{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,8]],"date-time":"2026-01-08T01:39:32Z","timestamp":1767836372729,"version":"3.49.0"},"reference-count":54,"publisher":"MDPI AG","issue":"21","license":[{"start":{"date-parts":[[2021,11,7]],"date-time":"2021-11-07T00:00:00Z","timestamp":1636243200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Background: Illness, surgery, and surgical hospitalization are significant stressors for children. Children exposed to such medical events may develop post-traumatic medical syndrome (PMTS, pediatric medical traumatic stress) that could slow their physical and emotional recovery. Objective: This study examined the relationship between the level of parental psychological resilience and the development of PMTS in young children. Method: We surveyed 152 parents of children aged 1\u20136 who were admitted to the pediatric surgery department. Parents completed questionnaires in two phases. In the first phase, one of the parents completed the Acceptance and Action Questionnaire (AAQ-ll) and the Parental Psychological Flexibility (PPF) Questionnaire. In the second phase, about three months after discharge, the same parent completed the Young Child PTSD (Post Traumatic Stress Disorder) Checklist (YCPC) and the UCLA (Los Angeles, CA, USA) PTSD Reaction Index for DSM-5 Parent\/Caregiver Version for Children Age 6 Years and Younger Evaluating Post-traumatic Disorder. In addition, the parent completed a Posttraumatic Stress Diagnostic Scale (PDS) questionnaire to assess the existence of post-traumatic symptoms in the parents. Results: The findings indicate that (1) a parent\u2019s psychological flexibility is significantly associated with the level of personal distress (r = \u22120.45, p &lt; 0.001), (2) a parents\u2019 level of distress is significantly correlated with the child\u2019s level of PTMS, and (3) a parent\u2019s level of psychological flexibility is a significant mediating factor between the level of parental post-traumatic distress and the child\u2019s level of PTMS. Conclusions: A parent\u2019s psychological flexibility may act as a protective factor against the development of the child\u2019s mental distress after hospitalization or surgery.<\/jats:p>","DOI":"10.3390\/ijerph182111699","type":"journal-article","created":{"date-parts":[[2021,11,7]],"date-time":"2021-11-07T20:41:14Z","timestamp":1636317674000},"page":"11699","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":13,"title":["Parental Psychological Flexibility as a Mediating Factor of Post-Traumatic Stress Disorder in Children after Hospitalization or Surgery"],"prefix":"10.3390","volume":"18","author":[{"given":"Amichai","family":"Ben-Ari","sequence":"first","affiliation":[{"name":"Department of Behavioral Sciences, Ariel University, Ben-Zakai 36\/8, Jerusalem 9318659, Israel"},{"name":"Herman Dana Division of Child and Adolescent Psychiatry, Hadassah-Hebrew University Medical Center, Jerusalem 91240, Israel"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roy","family":"Aloni","sequence":"additional","affiliation":[{"name":"Department of Behavioral Sciences, Ariel University, Ben-Zakai 36\/8, Jerusalem 9318659, Israel"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shiri","family":"Ben-David","sequence":"additional","affiliation":[{"name":"Department of Psychology, Hebrew University, Jerusalem 9190501, Israel"},{"name":"Hadassah Medical Center, Department of Psychiatry, Jerusalem 91120, Israel"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fortu","family":"Benarroch","sequence":"additional","affiliation":[{"name":"Herman Dana Division of Child and Adolescent Psychiatry, Hadassah-Hebrew University Medical Center, Jerusalem 91240, Israel"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniella","family":"Margalit","sequence":"additional","affiliation":[{"name":"Department of Behavioral Sciences, Ariel University, Ben-Zakai 36\/8, Jerusalem 9318659, Israel"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2021,11,7]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1080\/00797308.1979.11823018","article-title":"Children of Chowchilla: A study of psychic trauma","volume":"34","author":"Terr","year":"1979","journal-title":"Psychoanal. Study Child"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"244","DOI":"10.1111\/j.1939-0025.1983.tb03369.x","article-title":"Time sense following psychic trauma: A clinical study of ten adults and twenty children","volume":"53","author":"Terr","year":"1983","journal-title":"Am. J. Orthopsychiatry"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"176","DOI":"10.1111\/j.1475-3588.2005.00384.x","article-title":"A review of PTSD in children","volume":"11","author":"Dyregrov","year":"2006","journal-title":"Child