Concordance of parent proxy report and child self-report of posttraumatic stress in children with cancer and healthy children: influence of parental posttraumatic stress.

Assessing PTSS in children may be accomplished using both parent and child reports. While more information is beneficial, it can be challenging when the reports are not concordant. A factor that may be a particularly important determinant of parent-child concordance is the presence of parental PTSS. Most events that are traumatic for a child are likely to also be perceived as traumatic for his or her parents. In some instances, the parent and child may experience the same event (e.g., natural disasters, motor vehicle accidents). In others, an injury or serious illness incurred only by the child will constitute a traumatic event for the parent as well. It seems reasonable that parents’ own PTSS may influence the levels of symptomology they report for their children. Most studies in the pediatric cancer setting have shown that parents experience elevated levels of posttraumatic stress disorder (PTSD) or PTSS relative to controls or population norms [1-4], with only a few exceptions [5]. Parent proxy report of child PTSS may be influenced by parental PTSS in two ways: First, high levels of parental PTSS may be a contributing factor to the child’s actual symptomatology. This would be demonstrated by correlations between parental PTSS and child self-reported PTSS, independent of parent proxy report. Second, regardless of the veridical level of child symptoms, parents with greater PTSS may tend to report more symptoms in their children as well. This would be evidenced by correlations between parent self-reported PTSS and child proxy report. Some studies have noted associations between parental PTSS and child self-reported PTSS [3, 6, 7], whereas others have found an association only between parental PTSS and parental perception of child PTSS (i.e., parent proxy report), but not child self-reported PTSS [8, 9]. Research regarding the potentially traumatic impact of childhood cancer has produced mixed results, with some studies demonstrating increased PTSS and PTSD among children with cancer [10-14], but a preponderance of studies suggesting low rates [2, 3, 7, 15-17]. Differences in the methodology of assessing the child’s PTSS, particularly in regard to informant, may be one factor that plays a role in the contradictory findings that are present in the literature. Studies that have utilized the parent as the informant typically report higher levels of child PTSS than those that use the child as a self-reporter [1, 13, 14]. Previous research has demonstrated inconsistency between reports of parents and children when reporting on child PTSD [3, 18]. This may reflect the well-recognized finding of poorer parent-child concordance for internalizing versus externalizing disorders among children [19]. Given a number of potentially confounding factors that could dampen concordance in the medical setting, the need to examine the concordance of parent-child reports of PTSS in this context is particularly important. Parent-child concordance may also differ as a function of the acute vs. chronic nature of the stressor. In samples experiencing more acute stressors, such as motor vehicle accidents or other trauma necessitating emergency room visits, concordance rates have been poor [18, 20-23] In contrast, in more chronic conditions such as childhood cancer, concordance rates have been better. For example, Phipps et al. [7] found a high correlation between child self-reported PTSS and parent proxy report (r = 0.69), and no significant mean differences between reporters on child PTSS. Likewise, Ingerski and colleagues [8] reported moderate correlations between child report and parent proxy reported PTSS among children in three pediatric disease groups. A methodological challenge of research on PTSS in children with cancer is determining an appropriate comparison group. How do you compare levels of PTSS among youth with different potential stressors? Perhaps related to this difficulty, few studies have utilized control groups in their examination of PTSS among youth with cancer. Those that have included controls typically orient the children with cancer to their cancer and have the healthy controls focus on their self-generated most stressful event [1, 16, 17]. In the current study, we examined concordance of parent and child reports of child PTSS, and the role that parental PTSS may play in child-parent concordance, in a sample of children with cancer and a comparison group of healthy children. The study examined three primary aims: a) the concordance between parent and child reports of child PTSS; b) the relationship between parental PTSS and child PTSS (per both reporters); and c) the relationship between parental PTSS and parent-child concordance for child PTSS. For all aims, we also examined cancer-control differences in these outcomes. We hypothesized that parent-child concordance and the relationship between parental PTSS and child PTSS would be stronger in the cancer group than in the control group due to the chronic nature of the cancer experience. We also hypothesized that greater parental PTSS would be associated with poorer parent-child concordance.