Family Resiliency in Childhood Cancer*

• Author: Peggy Possin,Barbara Bryne,Karla Balling,Sharon Frierdich,Marilyn McCubbin
• DOI: http://doi.org/10.1111/j.1741-3729.2002.00103.x
• Published date: 01 April 2002
• Date: 01 April 2002

2002, Vol. 51, No. 2 103

Special Collection

Family Resiliency in Childhood Cancer*

Marilyn McCubbin,** Karla Balling, Peggy Possin, Sharon Frierdich, and Barbara Bryne

Based on in-depth interviews with 42 parents (25 mothers, 17 fathers) in 26 families who had had a child treated for cancer within

the previous 3 years, resiliency factors that helped the family recover were identified. The resiliency factors included internal family

rapid mobilization and reorganization; social support from the health care team, extended family, the community, and the workplace;

and changes in appraisal to make the situation more comprehensible, manageable, and meaningful.

Childhood cancer represents a life-threatening situation for

the child and a severe trauma for the family. When a

child is diagnosed with cancer, the family systemis faced

with many new stressors and demands (e.g., repeated hospital-

izations with extensive and often painful treatments for the child,

alterations in the parent–child relationship and sibling care, pa-

rental occupational and role changes, and concerns about the

long-term effects on both the child and family). Uppermost in

the minds of parents and other family members is the question

of whether the child will survive this serious illness.

Childhood cancer is indeed the second leading cause of mor-

tality in children (Ward, 2000). However, childhood cancer sur-

vival rates now approach 70 to 80% for some types of leukemia,

and rates above 90% for Hodgkins’ disease, retinoblastoma, and

germ cell tumors have been reported (Eiser, 1998). Improved

survival rates in childhood cancer have been brought about by

more potentially toxic and intensive treatment regimens, and the

long-term physical, psychosocial, and familial effects on this

population of children and families is still being determined.

Recent advances in pediatric cancer survival have led to a

need for a shift in the research away from an emphasis on coping

with a disease that was invariably fatal to gaining a better un-

derstanding of how the child, parents, and family unit adapt and

recover both during the active treatment phase and in long-term

survival. Identifying the modifiable family psychosocial risk and

resistance factors associated with treatment can help target those

who are at particular risk and identify and implement sound pro-

active intervention strategies.

One research emphasis of childhood cancer in the family

has focused on the prevalence of posttraumatic stress disorder

(PTSD) or posttraumatic stress symptoms (PTSS) in the parents.

Reports of current PTSD in mothers of survivors has ranged

from 6.2% (Manne, DuHamel, Gallelli, Sorgen, & Redd, 1998)

to 54% for lifetime PTSD in mothers of survivors, with inter-

view data supporting the assumption that this higher level of

stress was from the childhood cancer experience (Pelcovitz et

al., 1996). Symptoms reflecting a severe level of posttraumatic

stress were found in 39.7% of mothers by Stuber, Christalkis,

Housekamp, and Kazak (1996). These traumatic stress symptoms

in mothers are related to long-term adjustment difficulties (Bar-

akat, Kazak, Gallagher, Meeske, & Stuber, 2000). Fewer studies

have examined PTSD/PTSS in fathers, but rates of 7.1% and

28.3% for severe and moderate PTSD symptoms respectively

*This study was funded by the Midwest Athletes Against Childhood Cancer Foun-

dation.

**University of Hawaii–Manoa, School of Nursing, Webster Hall, 2528 McCarthy

Mall, Honolulu, HI 96822 (mccubbin@hawaii.edu).

Key Words: cancer, childhood, illness, resiliency, social support.

(Family Relations, 2002, 51, 103–111)

(Barakat et al., 1997) and overall PTSS rates of 33.3% in fathers

(Stuber et al.) are reported. Clearly both parents are affected by

their child’s cancer, and parents of childhood cancer survivors

have higher rates of PTSD/PTSS than parents of healthy children

(Barakat et al., 1997; Pelcovitz et al.). Although these findings

can be viewed as alarming, they also indicate that well over

half—and in some samples more than three fourths—of parents

do not show evidence of PTSD or PTSS.

Earlier work has indicated that family cohesion is strength-

ened by childhood cancer, with spouses being an important

source of support for each other; however, over time as the

child’s hospitalizations increase, marital quality and spousal sup-

port declines (Barbarin, Hughes, & Chesler, 1985). Later work

also has focused on the challenges to the marital relationship in

childhood cancer with parental emotional distress, discrepant pa-

rental anxiety levels, and couple’s use of sensitizingcoping strat-

egies predicting marital distress at the time of diagnosis (Da-

hlquist et al., 1993). Depression and marital satisfaction, but not

coping style, predicted marital adjustment for both mothers and

fathers at 2 and 20 months postdiagnosis, with the child’s health

status as an additional predictor for fathers (Dahlquist, Czy-

zweski, & Jones, 1996). However, another study (Hoekstra-Wee-

bers, Jaspers, Kamps, & Klip, 1998) found discrepant coping

styles of the couple and psychological distress were positively

associated with marital dissatisfaction at 6 and 12 months post-

diagnosis.

Although there is a body of research focusing on the more

traumatic family outcomes of childhood cancer so targets for

both prevention and intervention can be identified, another focus

of the research is on the positive predictors shown to enhance

coping and family relationships. Active or engaged parental cop-

ing is associated with greater marital satisfaction, less depression

and anxiety, and better relationships with medical personnel

(Barbarin & Chesler, 1986; Wittrock, Larson, & Sandgren,

1994). Symmetry between the parents’ coping style also is as-

sociated with higher marital quality in childhood cancer (Hoek-

stra-Weebers et al., 1998).

Kupst and colleagues’ (1994) longitudinal research was

based on the overall hypothesis that most families do cope well

with the childhood cancer experience. A lack of additional stress-

ors, absence of marital problems, higher marital relationship

quality, adequate support systems, and good coping of other fam-

ily members were shown to correlate with healthy family coping

with childhood cancer consistently over the 10 years of this

study. At various points, fathers’ occupational status (at 1 and 6

years), socioeconomic status (10 years), open family communi-

cation (2 and 6 years), and ‘‘living in the present’’ (2 years) also

were significantly correlated with healthier coping.

Using the concept of salutogenesis advocated by Antono-

vosky (1987, 1994), which focuses on how individuals and fam-

ilies stay healthy rather than why they become ill, further study

is needed. Only in this way can we continue to examine the