS. Although mother’s PTSS
during the peritrauma period did not contribute directly to child’s co-occurring PTSS, mother’s report of
child’s PTSS served as a mediator between mother’s
PTSS and child’s PTSS.
These findings are consistent with earlier studies
that found higher concordance between symptoms
when parents reported on both their and their child’s
symptoms (De Young et al., 2014; Landolt et al.,
2012) than in studies in which the parent and the child
each reported on their own symptoms (Dame et al.,
2014; Wise & Delahanty, 2017). These findings highlight the complexity underlying systemic family effects,
in which a mother’s perceptions of her child’s symptoms play a large role in the child’s development of
PTSS. Recently, the role of parents’ cognitive appraisals regarding their child’s recovery was reported as a
potentially central theme in the development of PTSS
in children, perhaps explaining why parents’ responses
are critical to their children’s outcomes (Schilpzand
et al., 2018). Parents’ reports of their child’s PTSS
might embody their cognitions regarding the child’s recovery, and might relate to the child’s PTSS by either
directly influencing how a parent helps the child appraise the traumatic experience in conversation, or indirectly by how these cognitions influence a parent’s
mental health and compromise parenting practices
(Schilpzand et al., 2018). However, this association
merits further study to better understands how parents’
stress symptoms and their report of their child’s symptoms can impact the child’s recovery.
Study Limitations
This study has several limitations. First, it is crosssectional, precluding conclusions about causality. In
order to examine mechanisms of interfamilial stress
responses, prospective studies—which would examine
risk and protective factors for PTSS within the child
and the parents and would provide valuable insight
into the family’s response to medical trauma—are
needed. In addition, due to the heterogeneity of etiologies, we could not examine the role of illness/injury severity on mother’s and child’s PTSS. As far as we
know, there is no single measure that can compare the
severity of illness among all the etiologies presented in
this study. In a previous study conducted in our department examining emotional distress among mothers of children with chronic physical disabilities,
emotional distress was not related to the child’s specific injury etiology (Silberg et al., 2016). In addition,
history of prior traumatic experiences is another significant risk factor which was not included in this
study and should be included in further studies
(Finkelhor et al., 2009).
Downloaded from https://academic.oup.com/jpepsy/article/45/9/1063/5910717 by Bar Ilan University user on 30 September 2020
With regard to the role of mothers’ PTSS in the development of child’s PTSS, our findings show that
mother’s PTSS significantly mediated the relationship
between child’s pre-existing emotional functioning,
family functioning, and family structure and resources, and the mother’s report of the child’s PTSS.
However, as opposed to our hypothesis, mothers’
PTSS did not mediate the relationship between the
above factors and child’s self-reported PTSS. These
mixed results may reflect discrepancies in the reports
of child’s symptoms between different informants
(i.e., parent or child). Studies indicate that following a
child’s TME, parents with more stress symptoms report higher symptoms in their child, suggesting
parents’ symptoms biasing them to recall more negative information in terms of child problems (Dame
et al., 2014; Shemesh et al., 2005). Thus, studies indicate that mother and child views on child traumatic
stress reactions differ, and the methods of assessing
PTSS might explain the equivocal nature of the findings (Egberts et al., 2018).
Beyond pretrauma factors, this study also examined
for the first time the potential mediational role of MTS,
in the association between pretrauma risk factors and
child’s levels of PTSS. We found that mothers who
reported higher pretrauma social support tended to require more support from the medical team in the peritrauma period. Such findings are consistent with the
biopsychosocial model (Marsac et al., 2014), and can
also be viewed in light of evolutionary approaches and
attachment theory. These suggest that human beings
have a basic need for social connection, and that social
disconnection is painful because it runs counter to this
fundamental need (Baumeister & Leary, 1995; Bowlby,
1981). Thus, although examining mothers’ attachment
processes is outside the scope of this study, the current
findings may demonstrate that a mother’s predisposition
towards receiving social support allows her to obtain
support from a medical team in times of stress.
