Impact of The Parent-Child Relationship On Psychological - 2019
Impact of The Parent-Child Relationship On Psychological - 2019
Impact of The Parent-Child Relationship On Psychological - 2019
DOI: 10.1002/pon.5258
PAPER
1
Department of Psychology, St. Jude
Children's Research Hospital, Memphis, Abstract
Tennessee Objectives: The primary objective of this research was to examine patterns of
2
Department of Psychology, The University of
parent-child relationship functioning among pediatric cancer survivors and their care-
Memphis, Memphis, Tennessee
givers across a variety of relationship indicators (ie, Involvement, Attachment, Com-
Correspondence
munication, Parenting Confidence, and Relational Frustration), and evaluate how
Rachel Tillery, Department of Psychology,
St. Jude Children's Research Hospital, these factors relate to psychosocial outcomes in survivors.
262 Danny Thomas Place, #740, Memphis, TN
Methods: Young survivors aged 10 to 18 and their caregivers (N = 165) completed
38105.
Email: rachel.tillery@stjude.org measures related to posttraumatic stress and general distress. Caregivers also com-
pleted assessments of parent-child relationship functioning, and survivors completed
Funding information
American Lebanese-Syrian Associated assessments of social functioning. Latent profile analysis was performed to identify
Charities, Grant/Award Number: ALSAC;
patterns of relationship functioning. Medical, demographic, and parent functioning
National Institutes of Health, Grant/Award
Number: NIH R01 CA136782 variables were examined as predictors, and youth's psychological and social function-
ing were examined as outcomes.
Results: A three-class solution was the best fit to the data. The struggling parent-
child relationship profile (15%) evidenced below average levels of parent-child rela-
tionship functioning across several domains. The normative parent-child relationship
(60%), was characterized by average levels of parent-child relationship functioning
across all domains. Finally, the high-involved parent-child relationship profile (25%)
demonstrated above average levels of parent-child relationship functioning in
involved activities, communication, and attachment and normative levels of function-
ing across all other domains. Medical and parent functioning factors predicted profile
membership. In turn, profile membership was associated with survivor psychological
and social outcomes.
Conclusion: Findings document the importance of extending existing research to
examine patterns of parent-child relationship functioning, which may serve as a clini-
cally relevant target to improve psychological and social outcomes in young survivors
of childhood cancer.
KEYWORDS
Psycho-Oncology. 2020;29:339–346. wileyonlinelibrary.com/journal/pon © 2019 John Wiley & Sons, Ltd. 339
340 TILLERY ET AL.
study as an indicator of PTSS associated with the identified event. The scores are converted to T-scores based on age and sex norms
IES-R has demonstrated strong test-retest reliability and internal valid- (M = 50, SD = 10), with scores below 60 indicating normal func-
ity ; α = .99 for the current study).
19
tioning, scores between 60 and 69 indicating “at risk“ behavior
implying mild to moderate impairment, and scores above 70 indicat-
Global distress ing “significant risk“ requiring follow-up. The BASC-2 has been
The Brief Symptom Inventory 18 (BSI)20 is an 18-item self-report mea- shown to be internally consistent (α = .80-.90) and has demon-
sure that was used to measure psychological symptoms among par- strated good test-retest reliability.24 The BASC-3 was not available
ents. The BSI-18 was shown to be a psychometrically sound short during the time of data collection.
form alternative for the BSI-53 and the originally developed Symptom
Checklist-90-Revised20 The BSI has three symptom scales and a widely Social functioning
used summary scale of overall distress, the Global Severity Index Youth also completed the Social and Emotional Assets and Resilience
(GSI). The GSI was used in the current study as a measure of care- Scale (SEARS).25 The SEARS is a 35-item measure of social-emotional
givers’ overall distress. The GSI has demonstrated excellent reliability strengths in youth across four subscales: self-regulation, empathy,
and validity (α = .92 for the current study). responsibility, and social competence. In the current study, a total score
was derived (by summing all 35 items) and used as an overall proxy of
Parent-child relationship quality social functioning. Raw scores were converted to T-scores based on age
Caregivers also completed the Parenting Relationship Questionnaire norms (M = 50, SD = 10). Reliability and validity with other well-known
(PRQ),21 which is a 71-item measure that assesses the parent-child measures of social functioning (eg, Social Skills Rating System)26 has
relationship. The PRQ consists of seven subscales, and the current been demonstrated (α = .95 for the current study).
