Temperament

as

a

predictor

of

internalising

and

externalising

problems

in

adolescent

children

of

parents

diagnosed

with

cancer

Objective

This

study

examined

the

relationship

between

temperament

and

internalising

and

externalising

problems

among

children

of

parents

diagnosed

with

cancer

beyond

the

effects

of

socio-demographics

illness-related

variables

and

life

events

Introduction

All

people

are

confronted

with

intense

experiences

during

the

course

of

their

lifetime

Even

children

are

not

spared

from

them

Adolescent

children

especially

are

vulnerable

to

stressful

events

-LSB-

-RSB-

One

stressful

incident

with

which

families

with

adolescent

children

are

increasingly

confronted

is

the

diagnosis

of

cancer

in

one

of

the

parents

Studies

have

shown

that

adolescent

children

in

such

situations

the

daughters

particularly

experience

more

emotional

problems

than

their

age

peers

do

-LSB-

-RSB-

Although

the

functioning

of

children

of

cancer

patients

has

received

increasing

attention

research

into

risk

and

resilience

factors

is

still

in

its

infancy

Recent

studies

found

evidence

for

the

impact

of

parental

characteristics

-LSB-

-RSB-

parent

child

communication

-LSB-

-RSB-

and

family

functioning

-LSB-

-RSB-

on

child

functioning

Increased

attention

is

given

to

the

different

effect

of

parental

cancer

for

boys

and

girls

and

children

of

different

ages

but

research

into

other

child

characteristics

is

lacking

Temperament

is

one

of

the

factors

that

may

have

an

important

influence

on

how

children

cope

with

stressful

events

and

therefore

why

some

children

are

more

vulnerable

to

the

development

of

problems

than

others

-LSB-

-RSB-

The

primary

hypothesis

of

most

models

of

temperament

is

that

specific

dimensions

are

related

to

prevalence

of

specific

problems

Research

into

the

role

of

temperament

can

provide

insight

into

which

children

are

at

greater

risk

in

such

situations

and

which

children

are

better

equipped

to

handle

the

situation

The

developmental

model

of

temperament

as

proposed

by

Rothbart

and

Derryberry

is

one

of

the

few

models

that

offers

a

measurement

tool

that

is

specifically

designed

for

use

with

adolescents

and

it

was

therefore

used

in

the

present

study

Rothbart

proposes

that

temperament

is

relatively

stable

but

that

the

expression

of

temperament

can

change

as

a

result

of

maturation

and

-LRB-

social

-RRB-

environmental

influences

including

life

events

-LSB-

-RSB-

The

model

distinguishes

between

two

concepts

reactivity

and

self-regulation

Reactivity

is

comprised

of

the

physical

and

emotional

differences

that

exist

among

individuals

in

reaction

to

stress

Children

who

have

a

high

degree

of

reactivity

are

more

easily

upset

and

need

more

time

to

recover

than

other

children

do

The

term

self-regulating

system

refers

to

such

processes

as

attention

activation

and

inhibition

These

processes

have

an

important

influence

on

the

regulation

of

emotions

and

behaviour

These

children

may

be

able

to

direct

attention

away

from

the

stressor

such

as

parental

cancer

To

our

knowledge

no

studies

have

reported

on

the

effect

of

different

temperament

dimensions

on

the

functioning

of

children

of

parents

who

have

been

diagnosed

with

cancer

The

aim

of

the

current

study

was

to

investigate

the

effects

of

temperament

on

prevalence

of

problems

in

these

children

beyond

the

possible

effects

of

socio-demographics

-LRB-

age

gender

educational

level

-RRB-

illness-related

variables

-LRB-

recurrent

disease

and

time

since

diagnosis

-RRB-

and

the

number

of

negative

life

events

that

children

experienced

during

the

year

before

assessment

Materials

and

methods

Procedure

Between

January

and

February

written

information

on

this

study

was

offered

to

all

cancer

patients

who

were

consecutively

hospitalised

or

who

visited

the

outpatient

's

clinic

at

the

University

Medical

Centre

Groningen

by

their

physicians

or

oncology

nurses

In

addition

information

was

sent

to

patients

and

their

family

members

who

had

contacted

the

researchers

in

response

to

media

attention

because

they

wished

to

participate

in

the

study

Families

were

eligible

if

patients

had

been

diagnosed

between

to

years

before

study

entry

and

if

they

had

children

between

to

years

of

age

Participants

had

to

be

fluent

in

Dutch

Patients

discussed

study

participation

with

their

partners

-LRB-

if

present

-RRB-

and

children

Informed

consent

was

obtained

according

to

the

regulations

of

the

Medical

Ethical

Committee

of

the

University

Medical

Centre

Groningen

After

informed

consent

was

received

questionnaires

and

prepaid

return

envelopes

were

provided

Participants

were

guaranteed

that

answers

were

treated

absolutely

confident

and

will

be

described

completely

anonymous

Participants

The

current

study

is

part

of

a

larger

study

in

which