Adolesc. Ment. Health"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"533","DOI":"10.1111\/j.1469-7610.2004.00243.x","article-title":"Comorbidity of PTSD and depression among refugee children during war conflict","volume":"45","author":"Thabet","year":"2004","journal-title":"J. Child Psychol. Psychiatry"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1002\/jts.21723","article-title":"Diagnosing PTSD in early childhood: An empirical assessment of four approaches","volume":"25","author":"Scheeringa","year":"2012","journal-title":"J. Trauma. Stress"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1526","DOI":"10.1016\/j.jpedsurg.2017.10.043","article-title":"Surgical procedures and pediatric medical traumatic stress (PMTS) syndrome: Assessment and future directions","volume":"53","author":"Ari","year":"2018","journal-title":"J. Pediatr. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"437","DOI":"10.1055\/s-0038-1660449","article-title":"Traumatic stress among school-aged pediatric surgery patients and their parents","volume":"29","author":"Ari","year":"2019","journal-title":"Eur. J. Pediatr. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"340","DOI":"10.1007\/s11920-012-0340-5","article-title":"Assessment and management of pediatric iatrogenic medical trauma","volume":"15","author":"Forgey","year":"2013","journal-title":"Curr. Psychiatry Rep."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1276","DOI":"10.1097\/01.chi.0000181045.13960.67","article-title":"Predicting posttraumatic stress symptoms in children after road traffic accidents","volume":"44","author":"Landolt","year":"2005","journal-title":"J. Am. Acad. Child Adolesc. Psychiatry"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"648","DOI":"10.1007\/s00134-002-1237-2","article-title":"Psychiatric adjustment following meningococcal disease treated on a PICU","volume":"28","author":"Judge","year":"2002","journal-title":"Intensive Care Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1177\/1367493509102472","article-title":"Psychological outcomes in children following pediatric intensive care unit hospitalization: A systematic review of the research","volume":"13","author":"Rennick","year":"2009","journal-title":"J. Child Health Care"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1093\/jpepsy\/jsh022","article-title":"Posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) in families of adolescent childhood cancer survivors","volume":"29","author":"Kazak","year":"2004","journal-title":"J. Pediatr. Psychol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"480","DOI":"10.1016\/j.jpeds.2003.12.048","article-title":"Posttraumatic stress disorder in children after cardiac surgery","volume":"144","author":"Connolly","year":"2004","journal-title":"J. Pediatr."},{"key":"ref_14","unstructured":"McGarry, S. (2013). Pediatric Medical Traumatic Stress: The Impact on Children, Parents and Staff. [Ph.D. Thesis, Edith Cowen University]."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1097\/PCC.0b013e3182196a8f","article-title":"Posttraumatic stress disorder in children and their parents following admission to the pediatric intensive care unit: A review","volume":"13","author":"Nelson","year":"2012","journal-title":"Pediatr. Crit. Care Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1097\/01.PCC.0000137354.19807.44","article-title":"Traumatic stress in parents of children admitted to the pediatric intensive care unit","volume":"5","author":"Balluffi","year":"2004","journal-title":"Pediatr. Crit. Care Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1097\/00003246-200612002-00080","article-title":"Children\u2019s factual and delusional memories of pediatrics intensive care","volume":"34","author":"Colville","year":"2006","journal-title":"Crit. Care Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"718","DOI":"10.1093\/jpepsy\/jsq115","article-title":"Predicting posttraumatic stress following pediatric injury: A systematic review","volume":"36","author":"Brosbe","year":"2011","journal-title":"J. Pediatr. Psychol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"576","DOI":"10.1097\/00004583-200005000-00011","article-title":"Predicting posttraumatic stress after hospitalization for pediatric injury","volume":"39","author":"Daviss","year":"2000","journal-title":"J. Am. Acad. Child Adolesc. Psychiatry"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1016\/j.jcbs.2016.03.001","article-title":"Parent\u2019s psychological flexibility: Associations with parenting and child psychosocial well-being","volume":"5","author":"Brassell","year":"2016","journal-title":"J. Contextual Behav. Sci."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1016\/j.jcbs.2016.06.002","article-title":"The relationship between psychological flexibility, early maladaptive schemas, perceived parenting and psychopathology","volume":"5","author":"Fischer","year":"2016","journal-title":"J. Contextual Behav. Sci."