study focused on the following subscales: Attachment (feelings of
closeness, empathy, and understanding), Communication (quality of
information exchanged), Involvement (participation together in vari- 1.3 | Planned analyses
ous activities), Parenting Confidence (comfort and confidence in
parental role), and Relational Frustration (overall parental stress and Latent profile analyses were conducted using Mplus Version 8.3 to
difficulties in relation to the identified child). Raw scores were empirically derive parent-child relationship functioning patterns across
converted to age- and sex-normed T-scores (M = 50, SD = 10). Stan- Involvement in shared activities, Attachment, Communication, Parenting
dardization data collection for the PRQ occurred between April 2013 Confidence, and Relational Frustration (aim 1). The model was specified
and December 2014.Scores between 40 and 60 indicate normal func- with uncorrelated indicators and freely estimated variances across clas-
tioning, scores above 60 indicate above average functioning, and ses. The Bayesian information criterion (BIC),27 was used to determine
scores below 40 are reflective of significant relationship risk. These model fit for each number of classes estimated, with lower BIC values
criteria are reverse for Relational Frustration. The PRQ has demon- indicating better model fit. The Lo-Mendell-Rubin (LMR)28 and the Boot-
strated high internal consistency and moderate to high convergent strap Likelihood Ratio Test (BLRT)29 were also used to compare model
21
validity (α = .87 for the current study). improvement between neighboring classes (eg, 2 class solution vs 3 class
solution, 3 class solution vs 4 class solution). A significant P-value
derived from these tests indicates statistically significant improvement
1.2.3 | Survivor-reported measures in fit by the addition of a class. To confirm that differences among clas-
ses were driven by multiple constructs, mean differences across profiles
Posttraumatic stress symptoms for each indicator were examined by creating additional copies of the
22
Youth completed the 22-item UCLA PTSD Reaction Index for DSM-IV indicators and treating them as auxiliary variables.30
as an assessment of PTSS. Specifically, youth reported on the fre- To evaluate predictors of the latent profiles (aim 2; demographic,
quency of PTSS symptoms within the past month about a spontane- medical, and caregiver psychological functioning), the three-step
ously identified traumatic event. Approximately half of youth reported approach was used to compare identified classes based on these vari-
a cancer-related event (n = 83) as their most stressful. This measure ables.31 The three-step approach allows covariates to be tested as
has demonstrated excellent psychometric properties including high predictors of latent classes in a multinomial logistic regression while
internal and test-retest reliability.23 The present study used an overall maintaining the probabilistic nature of the latent profile variable. In
total score as an indicator of PTSS (α = .88 for the current study). the first step, the model is estimated using only the latent class indica-
tors. In the second step, the most likely class variable is created for
Internalizing difficulties each subject. Finally, the most likely class is regressed on the predictor
The Behavior Assessment System for Children, Second Edition (BASC- variable taking into account the probability of misclassification of the
2)24 is a self-report questionnaire assessing behavioral, emotional and class assignment generated in step 2. Finally, to examine differences
adaptive functioning of children and individuals between 8 and in social and emotional functioning across latent profiles, the three-
21 years of age. The current study used the anxiety and depression step approach31 was again used; however variables were specified as
subscales as an assessment of youth's internalizing functioning. Raw outcomes rather than covariates.
