The Role of Contextual Threat in Predicting Self-Reported Distress among Siblings of Children with Cancer

  • Kristin A. Long
  • Melissa A. Alderfer
  • Linda J. Ewing
  • Anna L. Marsland


Each year, 14,000 children are diagnosed with cancer in the United States. Prolonged, intensive treatment regimens disrupt the entire family system, but effects on siblings are poorly understood. In this preliminary investigation, we employed a risk and resistance framework to study adjustment among 30 siblings (aged 10–17) of children undergoing cancer treatment. We examined whether or not objective stress associated with the cancer experience (contextual threat) predicted sibling distress and explored demographic and disease-related predictors of sibling adjustment. Contextual threat was positively associated with sibling-reported distress, independent of sibling age, gender, birth order relative to the child with cancer, and cancer treatment intensity. From among the demographic and disease-related factors, only younger birth order relative to the child with cancer was independently associated with sibling distress. These results suggest that a subset of siblings may be at increased risk for elevated distress in the face of their brother’s or sister’s illness.


Childhood cancer Sibling Stress Contextual threat 



Caroline Stanley & Tracy Hills (Children’s Hospital of Philadelphia); Doug Williamson (University of Texas Health Science Center San Antonio); Whitney Lerch & Aimee Kemmerer (Children’s Hospital of Pittsburgh); Chelsea Howe & Megan Ganley (University of Pittsburgh Medical Center); The work was supported, in part, by a grant from the American Cancer Society (MRSG 05-213 awarded to M.A.A.).


