The treatment of pediatric cancer involves a demanding medical regimen in which families are confronted with multiple and pervasive stressors including significant medical side effects (Bryant, 2003
), considerable changes in daily activities (Woodgate, Degner, & Yanofsky, 2003
), disruption of social and family roles (Kazak, Simms, & Rourke, 2002
), the burdens of adhering to complicated and often very intense treatment regimens (Crist & Kun, 1991
), and the threat of death. Recognizing the impact of such stressors, national and international recommendations for comprehensive cancer care include the provision of psychosocial services to families of children with cancer (American Academy of Pediatrics, 2004
Unfortunately, clear guidelines have not been established with regard to the delivery of these services. Systematic approaches for assessing psychosocial need and formulating types and levels of intervention for particular patients and families are not available. Although, collectively, the majority of children with cancer and their families are resilient in the face of cancer diagnosis and treatment (Kazak, 2006
), subgroups of children and their families are at risk for or evidence of clinically significant distress and impaired coping (Patenaude & Kupst, 2005
) and warrant more consistent evidence-based care (Kazak, 2005
The Pediatric Psychosocial Preventative Health Model (PPPHM; Kazak, 2006
; See ) may be helpful as a framework for conceptualizing psychosocial risk1
and formulating the type and level of interventions required. This model, adapted from the National Institute of Mental Health prevention framework, describes the pediatric health population by conceptualizing families in terms of psychosocial risk (National Institute of Mental Health, 1998
). Presented as a pyramid, PPPHM estimates that the majority of families, represented in the base of the pyramid, are transiently and understandably distressed, but resilient (Universal). Another smaller set of families, represented in the middle tier of the pyramid, experience acute distress and the presence of some psychosocial risk factors (Targeted). The remaining set of families, smallest in number, are at the apex of the pyramid, with multiple risk factors indicating intense, persistent and/or escalating distress (Clinical; Kazak et al., 2001
). An evidence-based assessment approach that could reliably classify families by level of psychosocial risk could streamline the delivery and increase specificity in the provision of psychosocial services in health care environments, which have limited resources to meet the needs of children diagnosed with cancer and their families.
The Psychosocial Assessment Tool (PAT) was a screening instrument designed to assess psychosocial risk in families of children newly diagnosed with cancer. The original PAT was a 20-item screening questionnaire that assessed a constellation of risk and resource factors including family structure, family resources, social support, child knowledge, school attendance, child emotional, and behavioral concerns, child maturity for age, marital/family problems, family beliefs, and other stressors (Kazak et al., 2001
). In a prospective study of 125 families of children newly diagnosed with cancer, preliminary reliability and validity data for the PAT was established (Kazak et al., 2001
). Higher PAT scores were associated with higher levels of psychosocial risk (Kazak et al., 2003
), and PAT scores at time of diagnosis were also significantly related to PAT scores 3–6 months later (p
< .01). Although, the PAT was a viable instrument, testing revealed that some items were difficult for respondents to understand and some open ended questions failed to elicit detailed information about child and family psychological symptoms.
Therefore, a data-driven revision of the original PAT was undertaken. The resulting PAT2.0 was modified to improve the clarity of questions, reformatted to be more appealing and user friendly, and expanded in item content based on new knowledge and data from the original PAT study. The PAT2.0 is a two-page self-report measure consisting of 15 item sets. The response format for the items was designed to be brief and simple (e.g., yes/no, categorical responses, Likert-type scales). Completion of the PAT2.0 takes approximately 10 min.
The purpose of the current study is to evaluate the psychometric properties of PAT2.0. First, we evaluate the internal consistency and test–retest reliability of the PAT2.0. In addition, the PAT2.0 scores for mothers and fathers are compared to identify whether there are differences between reporters on the PAT2.0. Next, we examine the content validity of the PAT2.0 subscales, correlating subscale scores with scores on standardized measures designed to measure similar constructs. We hypothesized that higher scores on PAT2.0 subscales would be significantly associated with higher scores on measures that correspond to the content the PAT2.0 subscale is intended to measure (e.g., PAT2.0 Child Behavior Problems subscale and the BASC-2 Behavioral Symptom Index). To assess criterion-related validity we test whether PAT2.0 Total Scores are significantly related to more adverse psychosocial outcomes typically associated with family psychosocial risk. We predicted that higher PAT2.0 Total scores would be significantly associated with higher scores on psychosocial outcomes including acute stress, child behavior symptoms, state anxiety, and family conflict and lower scores on family cohesion. The PPPHM categories were also examined to assess criterion-related validity. We predicted that families that score in the Clinical category would score higher on measures of psychological distress (i.e., PTSS and anxiety symptoms for parents and behavioral symptoms for children and family conflict) than families that fall in the Targeted or Universal categories. In addition, families in the Targeted category on their PAT2.0 score would score higher on measures of psychological distress and family functioning than those in the Universal category.
Evidence for convergent validity
is sought through investigation of correlations between PAT2.0 scores and a staff version of the PAT completed by physicians and nurses. Finally, the PAT2.0 does not merely reflect characteristics of the cancer diagnosis or treatment, but rather to capture characteristics and patterns of functioning within the family that put them at risk when confronting cancer diagnosis and treatment. Previous study findings have been mixed, with some showing a relationship between psychological outcomes and medical indicators (Phipps, Long, Hudson, & Rai, 2005
) and others not (Alderfer, Cnaan, Annunziato, & Kazak, 2005
). Therefore, no relationship between the PAT2.0 Total score and treatment intensity are anticipated (discriminative validity)
. Finally, we predicted that the PAT2.0 scores would discriminate between families that score high on the clinical outcomes [i.e., BASC-2 Behavioral Symptom Index and the Acute Stress Disorder Scale (ASDS)] and those who do not.