342 TILLERY ET AL.
F I G U R E 1 Patterns of parent-child
relationship functioning. For the
Involvement, Attachment, Communication
and Confidence subscales, higher scores are
indicative of better functioning. For the
Relational Frustration subscale, higher scores
are indicative of worse functioning. Note:
*P < .001. Different alpha superscripts
within columns indicate significant
differences between the profiles at least
at P < .05
TILLERY ET AL. 343
Youth in the struggling parent-child relationship profile reported 2.4.3 | Social functioning
elevated levels of PTSS compared to youth in the high-involved
parent-child relationship profile (χ2 [1, n = 165] = 35.06, P < .001) Youth-reported social functioning scores were lower in youth who fell in
and youth in the normative profile (χ2 [1, n = 165] = 48.83, the struggling group compared to those in the high-involved profile (χ2 [1,
P < .001). Differences did not emerge in youth's report of PTSS n = 165] = 16.38, P < .001) and the normative profile (χ2 [1, n = 165] = 7.33,
between the normative and high-involved profiles (χ2 [1, P = .007). Again, differences did not emerge between the normative and
n = 165] = 0.53, P = .47; Figure 2). high-involved profile (χ2 [1, n = 165] = 2.59, P = .11; Figure 2).
344 TILLERY ET AL.
F I G U R E 2 Differences in social and emotional symptoms across parent-child relationship functioning profiles. Note. ***P < .001,
**P < .01, *P < .05
design limits the interpretation of the study's findings regarding the key to promoting optimal social and emotional health in young survi-
implications of the caregiver-youth relationship on survivors’ psycho- vors of childhood cancer.
social outcomes. In the broader literature, the caregiver-youth rela-
tionship appears to drive youth's social and emotional outcomes,9 and CONFLIC T OF INT ER E ST
longitudinal studies will be important to further evaluate the impact of The authors declare no conflicts of interest.
this relation on youth's social and emotional adjustment into long-
term survivorship. Second, parent-child relationship patterns were DATA AVAILABILITY STAT EMEN T
only evaluated by the caregiver. Research has documented discrep- The data that support the findings of this study are available on
ancies in perceptions of functioning between caregivers and request from the corresponding author. The data are not publicly
youth,40 thus, it is imperative future studies investigate youth per- available due to privacy or ethical restrictions.
spectives as this also likely impacts youth's social-emotional func-
tioning into survivorship. Finally, the small sample of fathers and OR CID
other alternative caregivers limited our ability to examine how rela- Rachel Tillery https://orcid.org/0000-0001-6216-1502
tionship patterns between mothers and alternative caregivers may Victoria W. Willard https://orcid.org/0000-0003-3340-1460
differentially impact psychosocial outcomes. Previous research
with survivors has indicated the importance of the father-child rela- RE FE RE NCE S
tionship on social outcomes,17 calling for the need to include 1. Howlader, N., et al., SEER Cancer Statistics Review, 1975-2010.
fathers within this research. [Based on the November 2012 SEER data submission, posted to the
SEER web site, April 2013.]. Bethesda, MD: National Cancer Institute,
2013.
2. Zebrack BJ et al. Psychosocial service use and unmet need among
3.2 | Clinical implications recently diagnosed adolescent and young adult cancer patients. Can-
cer. 2013;119(1):201-214.
3. Muffly LS et al. Psychological morbidities in adolescent and young
The research based on the parent-child relationship within pediatric
adult blood cancer patients during curative-intent therapy and early
oncology is small, thus ongoing investigations within this area are survivorship. Cancer. 2016;122(6):954-961.
essential for the development of clinical recommendations and 4. Husson O et al. Cancer in adolescents and young adults: who remains
methods for evaluation. Consistent with the Standards of Psychoso- at risk for poor social functioning over time? Cancer. 2017;123(14):
2743-2751.
cial Care,41 these findings add further support for targeted interven-
5. Cox MJ, Paley B. Understanding families as systems. Curr Dir Psychol
tions for survivors and families. In conjunction with prior research in
Sci. 2003;12(5):193-196.
pediatric oncology36 our findings indicate family-based interventions 6. Van Schoors M et al. Systematic review: associations between family
may be an appropriate avenue for supporting young survivors’ psy- functioning and child adjustment after pediatric cancer diagnosis: a
chological and social health, particularly as it pertains to bolstering the meta-analysis. J Pediatr Psychol. 2017;42(1):6-18.
