Cancer-related Sources of Stress for Children With Cancer and Their Parents

Erin M. Rodriguez, MS; Madeleine J. Dunn, MS; Teddi Zuckerman, BS; Kathryn Vannatta, PHD; Cynthia A. Gerhardt, PHD; Bruce E. Compas, PHD


J Pediatr Psychol. 2012;37(2):185-197. 

In This Article

Abstract and Introduction


ObjectivesThe current study examines reports and correlates of cancer-specific stressors in children with cancer and their parents.
Measures Mothers (n = 191) and fathers (n = 95) reported on their own and their child's stressors, general perceived stress, and posttraumatic stress symptoms. Children (n = 106) completed self-reports of their own stressors and posttraumatic stress symptoms.
Results Mother and father self-reports were positively correlated, but mothers reported higher levels of stressors than fathers. Child and parent reports of children's stressors were positively correlated, but parents rated physical effects as more stressful while children rated role-functioning stressors as more stressful. Parents' and childrens' reports of stressors were also positively associated with general perceived stress and posttraumatic stress symptoms.
ConclusionsThe findings extend research on stress in children with cancer and their parents, and may help inform research on risk and intervention in pediatric cancer populations.


The diagnosis and treatment of childhood cancer present numerous challenges and sources of stress for children and their parents (Kupst & Bingen, 2006). Despite general agreement that cancer and its treatment can be stressful for families, more information is needed on the cancer-specific stressors that affect mothers, fathers, and children, how stressful they report these stressors to be, and how these stressors are associated with their adjustment to the disease and its treatment, particularly in children. Research on the nature, frequency, and correlates of cancer-related stressors experienced by children with cancer and their parents may provide important information regarding individual differences in risk for psychological distress and psychosocial interventions to help manage these stressors.

Several studies have examined sources of stress for parents of children with cancer. For example, Kazak and Barakat (1997) administered a general measure of parenting stress and found that higher levels of parenting stress were related to higher levels of posttraumatic stress symptoms (PTSS). Other studies have examined sources of stress directly associated with having a child with an illness using the Pediatric Inventory for Parents (PIP; Streisand, Braniecki, Tercyak, & Kazak, 2001). The PIP includes four domains of stressors related to caring for a child with a chronic illness, including communication, emotional functioning, medical care, and role function. In a sample of parents of children with cancer, Streisand et al. (2001) found that levels of stress on the PIP did not differ as a function of parental gender, marital status, education, employment status, or household income; however, the level of stress reported by parents was inversely correlated with child age. Another study with a pediatric cancer sample in the Netherlands found that higher PIP scores were correlated with younger child age, and mothers reported higher levels of stress than fathers (Vrijmoet-Wiersma et al., 2010). The finding that mothers may have higher levels of stressors is also consistent with research indicating that mothers have higher rates of cancer-related PTSS than fathers (Bruce, 2006). Several studies have also found that higher levels of parental stressors on the PIP were related to higher levels of psychological distress in parents of children with cancer (Streisand et al., 2001; Streisand, Kazak, & Tercyak, 2003; Vrijmoet-Wiersma et al., 2010). Additional research has also examined cancer-specific perceived stressors and psychological distress in childhood cancer survivors and their mothers using the Impact of Traumatic Stressors Interview Schedule (ITSIS), a semi-structured interview that measures cancer-related stressors relevant to childhood survivors of cancer and their parents in several domains, including distress, changes in perception of self, communication, and vigilance (Kazak et al., 2001; Kazak, Stuber, Barakat, & Meeske, 1996). Reports and perceptions of cancer- and treatment-related events as traumatic stressors on the ITSIS were positively associated with reports of PTSS and internalizing problems (Kazak et al., 1996, 2001).