families

with

children

aged

to

years

were

approached

and

information

was

mailed

to

families

who

had

contacted

us

for

information

about

participation

Of

these

families

from

the

first

group

and

families

from

the

second

group

consented

to

participate

-LRB-

response

and

respectively

-RRB-

Ill

parents

who

did

not

participate

did

not

significantly

differ

from

those

who

participated

with

respect

to

gender

tumour

type

and

time

since

diagnosis

The

current

study

focused

on

the

responses

of

children

of

years

of

age

and

older

as

they

completed

the

questionnaires

themselves

The

sample

for

the

present

study

consisted

of

adolescent

children

-LRB-

sons

and

daughters

-RRB-

between

the

ages

of

and

years

-LRB-

mean

age

years

SD

-RRB-

and

their

ill

parents

-LRB-

mothers

mean

age

years

SD

-RRB-

Twenty-one

percent

of

the

children

were

receiving

education

in

primary

school

at

the

lower

vocational

level

in

lower

general

secondary

education

in

intermediate

vocational

education

in

high

school

and

in

higher

vocational

education

or

university

Nine

percent

of

the

children

were

from

single-parent

families

Parents

-LRB-

fathers

mothers

mean

age

years

SD

-RRB-

had

been

diagnosed

with

various

types

of

cancer

breast

-LRB-

-RRB-

haematological

-LRB-

-RRB-

skin

-LRB-

-RRB-

gynaecological

-LRB-

-RRB-

urological

-LRB-

-RRB-

bone

tumours

-LRB-

-RRB-

gastrointestinal

-LRB-

-RRB-

or

other

cancers

such

as

cancer

of

the

central

nervous

system

or

head

and

neck

cancer

-LRB-

-RRB-

The

mean

time

since

diagnosis

was

years

-LRB-

SD

-RRB-

Twenty-nine

percent

of

the

parents

had

suffered

relapses

Children

and

parents

approached

in

the

hospital

did

not

significantly

differ

in

age

or

gender

from

children

and

parents

who

had

volunteered

for

participation

Educational

level

of

parents

of

the

last-named

group

was

significantly

higher

-LRB-

t

p

-RRB-

than

that

of

the

first-named

group

but

this

was

not

found

for

children

's

educational

level

Furthermore

children

and

parents

in

both

groups

reported

similar

levels

of

internalising

and

externalising

problems

and

children

did

not

differ

significantly

in

temperament

Measures

Temperament

Temperament

was

measured

using

the

adolescent

version

of

the

Revised

Early

Adolescent

Temperament

Questionnaire

-LRB-

EATQ-R

-RRB-

of

Rothbart

and

Derryberry

-LSB-

-RSB-

The

EATQ-R

consists

of

items

and

includes

ten

subscales

that

are

designed

to

measure

temperamental

attention

control

activation

control

inhibitory

control

high

intensity

pleasure

shyness

fear

frustration

affiliation

perceptual

sensitivity

and

pleasure

sensitivity

Answers

were

rated

on

a

Likert-type

scale

-LRB-

almost

always

untrue

to

almost

always

true

-RRB-

Higher

values

represent

a

higher

availability

of

the

temperamental

dimension

concerned

The

psychometric

quality

of

the

EATQ-R

was

reported

to

be

sufficient

among

American

adolescents

with

Cronbach

's

alpha

's

ranging

from

α

to

α

-LSB-

-RSB-

In

the

present

study

alpha

scores

ranged

from

α

to

α

and

mean

inter-item

correlations

from

r

to

r

Five

of

the

ten

dimensions

had

mean

inter-item

correlations

of

Therefore

factor

analyses

were

carried

out

to

study

the

extent

to

which

the

temperamental

dimensions

identified

by

Rothbart

and

colleagues

emerged

from

the

data

of

the

present

Dutch

study

-LRB-

see

preliminary

analyses

-RRB-

Internalising

and

externalising

problems

The

Youth

Self-Report

-LRB-

YSR

-RRB-

and

Child

Behaviour

Checklist

-LRB-

CBCL

-RRB-

were

used

to

assess

respectively

adolescent

children

's

self-reported

and

parent

's

reported

behavioural

and

emotional

problems

in

children

-LSB-

-RSB-

The

YSR/CBCL

consists

of

problem

items

with

three

response

options

-LRB-

not

true

somewhat

or

sometimes

true

and

very

true

or

often

true

-RRB-

Higher

scores

indicated

more

problems

The

Internalising

-LRB-

TIS

-RRB-

and

Externalising

Behaviour

Problem

Scales

-LRB-

TES

-RRB-

were

used

in

the

present

study

The

internalising

scale

-LRB-

items

-RRB-

consists

of

the

syndrome

subscales

withdrawal

somatic

complaints

and

anxiety/depression

The

externalising

scale

-LRB-

items

-RRB-

consists

of

the

syndrome

subscales

delinquent

behaviour

and

aggressive

behaviour

The

YSR

is

one

of

the

most

commonly

used

questionnaires

in

adolescent

research

Cronbach

's

alpha

scores

in

the

present

study

were

high

-LRB-

α

-RRB-

The

manual

provides

norm

data

based

on

a

randomly

selected

Dutch

sample

of

adolescent

boys

and

adolescent

girls

Life

events

The

Questionnaire

of

Recently

Experienced

Events

was

used

to

ask

children

and

parents

about

the

number

of

life

events

experienced

during

the

past

year

This

questionnaire

is

based

on

the

Recent

Life

Change

Questionnaire

-LRB-

RLCQ

-RRB-

developed

by

Rahe

-LSB-

-RSB-

Questions

measuring

negative

events

-LRB-

items

e.g.