Furthermore, mothers who made more use of MTS
(as perceived by the medical team) were also the ones
presenting higher levels of PTSS. Similar findings were
found in a recent study examining the consequences of
parental PTSS on service utilization by parents and children following serious illness or injury, where severity of
PTSS predicted being in a higher utilization group of
physical and psychological services 12 months later
(Thompson et al., 2017). These findings may be encouraging, suggesting that individuals with the greatest needs,
in terms of PTSS severity, are more likely than others to
engage MTS (Thompson et al., 2017). However, as this
study was cross-sectional, it is not possible to assess the
utility and effectiveness of the support given by the medical team. A prospective analysis of health service utilization in trauma-exposed parents may allow a better
understanding.
Sadeh, Dekel, Brezner, Landa, and Silberg
Child and Family Factors Associated With Posttraumatic Stress
Clinical Implications
This study highlights the importance of screening every family who has a member hospitalized after a
TME. Driven by a trauma-informed care approach
(Marsac et al., 2016), all children and families are
viewed as potentially experiencing a traumatic event
in the past or as experiencing their current medical
care as traumatic. Medical teams working in this context are a significant source of support for the family
during this period. Health-care providers who are
knowledgeable about medical traumatic stress have
the opportunity to minimize the potentially traumatic
aspects of medical care and identify children and families with persistent distress (Cutuli et al., 2019).
Acknowledgements
The authors thank the families for their participation
in this study. They also thank the psychosocial
pediatric rehabilitation team and Gal Hayuni (RA) for
their collaboration
collection.
and
assistance
with
data
Conflicts of interest: None declared.
References
American Psychiatric Association. (1994). Diagnostic and
statistical manual of mental disorders (4th edn). American
Psychiatric Association.
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders. (5th edn). American
Psychiatric Association. https://doi.org/10.1176/
Azevedo, M., de, S. N., Oliveira, I. C. D. S., Souza, T. V., de,
Moraes, de, J. R. M. M., Martinez, E. A., & Ara
ujo, B. D
S. (2018). Empowerment of the mothers of children in a
pediatric intensive care unit. Revista Brasileira de
Enfermagem, 71, 998–1006. https://doi.org/10.1590/
0034-7167-2016-0689
Baumeister, R. F., & Leary, M. R. (1995). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin, 117,
497–529. https://doi.org/10.1037/0033-2909.117.3.497
Bowlby, J. (1981). Attachment and loss (2nd edn). Basic
Books.
Brosbe, M. S., Hoefling, K., & Faust, J. (2011). Predicting
posttraumatic stress following pediatric injury: A systematic review. Journal of Pediatric Psychology, 36, 718–729.
https://doi.org/10.1093/jpepsy/jsq115
Brown, E. A., De Young, A., Kimble, R., & Kenardy, J.
(2018). Review of a parent’s influence on pediatric procedural distress and recovery. Clinical Child and Family
Psychology Review, 21, 224–245. https://doi.org/10.1007/
s10567-017-0252-3
Centers for Disease Control & Prevention. (2014). Injury
prevention and control: Data and statistics (WISQARS).
http://www.cdc.gov/ injury/wisqars/nonfatal.html.
Cohen, E. (2009). Parenting in the throes of traumatic events:
Risks and protection. In D. Brom, R. Pat-Horenczyk, & J.
D. Ford (Eds.), Treating traumatized children: Risk, resilience and recovery (pp. 72–84). Routledge.
Cohen, S. (2004). Social relationships and health. American
Psychologist, 59, 676–684. https://doi.org/10.1177/
01949813477823
Cox, C. M., Kenardy, J. A., & Hendrikz, J. K. (2008). A
meta-analysis of risk factors that predict psychopathology
following accidental trauma. Journal for Specialists in
Pediatric Nursing, 13, 98–110. https://doi.org/10..1111/j.
1744-6155.2008.00141.x
Cutuli, J. J., Alderfer, M. A., & Marsac, M. L. (2019).
Introduction to the special issue: Trauma-informed care
for children and families. Psychological Services, 16, 1–6.
https://doi.org/10.1037/ser0000330
Dame, K., Berkowitz, S., & Carla, S. S. (2014). Parenting
behaviors and posttraumatic symptoms in relation to
children’s symptomatology following a traumatic event.
Applied Computational Electromagnetics Society Journal,
29, 316–327. https://doi.org/10.1002/jts.
De Young, A. C., Hendrikz, J., Kenardy, J. A., Cobham, V.
