Commentary: Life Threat, Risk, and Resilience in Pediatric Medical Traumatic Stress

Since the initial descriptive studies in the 1980s, the medical traumatic stress field has grown substantially, with an estimated 8-fold increase in papers about children and their families from 2000 to 2007 compared to the 1990s (Kazak, Schneider & Kassam-Adams, in press). Pediatric conditions can be traumatic experiences across family members and a traumatic stress framework can help explain short- and long-term responses to illnesses and injuries. Traumatic stress is compelling, in part, because it maps on to a competency based framework for understanding the trajectory of adjustment, from acute stress through potential long-term effects. The two reports in this issue related to cancer (Jurbergs, Long, Ticono, & Phipps, 2007) and burns (Landolt, Buehlmann, Maag, & Schiestl, 2007) are largely consistent with the existing literature and help to advance our understanding of posttraumatic stress symptoms (PTSS) in pediatrics. In this commentary, we link these papers to three concepts key to PTSS—life threat, risk, and resiliency. Both papers highlight the importance of considering what circumstances place children and families at risk for developing PTSS (e.g., history of traumatic experiences and recurrent) or are associated with resiliency (e.g., maternal presence when the injury is occurring) and potentially growth enhancing aspects of traumatic events. Although Jurbergs et al. (2007) present some data that is somewhat discrepant from others (including some from our laboratory), we offer comments in terms of how we may understand variability across studies. In both investigations, the perception of life threat appears to be a key element that contributes to PTSS across developmental stage and type of medical condition. That is, for young children with burns, maternal presence at the time of the trauma may minimize the potential for children to perceive their burn as life-threatening (they may feel safer with their parents). This is consistent with evidence that separation anxiety may help explain traumatic stress responses for young children with burns (Stoddard et al., 2006). For parents of children with cancer, relapse could introduce or reintroduce child life-threat. Although relapse has not been studied as a discrete event, their finding is consistent with other evidence that parental perceptions of life-threat are related to PTSS (Kazak et al., 2001). Thus, a child’s severe burn or cancer diagnosis may be examples of actual or threatened harm to self or others, but yet not necessarily include the subjective experience of lifethreat that is important for not only the diagnosis of posttraumatic stress disorder (PTSD), but the development of PTSS. It is important to understand circumstances that may place children and parents at greater risk for developing PTSS after potentially traumatic events (PTE; Kazak et al., 2006) that occur as part of pediatric illness and injury. Jurbergs and colleagues (2007) highlight that increased exposure to traumatic events may result in greater PTSS. In parents of children who had relapsed, this traumatization was associated with substantively more PTSS, compared to parents of children with cancer who had not relapsed. The framing of relapse as a ‘‘second hit’’ for parents after the initial ‘‘first hit’’ of child cancer diagnosis seems useful. Indeed, parents may have more extensive trauma histories; cancer could realistically be the third, fourth, or fifth ‘‘hit.’’ Alternatively, if parents believe that their child’s chances of cure were high during initial treatment, relapse could mark the first time they perceive their child’s life as truly threatened. Both articles highlight resiliency in families of children. Acute short-term stress responses are ‘‘normal’’ and understandable in the face of potentially traumatic events. Landolt and colleagues (2007) show that interpersonal circumstances at the time can be associated with PTSS for