7. Cousino MK, Hazen RA. Parenting stress among caregivers of children
caregiver-youth relationship. At the very least, practitioners should be
with chronic illness: a systematic review. J Pediatr Psychol. 2013;38
mindful that although some caregivers and youth may present typi- (8):809-828.
cally across certain domains of functioning (ie, Relational Frustration), 8. Pai AL et al. A meta-analytic review of the influence of pediatric can-
they may be meaningfully struggling across other, less observable cer on parent and family functioning. J Fam Psychol. 2007;21(3):407.
9. Brown BB, Bakken JP. Parenting and peer relationships: reinvigorating
domains (ie, Communication, Involvement, Attachment) that carry sig-
research on family–peer linkages in adolescence. J Res Adolesc. 2011;
nificant implications for youth's social and emotional outcomes. 21(1):153-165.
Including parent-child relationship assessments as a part of clinical 10. Laible D. Attachment with parents and peers in late adolescence:
evaluations, such as the PRQ or other related instruments, may be Links with emotional competence and social behavior. Pers Indiv Dif-
fruitful for identifying these difficulties and informing clinical care. fer. 2007;43(5):1185-1197.
11. Chiariello MA, Orvaschel H. Patterns of parent-child communication:
relationship to depression. Clin Psychol Rev. 1995;15(5):395-407.
12. Hodge C et al. Family leisure: an integrative review of research from
3.3 | Conclusion select journals. J Leis Res. 2015;47(5):577-600.
13. Weymouth BB et al. A meta-analysis of parent–adolescent conflict:
Variability exists across domains of caregiver-youth relationship func- disagreement, hostility, and youth maladjustment. J Fam Theory Rev.
2016;8(1):95-112.
tioning, and it is critical for researchers and providers to more compre-
14. Siu AF, Ma Y, Chui FW. Maternal mindfulness and child social behav-
hensively examine the implications of these patterns on the social and ior: the mediating role of the mother-child relationship. Mindfulness.
emotional wellbeing of pediatric cancer survivors. Findings from this 2016;7(3):577-583.
research indicate a pattern indicative of a struggling relationship is 15. Pinquart M. Do the parent-child relationship and parenting behaviors
differ between families with a child with and without chronic illness?
related to caregiver distress as well as associations with young survi-
A meta-analysis. J Pediatr Psychol. 2013;38(7):708-721.
vors increased posttraumatic stress, elevated levels of internalizing 16. Bleil ME et al. The influence of parent-child relatedness on depressive
symptoms, and decreased social functioning scores. Thus, caregiver- symptoms in children with asthma: tests of moderator and mediator
youth relationship patterns warrant ongoing investigation and may be models. J Pediatr Psychol. 2000;25(7):481-491.
346 TILLERY ET AL.
17. Orbuch TL et al. Parent-child relationships and quality of life: resil- 33. Asparouhov T, Muthén B. Auxiliary variables in mixture modeling:
ience among childhood cancer survivors. Fam Relat. 2005;54(2): Three-step approaches using M plus. Struct Equ Modeling: Multidiscip
171-183. J. 2014;21(3):329-341.
18. Keim MC et al. Parent-child communication and adjustment 34. Bitsko MJ et al. Psychosocial late effects in pediatric cancer survivors:
among children with advanced and non-advanced cancer in the a report from the Children's Oncology Group. Pediatr Blood Cancer.
first year following diagnosis or relapse. J Pediatr Psychol. 2017; 2016;63(2):337-343.