divorce

illness

by

other

family

members

than

the

parent

with

cancer

-RRB-

were

used

Analyses

Factor

analyses

of

the

EATQ-R

were

executed

using

Simultaneous

Confirmatory

Analysis

-LRB-

SCA

-RRB-

and

Exploratory

Principal

Component

Analysis

-LRB-

PCA

-RRB-

to

investigate

factor

validity

Chi-square

and

t

tests

were

performed

to

compare

children

and

parents

who

had

been

recruited

in

the

hospital

and

those

who

had

volunteered

for

participation

on

demographic

characteristics

and

the

problems

reported

One-sample

t

tests

were

performed

to

compare

prevalence

of

internalising

and

externalising

problems

reported

by

children

and

parents

diagnosed

with

cancer

with

those

of

the

norm

group

Univariate

statistics

-LRB-

t

tests

and

pearson

correlation

analyses

-RRB-

were

performed

to

investigate

effects

of

study

variables

-LRB-

age

gender

educational

level

time

since

diagnosis

recurrence

number

of

negative

life

events

and

temperament

-RRB-

and

problems

in

children

Hierarchical

regression

analyses

were

conducted

to

examine

the

contribution

of

temperament

dimensions

to

prediction

of

internalising

and

externalising

problems

in

children

Socio-demographics

and

illness-related

variables

-LRB-

first

step

-RRB-

and

number

of

life

events

-LRB-

second

step

-RRB-

significantly

related

to

temperament

were

entered

into

regression

analyses

to

ensure

that

any

effect

found

for

temperament

-LRB-

third

step

-RRB-

on

children

's

problems

would

not

be

attributed

to

these

variables

To

examine

whether

multicollinearity

exists

between

the

independent

variables

Pearson

correlation

analyses

and

Variance

Inflation

Factors

-LRB-

VIF

-RRB-

were

performed

If

the

mean

VIF

is

considerably

larger

than

one

and

the

largest

VIF

is

greater

than

multi-collinearity

exists

-LSB-

-RSB-

There

is

evidence

that

sons

and

daughters

may

respond

differently

to

the

cancer

in

the

parent

-LSB-

-RSB-

and

that

they

differ

in

temperament

-LSB-

-RSB-

Two-way-interaction

terms

-LRB-

using

standardised

scores

-RRB-

were

computed

to

examine

whether

the

pattern

of

the

relationship

between

temperament

and

prevalence

of

problems

differ

between

sons

and

daughters

Only

when

the

interaction

accounted

for

a

unique

significant

effect

was

it

included

in

the

model

Owing

to

the

large

number

of

comparisons

in

relation

to

the

sample

size

significance

was

set

at

p

Results

Preliminary

analyses

Simultaneous

Confirmatory

Analysis

-LRB-

SCA

-RRB-

was

conducted

to

examine

differences

in

the

percentage

of

variance

explained

by

the

original

structure

and

by

the

exploratory

structure

over

the

same

number

of

factors

The

difference

in

the

variance

explained

by

the

original

structure

-LRB-

-RRB-

and

by

the

exploratory

structure

-LRB-

-RRB-

was

considered

too

large

-LRB-

rule

of

thumb

-LSB-

-RSB-

-RRB-

to

continue

with

the