E., & Kimble, R. M. (2014). Prospective evaluation of parent distress following pediatric burns and identification of
risk factors for young child and parent posttraumatic stress
Downloaded from https://academic.oup.com/jpepsy/article/45/9/1063/5910717 by Bar Ilan University user on 30 September 2020
In this study MTS was evaluated using the medical
team’s perceptions regarding their relationship with
the family throughout rehabilitation. The use of a
standardized measure regarding utilization of health
care resources during rehabilitation (e.g., meetings
with psychologist/social worker), so as to gauge the
family’s perceptions regarding their relationship with
the medical team, is recommended for future research.
This study presented only mother-child PTSS
reports. The reason for focusing solely on the role of
mothers (rather than fathers) in this study lies in the
fact that in most families mothers are still the primary
caregivers for children with medical conditions, both at
home (Thyen et al., 1999) and during hospitalization
(Azevedo et al., 2018). That said, by examining the role
of fathers as well, we could gain a broader understanding of within-family systemic influences of PTSS following TMEs, critically important data when adopting a
biopsychosocial framework (Egberts et al., 2018).
In addition, it may be that some of the families who
did not agree to complete the PTSS questionnaire or to
accept the MTS that was offered them were families
with high levels of PTSS. We assume that for these
families any reminder of the traumatic event might
have been threatening and unbearable at the peritrauma phase and avoiding questionnaires or MTS
may have constituted an attempt to avoid reminders
of the traumatic event (a prominent PTSS in and of itself). In addition, because of the timing of the study
(during the transition from DSM-IV to DSM-V), we
used a PTSS measure based on DSM-IV criteria which
differ slightly from DSM-V criteria. In the revised
DSM-V fifth edition, the three clusters are divided
into two distinct clusters: avoidance, and persistent
negative alterations in cognitions and mood.
1071
1072
version 3. Journal of Pediatric Psychology, 43, 737–748.
https://doi.org/10.1093/jpepsy/jsy012
Landolt, M. A., Ystrom, E., Sennhauser, F. H., Gnehm, H.
E., & Vollrath, M. E. (2012). The mutual prospective influence of child and parental post-traumatic stress symptoms in pediatric patients. Journal of Child Psychology
and Psychiatry and Allied Disciplines, 53, 767–774.
https://doi.org/10.1111/j.1469-7610.2011.02520.x
Le Brocque, R. M., Hendrikz, J., & Kenardy, J. A. (2010).
The course of posttraumatic stress in children:
Examination of recovery trajectories following traumatic
injury. Journal of Pediatric Psychology, 35, 637–645.
https://doi.org/10.1093/jpepsy/jsp050
Little, R. J. A., & Rubin, D. B. (1987). Statistical analysis
with missing data. Wiley.
MacKinnon, D. P. (2008). Introduction to statistical mediational analyses. Erlbaum.
Manstead, A. S. R. (2018). The psychology of social class:
How socioeconomic status impacts thought, feelings, and
behaviour. British Journal of Social Psychology, 57,
267–291. https://doi.org/10.1111/bjso.12251
Marsac, M. L., Kassam-Adams, N., Delahanty, D. L., Ciesla,
J., Weiss, D., Widaman, K. F., & Barakat, L. P. (2017). An
initial application of a biopsychosocial framework to predict posttraumatic stress following pediatric injury. Health
Psychology, 36, 787–796. https://doi.org/10.1037/
hea0000508
Marsac, M. L., Kassam-Adams, N., Delahanty, D. L.,
Widaman, K. F., & Barakat, L. P. (2014). Posttraumatic
stress following acute medical trauma in children: A proposed model of Bio-Psycho-Social processes during the
peri-trauma period. Clinical Child and Family Psychology
Review, 17, 399–411. https://doi.org/10.1007/s10567014-0174-2
Marsac, M. L., Kassam-Adams, N., Hildenbrand, A. K.,
Nicholls, E., Winston, F. K., Leff, S. S., & Fein, J.
(2016). Implementing a trauma-informed approach in
pediatric health care networks. JAMA Pediatrics, 170,
70–77.
https://doi.org/10.1001/jamapediatrics.2015.