42(8):871-881. 35. Kearney JA, Salley CG, Muriel AC. Standards of psychosocial care for
19. Werba BE et al. Classifying the intensity of pediatric cancer treatment parents of children with cancer. Pediatr Blood Cancer. 2015;62(S5):
protocols: the intensity of treatment rating scale 2.0 (ITR-2). Pediatr S632-S683.
Blood Cancer. 2007;48(7):673-677. 36. Kazak AE et al. Surviving Cancer Competently Intervention Program
20. Barratt, W., The Barratt simplified measure of social status (BSMSS): mea- (SCCIP): a cognitive-behavioral and family therapy intervention for
suring SES. Unpublished manuscript, Indiana State University, 2006. adolescent survivors of childhood cancer and their families. Fam Pro-
21. Weiss DS. The Impact of Event Scale: Revised, In Cross-cultural Assess- cess. 1999;38(2):176-191.
ment of Psychological Trauma and PTSD. Springer; 2007:219-238. 37. Katz LF et al. Trajectories of marital, parent-child, and sibling conflict
22. Derogatis, L.R., BSI 18, Brief Symptom Inventory 18: Administration, during pediatric cancer treatment. Health Psychol. 2018;37(8):736.
Scoring and Procedures Manual. 2001: NCS Pearson, Incorporated. 38. Burke JD, Pardini DA, Loeber R. Reciprocal relationships between
23. Kamphaus RW, Reynolds CR. PRQ: Parenting Relationship Question- parenting behavior and disruptive psychopathology from childhood
naire Manual. Minneapolis, MN: NCS Pearson; 2006. through adolescence. J Abnorm Child Psychol. 2008;36(5):679-692.
24. Pynoos R et al. UCLA PTSD Index for DSM-IV. Los Angeles, CA: UCLA 39. Dolgin MJ et al. Trajectories of adjustment in mothers of children
Trauma Psychiatry Service; 1998:101998. with newly diagnosed cancer: a natural history investigation. J Pediatr
25. Steinberg AM et al. The University of California at Los Angeles post- Psychol. 2007;32(7):771-782.
traumatic stress disorder reaction index. Curr Psychiatr Rep. 2004;6 40. De Los Reyes A, Ohannessian CM, Racz SJ. Discrepancies between
(2):96-100. adolescent and parent reports about family relationships. Child Dev
26. Reynolds, C. and Kamphaus, R. Behavior Assessment System for Chil- Perspect. 2019;13(1):53-58.
dren (BASC-2) Handout. 2004(4201):p. 55014-51796. 41. Lown EA et al. Psychosocial follow-up in survivorship as a standard of
27. Merrell KW. Social Emotional Assets and Resilience Scales. PAR Lutz: care in pediatric oncology. Pediatr Blood Cancer. 2015;62(S5):S514-
FL; 2011. S584.
28. Nese RN et al. Social Emotional Assets and Resilience Scales: devel-
opment of a strength-based short-form behavior rating scale system.
J Educ Res Online. 2012;4(1):124-139.
29. Schwarz G. Estimating the dimension of a model. Ann Stat. 1978;6(2):
461-464. How to cite this article: Tillery R, Willard VW, Howard
30. Lo Y, Mendell NR, Rubin DB. Testing the number of components in a Sharp KM, Klages KL, Long AM, Phipps S. Impact of the
normal mixture. Biometrika. 2001;88(3):767-778. parent-child relationship on psychological and social resilience
31. McLachlan G, Peel D. Finite Mixture Models. New York, NY: Wiley; 2000.
in pediatric cancer patients. Psycho-Oncology. 2020;29:
32. Berlin KS, Williams NA, Parra GR. An introduction to latent variable
mixture modeling (part 1): overview and cross-sectional latent class
339–346. https://doi.org/10.1002/pon.5258
and latent profile analyses. J Pediatr Psychol. 2014;39(2):174-187.
Copyright of Psycho-Oncology is the property of John Wiley & Sons, Inc. and its content
may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder's express written permission. However, users may print, download, or email articles for
individual use.