  1. Alderfer, M. A., & Kazak, A. E. (2006). Family issues when a child is on treatment for cancer. In R. T. Brown (Ed.), Comprehensive handbook of childhood cancer and sickle cell disease: A biopsychosocial approach. New York: Oxford University Press.Google Scholar
  2. Alderfer, M., Labay, L., & Kazak, A. (2003). Brief report: Does posttraumatic stress apply to siblings of childhood cancer survivors? Journal of Pediatric Psychology, 28, 281–286.PubMedCrossRefGoogle Scholar
  3. Alderfer, M. A., Long, K. A., Lown, A., Marsland, A. L., Ostrowski, N. L., Hock, J. M., et al. (2010). Psychosocial adjustment of siblings of children with cancer: A systematic review. Psycho-Oncology, 19, 789–805.PubMedCrossRefGoogle Scholar
  4. Alderfer, M., & Noll, R. (2006). Identifying and addressing the needs of siblings of children with cancer. Pediatric Blood and Cancer, 47, 537–538.CrossRefGoogle Scholar
  5. Brown, G. W., & Harris, T. O. (1978). Social origins of depression: A study of psychiatric disorder in women. New York: Free Press.Google Scholar
  6. Carey, M. P., Faulisch, M. E., Greshman, F. M., Ruggiero, L., & Enyart, P. (1987). Children’s Depression Inventory: Construct and discriminant validity across clinical and nonreferred (control) populations. Journal of Consulting and Clinical Psychology, 55, 755–761.PubMedCrossRefGoogle Scholar
  7. Chen, E., Hanson, E. D., Paterson, L. Q., Griffin, M. J., Walker, H. A., & Miller, G. E. (2006). Socioeconomic status and inflammatory processes in childhood asthma: The role of psychosocial stress. Journal of Allergy and Clinical Immunology, 117, 1014–1020.PubMedCrossRefGoogle Scholar
  8. Cohen, S., Kamarck, T., & Marmelstein, R. (1983). A global measure of perceived stress. Journal of Health and Human Behavior, 24, 385–396.CrossRefGoogle Scholar
  9. Dunn, V. J., Abbott, R. A., Croudace, T. J., Wilkinson, P., Jones, P. B., Herbert, J., et al. (2011). Profiles of family-focused adverse experiences through childhood and early adolescence: The ROOTS project, a community investigation of adolescent mental health. BMC Psychiatry, 11, 109.PubMedCrossRefGoogle Scholar
  10. Hamama, R., Ronen, T., & Feigin, R. (2000). Self-control, anxiety, and loneliness in siblings of children with cancer. Social Work in Health Care, 31, 63–83.PubMedCrossRefGoogle Scholar
  11. Houtzager, B. A., Grootenhuis, M. A., Hoekstra-Weebers, J. E., Caron, H. N., & Last, B. F. (2003). Psychosocial functioning in siblings of paediatric cancer patients one to six months after diagnosis. European Journal of Cancer, 39, 1423–1432.PubMedCrossRefGoogle Scholar
  12. Howlader, N., Noone, A. M., Krapcho, M., Neyman, N., Aminou, R., Altekruse, S. F.,…, Cronin, K. A. (Eds). (2012). SEER cancer statistics review, 19752009 (vintage 2009 populations). Retrieved from
  13. Ialongo, N. S., Edelsohn, G., & Kellam, S. G. (2001). A further look at the prognostic power of young children’s reports of depressed mood and feelings. Child Development, 72, 736–747.PubMedCrossRefGoogle Scholar
  14. Johnson, J. H., & McCutcheon, S. M. (1980). Assessing life stress in older children and adolescents: Preliminary findings with the Life Events Checklist. In I. G. Sarason & C. D. Spielberger (Eds.), Stress and anxiety. Washington, DC: Hemisphere.Google Scholar
  15. Kim, E. Y., Miklowitz, D. J., Biuckians, A., & Mullen, K. (2007). Life stress and the course of early-onset bipolar disorder. Journal of Affective Disorders, 99, 37–44.PubMedCrossRefGoogle Scholar
  16. Koinis-Mitchell, D., McQuaid, E. L., Kopel, S. J., Esteban, C. A., Ortega, A. N., Seifer, R.,…, Canino, G. (2008). Cultural-related, contextual, and asthma-specific risks associated with asthma morbidity in urban children. Journal of Clinical Psychology in Medical Settings, 17, 38–48.Google Scholar
  17. Kovacs, M. (1981). Rating scales to assess depression in school-aged children. Acta Paedopsychiatry, 46, 305–315.Google Scholar
  18. Long, K. A., & Marsland, A. L. (2011). Family adjustment to childhood cancer: A systematic review. Clinical Child and Family Psychology Review, 14, 57–88.PubMedCrossRefGoogle Scholar
  19. Mattison, R. E., Handford, H. A., Kales, H. C., & Goodman, A. L. (1990). Four-year predictive value of the Children’s Depression Inventory. Psychological Assessment, 2, 169–174.CrossRefGoogle Scholar
  20. Maurice-Stam, H., Grootenhuis, M. A., Brons, P. P., Caron, H. N., & Last, B. F. (2007). Psychosocial indicators of health-related quality of life in children with cancer 2 months after end of successful treatment. Journal of Pediatric Hematology/oncology, 29, 540–550.PubMedCrossRefGoogle Scholar
  21. Monck, E., & Dobbs, R. (1985). Measuring life events in an adolescent population: Methodological issues and related findings. Psychological Medicine, 15, 841–850.PubMedCrossRefGoogle Scholar
  22. Muris, P., Merckelbach, H., Ollendick, T., King, N., & Bogie, N. (2002). Three traditional and three new childhood anxiety questionnaires: Their reliability and validity in a normal adolescent sample. Behaviour Research and Therapy, 40, 753–772.PubMedCrossRefGoogle Scholar
