[Skip to Content]
[Skip to Content Landing]
Visual Abstract. Online Videoconference-Based Group Intervention for Traumatic Stress in Parents of Children With Life-threatening Illness
Online Videoconference-Based Group Intervention for Traumatic Stress in Parents of Children With Life-threatening Illness
Figure.  The Recruitment Flow of Participants
The Recruitment Flow of Participants

ASDS indicates Acute Stress Disorder Scale; DHHS, Department of Health and Human Services.

Table 1.  Demographic Comparison of Study Groups
Demographic Comparison of Study Groups
Table 2.  Scores for Main Outcomes Between Groups Before and After the Intervention
Scores for Main Outcomes Between Groups Before and After the Intervention
Table 3.  Functional Outcomes Scores Between Groups, Before and After Intervention
Functional Outcomes Scores Between Groups, Before and After Intervention
1.
Stremler  R, Haddad  S, Pullenayegum  E, Parshuram  C.  Psychological outcomes in parents of critically ill hospitalized children.   J Pediatr Nurs. 2017;34:36-43. doi:10.1016/j.pedn.2017.01.012PubMedGoogle Scholar
2.
Franck  LS, Wray  J, Gay  C, Dearmun  AK, Lee  K, Cooper  BA.  Predictors of parent post-traumatic stress symptoms after child hospitalization on general pediatric wards: a prospective cohort study.   Int J Nurs Stud. 2015;52(1):10-21. doi:10.1016/j.ijnurstu.2014.06.011PubMedGoogle Scholar
3.
McCarthy  MC, Ashley  DM, Lee  KJ, Anderson  VA.  Predictors of acute and posttraumatic stress symptoms in parents following their child’s cancer diagnosis.   J Trauma Stress. 2012;25(5):558-566. doi:10.1002/jts.21745PubMedGoogle Scholar
4.
Price  J, Kassam-Adams  N, Alderfer  MA, Christofferson  J, Kazak  AE.  Systematic review: a reevaluation and update of the integrative (trajectory) model of pediatric medical traumatic stress.   J Pediatr Psychol. 2016;41(1):86-97. doi:10.1093/jpepsy/jsv074PubMedGoogle Scholar
5.
Landolt  MA, Ystrom  E, Sennhauser  FH, Gnehm  HE, Vollrath  ME.  The mutual prospective influence of child and parental post-traumatic stress symptoms in pediatric patients.   J Child Psychol Psychiatry. 2012;53(7):767-774. doi:10.1111/j.1469-7610.2011.02520.xPubMedGoogle Scholar
6.
Wagner  JL, Chaney  JM, Hommel  KA,  et al.  The influence of parental distress on child depressive symptoms in juvenile rheumatic diseases: the moderating effect of illness intrusiveness.   J Pediatr Psychol. 2003;28(7):453-462. doi:10.1093/jpepsy/jsg036PubMedGoogle Scholar
7.
Colletti  CJ, Wolfe-Christensen  C, Carpentier  MY,  et al.  The relationship of parental overprotection, perceived vulnerability, and parenting stress to behavioral, emotional, and social adjustment in children with cancer.   Pediatr Blood Cancer. 2008;51(2):269-274. doi:10.1002/pbc.21577PubMedGoogle Scholar
8.
Bronner  MB, Peek  N, Knoester  H, Bos  AP, Last  BF, Grootenhuis  MA.  Course and predictors of posttraumatic stress disorder in parents after pediatric intensive care treatment of their child.   J Pediatr Psychol. 2010;35(9):966-974. doi:10.1093/jpepsy/jsq004PubMedGoogle Scholar
9.
Long  KA, Marsland  AL.  Family adjustment to childhood cancer: a systematic review.   Clin Child Fam Psychol Rev. 2011;14(1):57-88. doi:10.1007/s10567-010-0082-zPubMedGoogle Scholar
10.
Landolt  MA, Vollrath  M, Ribi  K, Gnehm  HE, Sennhauser  FH.  Incidence and associations of parental and child posttraumatic stress symptoms in pediatric patients.   J Child Psychol Psychiatry. 2003;44(8):1199-1207. doi:10.1111/1469-7610.00201PubMedGoogle Scholar
11.
Bakker  A, Van Loey  NE, Van der Heijden  PG, Van Son  MJ.  Acute stress reactions in couples after a burn event to their young child.   J Pediatr Psychol. 2012;37(10):1127-1135. doi:10.1093/jpepsy/jss083PubMedGoogle Scholar
12.
Kassam-Adams  N, Fleisher  CL, Winston  FK.  Acute stress disorder and posttraumatic stress disorder in parents of injured children.   J Trauma Stress. 2009;22(4):294-302. doi:10.1002/jts.20424PubMedGoogle Scholar
13.
Shaw  RJ, Deblois  T, Ikuta  L, Ginzburg  K, Fleisher  B, Koopman  C.  Acute stress disorder among parents of infants in the neonatal intensive care nursery.   Psychosomatics. 2006;47(3):206-212. doi:10.1176/appi.psy.47.3.206PubMedGoogle Scholar
14.
Balluffi  A, Kassam-Adams  N, Kazak  A, Tucker  M, Dominguez  T, Helfaer  M.  Traumatic stress in parents of children admitted to the pediatric intensive care unit.   Pediatr Crit Care Med. 2004;5(6):547-553. doi:10.1097/01.PCC.0000137354.19807.44PubMedGoogle Scholar
15.
Lefkowitz  DS, Baxt  C, Evans  JR.  Prevalence and correlates of posttraumatic stress and postpartum depression in parents of infants in the neonatal intensive care unit (NICU).   J Clin Psychol Med Settings. 2010;17(3):230-237. doi:10.1007/s10880-010-9202-7PubMedGoogle Scholar
16.
Kazak  AE, Kassam-Adams  N, Schneider  S, Zelikovsky  N, Alderfer  MA, Rourke  M.  An integrative model of pediatric medical traumatic stress.   J Pediatr Psychol. 2006;31(4):343-355. doi:10.1093/jpepsy/jsj054PubMedGoogle Scholar
17.
Kazak  AE, Rourke  MT, Alderfer  MA, Pai  A, Reilly  AF, Meadows  AT.  Evidence-based assessment, intervention and psychosocial care in pediatric oncology: a blueprint for comprehensive services across treatment.   J Pediatr Psychol. 2007;32(9):1099-1110. doi:10.1093/jpepsy/jsm031PubMedGoogle Scholar
18.
Sahler  OJ, Varni  JW, Fairclough  DL,  et al.  Problem-solving skills training for mothers of children with newly diagnosed cancer: a randomized trial.   J Dev Behav Pediatr. 2002;23(2):77-86. doi:10.1097/00004703-200204000-00003PubMedGoogle Scholar
19.
Kazak  AE, Simms  S, Barakat  L,  et al.  Surviving cancer competently intervention program (SCCIP): a cognitive-behavioral and family therapy intervention for adolescent survivors of childhood cancer and their families.   Fam Process. 1999;38(2):175-191. doi:10.1111/j.1545-5300.1999.00176.xPubMedGoogle Scholar
20.
Rayner  M, Dimovski  A, Muscara  F,  et al.  Participating from the comfort of your living room: feasibility of a group videoconferencing intervention to reduce distress in parents of children with a serious illness or injury.   Child Fam Behav Ther. 2016;38(3):209-224. doi:10.1080/07317107.2016.1203145Google Scholar
21.
