Assessment of PTSS, pain, depression and family functioning
We assessed the Children’s PTSS using the Chinese version of the 22-item self-report University of California at Los Angeles PTSD Reaction Index for DSM-IV (PTSDI)23, which is designed to assess PTSS in children and adolescents aged 6-18 years. The children rated their response to the medical treatment they had received in the last month on a 5-point scale from 0 (never before) to 4 (most of the time). The total score ranges from 0 to 88, with a higher total score indicating a greater symptom severity. A value of 38 or above on the full scale suggests a high sensitivity and specificity of PTSD diagnosis. In this study, Cronbach’s α was 0.892 for the overall scale.
Cancer pain in the children was assessed using the Visual Analog Scale (VAS). The child marked a point on a 10-cm-long line with the two ends representing “no pain” and “unbearable pain” according to the pain severity he or she felt at that time. The length of the straight line from the starting point to the mark was measured to represent the pain severity. Study has shown that VAS is reliable and reproducible for assessing pain in children24.
We measured PTSS in the enrolled parents using the Chinese version of the 17-item self-report Post-Traumatic Stress Checklist-Civilian Version (PCL-C)25. For each item, a 5-point scale from 1 (not at all) to 5 (extremely) was rated by the parents based on how much they endorsed PTSS when experiencing and witnessing their children’s illness and treatment in the last month. The total score ranges from 17 to 85, with a score of 38-49 suggesting mild to moderate PTSS, a score above 50 indicating severe PTSS and possible diagnosis of PTSD. In this study, Cronbach’s α was 0.932 for the total scale.
The depression symptoms of the parents were evaluated using the Patient Health Questionnaire Depression Scale (PHQ-9), which is a 9-item scale for simple and effective depression screening and diagnosis26. According to how they felt in the past week, the parents rated on a 4-point scale from 0 (not true at all) to 3 (almost every day). The total score ranges from 0 to 27, and a higher score suggesting greater severity of depression. In this study, Cronbach’s α of the total scale was 0.908.
The family functioning was assessed using the 12-item General Functioning Sub-scale of McMaster Family Assessment Device (GF-FAD), which is a simplified version of FAD27. A 4-point scale from 1 (strongly agree) to 4 (strongly disagree) was used to rate how well each statement matched the circumstances of the family. The total score ranges from 12 to 48, with a higher score indicating a poorer family functioning. In this study, Cronbach’s α of the total scale was 0.70.