  23. Packman, W., Gong, K., VanZutphen, K., Shaffer, T., & Crittenden, M. (2004). Psychosocial adjustment of adolescent siblings of hematopoietic stem cell transplant patients. Journal of Pediatric Oncology Nursing, 21, 233–248.PubMedCrossRefGoogle Scholar
  24. Patenaude, A., & Kupst, M. (2005). Psychosocial functioning in pediatric cancer. Journal of Pediatric Psychology, 30, 9–27.PubMedCrossRefGoogle Scholar
  25. Pynoos, R., Frederick, S., Nader, K., & Arroyo, W. (1987). Life threat and posstraumatic threat in school age children. Archives of General Psychiatry, 44, 1057–1063.PubMedCrossRefGoogle Scholar
  26. Pynoos, R., Goenjian, A., Tashjian, M., Karakashian, M., Manjikian, R., Manoukian, G.,…, Fairbanks, L. (1993). Post-traumatic stress reactions in children after the 1988 Armenian earthquake. British Journal of Psychiatry, 163, 239–247.Google Scholar
  27. Reynolds, C. R. (1981). Long-term stability of scores on the Revised Children’s Manifest Anxiety Scale. Perception and Motor Skills, 53, 702.CrossRefGoogle Scholar
  28. Reynolds, C. R., & Richmond, B. O. (1985). Revised children’s Manifest Anxiety Scale: Manual. Los Angeles: Western Psychological Services.Google Scholar
  29. Robinson, K. E., Gerhardt, C. A., Vannatta, K., & Noll, R. B. (2007). Parent and family factors associated with child adjustment to pediatric cancer. Journal of Pediatric Psychology, 32, 400–410.PubMedCrossRefGoogle Scholar
  30. Rojo, L., Conesa, L., Bermudez, O., & Livianos, L. (2006). Influence of stress in the onset of eating disorders: Data from a two-stage epidemiologic controlled study. Psychosomatic Medicine, 68, 628–635.PubMedCrossRefGoogle Scholar
  31. Rudolph, K., & Hammen, C. (1999). Age and gender as determinants of stress exposure, generation, and reactions in youngsters: A transactional perspective. Child Development, 70, 660–677.PubMedCrossRefGoogle Scholar
  32. Rudolph, K. D., Hammen, C., Burge, D., Landberg, N., Herzberg, D., & Daley, S. E. (2000). Toward an interpersonal life-stress model of depression: The developmental context of stress generation. Development and Psychopathology, 12, 215–234.PubMedCrossRefGoogle Scholar
  33. Sameroff, A. J. (2000). Developmental systems and psychopathology. Development and Psychopathology, 12, 297–312.PubMedCrossRefGoogle Scholar
  34. Taylor, V., Fuggle, P., & Charman, T. (2001). Well sibling psychological adjustment to chronic physical disorder in a sibling: How important is maternal awareness of their illness attitudes and perceptions? Journal of Child Psychology and Psychiatry, 42, 953–962.PubMedCrossRefGoogle Scholar
  35. Vermaes, I. P. R., van Susante, A. M. J., & van Bakel, J. A. (2012). Psychological functioning of siblings in families of children with chronic health conditions: A meta-analysis. Journal of Pediatric Psychology, 37, 166–184.PubMedCrossRefGoogle Scholar
  36. Vrijmoet-Wiersma, C. M. J., van Klink, J. M. M., Kolk, A. M., Koopman, H. M., Ball, L. M., & Egeler, M. (2008). Assessment of parental psychological stress in pediatric cancer: A review. Journal of Pediatric Psychology, 33, 694–706.PubMedCrossRefGoogle Scholar
  37. Wallander, J. L., & Varni, J. W. (1998). Effects of pediatric chronic physical disorders on child and family adjustment. Journal of Child Psychology and Psychiatry, 39, 29–46.PubMedCrossRefGoogle Scholar
  38. Wallander, J. L., Varni, J. W., Babani, L., Banis, H. T., & Wilcox, K. T. (1989). Family resources as resistance factors for psychological maladjustment in chronically ill and handicapped children. Journal of Pediatric Psychology, 14, 157–173.PubMedCrossRefGoogle Scholar
  39. Werba, B. E., Hobbie, W., Kazak, A. E., Ittenbach, R. F., Reilly, A. F., & Meadows, A. T. (2007). Classifying the intensity of pediatric cancer treatment protocols: The Intensity of Treatment Rating Scale 2.0 (ITR-2-2). Pediatric Blood and Cancer, 48, 673–677.CrossRefGoogle Scholar
  40. Williamson, D. E., Birmaher, B., Ryan, N. D., Shiffrin, T. P., Lusky, J. A., Protopapa, J.,…, Brent, D. A. (2003). The Stressful Life Events Schedule for children and adolescents: Development and validation. Psychiatry Research, 119, 225–241.Google Scholar
  41. Wisniewski, J. J., Mulick, J. A., Genshaft, J. L., & Coury, D. L. (1987). Test-restest reliability of the Revised Children’s Manifest Anxiety Scale. Perception and Motor Skills, 65, 67–70.CrossRefGoogle Scholar
  42. Wolf, J. M., Nicholls, E., & Chen, E. (2008). Chronic stress, salivary control, and alpha-amylase in children with asthma and healthy children. Biological Psychology, 78, 20–28.PubMedCrossRefGoogle Scholar
  43. Worchel, F. F., Rae, W. A., Olson, T. K., & Crowley, S. L. (1992). Selective responsiveness of chronically ill children to assessments of depression. Journal of Personality Assessment, 59, 605–615.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Kristin A. Long
    • 1
    • 2
  • Melissa A. Alderfer
    • 3
  • Linda J. Ewing
    • 4
  • Anna L. Marsland
    • 1
  1. 1.Department of PsychologyUniversity of PittsburghPittsburghUSA
  2. 2.Bradley Hasbro Children’s Research CenterProvidenceUSA
  3. 3.Division of Oncology, The Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  4. 4.Department of PsychiatryUniversity of PittsburghPittsburghUSA

Personalised recommendations