Burke  K, Muscara  F, McCarthy  M,  et al.  Adapting acceptance and commitment therapy for parents of children with life-threatening illness: pilot study.   Fam Syst Health. 2014;32(1):122-127. doi:10.1037/fsh0000012PubMedGoogle Scholar
22.
Hayes  SC, Luoma  JB, Bond  FW, Masuda  A, Lillis  J.  Acceptance and commitment therapy: model, processes and outcomes.   Behav Res Ther. 2006;44(1):1-25. doi:10.1016/j.brat.2005.06.006PubMedGoogle Scholar
23.
Stehl  ML, Kazak  AE, Alderfer  MA,  et al.  Conducting a randomized clinical trial of an psychological intervention for parents/caregivers of children with cancer shortly after diagnosis.   J Pediatr Psychol. 2009;34(8):803-816. doi:10.1093/jpepsy/jsn130PubMedGoogle Scholar
24.
Sahler  OJ, Dolgin  MJ, Phipps  S,  et al.  Specificity of problem-solving skills training in mothers of children newly diagnosed with cancer: results of a multisite randomized clinical trial.   J Clin Oncol. 2013;31(10):1329-1335. doi:10.1200/JCO.2011.39.1870PubMedGoogle Scholar
25.
Rayner  M, Muscara  F, Dimovski  A,  et al.  Take a Breath: study protocol for a randomized controlled trial of an online group intervention to reduce traumatic stress in parents of children with a life threatening illness or injury.   BMC Psychiatry. 2016;16:169. doi:10.1186/s12888-016-0861-2PubMedGoogle Scholar
26.
Bryant  RA, Moulds  ML, Guthrie  RM.  Acute Stress Disorder Scale: a self-report measure of acute stress disorder.   Psychol Assess. 2000;12(1):61-68. doi:10.1037/1040-3590.12.1.61PubMedGoogle Scholar
27.
May  FS, McLean  LA, Anderson  A, Hudson  A, Cameron  C, Matthews  J.  Father participation with mothers in the Signposts Program: an initial investigation.   J Intellect Dev Disabil. 2013;38(1):39-47. doi:10.3109/13668250.2012.748184PubMedGoogle Scholar
28.
Harvey  AG, Bryant  R.  The relationship between acute stress disorder and posttraumatic stress disorder: a prospective evaluation of motor vehicle accident survivors.   J Consult Clin Psychol. 1998;66:507-512. doi:10.1037/0022-006X.66.3.507PubMedGoogle Scholar
29.
Blevins  CA, Weathers  FW, Davis  MT, Witte  TK, Domino  JL.  The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation.   J Trauma Stress. 2015;28(6):489-498. doi:10.1002/jts.22059PubMedGoogle Scholar
30.
Bovin  MJ, Marx  BP, Weathers  FW,  et al.  Psychometric properties of the PTSD checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans.   Psychol Assess. 2016;28(11):1379-1391. doi:10.1037/pas0000254PubMedGoogle Scholar
31.
Rosendahl  J, Kisyova  H, Gawlytta  R, Scherag  A.  Comparative validation of three screening instruments for posttraumatic stress disorder after intensive care.   J Crit Care. 2019;53:149-154. doi:10.1016/j.jcrc.2019.06.016PubMedGoogle Scholar
32.
Lovibond  P, Lovibond  S.  Depression Anxiety Stress Scale. Psychology Foundation; 1995.
33.
Dreyer  Z, Henn  C, Hill  C.  Validation of the Depression Anxiety Stress Scale-21 (DASS-21) in a non-clinical sample of South African working adults.   J Psychol Afr. 2019;29(4):346-353. doi:10.1080/14330237.2019.1647499Google Scholar
34.
Bonner  MJ, Hardy  KK, Guill  AB, McLaughlin  C, Schweitzer  H, Carter  K.  Development and validation of the parent experience of child illness.   J Pediatr Psychol. 2006;31(3):310-321. doi:10.1093/jpepsy/jsj034PubMedGoogle Scholar
35.
Knafl  K, Deatrick  JA, Gallo  A,  et al.  Assessment of the psychometric properties of the Family Management Measure.   J Pediatr Psychol. 2011;36(5):494-505. doi:10.1093/jpepsy/jsp034PubMedGoogle Scholar
36.
Bond  FW, Hayes  SC, Baer  RA,  et al.  Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance.   Behav Ther. 2011;42(4):676-688. doi:10.1016/j.beth.2011.03.007PubMedGoogle Scholar
37.
Costa  J, Marôco  J, Pinto-Gouveia  J, Galhardo  A.  Validation of the Psychometric Properties of Acceptance and Action Questionnaire-II in clinical and nonclinical groups of Portuguese population.   Int J Psychol Ther. 2014;14:353-364. Accessed June 25, 2020. https://www.ijpsy.com/volumen14/num3/392/validation-of-the-psychometric-properties-EN.pdfGoogle Scholar
38.
Bohlmeijer  E, ten Klooster  PM, Fledderus  M, Veehof  M, Baer  R.  Psychometric properties of the five facet mindfulness questionnaire in depressed adults and development of a short form.   Assessment. 2011;18(3):308-320. doi:10.1177/1073191111408231PubMedGoogle Scholar
39.
Baer  RA, Smith  GT, Hopkins  J, Krietemeyer  J, Toney  L.  Using self-report assessment methods to explore facets of mindfulness.   Assessment. 2006;13(1):27-45. doi:10.1177/1073191105283504PubMedGoogle Scholar
40.
Smout  M, Davies  M, Burns  N, Christie  A.  Development of the Valuing Questionnaire (VQ).   J Contextual Behav Sci. 2014;3(3):164-172. doi:10.1016/j.jcbs.2014.06.001Google Scholar
41.
Burke  K, Moore  S.  Development of the parental psychological flexibility questionnaire.   Child Psychiatry Hum Dev. 2015;46(4):548-557. doi:10.1007/s10578-014-0495-xPubMedGoogle Scholar
42.
Carvalho  SA, Palmeira  L, Pinto-Gouveia  J, Gillanders  D, Castilho  P.  The utility of the Valuing Questionnaire in Chronic Pain.   J Contextual Behav Sci. 2018;9:21-29. doi:10.1016/j.jcbs.2018.06.002Google Scholar
43.
Cohen  J.  Statistical Power Analysis for the Behavioural Sciences. 2nd ed. Lawrence Erlbaum Associates; 1988.
44.
Wakefield  CE, Sansom-Daly  UM, McGill  BC,  et al.  Acceptability and feasibility of an e-mental health intervention for parents of childhood cancer survivors: “Cascade”.   Support Care Cancer. 2016;24(6):2685-2694. doi:10.1007/s00520-016-3077-6PubMedGoogle Scholar
45.
Richards  D, Richardson  T.  Computer-based psychological treatments for depression: a systematic review and meta-analysis.   Clin Psychol Rev. 2012;32(4):329-342. doi:10.1016/j.cpr.2012.02.004PubMedGoogle Scholar
46.
Kazak  AE, Alderfer  MA, Streisand  R,  et al.  Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial.   J Fam Psychol. 2004;18(3):493-504. doi:10.1037/0893-3200.18.3.493PubMedGoogle Scholar
47.
World Medical Association.  World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.   JAMA. 2013;310(20):2191-2194. doi:10.1001/jama.2013.281053Google Scholar
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Views 1,819
    Citations 0
    Original Investigation
    Pediatrics
    July 31, 2020