2206
McCarthy, M. C., Hearps, S. J. C., Muscara, F., Anderson,
V. A., Burke, K., Hearps, S. J., & Kazak, A. E. (2016).
Family psychosocial risk screening in infants and older
children in the acute pediatric hospital setting using the
Psychosocial Assessment Tool. Journal of Pediatric
Psychology, 41, 820–829. https://doi.org/10.1093/jpepsy/
jsw055
McLaughlin, K. A., & Lambert, H. K. (2017). Child trauma
exposure and psychopathology: Mechanisms of risk and
resilience. Current Opinion in Psychology, 14, 29–34.
https://doi.org/10.1016/j.copsyc.2016.10.004
Muscara, F., McCarthy, M. C., Thompson, E. J., Heaney,
C.-M., Hearps, S. J. C., Rayner, M.Burke, K., Nicholson,
J. M., & Anderson, V. A. (2017). Psychosocial, demographic, and illness-related factors associated with acute
traumatic stress responses in parents of children with a serious illness or injury. Journal of Traumatic Stress, 30,
237–244. https://doi.org/10.1002/jts.22193
Nir, N., Ofir, Y.Oshri Weis, S. L. (2017). Child injuries in
Israel: ‘Beterem’ national report 2017. Petach-Tikva.
Downloaded from https://academic.oup.com/jpepsy/article/45/9/1063/5910717 by Bar Ilan University user on 30 September 2020
disorder.
Journal
of
Child
and
Adolescent
Psychopharmacology, 24, 9–17. https://doi.org/10.1089/
cap.2013.0066
Delahanty, D. L., Nugent, N. R., Christopher, N. C., &
Walsh, M. (2005). Initial urinary epinephrine and cortisol
levels predict acute PTSD symptoms in child trauma victims. Psychoneuroendocrinology, 30, 121–128. https://
doi.org/10.1016/j.psyneuen.2004.06.004
Egberts, M. R., van de Schoot, R., Geenen, R., & Van Loey,
N. E. E. (2018). Mother, father and child traumatic stress
reactions after paediatric burn: Within-family co-occurrence and parent-child discrepancies in appraisals of child
stress. Burns, 44, 861–869. https://doi.org/10.1016/j.
burns.2018.01.003
Enders, C. K. (2010). Applied missing data analysis. Guilford
Press.
Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2009). Lifetime
assessment of poly-victimization in a national sample of children and youth. Child Abuse and Neglect, 33, 403–411.
https://doi.org/10.1016/j.chiabu.2008.09.012
Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The
validation of a self-reported measure of post-traumatic
stress disorder. Psychological Assessment, 9, 445–451.
https://doi.org/10.1037/1040-3590.9.4.445
Foa, E. B., Johnson, K. M., Feeny, N. C., & Treadwell, K. R.
H. (2001). The Child PTSD Symptom Scale: A preliminary
examination of its psychometric properties. Journal of
Clinical Child & Adolescent Psychology, 30, 376–384.
https://doi.org/10.1207/S15374424JCCP3003_9
Fonagy, P., & Target, M. (2013). Evolution of the interpersonal interpretive function: Clues for effective preventive
intervention in early childhood. In S. W. Coates, J. L.
Rosenthal, & D. S. Schechte (Eds.), Trauma and human
bonds (pp. 99–114). The Analytic Press/Taylor & Francis
Group. https://doi.org/10.4324/9780203780527
Hilliard, M. E., McQuaid, E. L., Nabors, L., & Hood, K. K.
(2015). Resilience in youth and families living with pediatric health and developmental conditions: Introduction to
the special issue on resilience. Journal of Pediatric
Psychology, 40, 835–839. https://doi.org/10.1093/jpepsy/
jsv072
Jenness, J. L., Jager-Hyman, S., Heleniak, C., Beck, A. T.,
Sheridan, M. A., & McLaughlin, K. A. (2016).
Catastrophizing, rumination, and reappraisal prospectively predict adolescent PTSD symptom onset following a
terrorist attack. Depression and Anxiety, 33, 1039–1047.
https://doi.org/10.1002/da.22548
Kassam-Adams, N., Marsac, M. L., Garcia-Espana, J. F., &
Winston, F. (2015). Evaluating predictive screening for
children’s post-injury mental health: New data and a replication. European Journal of Psychotraumatology, 6,
29313.https://doi.org/10.3402/ejpt.v6.29313
Kassam-Adams, N., Marsac, M. L., Hildenbrand, A., &
Winston, F. (2013). Posttraumatic stress following pediatric injury. JAMA Pediatrics, 167, 1158–1165. https://doi.
org/10.1001/jamapediatrics.2013.2741
Kazak, A. E., Hwang, W.-T., Chen, F. F., Askins, M. A.,
Carlson, O., Argueta-Ortiz, F., & Barakat, L. P. (2018).
