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In Reply:

Division of Oncology, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA

Axia et al offer data on post-traumatic stress reactions from a sample of 58 mothers of children on treatment for cancer in Italy. In doing so, they unfortunately misrepresent the findings of our recent study.¹

It appears that Axia et al have failed to recognize that traumatic stress responses may be understood and measured in two different ways. Post-traumatic stress symptoms (PTSS) refers to symptoms that are the hallmarks of trauma responses: intrusive thoughts, avoidance, and physiologic arousal. Post-traumatic stress disorder (PTSD) is a psychiatric diagnosis² requiring a specific constellation of symptoms, lasting for a requisite amount of time, and interfering with functioning. PTSS are typically assessed using self-report questionnaires and represented on a continuum of mild to severe. PTSD is dichotomous (present, absent) and is best confirmed by clinical interview or research measures based closely on American Psychiatric Association diagnostic criteria.

Axia et al incorrectly cite our paper as indicating "99% of parents of children under treatment for cancer have PTSD." This is not true. We reported on PTSS in a sample of parents from 125 families of children with cancer that "68% of mothers and 57% of fathers reported PTSS in the moderate to severe range" and that "all but one parent reported symptoms consistent with at least mild PTSS." We did not report PTSD data in the cited paper. To suggest that many, much less the majority, have a psychiatric diagnosis is simply inaccurate.

Given the authors' apparent confusion regarding the distinction between PTSS and PTSD, we wonder if they indeed measured PTSD in their sample and whether their methodology could have provided a reliable and valid assessment of PTSD. If they did measure PTSD, our data are not incompatible. A large body of literature supports the competence of most parents in coping with their child's illness. However, clarifying whether it is PTSS or PTSD is essential.

The broader question of the cross-cultural relevance of traumatic stress responses is interesting. Research on PTSD in response to war, violence, and natural disasters has shown that traumatic stress responses tend to be remarkably consistent across cultures and countries.^3,4 Similarly, data on PTSS for a range of pediatric illnesses and injuries from the United Kingdom, Switzerland, the Netherlands, and Australia indicate comparable ranges of PTSS in parents and patients.⁵ Clerici et al⁶ report on PTSS-like symptoms in 22 pediatric oncology patients undergoing amputation in Milan, Italy. Further research in this area will require attention to measurement issues (including conceptualization and translation) to accurately reflect the experience of parents in other cultures as they care for their children during cancer treatment.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

1. Kazak AE, Boeving CA, Alderfer MA, et al: Posttraumatic stress symptoms during treatment in parents of children with cancer. J Clin Oncol 30:7405-7410, 2005

2. American Psychiatric Association. Diagnostic and Statistical Manual of the American Psychiatric Association (ed 4). Washington, DC, American Psychiatric Press, 1994

3. Marsella A, Friedman M, Spain EH: A selective review of the literature on ethnocultural aspects of PTSD. PTSD Res Q 3:1-7, 1992

4. Ruchkin V, Schwab-Stone M, Jones S, et al: Is posttraumatic stress in youth a culture-bound phenomenon? A comparison of symptom trends in selected US and Russian communities. Am J Psychiatry 162:538-544, 2005[Abstract/Free Full Text]

5. Kazak A, Kassam-Adams N, Schneider S, et al: An integrative model of pediatric medical traumatic stress. J Pediatric Psychol 10.1093/jpepsy/jsj054 [epub ahead of print on August 10, 2005]

6. Clerici CA, Ferrari A, Luksch R, et al: Clinical experience with psychological aspects in pediatric patients amputated for malignancies. Tumori 90:399-404, 2004[Medline]

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Related Correspondence

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  Giovanna Axia, Marta Tremolada, Marta Pillon, Luigi Zanesco, and Modesto Carli
  JCO 2006 24: 2216 [Full Text]

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