    Effect of a Videoconference-Based Online Group Intervention for Traumatic Stress in Parents of Children With Life-threatening Illness: A Randomized Clinical Trial

    Author Affiliations
    • 1Clinical Sciences, Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, Victoria, Australia
    • 2Children’s Cancer Centre, The Royal Children’s Hospital, Parkville, Victoria, Australia
    • 3Judith Lumley Centre, La Trobe University, Bundoora, Victoria, Australia
    • 4Parenting and Family Support Centre, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
    • 5Department of Psychology, University of California, Berkeley
    • 6TL Consultation Services, Menlo Park, California
    JAMA Netw Open. 2020;3(7):e208507. doi:10.1001/jamanetworkopen.2020.8507
    Key Points español 中文 (chinese)

    Question  Is an acceptance and commitment therapy–based group intervention, delivered using videoconferencing, effective in reducing posttraumatic stress symptoms in parents of very ill children?

    Findings  This randomized clinical trial found that videoconference-based acceptance and commitment therapy (compared with a waiting list) was effective in reducing posttraumatic stress symptoms in parents of very ill children.

    Meaning  This study supports the use of acceptance and commitment therapy as an approach to reduce posttraumatic stress symptoms in parents of very ill children, following an acute or unexpected illness or diagnosis, and finds that a videoconferencing platform can be used effectively to access hard-to-reach populations.

    Abstract

    Importance  A substantial proportion of parents whose child is diagnosed with a life-threatening illness experience high levels of distress that can lead to long-term mental health difficulties. This can affect the child’s recovery.

    Objective  To evaluate the efficacy of an acceptance and commitment therapy–based group intervention, delivered using videoconferencing, in reducing posttraumatic stress symptoms (PTSS) in these parents.

    Design, Setting, and Participants  This study was a randomized clinical trial of an intervention for parents with elevated acute stress symptoms. It was a single-site study conducted in a tertiary pediatric hospital in Australia. Parents of children aged 0 to 18 years admitted for a life-threatening illness or injury to the oncology, cardiology, or pediatric intensive care departments were eligible. Participants were screened for eligibility within the first month after diagnosis or admission and then were randomized to the intervention group or the waiting list control group 4 to 10 months after diagnosis or admission. Recruitment commenced January 2014, and final postintervention follow-up was completed in February 2018. Data analysis was performed from July to September 2018.

    Interventions  Treatment was a psychological acceptance and commitment therapy–based group therapy program called Take a Breath, which consisted of a 6-session parent-mediated psychological intervention delivered via online videoconferences over the course of 8 weeks. Waiting list control participants received treatment as usual and were offered the intervention 3 months after randomization.

    Main Outcomes and Measures  The primary outcome was PTSS, as measured by the Posttraumatic Stress Disorder Checklist–Version 5 (total score range, 0-80, with higher scores indicating greater symptom severity). The PTSS was measured both before and immediately after the intervention. Changes in psychological skills taught within the intervention were also evaluated, including acceptance, mindfulness, values-based living, and psychological flexibility.

    Results  Of 1232 parents who were assessed for eligibility, 313 were randomized; 161 were allocated to the waiting list control group, and 152 were allocated to the intervention group. Of those allocated, 44 parents in the waiting list group and 37 in the intervention group completed the postintervention questionnaire and were analyzed (81 participants total; mean [SD] age, 37.17 [6.43] years). Sixty-five participants (80.2%) were women, 48 participants (59.3%) were married, and 40 participants (49.4%) lived in rural or regional areas, or in a different state. In addition, 24 parents (29.6%) were in the cardiology illness group, 32 parents (39.5%) were in the oncology group, and 25 parents (30.9%) were in the pediatric intensive care unit group. The intervention group demonstrated significantly greater improvements in PTSS compared with the waiting list group (Cohen d = 1.10; 95% CI, 0.61-1.59; P = .03). The mean Posttraumatic Stress Disorder Checklist–Version 5 scores decreased from 31.7 (95% CI, 27.0-36.4) to 26.2 (95% CI, 21.8-30.7) in the waiting list control group and from 23.3 (95% CI, 18.6-28.1) to 17.8 (95% CI, 13.8-21.8) in the intervention group.

    Conclusions and Relevance  The findings of this study support the use of acceptance and commitment therapy to reduce PTSS in parents of very ill children, regardless of diagnosis. These findings also suggest that a brief, group format using a videoconferencing platform can be used effectively to access hard-to-reach populations, particularly fathers and caregivers living in nonmetropolitan areas.

    Trial Registration  Australian New Zealand Clinical Trials Registry Identifier: ACTRN12611000090910

    Introduction

    Parents of children diagnosed with a life-threatening illness or injury are faced with significant psychosocial demands that may challenge their own psychological well-being. Although most parents adapt with time, a proportion suffer from psychiatric conditions, including posttraumatic stress disorder, as a direct result of their child’s illness.1,2 Others experience subthreshold, but clinically significant, psychiatric symptoms that can lead to longer-term mental health problems.3,4 Parental mental health problems may have implications for long-term psychological, behavioral, and emotional problems for the child,5-8 because high levels of distress can impair the parent’s capacity to respond to the demands of their child’s illness9 and can affect the home environment after discharge.10 A systematic review9 of family adjustment to childhood cancer described the complex effects of child illness on family life, including the lack of time for nonessential activities, the needs of the child who is ill taking priority over those of parents and siblings, and extended periods of family separation during treatment. Importantly, these clinically significant distress reactions in parents have been found across many illnesses, including children who have experienced trauma,11,12 those admitted to pediatric or neonatal intensive care units,13-15 and those newly diagnosed with type 1 diabetes.

    Interventions targeting these early distress reactions in parents are critical, because these initial reactions have been found to be associated with long-term outcomes.3 This is consistent with the Pediatric Medical Traumatic Stress Model,16,17 which provides a useful framework in which to understand important associated factors and the development and trajectory of psychological disorders in parents associated with child medical trauma, as well as identifying the optimal time for treatment.

    Despite the emotional vulnerability of this population, evidence-based, preventive mental health interventions are lacking. The few studies18,19 that have attempted to develop and test interventions have demonstrated limited success, with some evidence supporting problem-solving and family therapy approaches in parents of children with cancer.

    Our study builds on promising pilot results20,21 to evaluate the effectiveness of Take a Breath, a brief group intervention for parents of children with a range of life-threatening illnesses and injuries. It is based on acceptance and commitment therapy (ACT)22 and comprises key elements of acceptance, mindfulness, values clarification, and goal setting. Given that intrusive thoughts, avoidance, and high levels of emotional arousal are among the most common distressing symptoms in parents of children with a serious illness or injury,23,24 the group-based ACT model was selected because it provides peer support and modeling of coping strategies and helps normalize the challenges faced by parents. The ACT-based intervention is delivered using videoconferencing to maximize accessibility for a highly stressed and geographically dispersed population.