Screening for family psychosocial risk in pediatric cancer:
Validation of the Psychosocial Assessment Tool (PAT)
Sadeh, Dekel, Brezner, Landa, and Silberg
1073
http://www.beterem.org/download/files/Beterem_Child
Injury2017.pdf.
Nixon, R. D. V., Meiser-Stedman, R., Dalgleish, T., Yule,
W., Clark, D. M., Perrin, S., & Smith, P. (2013). The
Child PTSD Symptom Scale: An update and replication of
its psychometric properties. Psychological Assessment, 25,
1025–1031. https://doi.org/10.1037/a0033324
Ostrowski, S. A., Ciesla, J. A., Lee, T. J., Irish, L.,
Christopher, N. C., & Delahanty, D. L. (2011). The
impact of caregiver distress on the longitudinal development of child acute post-traumatic stress disorder
symptoms in pediatric injury victims. Journal of
Pediatric Psychology, 36, 806–815. https://doi.org/10.
1093/jpepsy/jsq113
Pai, A. L. H., Pati~
no-Fernandez, A. M., McSherry, M., Beele,
D., Alderfer, M. A., Reilly, A. T., Hwang, W.-., & Kazak,
A. E. (2008). The Psychosocial Assessment Tool (PAT
2.0): Psychometric properties of a screener for psychosocial distress in families of children newly diagnosed with
cancer. Journal of Pediatric Psychology, 33, 50–62.
https://doi.org/10.1093/jpepsy/jsm053
Pai, A. L. H., Tackett, A., Ittenbach, R. F., & Goebel, J.
(2012). Psychosocial Assessment Tool 2.0-general: Validity
of a psychosocial risk screener in a pediatric kidney transplant sample. Pediatric Transplantation, 16, 92–98. https://
doi.org/10.1111/j.1399-3046.2011.01620.x
Powers, M. B., Gillihan, S. J., Rosenfield, D., Jerud, A. B., &
Foa, E. B. (2012). Reliability and validity of the PDS and
PSS-I among participants with PTSD and alcohol dependence. Journal of Anxiety Disorders, 26, 617–623. https://
doi.org/10.1016/j.janxdis.2012.02.013
Price, J., Kassam-Adams, N., Alderfer, M. A.,
Christofferson, J., & Kazak, A. E. (2016). Systematic review: A reevaluation and update of the integrative (trajectory) model of pediatric medical traumatic stress. Journal
of Pediatric Psychology, 41, 86–12. https://doi.org/10.
1093/jpepsy/jsv074
Rachamim, L., Helpman, L., Foa, E. B., Aderka, I. M., &
Gilboa-Schechtman, E. (2011). Validation of the child
posttraumatic symptom scale in a sample of treatmentseeking Israeli youth. Journal of Traumatic Stress, 24,
356–360. https://doi.org/10.1002/jts.20639
Raykov, T., & Marcoulides, G. A. (2006). A first course in structural equation modeling (2nd edn). Mahwah, NJ: Erlbaum.
Reader, S. K., Keeler, C. N., Chen, F. F., Ruppe, N. M.,
Rash-Ellis, D. L., Wadman, J. R., Miller, R. E., & Kazak,
A. E. (2020). Psychosocial screening in sickle cell disease:
Validation of the Psychosocial Assessment Tool. Journal
of Pediatric Psychology, 45, 423–411. https://doi.org/10.
1093/jpepsy/jsaa002
Schilpzand, E. J., Conroy, R., Anderson, V., & Alisic, E. (2018).
Development and evaluation of the thinking about recovery
scale: Measure of parent posttraumatic cognitions following
children’s exposure to trauma. Journal of Traumatic Stress,
31, 71–78. https://doi.org/10.1002/jts.22258
Sheeran, T., & Zimmerman, M. (2002). Screening for posttraumatic stress disorder in a general psychiatric outpatient setting.