Fewer studies have focused on stressors faced by children with cancer, and most of these studies have used general measures of life stress. For example, Currier, Jobe-Shields, and Phipps (2009) examined stressful life events that were not directly related to the child's cancer, and found that they predicted PTSS in these children. Brown, Madan-Swain, and Lambert (2003) examined stressful life events unrelated to cancer in childhood cancer survivors and found that they reported more recent and past stressful events than healthy controls. In contrast, some studies have focused directly on cancer-related stressors for children undergoing treatment (e.g., Hockenberry-Eaton, Kemp, & Dilorio 1994; Varni & Katz, 1997) or off-treatment (e.g., Kazak et al., 1996, 2001). Findings from these studies have been mixed, as some studies suggested that cancer-related stressors were not associated with children's physiological distress (Hockenberry-Eaton et al., 1994), while others found that perceived stressors were associated with higher levels of negative affect (Varni & Katz, 1997) and PTSS (Kazak et al., 2001; Kazak et al., 1996). Further, no studies with a pediatric cancer sample have measured cross-informant (e.g., parents and children) correlations of reports of children's stressors. Research and theory in developmental psychopathology and pediatric psychology has highlighted the importance of obtaining reports from the self and others for both children and adults (e.g., Achenbach, 2006, 2010; Felder-Puig, Topf, Gadner, & Formann, 2008). Significant cross-informant correlations have been found for emotional and behavioral symptoms in children, with small effects for parent–child cross-informant reports and larger effects for mother–father reports of children (Achenbach, McConaughy, & Howell, 1987). Therefore, we expected that parent–child reports of children's stressors would be moderately associated and mother–father reports of children's stressors would be more strongly associated.

In general, there is relatively little research that describes which types or domains stressors are most salient and what types of stressors are most stressful to children with cancer and their parents. To address this gap and guided by research and theory on the importance of considering specific domains and sources of stress in children and adolescents (e.g., Grant et al., 2003; McMahon, Grant, Compas, Thurm, & Ey, 2003), the current study examined cancer-related stressors in a sample of children with first diagnoses of cancer or relapsed disease and their parents. Similar to the domains of stress included on the PIP (Streisand et al., 2001), we examined stressors faced by mothers and fathers of children with cancer in several domains: daily role functioning, cancer communication, and cancer caregiving. Recent theory and research on stress has highlighted the role of the "tend-and-befriend" response that engages caretaking behaviors in parents and is heightened in women as compared with men (e.g., Han-Holbrook, Holbrook, & Haleston, 2011; Taylor & Master, 2011). We also extended this work by examining child self-reports and parents' reports of children's stressors in the domains of daily role functioning, physical effects of treatment, and uncertainty about cancer. Further, we examined how cancer-related stressors in these families were related to general perceived stress and PTSS, as previous research specifically indicates that PTSS may be elevated in these parents (e.g., Bruce, 2006; Kazak, Boeving, Alderfer, Hwang, & Reilly, 2005) and that higher levels of stressors may be related to higher levels of PTSS (e.g., Kazak & Barakat, 1997).

With regard to stressors faced by parents, we hypothesized: (a) mean levels of cancer-related stressors would be higher for mothers than fathers; (b) mothers' and fathers' levels of stressors would be positively correlated; and (c) higher levels of cancer-related stressors experienced by mothers and fathers would be positively correlated with levels of general perceived stress, younger child age, and higher levels of PTSS. We also conducted exploratory analyses comparing the different subdomains of stress (role functioning, communication, and caregiving) for mothers and fathers.

We hypothesized that with regard to stressors faced by children with cancer: (a) cross-informant reports (children's, mothers', and fathers' reports) of children's stressors would be positively correlated, and (b) higher levels of children's cancer-related stressors would be positively correlated with higher levels of PTSS. In addition, we explored the question of whether the mean levels of cancer-related stressors for children differed across informants (i.e., children, mothers, and fathers), and whether higher levels of stress for children were associated with family income and child age. We also conducted exploratory analyses comparing subdomains of stressors (role functioning, physical effects, and cancer uncertainty) for children.


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