    This study aimed to determine the efficacy of the ACT-based program in reducing posttraumatic stress symptoms (PTSS) in parents. It was hypothesized that the program would result in a significant reduction in PTSS in the intervention group compared with a control group assigned to a waiting list for the intervention. The study also investigated whether the ACT-based program resulted in improvements in the psychological skills addressed in the intervention, such as mindfulness, values-based living, and psychological flexibility. Secondary outcomes explored whether there were improvements in other aspects of parental well-being, specifically, the parent’s experience of their child’s illness and family functioning. We hypothesized that the intervention group would show significantly better functioning within these areas compared with the waiting list group.

    Method
    Study Design

    Ethics approval for this randomized clinical trial was granted by the Royal Children’s Hospital Human Research Ethics Committee. All procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Declaration of Helsinki of 1975, as revised in 2008.47 Written informed consent was obtained from eligible parents. This study follows the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline. The full protocol is available in Supplement 1 and has been published elsewhere.25

    Eligible participants were randomized to either an intervention or a waiting list control group. Parents completed questionnaires at 3 time points: within 4 weeks of their child’s diagnosis or admission (T1, screening), 2 weeks before intervention commencement, or approximately 4 to 6 months after the diagnosis or admission (T2, preintervention), and immediately after intervention completion (T3, postintervention).

    Participants

    Participants were parents of children with a recently diagnosed life-threatening illness or injury admitted to the oncology or cardiology departments or the pediatric intensive care unit (PICU) at the Royal Children’s Hospital, Melbourne, Australia. Admissions into these departments were chosen because of the sudden onset of the child’s illness and the significant threat posed to the child’s life and future functioning. Participants were recruited from consecutive first admissions to these departments from January 2014 to February 2016. Eligible participants were (1) the primary caregiver (aged ≥18 years) of a child aged 0 to 18 years; (2) parents of a child with a first-time presentation for a new cancer diagnosis, cardiac surgery within the first month of life, or admitted to the PICU for more than 48 hours; (3) parents reporting elevated levels of acute stress symptoms as measured by the Acute Stress Disorder Scale (ASDS)26; and (4) parents who were sufficiently fluent in English to complete questionnaires and participate in the program. Parents were excluded if they presented with a pre-existing psychiatric disorder, they had experienced another trauma (eg, death of family member) in the 2 months before the child’s diagnosis, they were no longer the primary caregiver at the time of the intervention, or their child was deemed eligible for palliative care (as determined by the hospital clinical care team) or had died.

    Procedure

    The child’s medical team was consulted to determine study eligibility. Parents were approached on the hospital wards (or by telephone if the child had been discharged) by the research team to discuss participation and to screen for eligibility. Screening included completion of the ASDS26 and collection of demographic information at T1. At 4 months after admission, eligible parents were contacted by telephone and invited to take part in the trial. The intervention was not undertaken in the early stages of admission to allow for natural recovery of parents’ initial acute stress reactions. The timing of the ACT-based intervention is consistent with the Kazak Pediatric Medical Traumatic Stress Model.4 In some families, both parents were eligible; however, randomization occurred at the family level. Thus, parents from the same family were always in the same condition. Partners of eligible parents who did not meet eligibility criteria were also invited to participate because they were seen as a key source of support for enacting changes27 and may have also benefited from the program. Data from parents who were invited but not eligible were not included in analyses.

    Parents were asked to consent to trial participation and were enrolled at T2 before randomization. The Murdoch Children’s Research Institute’s Clinical Epidemiology and Biostatistics Unit, independently of the research team, generated the randomization list with a computerized randomization plan generator using the method of randomly permuted blocks. Three randomly allocated lists were created, 1 for each hospital department (cardiology, oncology, and PICU). A researcher independent of participant recruitment and intervention delivery managed the lists and allocated parents to intervention or the waiting list using sequentially numbered, sealed envelopes. This process ensured that parents and the research team were blind to participant allocation at assessment. Once the intervention was completed, both the intervention and waiting list groups completed their surveys at T3.

    Intervention or Treatment

    The program is a 6-session, parent-mediated, psychological intervention based on ACT.25 It consists of five 90-minute consecutive weekly sessions, with a sixth and final session held 3 weeks after the fifth session. Parents participated from their homes using the Google Hangouts videoconferencing application (Alphabet) on a study-provided iPad (16 GB with Retina Display Wi-Fi +3G; Apple).

    Each ACT session was delivered by 2 trained mental health clinicians. Session content and structure are reported in eTable1 in Supplement 2. Intervention materials (a set of values cards, a session booklet, and guided mindfulness CD and MP3 file) were sent to parents to enhance online participation. Each ACT group consisted of a maximum of 8 parents and partners, and each participant was able to interact via video with the facilitators and other participants. Each group included parents across different stratified illness groups. Waiting list participants received standard medical treatment and allied health support that was routinely provided within their treating teams throughout their treatment.

    Facilitator Training and Program Fidelity

    A total of 4 facilitators received training in ACT and in the delivery of the intervention from a senior ACT clinician, who is a specialist in trauma-focused psychotherapy. Each session was audio recorded and reviewed fortnightly during team supervision sessions. Fidelity of program delivery was recorded and assessed using session monitoring checklists completed by both facilitators after each session. An audio recording of 1 session from each group was randomly selected and reviewed for fidelity by an independent clinician, using a fidelity monitoring checklist.

    Screening Measures

    The ASDS and a demographic information questionnaire were completed at T1 only. All other measures were completed at T2 and T3 by parents in both groups. Each measure has been evaluated as a valid and reliable measure in these clinical populations.

    The ASDS26 measures acute stress reactions within 4 weeks after a traumatic event and is highly predictive of the development of longer-term PTSS and mental health problems.3,28 The ASDS measures symptoms of dissociation, re-experiencing, avoidance, and arousal and can be scored using a total score cutoff (a score ≥56 was recommended for identifying individuals at risk of later developing posttraumatic stress disorder)26 or in terms of symptom clusters. A score of 9 or higher on the dissociative cluster, as well as a score of 28 or higher on the combined re-experiencing, avoidance, and arousal cluster scores, indicates the presence of clinically significant levels of acute stress disorder symptoms26. Both scoring methods were used in this study to determine eligibility, with parents required to be eligible on at least 1 scoring method to be invited to participate. Internal consistency (Cronbach α) was 0.80 for the ASDS total score, 0.71 for dissociation, 0.32 for re-experiencing, 0.75 for avoidance, and 0.64 for arousal.

