Mothers and fathers coping with their children's cancer: Individual and interpersonal processes.

The diagnosis and treatment of cancer in a child are significant sources of stress for mothers and fathers, affecting the parents of over 12,000 children in the U.S. annually (Jemal, Siegel, Xu, & Ward, 2010). Parents are faced with a range of different stressors, with the greatest threat being the potential death of their child. This high level of stress can be associated with acute and prolonged symptoms of emotional distress, including depressive symptoms, in a subgroup of parents (Kazak, Boeving, Alderfer, Hwang, & Reilly, 2005; Pai et al., 2007). Therefore, it is important to understand the ways that parents cope with a child’s cancer in order to inform interventions that may facilitate more adaptive coping for these parents This includes possible interpersonal processes of coping and adjustment by which there may be bidirectional effects of distress and coping strategies between partners within a couple. Parents of children with cancer encounter multiple sources of stress, including the emotional challenges of caring for their child, disruptions in daily routines, financial challenges due to income loss and medical expenses, and challenges communicating with medical professionals and their child about complex aspects of the disease and treatment (Rodriguez et al., 2012). Research has indicated that although many parents do not report significant levels of distress, a significant subgroup of parents may be at risk for emotional distress, including depressive symptoms (e.g., Iobst et al., 2009; Kazak et al., 2005; Norberg, Lindblad, & Boman, 2005). Although studies generally have shown a decline in parents’ depressive symptoms and other forms of emotional distress over several years following a child’s cancer diagnosis, mean levels of distress are significantly higher than normative levels near the time of diagnosis (Maurice-Stam, Oort, Last, & Grootenhuis, 2008; Pai et al., 2007). Given the variability in levels of depressive symptoms and other forms of emotional distress among parents of children with cancer, it is important to identify patterns of coping that may be associated with higher versus lower levels of symptoms and distress. Researchers have examined the relationships between coping and parental distress among parents of pediatric cancer patients (e.g., Maurice-Stam et al., 2008; Bennett Murphy, Flowers, McNamara, & Young-Saleme, 2008; Norberg et al., 2005). However, it is difficult to synthesize findings because of heterogeneity in measures of coping, types of coping strategies assessed, time since the child’s diagnosis, and sample characteristics. A review by Clarke, McCarthy, Downie, Ashley, and Anderson (2009) noted that eight studies of parents coping with a child’s cancer all used different measures and different subtypes of coping, mirroring problems in the field of research on coping in general (Skinner, Edge, Altman, & Sherwood, 2003). The majority of studies of parents’ coping with their child’s cancer have not examined the association of coping and emotional distress between partners. Although some studies (e.g., Bennett Murphy et al., 2008; Patistea, 2005) have compared the ways that mothers and fathers cope with a child’s cancer, these studies analyzed mean-level differences between mothers and fathers rather than associations between coping and partners’ emotional distress for mothers and fathers. Two studies that reported analyses of couples (Dahlquist et al., 1993; Hoekstra-Weebers, Jaspers, Kamps, & Klip, 1998) found that parents’ discrepant use of coping strategies may be related to their distress, but the association between coping and partners’ depressive symptoms is still unclear. It is plausible that partners’ coping may have either interference or compensatory effects on one another’s emotional distress (Aldao & Nolen-Hoeksema, 2012). Drawing on dyadic models of coping (e.g., Berg & Upchurch, 2007), interference effects may occur when one partner’s use of maladaptive coping strategies undermines the effects of the other partner’s use of potentially beneficial coping strategies for themselves and their partner (Kraemer, Stanton, Meyerowitz, Rowland, & Ganz, 2011). In contrast, compensatory effects may be reflected when one’s own, or a partner’s, use of potentially beneficial types of coping serves as a buffer against personal or one’s partner’s use of maladaptive types of coping. The current study was guided by a control-based model of coping with stress in which the level of actual and perceived controllability of illness-related stress is central for understanding the ways that children and their parents cope with chronic illness (Compas, Jaser, Dunn, & Rodriguez, 2012). Drawing on Weisz and colleagues’ model of perceived control (Rudolph, Dennig, & Weisz, 1995; Weisz, McCabe, & Dennig, 1994), three types of coping can be distinguished: primary control coping, secondary control coping, and disengagement coping (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001; Compas et al., 2012). Primary control coping includes strategies intended to directly change the source of stress (e.g., problem solving) or one’s emotional reactions to the stressor (e.g., emotional expression, emotional modulation). Secondary control coping encompasses efforts to adapt to stress, including cognitive reappraisal, positive thinking, acceptance, and distraction. Disengagement coping includes efforts to orient away from the source of stress or one’s reactions to it (e.g., avoidance, denial, wishful thinking). Secondary control coping has been found to be most adaptive for coping with uncontrollable stress, whereas primary control is better suited for controllable stressors (Compas et al., 2012). These three factors of coping, as measured by the Responses to Stress Questionnaire (RSQ; Connor-Smith, Compas, Wadsworth, Thomsen, & Saltzman, 2000), have been supported by confirmatory factor analyses with adult samples of women coping with breast cancer (Compas et al., 2006) and parents coping with economic stress (Wadsworth, Raviv, Compas, & Connor-Smith, 2005). This control-based model may be particularly suited to understanding coping in parents of children with cancer because they face stressors that vary considerably in their degree of controllability. Applying this model in a sample of parents within the initial months after their child’s cancer diagnosis, we examined the association between coping and emotional distress in individual and interpersonal analyses (see Figure 1). First, we hypothesized that, at the individual level for mothers and fathers, primary and secondary control would be associated with lower depressive symptoms, whereas disengagement coping would be related to higher levels of symptoms (see Figure 1a). Second, we hypothesized that there would be moderate concordance within dyads for both coping strategies and levels of depressive symptoms. Third, we hypothesized that mothers’ and fathers’ coping would be significantly related to their spouses’ depressive symptoms. Specifically, we expected that primary and secondary control coping in one parent would be related to lower distress for their partner, while disengagement coping would be associated with higher partner depressive symptoms (see Figure 1b). Finally, we conducted exploratory analyses of potential interpersonal interference effects of disengagement coping and potential compensatory effects of secondary control coping in relation to a partner’s use of disengagement coping by testing the interactions of secondary control and disengagement coping between mothers and fathers (see Figure 1c). We chose secondary control coping because it may be especially well-suited to coping with uncontrollable aspects of a child’s cancer diagnosis and treatment, whereas disengagement coping has been associated with greater depressive symptoms. Figure 1 Hypothesized models of individual, interpersonal, interference, and compensatory relations of coping and emotional distress for mothers and fathers.