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"235","DOI":"10.1016\/j.jpain.2014.11.013","article-title":"The role of parent psychological flexibility in relation to adolescent chronic pain: Further instrument development","volume":"16","author":"Wallace","year":"2015","journal-title":"J. Pain"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"166","DOI":"10.1016\/j.jcbs.2017.02.003","article-title":"Psychological flexibility as a malleable public health target: Evidence from a representative sample","volume":"6","author":"Gloster","year":"2017","journal-title":"J. Contextual Behav. Sci."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1016\/j.jcbs.2018.02.006","article-title":"Improving flexible parenting with Acceptance and Commitment Therapy: A case study","volume":"8","year":"2018","journal-title":"J. Contextual Behav. Sci."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1016\/j.jcbs.2017.04.010","article-title":"Psychological inflexibility as a mediator of the relationship between depressive symptom severity and public stigma in depression","volume":"6","author":"Gaudiano","year":"2017","journal-title":"J. Contextual Behav. Sci."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.brat.2005.06.006","article-title":"Acceptance and commitment therapy: Model, processes and outcomes","volume":"44","author":"Hayes","year":"2006","journal-title":"Behav. Res. Ther."},{"key":"ref_27","unstructured":"Hayes, S.C., Strosahl, K.D., and Wilson, K.G. (2011). Acceptance and Commitment Therapy: The Process and Practice of Mindful Change, Guilford Press."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1016\/j.paid.2010.09.037","article-title":"Psychological flexibility mediates the relations between self-concealment and negative psychological outcomes","volume":"50","author":"Masuda","year":"2011","journal-title":"Personal. Individ. Differ."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1016\/j.paid.2018.01.024","article-title":"The indirect effect of self-concealment on distress through psychological inflexibility in Asian American, Black American, and White American college students","volume":"126","author":"Mendoza","year":"2018","journal-title":"Personal. Individ. Differ."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Sairanen, E., Lappalainen, P., and Hiltunen, A. (2018). Psychological inflexibility explains distress in parents whose children have chronic conditions. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0201155"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"865","DOI":"10.1016\/j.cpr.2010.03.001","article-title":"Psychological flexibility as a fundamental aspect of health","volume":"30","author":"Kashdan","year":"2010","journal-title":"Clin. Psychol. Rev."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1406","DOI":"10.1007\/s10826-014-9947-y","article-title":"The role of psychological flexibility in the relationship between parent and adolescent distress","volume":"24","author":"Moyer","year":"2015","journal-title":"J. Child Fam. Stud."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1053","DOI":"10.1007\/s10964-012-9744-0","article-title":"Inflexible parents, inflexible kids: A 6-year longitudinal study of parenting style and the development of psychological flexibility in adolescents","volume":"41","author":"Williams","year":"2012","journal-title":"J. Youth Adolesc."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"383","DOI":"10.1007\/s10578-009-0135-z","article-title":"Assessment of parental experiential avoidance in a clinical sample of children with anxiety disorders","volume":"40","author":"Cheron","year":"2009","journal-title":"Child Psychiatry Hum. Dev."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"676","DOI":"10.1016\/j.beth.2011.03.007","article-title":"Preliminary psychometric properties of the Acceptance and Action Questionnaire\u2013II: A revised measure of psychological inflexibility and experiential avoidance","volume":"42","author":"Bond","year":"2011","journal-title":"Behav. Ther."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"548","DOI":"10.1007\/s10578-014-0495-x","article-title":"Development of the parental psychological flexibility questionnaire","volume":"46","author":"Burke","year":"2015","journal-title":"Child Psychiatry Hum. Dev."