    Primary and Secondary Outcomes

    The primary outcome was PTSS in parents as measured by the Posttraumatic Stress Disorder Checklist–Version 5 (PCL-5).29 It contains 20 items that assessed 20 criteria for posttraumatic stress disorder in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition).30 Parents were asked to complete the measure in relation to their child’s diagnosis. The total score (range, 0-80) was used, with higher scores indicating greater PTSS. The PCL-5 has been found to be a valid and reliable measure across many populations.29-31 Internal consistency for the total score in the current study was α = .93. Secondary outcomes measured included depression, anxiety, and stress (Depression, Anxiety, and Stress Scale–21)32,33; the parents’ adjustment and experience of the illness (Parent Experience of Child Illness Scale [PECI])34; and the family’s ability to manage caring for a child with a chronic condition (condition management ability subscale of the Family Management Measure).35

    Functional Outcomes: Psychological Skills Addressed by the Intervention

    Changes in the psychological skills taught within the intervention were also evaluated. These included acceptance (Acceptance and Action Questionnaire–II),36,37 various aspects of day-to-day mindfulness (Five Facet Mindfulness Questionnaire–Short Form),38,39 values-based living and the degree to which people live by their values (Valuing Questionnaire),40 and the level of psychological flexibility in parents (Parental Psychological Flexibility Questionnaire).41,42

    Demographic and Medical Information

    Information was collected regarding parent age, sex, marital and employment status, level of education, and country of birth, as well as their child’s age and sex. Medical diagnosis, date of diagnosis, and treating department were extracted from hospital medical records.

    Statistical Analysis

    To detect a difference of 7.5 (SD, 13.94) in the primary outcome measure (PCL-5), between the 2 treatment groups, with a significance level of 2-sided P < .05 and power of 0.80, 72 participants were required per group. Allowing for an estimated 35% lost to follow-up, it was projected that a total of 210 participants was needed to be randomized across the 2 groups.

    Demographic, illness group (oncology, PICU, or cardiac), and ASDS screener characteristics were compared between groups. For parent-level data (for couples that were both eligible), categorical variables were compared using generalized estimating equation models to account for within-couple correlation (with the exception of parent sex and illness group). A generalized estimating equation with a Gaussian distribution was used to compare group means of the ASDS screener. For child-level characteristics, child ages at diagnosis and at each subsequent time point were compared using negative binomial regression models because of positive skew. Time between measurements using linear regression models and illness group distributions were compared using a χ2 test.

    Generalized estimating equation models also compared mean outcome measures between groups at T3, adjusting for scores at T2 (included as a model covariate). Again, models accounted for within-couple correlations. Effect size Cohen d values were calculated between groups for T3 scores (adjusted for T2 scores) and were interpreted as small (<0.2), medium (0.2 to <0.5), large (0.5 to 0.8), and very large (>0.8).43 These analyses were all stratified by illness group.

    All analyses were performed using Stata statistical software version 15.1 (StataCorp). Two-sided statistical significance was set at P < .05. To not unduly penalize the data, multiple comparison adjustment was not applied. Data analysis was performed from July to September 2018.

    Results

    The recruitment flow of participants can be seen in the Figure. In total, 1232 parents were assessed for eligibility, and 313 were randomized (161 to the waiting list control group and 152 to the intervention group). A total of 114 of 313 parents (36.4%) who initially consented and were randomized completed the questionnaire at T2 and were enrolled in an intervention, for an attrition rate of 64%. Of those allocated, 44 parents in the waiting list group and 37 in the intervention group completed the postintervention questionnaire and were analyzed (81 participants total; mean [SD] age, 37.17 [6.43] years). Sixty-five participants (80.2%) were women, 48 (59.3%) were married, and 40 (49.4%) lived in rural or regional areas, or in a different state. In addition, 24 participants (29.6%) were in the cardiology illness group, 32 participants (39.5%) were in the oncology group, and 25 participants (30.9%) were in the PICU group.

    Reasons for nonenrollment included parents being unable to be contacted (65 parents [20.8%]), declining participation for various reasons, including time constraints (124 parents [39.6%]), and child death or unstable health since screening (8 parents [2.6%]). Results from between-group analyses are presented in Table 1, with no differences found between groups. Most parents were women (34 parents [77.3%] in the waiting list group vs 31 parents [83.8%] in the intervention group) and married (26 parents [59.1%] in the waiting list group vs 22 parents [59.9%] in the intervention group), and similar numbers were employed full time (11 parents [25.0%] in the waiting list group vs 7 parents [18.9%] in the intervention group). The mean (SD) scores on the ASDS at screening were 57.4 (10.4) for the waiting list group and 56.8 (11.4) for the intervention group.

    Preliminary analyses also explored the differences between participants who consented and participated, and those who consented but did not participate across these same sociodemographic factors (eTable 2 in Supplement 2). There were differences between the groups regarding sex, with a greater proportion of men dropping out (48 parents [34.0%] vs 16 parents [19.8%]), as well as the primary language spoken at home, with families whose primary language was not English more likely to drop out (34 parents [24.1%] vs 9 parents [11.1%]). No other significant differences were identified. Approximately half of the sample (41 parents [50.6%]) lived in metropolitan Melbourne, and half (40 parents [49.4%]) lived in rural or regional areas or in other Australian states.

    Fidelity of program delivery was rated at 98% across all sessions. There was a total of 26 groups, with group sizes ranging from 3 to 8 parents. Table 2 shows the mean scores for all outcome measures at both the T2 and T3 time points, across both groups. Analyses compared T3 group means, adjusting for T2 scores as well as illness group, with the latter being nonsignificant in all models. Significant differences were found between the intervention and waiting list groups at T2 across many outcome measures, with the ACT-based intervention group commencing the trial with fewer symptoms and higher functioning in many areas compared with the waiting list group, including PCL-5 total (mean score, 23.3 [95% CI, 18.6-28.1] vs 31.7 [95% CI, 27.0-36.4]; P = .03), PECI unresolved sorrow and anger (mean score, 1.3 [95% CI, 1.1-1.6] vs 1.8 [95% CI, 1.6-2.1]; P = .004), PECI uncertainty (mean score, 1.5 [95% CI, 1.2-1.8] vs 2.0 [95% CI, 1.8-2.3]; P < .001), and PECI negative appraisal (mean score, 1.6 [95% CI, 1.4-1.8 vs 2.1 [95% CI, 1.8-2.3; P = .03). Preintervention functioning at T2 was therefore controlled for in subsequent analyses as a model covariate. Concerning the investigation of the differences between the intervention and waiting list groups from T2 to T3, significant differences were found on the primary outcome measure (PCL-5), after accounting for preinjury functioning at T2, with greater improvements in the PTSS after the intervention. For the intervention group, mean PTSS scores decreased from 23.3 (95% CI, 18.6-28.1) at T2 to 17.8 (95% CI, 13.8-21.8) at T3. For the waiting list group, mean PTSS scores decreased from 31.7 (95% CI, 27.0-36.4) at T2 to 26.2 (95% CI, 21.8-30.7) at T3 waiting list (Cohen d = 1.10; 95% CI, 0.61-1.59; P = .03), for a mean reduction of 5.5 points for both groups. Significantly greater improvements were also found at T3 for the experience and impact of the illness on parents (ie, PECI), with greater improvements found in the emotional resources (Cohen d = 0.95; 95% CI, 0.48-1.42; P = .002), uncertainty (Cohen d = 1.34; 95% CI, 0.84-1.83; P < .001), and the overall negative appraisal subscales (Cohen d = 0.98; 95% CI, 0.51-1.44; P = .03). No additional group differences were identified in the other mental health (ie, Depression, Anxiety, and Stress Scale–21), family functioning (ie, Condition Management Ability Subscale of the Family Management Measure), and other parent experience measures (ie, PECI unresolved anger and guilt and worry subscales).