Journal of Consulting and Clinical Psychology, 70, 961–966.
https://doi.org/10.1037/0022-006X.70.4.961
Shemesh, E., Newcorn, J. H., Rockmore, L., Shneider, B. L.,
Emre, S., Gelb, B. D., Rapaport, R., Noone, S. A., Annunziato,
R., Schmeidler, J., & Yehuda, R. (2005). Comparison of parent
and child reports of emotional trauma symptoms in pediatric
outpatient settings. Pediatrics, 115, e582–e589.https://doi.org/
10.1542/peds.2004-2201
Silberg, T., Brezner, A., Gal, G., Ahonniska-Assa, J., &
Levav, M. (2016). The role of maternal distress in the report of behavioral and emotional problems among children with chronic disabilities. Israel Journal of Psychiatry
and Related Sciences, 53, 17–24. https://search.proquest.
com/docview/1921108553? accountid¼14483
Sint Nicolaas, S. M., Schepers, S. A., Hoogerbrugge, P. M.,
Caron, H. N., Kaspers, G. J. L., van den Heuvel-Eibrink, M.
M., Grootenhuis, M. A., & Verhaak, C. M. (2016). Screening
for psychosocial risk in Dutch families of a child with cancer:
Reliability, validity, and usability of the Psychosocial
Assessment Tool. Journal of Pediatric Psychology, 41,
810–819. https://doi.org/10.1093/jpepsy/jsv119
Storr, C. L., Ialongo, N. S., Anthony, J. C., & Breslau, N. (2007).
Childhood antecedents of exposure to traumatic events and
posttraumatic stress disorder. American Journal of Psychiatry,
164, 119–125. https://doi.org/10.1176/ajp.2007.164.1.119
Thyen, U., Kuhlthau, K., & Perrin, J. M. (1999).
Employment, child care, and mental health of mothers caring for children assisted by technology. Pediatrics, 103,
1235–1242. https://doi.org/10.1542/peds.103.6.1235
Thompson, E. J., Anderson, V. A., Hearps, S. J. C.,
McCarthy, M. C., Mihalopoulos, C., Nicholson, J. M.,
Rayner, M., & Muscara, F. (2017). Posttraumatic stress
symptom severity and health service utilization in traumaexposed parents. Health Psychology, 36, 779–786. https://
doi.org/10.1037/hea0000476
Trickey, D., Siddaway, A. P., Meiser-Stedman, R., Serpell,
L., & Field, A. P. (2012). A meta-analysis of risk factors
for post-traumatic stress disorder in children and adolescents. Clinical Psychology Review, 32, 122–138. https://
doi.org/10.1016/j.cpr.2011.12.001
Udwin, O., Boyle, S., Yule, W., Bolton, D., & O’Ryan, D.
(2000). Risk factors for long-term psychological effects of
a disaster experienced in adolescence: Predictors of post
traumatic stress disorder. Journal of Child Psychology and
Psychiatry and Allied Disciplines, 41, 969–979. https://
doi.org/10.1017/S0021963099006460
Vanderbilt, D., Bushley, T., Young, R., & Frank, D. A. (2009).
Acute posttraumatic stress symptoms among urban mothers
with newborns in the neonatal intensive care unit: A preliminary study. Journal of Developmental & Behavioral
Pediatrics,
1,
50–56.
https://doi.org/10.1097/DBP.
0b013e318196b0de
Williams, M. E., Carson, M. C., Zamora, I., Harley, E. K., &
Lakatos, P. P. (2014). Child-parent psychotherapy in the
context of the developmental disability and medical service
systems. Pragmatic Case Studies in Psychotherapy, 10,
212–226. https://doi.org/10.14713/pcsp.v10i3.1871
Wise, A. E., & Delahanty, D. L. (2017). Parental factors associated with child post-traumatic stress following injury: A consideration of intervention targets. Frontiers in Psychology, 8,
1–10. https://doi.org/10.3389/fpsyg.2017.01412
Downloaded from https://academic.oup.com/jpepsy/article/45/9/1063/5910717 by Bar Ilan University user on 30 September 2020
Child and Family Factors Associated With Posttraumatic Stress