1. Parenting behaviors predict effortful control and internalizing/externalizing problems among children during the first year of a cancer diagnosis
Emily Shultz, B.S.,1 Madelaine Keim, B.A.,1 Kathryn Vannatta, PhD,1 Bruce E. Compas, PhD,2 & Cynthia A. Gerhardt, PhD 1
1The Research Institute at Nationwide Children’s Hospital and The Ohio State University, 2 Vanderbilt University
Background
Specifically, a child’s effortful mediated the relationship between positive parenting and fewer externalizing problems in a longitudinal study.
For internalizing and externalizing, the cut-off point for the normal range is a T-score <60, borderline-clinical is from 60 to 63, and the clinical range is ≥64.
Sample items PACS: I can discuss my beliefs with my mother without feeling restrained or embarrassed (openness)
Sample items CRPBI: Likert scale 1-3 My mother is a person who… makes me feel better after talking over my worries with her (warmth); ... says that if I really cared for her,
I would not do things that cause her to worry (psych control); …gives hard punishment (beh control)
Sample Items EAT-Q: Likert scale 1-5, Has a hard time waiting his/her turn to speak when excited; Finds it easy to really concentrate on a problem; Is able to stop him/herself from laughing at inappropriate times.
Results: Not moderated by age or gender
background
Nearly 16 thousand families are affected by pediatric cancer every year, which is an experience that may disrupt family relationships and place family members at an increased risk for psychosocial difficulties.
Effortful control (EC), the efficiency of executive attention and the ability to inhibit a dominant response, plays a fundamental role in emotional regulation. Therefore, EC contributes to the development of psychosocial difficulties.
Although EC is traditionally conceptualized as a stable temperamental characteristic, it can also be shaped by parental interactions which are susceptible to change in the context of pediatric cancer.
Considering that family relationships may be disrupted following a child’s diagnosis of cancer, we examined how parenting behaviors contribute to a child’s EC, which in turn, contribute to the development of internalizing and externalizing problems.
Hypothesis 1: Children with recently diagnosed cancer will exhibit elevated internalizing and externalizing problems in comparison to measure norms.
Hypothesis 2: EC will account for significant variance between mother’s parenting behaviors and child’s internalizing and externalizing problems. Specifically, when the mother-child communication quality is better (more open, fewer problems) and when the mother parents with more warmth and less behavioral/psychological control, the child will exhibit more effortful control and have fewer internalizing/externalizing problems.
method (continued)
results (continued)
Analysis
Hypothesis 1: Descriptive statistics compared pediatric cancer patients to measure norms.
Hypothesis 2: Analysis of direct and indirect effects were conducted using multiple regression analysis. Post-hoc bootstrapping was used to test the significance of indirect effects.
Figure 2: Mediation Model, Communication Problems
Indirect effect = 0.19, 95% CI [0.06, 0.42]
Internalizing/ Externalizing
Communication Problems
Effortful Control
b = -0.37, p < .05
cʹ = 0.11, p = .41
Outcome
Internalizing
Externalizing
b = -0.56, p < .001
a = -0.34, p < .01
Figure 1: Conceptual mediation model
Indirect effect = 0.11, 95% CI [0.26, 0.27]
Internalizing or Externalizing Problems 3
Mother Parenting 1
Effortful Control 2
c = .22, p = .08
c =.33, p < .01
cʹ = 0.14, p = .20
Fewer communication problems predicted both fewer internalizing and externalizing problems at T2 and was partially mediated by child EC (p < .01).
1 Child report of parenting on the PACS: Openness or Communication Problems, OR CRPBI: Warmth, Psychological control or Behavioral control at T1
2 Mother report of effortful control on the EAT-Q at T2
3 Mother report of internalizing or externalizing problems on the CBCL at T2
Figure 3: Mediation Model, Psychological Control
results
Indirect effect = 0.16, 95% CI [0.01, 0.40]
Internalizing/ Externalizing
Psychological Control
Effortful Control
b = , p < .01
cʹ = 0.26, p = .08
Outcome
Internalizing
Externalizing
Hypothesis 1
b = -0.33, p = .07
a = -.47, p < .01
Children with pediatric cancer have less externalizing problems than we would expect in a normative sample; 11% of children had borderline-clinical externalizing problems (T-score 60-63), and 3.2% had clinically significant externalizing problems (T-score > 64).