    Functional outcomes are displayed in Table 3, which report differences between the intervention and waiting list groups in the psychological skills taught in the intervention, from T2 to T3. The intervention group displayed improvements that were of a significantly larger magnitude in experiential avoidance (Acceptance and Action Questionnaire–II; specifically that parents were less avoidant and more flexible) (Cohen d = 0.80; 95% CI, 0.33-1.27; P = .02), as well as greater improvements in mindfulness, specifically in nonjudging of inner experience (Five Facet Mindfulness Questionnaire–Short Form) (Cohen d = 1.51; 95% CI, 0.99-2.01; P = .006), living according to values (Valuing Questionnaire) (Cohen d = 1.14; 95% CI, 0.65-1.62; P = .006), and committed action (Parental Psychological Flexibility Questionnaire) (Cohen d = 0.86; 95% CI, 0.39-1.34; P = .03). There were no other significant improvements in the other functional outcomes from T2 to T3.

    Discussion

    The Take a Breath program is an ACT-based group intervention designed to prevent and reduce parents’ PTSS after the diagnosis of a serious illness in their child. Delivery via online videoconferencing sought to increase accessibility. To our knowledge, this randomized clinical trial provides the first evidence internationally to support the use of this type of approach for parents of children with diverse illnesses. Before the intervention, parents randomly allocated to the intervention condition were significantly less distressed across a range of measures than parents allocated to the waiting list control group. On our primary outcome measure, parents in both the intervention and control conditions had a mean reduction on their PTSS score of 5.5 points between T2 and T3. This represented a significantly larger relative reduction for intervention parents when their lower initial distress was taken into account. On the secondary outcome measures, parents in the intervention group showed significantly greater improvements than parents in the control group on 3 aspects of their subjective experience of the illness: improved emotional resources to manage the illness, reduced perceptions of uncertainty, and reduced negative appraisal associated with their child’s illness. Inspection of the measures of psychological skills addressed by the intervention suggests that these improvements may be associated with greater acceptance, mindfulness (specifically, nonjudging inner experiences), values-based living, and committed action in parenting flexibility. Together, these results suggest that participation in the intervention improved parents’ capacity to better manage the demands of caring for a sick child and potentially ameliorated the negative impact of parental PTSS on the child.5

    The application of an ACT-based intervention is highly novel in this population, with past studies using traditional cognitive behavioral therapy18,19,43,44 or problem-solving therapy.18,24 Although we found significantly greater improvements in PTSS for parents receiving the 6-session intervention, there was no difference between groups for our secondary mental health measures of anxiety, depression, and stress. It is possible that a longer intervention is required to successfully address these additional mental health concerns; however, the program was not designed to address these symptoms. Past intervention studies in this field have all focused on the parents of children with cancer.14-16,21,41 The ACT-based intervention was beneficial regardless of the child’s illness or injury, providing support for intervention approaches that target parents across the wider hospital system. The findings also support the use of videoconferencing as a promising approach to enhance accessibility, which is a key barrier to the provision of evidence-based treatments for this population.45 Approximately half of our participants lived in rural or regional Victoria, Australia, or in another state. Use of the videoconferencing platform provided access to these parents who would not have been able to attend a traditional face-to-face service. Engaging parents within a tertiary hospital setting has been recognized as particularly challenging.20,23,44,46 Our approach also demonstrates the feasibility of using videoconferencing for a group program to provide opportunity for peer support and the normalization of experiences.

    Limitations

    Implementation of this trial presented many challenges, and our study has some limitations. Recruiting parents when their child was seriously ill was difficult, and it took 2 years to recruit the sample despite working within a large tertiary hospital. As a result, our modest sample size meant that we were only able to detect large differences between the intervention and control groups. In addition, attrition rate of parents initially screened and enrolled but then lost to follow-up before commencement of the program was 64%. Primary reasons for attrition at this stage were time constraints or feeling that intervention was not needed. Fathers and parents whose primary language was not English were overrepresented in the study dropouts. This finding is not uncommon in intervention studies and further highlights the need to ensure that recruitment and intervention materials reflect diversity and are engaging to all.23,46 Other limitations that may have biased the findings include that the study only used self-reported measures and that, at the time of postintervention assessment at T3, the participants were no longer blinded as to group allocation. Additionally, multiple comparison adjustments were not applied to secondary and functional outcomes, potentially inflating the type I error rate. Furthermore, significant baseline differences in mental health symptoms between the intervention and waiting list groups indicate that randomization did not successfully allocate equivalent groups to treatment groups. It is unclear why this occurred; hence, replication of differential postintervention improvements using a sample with equivalent groups at baseline is required to substantiate the important findings reported here.

    Conclusions

    The findings of this randomized clinical trial support the use of an ACT approach to reduce PTSS in parents of children who are seriously ill, across various illness groups, indicating that Take a Breath has potential for wide use within the pediatric hospital system. The findings also suggest that a videoconferencing format can be used in a clinically effective way to access geographically dispersed populations and engage their participation in a group program.

    Back to top
    Article Information

    Accepted for Publication: March 28, 2020.

    Published: July 31, 2020. doi:10.1001/jamanetworkopen.2020.8507

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Muscara F et al. JAMA Network Open.

    Corresponding Author: Frank Muscara, BSc (Hons), DPsych, Clinical Sciences, Murdoch Children’s Research Institute, The Royal Children’s Hospital, Flemington Road, Parkville, Victoria 3052, Australia (frank.muscara@mcri.edu.au).

    Author Contributions: Dr Muscara had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Muscara, McCarthy, Nicholson, Dimovski, McMillan, Yamada, Burke, Walser, Anderson.

    Acquisition, analysis, or interpretation of data: Muscara, McCarthy, Rayner, Nicholson, Dimovski, McMillan, Hearps.

    Drafting of the manuscript: Muscara, McCarthy, Dimovski, Hearps, Yamada.

    Critical revision of the manuscript for important intellectual content: Muscara, McCarthy, Rayner, Nicholson, Dimovski, McMillan, Hearps, Burke, Walser, Anderson.

    Statistical analysis: McCarthy, Hearps.

    Obtained funding: Muscara, Rayner, Nicholson, Anderson.

    Administrative, technical, or material support: McCarthy, Rayner, Nicholson, Dimovski, McMillan, Yamada, Burke, Walser, Anderson.

    Supervision: Muscara, McCarthy, Rayner, Nicholson, Dimovski, Burke, Walser, Anderson.

    Conflict of Interest Disclosures: Dr Nicholson reported receiving personal fees from the Australian Federal Government and grants from National Health and Medical Research Council, Roberta Holmes, and the Victoria State government outside the submitted work. No other disclosures were reported.

    Funding/Support: This project received internal funding support from the Royal Children’s Hospital Foundation and the Victorian Department of Human Services, infrastructure funding from the Victorian Government’s Operational Infrastructure Support Program, and further funding support from the Parenting Research Centre.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Data Sharing Statement: See Supplement 3.

