Systematic Review: Family Resilience After Pediatric Cancer Diagnosis

Marieke Van Schoors, MSc; Line Caes, PHD; Lesley L. Verhofstadt, PHD; Liesbet Goubert, PHD; Melissa A. Alderfer, PHD


J Pediatr Psychol. 2015;40(9):856-868. 

In This Article

Abstract and Introduction


Objectives A systematic review was conducted to (1) investigate family resilience in the context of pediatric cancer, and (2) examine theoretical, methodological, and statistical issues in this literature. Family resilience was operationalized as competent family functioning after exposure to a significant risk.

Methods Following guidelines for systematic reviews, searches were performed using Web of Science, Pubmed, Cochrane, PsycInfo, and Embase. After screening 5,563 articles, 85 fulfilled inclusion criteria and were extracted for review.

Results Findings indicated that most families are resilient, adapting well to the crisis of cancer diagnosis. However, a subset still experiences difficulties. Methodological issues in the current literature hamper strong nuanced conclusions.

Conclusions We suggest future research with a greater focus on family resilience and factors predicting it, based on available theory, and conducted with attention toward unit of measurement and use of appropriate statistical analyses. Improvements in research are needed to best inform family-based clinical efforts.


Pediatric cancer is an unpredictable and uncontrollable stressor that puts the diagnosed child, his/her family members, and the family as a whole at risk for adjustment difficulties (Alderfer & Kazak, 2006). Research examining individuals' responses to the challenges posed by pediatric cancer, however, reveals resilience. For example, when compared with population norms, children diagnosed with cancer typically show no greater evidence of emotional maladjustment or psychological dysfunction (Phipps, 2007; Stam, Grootenhuis, & Last, 2001). In fact, in some studies, children with cancer demonstrate better emotional functioning than comparison groups and report benefit from their experience during treatment (Phipps, Steele, Hall, & Leigh, 2001) and positive changes within themselves, their relationships, and their plans for the future after treatment (Barakat, Alderfer, & Kazak, 2006). Similarly, most siblings of children with cancer score within normal limits on standardized measures of internalizing and externalizing disorders and may display increased empathy, maturity, and responsibility after cancer diagnosis (Alderfer et al., 2010; Houtzager, Grootenhuis, & Last, 1999). Most parents of children with cancer also exhibit resilience. After diagnosis, moderate levels of emotional distress, anxiety, and acute or posttraumatic stress symptoms are observed (Grootenhuis & Last, 1997; Patino-Fernandez et al., 2008), but most improve within a matter of months to levels of distress comparable with normative samples (Dolgin et al., 2007; Ljungman et al., 2014). Parents also report posttraumatic growth, for example, being more patient and having a better understanding of what is important in life after their child's successful cancer treatment (Barakat et al., 2006).

Although there is evidence of resilience after childhood cancer diagnosis for individual family members, research into the resilience of the family system after diagnosis of pediatric cancer is less common. Given the presumptions that a family is more than the sum of its parts (Von Bertalanffy, 1973), and that a cancer diagnosis not only affects the individuals within the family, but also their relationships with one another and the way in which the family functions (Alderfer & Kazak, 2006), it is important to understand the impact of cancer on the family as a whole. Furthermore, given the complex medical regimens of pediatric cancer, families must be able to alter roles and responsibilities, effectively communicate, manage emotions, and successfully work as a team to meet treatment demands. In short, family-level processes and outcomes are important in pediatric cancer.

While systematic reviews are available for the literature regarding family adjustment after a diagnosis of pediatric cancer (Long & Marsland, 2011; Pai et al., 2007), this work has not been conceptualized within the framework of family resilience theory. Consistent with Hilliard, Harris, and Weissberg-Benchell (2012), in which resilience was defined as achieving one or more positive outcomes despite exposure to significant risk, we defined resilient families as those that return to, sustain, or achieve competent levels of functioning in one or more domains of functioning (i.e., cohesion, adaptation, communication) after being challenged by childhood cancer. A systematic review was deemed necessary to synthesize the relevant empirical literature, which emerges across various disciplines (e.g., psychology, nursing, and medicine) using divergent (i.e., qualitative and quantitative) methods. The primary aim of the review was to determine whether there is evidence of family resilience after a diagnosis of childhood cancer. The secondary aim was to examine theoretical, methodological, and statistical issues in the existing literature and formulate recommendations for future family resilience research.