However, 6.5% of the sample had borderline-clinical internalizing problems and 16.1% had clinically significant internalizing problems, which is more than we would expect in a normative sample (22.6% vs. 15.9%).
Indirect effect = 0.24, 95% CI [0.06, 0.56]
c = .24 , p = .17
c = .50, p <.01
method
cʹ = 0.08, p = .17
Lower psychological control predicted both fewer internalizing and externalizing problems at T2 and were each partially mediated by child EC (p < .01).
Procedure
As part of a larger, ongoing longitudinal study, families (N = 62) of children diagnosed with cancer were recruited from cancer registries at two children’s hospitals in the United States.
One month after a diagnosis of cancer (T1), children (ages 10-18; M = 13.5, SD = 2.4) reported on their mother’s parenting. One year after diagnosis (T2), mothers reported on their child’s effortful control and internalizing/ externalizing problems.
Table 1: Descriptive statistics
Measure
Subscale
M (SD)
PACS
Openness
42.27 (6.71)
Communication Problems
23.38 (7.03)
CRPBI
Warmth
28.23 (2.13)
Psychological Control
15.28 (3.96)
Behavioral Control
19.75 (2.38)
EAT-Q
Effortful Control
3.38 (0.66)
CBCL
Internalizing
50.73 (10.99)
Externalizing
47.65 (9.90)
Although in general children with a recent cancer diagnosis do not have elevated internalizing and externalizing problems, it is important to identify factors that contribute to the development of these problems for the subset of children who meet clinical cut-offs.
Specific maternal parenting behaviors shortly after a cancer diagnosis were significantly associated with a child’s EC, which then in turn was associated with externalizing and internalizing problems one year from the diagnosis.
One limitation is that we did not analyze how effortful control could be related to central nervous system-directed cancer treatments. Future research should aim to isolate these effects from those of parenting.
Another limitation is the problematic measurement of internalizing problems in chronic illness samples due to the inclusion of the somatic scale on the CBCL.
Our results support the idea that parenting, which may be altered within the context of pediatric cancer, can shape a child’s EC and contribute to their psychosocial adjustment.
Interventions specifically designed to reduce communication problems and psychological control among mothers may be effective in preventing psychosocial difficulties shortly after a cancer diagnosis. Future studies should examine the role of father’s parenting behaviors as well.
discussion
Measure
Description
Construct
PACS
Parent-Adolescent Communication Scale
Child report of mother-child communication quality. Subscales range from
Parenting Behavior:
Openness
Communication Problems
Warmth
Psychological Control
Behavioral Control
CRPBI
Child Report of Parenting Behavior Inventory
Child report of mother parenting practices. Subscales range from
EAT-Q
Early Adolescent Temperament Questionnaire
Mother report of child’s temperament.
The EC subscale ranges from 1-5.
Effortful control
CBCL
Child Behavior Checklist
Mother report of frequency/intensity of child’s internalizing and externalizing problems. Scales reported in T-scores.
Internalizing Problems
Externalizing Problems
Hypothesis 2
Table 2: Indirect effects of parenting via effortful control
Openness
Communication Problems
Warmth
Psychological Control
Behavioral Control
Internalizing problems
-0.09
0.11*
0.04
0.16*
Externalizing problems
-0.15
0.19*
0.07
0.24*
-0.18
We would like to thank the families who participated and our funding source, the National Cancer Institute.
Correspondence to:
Note: Standardized betas are reported; * Indicates that the indirect path of a specified dimension of parenting via effortful control on internalizing or externalizing was significant according to bootstrapping analyses, CI 95%.