    Additional Contributions: We thank the social workers and medical staff across the cardiology, oncology, pediatric intensive care unit, neurology, general medicine, and neonatal intensive care wards of the Royal Children’s Hospital and the pediatric intensive care unit reception staff for their support of this research, as well as all students and volunteers. Amy Coe, BSc; Claire-Marie Heaney; Melissa Dunning, MPsych; Michelle Tennant, MPsych; and Kate Noone PhD, assisted in the running of this research project.

    References
    1.
    Stremler  R, Haddad  S, Pullenayegum  E, Parshuram  C.  Psychological outcomes in parents of critically ill hospitalized children.   J Pediatr Nurs. 2017;34:36-43. doi:10.1016/j.pedn.2017.01.012PubMedGoogle Scholar
    2.
    Franck  LS, Wray  J, Gay  C, Dearmun  AK, Lee  K, Cooper  BA.  Predictors of parent post-traumatic stress symptoms after child hospitalization on general pediatric wards: a prospective cohort study.   Int J Nurs Stud. 2015;52(1):10-21. doi:10.1016/j.ijnurstu.2014.06.011PubMedGoogle Scholar
    3.
    McCarthy  MC, Ashley  DM, Lee  KJ, Anderson  VA.  Predictors of acute and posttraumatic stress symptoms in parents following their child’s cancer diagnosis.   J Trauma Stress. 2012;25(5):558-566. doi:10.1002/jts.21745PubMedGoogle Scholar
    4.
    Price  J, Kassam-Adams  N, Alderfer  MA, Christofferson  J, Kazak  AE.  Systematic review: a reevaluation and update of the integrative (trajectory) model of pediatric medical traumatic stress.   J Pediatr Psychol. 2016;41(1):86-97. doi:10.1093/jpepsy/jsv074PubMedGoogle Scholar
    5.
    Landolt  MA, Ystrom  E, Sennhauser  FH, Gnehm  HE, Vollrath  ME.  The mutual prospective influence of child and parental post-traumatic stress symptoms in pediatric patients.   J Child Psychol Psychiatry. 2012;53(7):767-774. doi:10.1111/j.1469-7610.2011.02520.xPubMedGoogle Scholar
    6.
    Wagner  JL, Chaney  JM, Hommel  KA,  et al.  The influence of parental distress on child depressive symptoms in juvenile rheumatic diseases: the moderating effect of illness intrusiveness.   J Pediatr Psychol. 2003;28(7):453-462. doi:10.1093/jpepsy/jsg036PubMedGoogle Scholar
    7.
    Colletti  CJ, Wolfe-Christensen  C, Carpentier  MY,  et al.  The relationship of parental overprotection, perceived vulnerability, and parenting stress to behavioral, emotional, and social adjustment in children with cancer.   Pediatr Blood Cancer. 2008;51(2):269-274. doi:10.1002/pbc.21577PubMedGoogle Scholar
    8.
    Bronner  MB, Peek  N, Knoester  H, Bos  AP, Last  BF, Grootenhuis  MA.  Course and predictors of posttraumatic stress disorder in parents after pediatric intensive care treatment of their child.   J Pediatr Psychol. 2010;35(9):966-974. doi:10.1093/jpepsy/jsq004PubMedGoogle Scholar
    9.
    Long  KA, Marsland  AL.  Family adjustment to childhood cancer: a systematic review.   Clin Child Fam Psychol Rev. 2011;14(1):57-88. doi:10.1007/s10567-010-0082-zPubMedGoogle Scholar
    10.
    Landolt  MA, Vollrath  M, Ribi  K, Gnehm  HE, Sennhauser  FH.  Incidence and associations of parental and child posttraumatic stress symptoms in pediatric patients.   J Child Psychol Psychiatry. 2003;44(8):1199-1207. doi:10.1111/1469-7610.00201PubMedGoogle Scholar
    11.
    Bakker  A, Van Loey  NE, Van der Heijden  PG, Van Son  MJ.  Acute stress reactions in couples after a burn event to their young child.   J Pediatr Psychol. 2012;37(10):1127-1135. doi:10.1093/jpepsy/jss083PubMedGoogle Scholar
    12.
    Kassam-Adams  N, Fleisher  CL, Winston  FK.  Acute stress disorder and posttraumatic stress disorder in parents of injured children.   J Trauma Stress. 2009;22(4):294-302. doi:10.1002/jts.20424PubMedGoogle Scholar
    13.
    Shaw  RJ, Deblois  T, Ikuta  L, Ginzburg  K, Fleisher  B, Koopman  C.  Acute stress disorder among parents of infants in the neonatal intensive care nursery.   Psychosomatics. 2006;47(3):206-212. doi:10.1176/appi.psy.47.3.206PubMedGoogle Scholar
    14.
    Balluffi  A, Kassam-Adams  N, Kazak  A, Tucker  M, Dominguez  T, Helfaer  M.  Traumatic stress in parents of children admitted to the pediatric intensive care unit.   Pediatr Crit Care Med. 2004;5(6):547-553. doi:10.1097/01.PCC.0000137354.19807.44PubMedGoogle Scholar
    15.
    Lefkowitz  DS, Baxt  C, Evans  JR.  Prevalence and correlates of posttraumatic stress and postpartum depression in parents of infants in the neonatal intensive care unit (NICU).   J Clin Psychol Med Settings. 2010;17(3):230-237. doi:10.1007/s10880-010-9202-7PubMedGoogle Scholar
    16.
    Kazak  AE, Kassam-Adams  N, Schneider  S, Zelikovsky  N, Alderfer  MA, Rourke  M.  An integrative model of pediatric medical traumatic stress.   J Pediatr Psychol. 2006;31(4):343-355. doi:10.1093/jpepsy/jsj054PubMedGoogle Scholar
    17.
    Kazak  AE, Rourke  MT, Alderfer  MA, Pai  A, Reilly  AF, Meadows  AT.  Evidence-based assessment, intervention and psychosocial care in pediatric oncology: a blueprint for comprehensive services across treatment.   J Pediatr Psychol. 2007;32(9):1099-1110. doi:10.1093/jpepsy/jsm031PubMedGoogle Scholar
    18.
    Sahler  OJ, Varni  JW, Fairclough  DL,  et al.  Problem-solving skills training for mothers of children with newly diagnosed cancer: a randomized trial.   J Dev Behav Pediatr. 2002;23(2):77-86. doi:10.1097/00004703-200204000-00003PubMedGoogle Scholar
    19.
    Kazak  AE, Simms  S, Barakat  L,  et al.  Surviving cancer competently intervention program (SCCIP): a cognitive-behavioral and family therapy intervention for adolescent survivors of childhood cancer and their families.   Fam Process. 1999;38(2):175-191. doi:10.1111/j.1545-5300.1999.00176.xPubMedGoogle Scholar
    20.
    Rayner  M, Dimovski  A, Muscara  F,  et al.  Participating from the comfort of your living room: feasibility of a group videoconferencing intervention to reduce distress in parents of children with a serious illness or injury.   Child Fam Behav Ther. 2016;38(3):209-224. doi:10.1080/07317107.2016.1203145Google Scholar
    21.
    Burke  K, Muscara  F, McCarthy  M,  et al.  Adapting acceptance and commitment therapy for parents of children with life-threatening illness: pilot study.   Fam Syst Health. 2014;32(1):122-127. doi:10.1037/fsh0000012PubMedGoogle Scholar
