Association Between Parent and Child Distress and the Moderating Effects of Life Events in Families With and Without a History of Pediatric Cancer

Parental psychological distress, including symptoms of depression, anxiety, and posttraumatic stress, has received much attention in the pediatric psychology literature as a potential risk factor for child distress (e.g., Sawyer, Streiner, Antoniou, Toogood, & Rice, 1998; Trask, Paterson, Trask, Bares, Blirt, & Maan, 2003). Numerous mechanisms are proposed for the link between parental distress and such symptoms in the child. For example, parental distress may be an expression of biological susceptibility to certain disorders that may be passed on to children, including depression (Beardslee, Gladstone, & O'Connor, 2011), anxiety (Hettema, Neale, & Kendler, 2001), and posttraumatic stress (PTS; Cornelis, Nugent, Amstadter, & Koenen, 2010). Alternately, parental distress may interfere with the parent’s provision of emotional support necessary for healthy child adaptation and development. For instance, parental depression may exacerbate child maladjustment (Goodman et al., 2011) and contribute specifically to child depressive symptoms (McLeod, Weisz, & Wood, 2007) via parenting behaviors characterized by lowered sensitivity and consistency (Cummings & Davies, 1994), increased hostility, coerciveness, or withdrawal (Lovejoy, Graczyk, O'Hare, & Neuman, 2000), or decreased scaffolding (Hoffman, Crnic, & Baker, 2006). Prospective links between parental depression and later child anxiety and depression have been found (Halligan, Murray, Martins, & Cooper, 2007), and parental symptoms have been found to predict child symptoms rather than vice versa (Garber & Cole, 2010). The effects of parental distress on child maladjustment have also been noted for other outcomes such as anxiety and PTS. Elevated parental anxiety may increase the child’s internalizing problems via such processes as providing too much control and granting too little autonomy (McLeod, Wood, & Weisz, 2007), modeling of anxious behaviors (Wood, McLeod, Sigman, Hwang, & Chu, 2003), and reinforcement of anxious or avoidant behaviors (Fisak & Grills-Taquechel, 2007). These parental behaviors also appear to exacerbate PTS in children (Pynoos, Steinberg, & Piacentini, 1999). Transmission of distress from the parent to the child may occur more readily in families with a serious child illness or injury, given increased levels of distress in these parents compared with parents of healthy children (Cohen, 1999; Landolt, Ystrom, Sennhauser, Gnehm, & Vollrath, 2012). In families coping specifically with pediatric cancer, at least temporary increases in parental distress are reported compared with norms and controls (Dolgin etal., 2007; Pai et al., 2007; Vrijmoet-Wiersma et al., 2008). In turn, increased parental distress has been linked to child distress within some pediatric samples. For example, a meta-analysis found an association between maternal maladjustment and child maladjustment (Lavigne & Faier-Routman, 1993), and increased paternal maladjustment has been linked to child psychopathology 1 year later (Chaney et al., 1997). Higher parental PTS has been associated with smaller decreases in child PTS across 1 year (Landolt et al., 2012) as well. In samples specifically with pediatric cancer, cross-sectional (Trask et al., 2003) and prospective (Sawyer et al., 1998) associations between parental distress and child maladjustment have also been found. However, to ascertain whether these associations between parent and child distress are exacerbated by experiences of child cancer, comparisons with parent–child dyads in demographically matched control or normative samples are needed. The present study sought to fill this gap using a sample of parent–child dyads with pediatric cancer and demographically matched controls. In addition to examining the association between parental distress and child adjustment, moderators that affect the strength of such association need to be further explored (Drotar, 1997). The present study examined the potential moderating effects of the child's exposure to life events. Life events refer to events in one's life that require significant adaptation, adjustment, or coping, such as moving, loss, or illness of a close family member, exposure to violence, or change in family structure (Coddington, 1972a). Exposure to life events, including illness or death of a family member, parental divorce, and abuse, is linked to increased odds of later psychopathology (Clark, Caldwell, Power, & Stansfeld, 2010; Grant, Compas, Thurm, McMahon, & Gipson, 2004; Harland, Reijneveld, Brugman, Verloove-Vanhorick, & Verhulst, 2002). Exposure to negative life events has been linked to child maladjustment in pediatric samples also (Bruce, 2006; Lavigne & Faier-Routman, 1993). Because existing research has not yet examined the impact of a child’s exposure to life events on the association between parent and child distress, it is unknown whether such exposure makes the child more or less influenced by parental distress. As existing research suggests that exposure to life events significantly increases child distress even after accounting for family influences, we hypothesized that it would weaken the link between parent and child distress because the child would be distressed at higher levels of life events regardless of parental distress. This view would be consistent with existing models of allostatic load, which suggests that exposure to early stress (e.g., parental conflict or separation, chronic poverty) can alter the child's biological and psychological capacity for adaptation (Juster et al., 2011) in ways that render the child vulnerable to psychopathology even without a precipitating stressor, such as is proposed by diathesis-stress models of psychopathology. For instance, stressful life events, such as illness/death in the family, or parental divorce/separation, have been linked to child maladjustment even after controlling for maternal depression (Fergusson, Horwood, Gretton, & Shannon, 1985) and family characteristics (Harland et al., 2002). Cumulative exposure to life events predicts PTS in children with cancer even after accounting for demographic and medical factors and parental PTS (Currier, Jobe-Shields, & Phipps, 2009). Exposure to potentially traumatic life events (e.g., natural disasters, exposure to violence, sudden loss of a loved one) predicts symptoms of PTS and depression in adolescents admitted for surgery, even after controlling for parental symptoms of PTS and depression (Zatzick et al., 2006). Thus, existing research suggests that exposure to life events is a powerful predictor of child distress, perhaps more so than concurrent parental functioning. Based on existing findings, we hypothesized that parental functioning would influence child distress only at lower levels of child exposure to life events, whereas at higher levels of exposure to life events, the child’s distress would be less contingent on parent distress. In summary, the present study aimed to examine the association between parental and child distress in families with and without a pediatric cancer experience and how such an association is affected by the child's exposure to life events. Based on the literature reviewed above, we hypothesized that (1) Parental distress will be significantly linked to child distress; (2) Parental distress will be more strongly linked to child distress within families with pediatric cancer than in controls; and (3) The total number of stressful life experiences to which the child has been exposed moderates the link between parent and child distress, such that this link is weakened with greater child exposure to stressful life events.