The National Child Traumatic Stress Network defines pediatric medical traumatic stress as “a set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences”. These responses frequently involve (but are not limited to) post-traumatic stress symptoms (PTSS), including re-experiencing, avoiding reminders of the trauma, and hyperarousal among children and their families. These findings prove to be cross-cultural, with multiple studies emphasizing the impact of a child’s medical condition on parents’ level of distress in various societies and ethnic groups worldwide [1–4].
Parents of children who have experienced a traumatic medical event (TME) are known to be at a high risk for developing severe stress responses [5–8]. Recently, the integrative biopsychosocial model of PTSS was developed by Marsac and colleagues [9, 10], with the aim of identifying child, family and environmental factors associated with children’s and parents’ risk for developing PTSS, following these TMEs.
Research shows that a child’s pre-trauma biological factors, such as gender and age, are associated with parents’ PTSS, with female gender and younger age as risk factors for parental PTSS following various types of traumatic events [11–14]. In addition, severity of a child’s medical condition has been positively associated with intensity of parents’ traumatic response [7, 15] as well as with parent’s general psychological distress [13, 16]. A child’s pre-existing emotional and behavioral problems, as well diagnosis of PTSD following a TME, were also shown to be associated with a higher risk for parental PTSD [6, 7].
In addition to the child’s personal and clinical factors, family-related factors were also shown to be associated with parents’ post-traumatic responses. For example, younger parental age has been associated with higher levels of PTSS [7, 12, 15]. Higher parental education levels were linked with positive coping strategies and lower levels of maternal distress . In contrast, other studies have indicated that more educated mothers of children with chronic medical conditions experienced higher levels of anxiety and psychological distress than less educated mothers . Psychosocial factors such as parents’ anxiety or depression have also been associated with parents’ emotional distress following a child’s TME, with such variables accounting for approximately 37% of overall variance in the distress responses among parents of children following TMEs . These factors have also been associated with parents’ risk for developing PTSD .
Environmental and social factors, such as culture and ethnicity, may also play a significant role in the manifestation of PTSS. For example, the literature indicates a difference in the frequency of PTSS and/or PTSD, and even in referral to mental health treatments, among different ethnic groups [17, 18]. In general, findings on the negative impact of a TME on parents’ emotional state have been described in different cultures and societies worldwide [1, 2, 4, 19]. However, in some cases, a specific ethnic group may also constitute a minority within a given region or a country, contributing to an increased risk for parental traumatic stress responses following a child’s TME.
These differences might have various sources. A recent review by Asnaani and Hall-Clark  addressed the role of cultural factors, such as norms related to symptom disclosure, reporting style, cultural interpretations of symptoms and distress, and of specific coping styles, all associated with ethnical differences in PTSD risk. Nevertheless, with regard to identifying and treating PTSD, research has repeatedly shown that minority groups encounter disparities in access to social and economic resources (health care, education, etc.) . Members of minority groups may also have fewer resources; thus, any loss of a single resource may negatively affect their ability to recover from a medical traumatic event [22, 23]. Moreover, the perception of discrimination in minority groups may itself prevent individuals from seeking social support and/or making use of available resources after traumatic events [21, 24]. As suggested by the biopsychosocial model, social support is considered an important environmental factor associated with reduced parental distress following a child’s TME [9, 10]. Furthermore, because culture and attribution to a specific ethnic group may influence people’s beliefs, attitudes, expectations and behavior regarding the role of social support, the latter should be acknowledged when treating parents and families following TMEs [25, 26].
In Israel, a multicultural pluralistic society that includes diverse ethnic and religious identities, the Arab population constitutes a relatively large minority group (20.3% of the general population, according to the Israel Central Bureau of Statistics ). Arabs in Israel are at a significant disadvantage for a wide range of health indicators compared with the Jewish majority, including shorter life expectancy and higher infant mortality rates . Traumatic injuries in children are, unfortunately, no exception. According to a national report on child injuries in Israel , the relative risk of hospitalization for an Arab child is 2.5 times greater than the risk for a Jewish child. Moreover, as the severity of injury increases, the proportion of Arab children among those hospitalized increases as well. Additionally, Arab children have different injury patterns, resulting in a tendency for them to be injured more frequently in the types of accidents that have more severe consequences (motor vehicle accidents, burns, falls, etc. (. According to the report, despite universal health coverage under the Israeli Health Insurance Law, the higher risks among Arab children are related to differential access to high-quality preventive and medical care. Subsequently, Arab children and their families might be at higher risk of developing post-traumatic responses, which, in turn, may also affect their recovery.
Differences in traumatic stress responses between Israeli Arab and Jewish ethnic groups indicate that Arabic ethnicity is a significant risk factor for the development of PTSS due to various traumatic events such as terrorism and political violence [22, 30–32]. This finding was also evident among Jewish and Arab Israeli youth, with the latter reporting more severe post traumatic symptoms . Similarly, a study conducted among children in Israel showed that Arab children reported higher levels of PTSD than their Jewish counterparts . These findings highlight that within the Israeli context, Arab ethnicity is a relatively significant risk factor for the development of PTSS and even PTSD, however such effect was not examined in relation to a child’s TME.
Research on parental response to children with special needs in Arab populations in Israel is limited. One study of Arab mothers of children with special needs in Israel found that they had higher overall stress levels than Arab mothers of healthy children. Moreover, the increase in stress levels was associated with these mothers’ poorer well-being . However, the levels of symptomatology among the Arab mothers in this study were not compared with those of Israeli Jewish mothers, limiting the ethnicity-related conclusions that could be drawn from the study. Thus, an in-depth examination of post-traumatic responses among mothers of children following TMEs within the Israeli Arab and Jewish population is warranted. Nonetheless, no previous study has addressed the role of the different pre-trauma factors associated with mothers’ PTSS within the biopsychosocial framework (Figure 1), in the context of specific ethnic minority groups (such as that of the Israeli-Arab population). Improved understanding of the relationship between risk and protective factors and the post traumatic symptoms, while taking into account the role of ethnic and socio-cultural factors, may improve understanding and management of pediatric medical traumatic stress.
Thus, the major aim of this study was to examine differences between Israeli Arab and Jewish mothers’ post-traumatic responses following their child’s TME. More specifically, we aimed to examine child- and family-related risk factors affecting mothers’ PTSS according to the integrative biopsychosocial model of Marsac et al. [9, 10]. Our emphasis was on specific pre-trauma risk factors associated with PTSS, such as family problems, family structure and resources, child’s and siblings’ emotional and behavioral problems and family’s social support. Biological factors such as child’s age, gender and injury etiology were also included. We hypothesized that Israeli-Arab mothers will self-report higher levels of PTSS than will their Jewish counterparts and that the levels of high PTSS will be associated with child, family and social pre-trauma risk factors.