    22.
    Hayes  SC, Luoma  JB, Bond  FW, Masuda  A, Lillis  J.  Acceptance and commitment therapy: model, processes and outcomes.   Behav Res Ther. 2006;44(1):1-25. doi:10.1016/j.brat.2005.06.006PubMedGoogle Scholar
    23.
    Stehl  ML, Kazak  AE, Alderfer  MA,  et al.  Conducting a randomized clinical trial of an psychological intervention for parents/caregivers of children with cancer shortly after diagnosis.   J Pediatr Psychol. 2009;34(8):803-816. doi:10.1093/jpepsy/jsn130PubMedGoogle Scholar
    24.
    Sahler  OJ, Dolgin  MJ, Phipps  S,  et al.  Specificity of problem-solving skills training in mothers of children newly diagnosed with cancer: results of a multisite randomized clinical trial.   J Clin Oncol. 2013;31(10):1329-1335. doi:10.1200/JCO.2011.39.1870PubMedGoogle Scholar
    25.
    Rayner  M, Muscara  F, Dimovski  A,  et al.  Take a Breath: study protocol for a randomized controlled trial of an online group intervention to reduce traumatic stress in parents of children with a life threatening illness or injury.   BMC Psychiatry. 2016;16:169. doi:10.1186/s12888-016-0861-2PubMedGoogle Scholar
    26.
    Bryant  RA, Moulds  ML, Guthrie  RM.  Acute Stress Disorder Scale: a self-report measure of acute stress disorder.   Psychol Assess. 2000;12(1):61-68. doi:10.1037/1040-3590.12.1.61PubMedGoogle Scholar
    27.
    May  FS, McLean  LA, Anderson  A, Hudson  A, Cameron  C, Matthews  J.  Father participation with mothers in the Signposts Program: an initial investigation.   J Intellect Dev Disabil. 2013;38(1):39-47. doi:10.3109/13668250.2012.748184PubMedGoogle Scholar
    28.
    Harvey  AG, Bryant  R.  The relationship between acute stress disorder and posttraumatic stress disorder: a prospective evaluation of motor vehicle accident survivors.   J Consult Clin Psychol. 1998;66:507-512. doi:10.1037/0022-006X.66.3.507PubMedGoogle Scholar
    29.
    Blevins  CA, Weathers  FW, Davis  MT, Witte  TK, Domino  JL.  The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation.   J Trauma Stress. 2015;28(6):489-498. doi:10.1002/jts.22059PubMedGoogle Scholar
    30.
    Bovin  MJ, Marx  BP, Weathers  FW,  et al.  Psychometric properties of the PTSD checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans.   Psychol Assess. 2016;28(11):1379-1391. doi:10.1037/pas0000254PubMedGoogle Scholar
    31.
    Rosendahl  J, Kisyova  H, Gawlytta  R, Scherag  A.  Comparative validation of three screening instruments for posttraumatic stress disorder after intensive care.   J Crit Care. 2019;53:149-154. doi:10.1016/j.jcrc.2019.06.016PubMedGoogle Scholar
    32.
    Lovibond  P, Lovibond  S.  Depression Anxiety Stress Scale. Psychology Foundation; 1995.
    33.
    Dreyer  Z, Henn  C, Hill  C.  Validation of the Depression Anxiety Stress Scale-21 (DASS-21) in a non-clinical sample of South African working adults.   J Psychol Afr. 2019;29(4):346-353. doi:10.1080/14330237.2019.1647499Google Scholar
    34.
    Bonner  MJ, Hardy  KK, Guill  AB, McLaughlin  C, Schweitzer  H, Carter  K.  Development and validation of the parent experience of child illness.   J Pediatr Psychol. 2006;31(3):310-321. doi:10.1093/jpepsy/jsj034PubMedGoogle Scholar
    35.
    Knafl  K, Deatrick  JA, Gallo  A,  et al.  Assessment of the psychometric properties of the Family Management Measure.   J Pediatr Psychol. 2011;36(5):494-505. doi:10.1093/jpepsy/jsp034PubMedGoogle Scholar
    36.
    Bond  FW, Hayes  SC, Baer  RA,  et al.  Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance.   Behav Ther. 2011;42(4):676-688. doi:10.1016/j.beth.2011.03.007PubMedGoogle Scholar
    37.
    Costa  J, Marôco  J, Pinto-Gouveia  J, Galhardo  A.  Validation of the Psychometric Properties of Acceptance and Action Questionnaire-II in clinical and nonclinical groups of Portuguese population.   Int J Psychol Ther. 2014;14:353-364. Accessed June 25, 2020. https://www.ijpsy.com/volumen14/num3/392/validation-of-the-psychometric-properties-EN.pdfGoogle Scholar
    38.
    Bohlmeijer  E, ten Klooster  PM, Fledderus  M, Veehof  M, Baer  R.  Psychometric properties of the five facet mindfulness questionnaire in depressed adults and development of a short form.   Assessment. 2011;18(3):308-320. doi:10.1177/1073191111408231PubMedGoogle Scholar
    39.
    Baer  RA, Smith  GT, Hopkins  J, Krietemeyer  J, Toney  L.  Using self-report assessment methods to explore facets of mindfulness.   Assessment. 2006;13(1):27-45. doi:10.1177/1073191105283504PubMedGoogle Scholar
    40.
    Smout  M, Davies  M, Burns  N, Christie  A.  Development of the Valuing Questionnaire (VQ).   J Contextual Behav Sci. 2014;3(3):164-172. doi:10.1016/j.jcbs.2014.06.001Google Scholar
    41.
    Burke  K, Moore  S.  Development of the parental psychological flexibility questionnaire.   Child Psychiatry Hum Dev. 2015;46(4):548-557. doi:10.1007/s10578-014-0495-xPubMedGoogle Scholar
    42.
    Carvalho  SA, Palmeira  L, Pinto-Gouveia  J, Gillanders  D, Castilho  P.  The utility of the Valuing Questionnaire in Chronic Pain.   J Contextual Behav Sci. 2018;9:21-29. doi:10.1016/j.jcbs.2018.06.002Google Scholar
    43.
    Cohen  J.  Statistical Power Analysis for the Behavioural Sciences. 2nd ed. Lawrence Erlbaum Associates; 1988.
    44.
    Wakefield  CE, Sansom-Daly  UM, McGill  BC,  et al.  Acceptability and feasibility of an e-mental health intervention for parents of childhood cancer survivors: “Cascade”.   Support Care Cancer. 2016;24(6):2685-2694. doi:10.1007/s00520-016-3077-6PubMedGoogle Scholar
    45.
    Richards  D, Richardson  T.  Computer-based psychological treatments for depression: a systematic review and meta-analysis.   Clin Psychol Rev. 2012;32(4):329-342. doi:10.1016/j.cpr.2012.02.004PubMedGoogle Scholar
    46.
    Kazak  AE, Alderfer  MA, Streisand  R,  et al.  Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial.   J Fam Psychol. 2004;18(3):493-504. doi:10.1037/0893-3200.18.3.493PubMedGoogle Scholar
    47.
    World Medical Association.  World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.   JAMA. 2013;310(20):2191-2194. doi:10.1001/jama.2013.281053Google Scholar
    ×