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1002\/jts.21780","article-title":"Psychometric properties of the UCLA PTSD reaction index: Part I","volume":"26","author":"Steinberg","year":"2013","journal-title":"J. Trauma. Stress"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"186","DOI":"10.1016\/j.jaac.2018.10.019","article-title":"Validation of the UCLA PTSD reaction index for DSM-5: A developmentally informed assessment tool for youth","volume":"59","author":"Kaplow","year":"2020","journal-title":"J. Am. Acad. Child Adolesc. Psychiatry"},{"key":"ref_39","unstructured":"Scheeringa, M.S. (2013). Young Child PTSD Checklist (YCPC), Tulane University. Available online: https:\/\/medicine.tulane.edu\/departments\/psychiatry\/dr-scheeringas-lab\/manuals-measures-trainings."},{"key":"ref_40","unstructured":"Foa, E.B. (1995). The Posttraumatic Diagnostic Scale (PDS) Manual, National Computer Systems."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1166","DOI":"10.1037\/pas0000258","article-title":"Psychometric properties of the Posttraumatic Diagnostic Scale for DSM\u20135 (PDS\u20135)","volume":"28","author":"Foa","year":"2016","journal-title":"Psychol. Assess."},{"key":"ref_42","first-page":"269","article-title":"Health-related quality of life two years after injury due to terrorism","volume":"47","author":"Tuchner","year":"2010","journal-title":"Isr. J. Psychiatry Relat. Sci."},{"key":"ref_43","unstructured":"Arbuckle, J. (2013). AMOS 22 Users Guide, SmallWaters Corporation."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1111\/j.1744-6155.2008.00141.x","article-title":"A meta-analysis of risk factors that predict psychopathology following accidental trauma","volume":"13","author":"Cox","year":"2008","journal-title":"J. Spec. Pediatr. Nurs."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.jcbs.2019.06.001","article-title":"Cross-sectional relations between psychological inflexibility and symptoms of depression and anxiety among adults reporting migraines or risk factors for cardiovascular disease","volume":"13","author":"Dindo","year":"2019","journal-title":"J. Contextual Behav. Sci."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"666","DOI":"10.1213\/01.ANE.0000175212.17642.45","article-title":"Acupressure and preoperative parental anxiety: A pilot study","volume":"101","author":"Wang","year":"2005","journal-title":"Anesth. Analg."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"478","DOI":"10.1097\/00000542-200509000-00008","article-title":"Motivation and maternal presence during induction of anesthesia","volume":"103","author":"Kain","year":"2005","journal-title":"Anesthesiology"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"651","DOI":"10.1542\/peds.2005-2920","article-title":"Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery","volume":"118","author":"Kain","year":"2006","journal-title":"Pediatrics"},{"key":"ref_49","first-page":"e25036","article-title":"Preoperative education and decreasing preoperative anxiety among children aged 8\u201310 years old and their mothers","volume":"5","author":"Tabrizi","year":"2015","journal-title":"Anesth. Pain Med."},{"key":"ref_50","first-page":"1","article-title":"Parenting styles and aggressive adolescents: Relationships with self-esteem and personal maladjustment","volume":"12","author":"Garcia","year":"2020","journal-title":"Eur. J. Psychol. Appl. Leg. Context"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1387\/RevPsicodidact.10876","article-title":"Parental Socialization Styles and Psychological Adjustment. A Study in Spanish Adolescents\/\/Los estilos parentales de socializaci\u00f3n y el ajuste psicol\u00f3gico. Un estudio con adolescentes espa\u00f1oles","volume":"20","author":"Fuentes","year":"2015","journal-title":"Rev. Psicodid\u00e1ct."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1016\/j.jcbs.2018.06.008","article-title":"Development of an ACT prototype for therapeutic skill assessment","volume":"9","author":"Long","year":"2018","journal-title":"J. Contextual Behav. Sci."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/j.jcbs.2014.06.003","article-title":"Examining psychological inflexibility as a transdiagnostic process across psychological disorders","volume":"3","author":"Levin","year":"2014","journal-title":"J. Contextual Behav. Sci."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.jcbs.2012.09.004","article-title":"Contextual behavioral science: Creating a science more adequate to the challenge of the human condition","volume":"1","author":"Hayes","year":"2012","journal-title":"J. Contextual Behav. Sci."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/21\/11699\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:27:10Z","timestamp":1760167630000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/21\/11699"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,11,7]]},"references-count":54,"journal-issue":{"issue":"21","published-online":{"date-parts":[[2021,11]]}},"alternative-id":["ijerph182111699"],"URL":"https:\/\/doi.org\/10.3390\/ijerph182111699","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,11,7]]}}}