original

structure

An

exploratory

Principal

Component

Analysis

-LRB-

PCA

-RRB-

was

conducted

using

orthogonal

rotation

followed

by

varimax

procedure

The

number

of

constituting

factors

was

determined

based

on

the

scree

test

Items

that

loaded

consistently

low

-LRB-

-RRB-

or

on

varying

components

were

excluded

In

addition

all

items

particularly

those

with

loadings

between

and

were

critically

examined

for

the

degree

to

which

they

formed

a

good

reflection

of

the

dimensions

on

which

they

loaded

-LRB-

face

validity

-RRB-

Dimensions

were

assessed

as

consistent

by

an

alpha

above

and

an

inter-item

correlation

above

On

the

basis

of

these

criteria

items

were

excluded

including

the

entire

inhibition-control

-LRB-

five

items

-RRB-

and

the

affiliativeness

scale

-LRB-

five

items

-RRB-

Thirty-six

items

remained

distinguishing

seven

temperamental

dimensions

The

first

dimension

was

called

effortful

control

and

consists

of

all

five

items

from

activation

control

and

four

of

the

six

items

from

attention

control

One

of

the

attention

control

items

was

excluded

and

the

other

was

added

to

the

original

four

perceptual

sensitivity

items

-LRB-

I

am

good

at

keeping

track

of

several

things

that

are

happening

around

me

-RRB-

that

represent

the

second

dimension

The

third

dimension

is

pleasure

sensitivity

just

one

item

did

not

meet

the

criteria

and

was

excluded

The

fear/worry

dimension

forms

the

fourth

dimensions

Three

of

the

six

items

loaded

on

this

scale

One

of

the

other

items

was

excluded

one

was

added

to

pleasure

intensity

-LRB-

I

get

frightened

when

I

ride

with

a

person

who

likes

to

speed

-RRB-

and

one

was

added

to

the

original

four

items

of

the

shyness

scale

-LRB-

Some

of

the

kids

at

school

make

me

nervous

-RRB-

Shyness

was

the

fifth

dimension

The

sixth

dimensions

form

the

pleasure

intensity

Three

of

the

six

items

loaded

low

or

were

not

consistent

and

were

therefore

excluded

The

seventh

dimension

forms

frustration

One

of

the

seven

items

did

not

meet

the

criteria

and

was

excluded

The

seven

temperamental

dimensions

can

be

defined

as

follows

Effortful

control

measures

the

capacity

to

start

and

persist

in

an

action

and

to

focus

attention

Pleasure

sensitivity

is

the

pleasure

related

to

stimuli

involving

low

intensity

complexity

novelty

and

incongruity

Perceptual

sensitivity

pointed

to

detection

or

perceptual

awareness

of

slight

low-intensity

stimulation

in

the

environment

Pleasure

intensity

represents

the

pleasure

derived

from

activities

involving

high

intensity

Shyness

is

the

behavioural

inhibition

to

novelty

and

challenge

especially

social

Frustration

measures

the

negative

effect

related

to

interruption

of

ongoing

tasks

or

goal

blocking

Fear/worry

represents

the

worry

for

occurrence

of

unpleasant

situations

The

seven

factors

that

were

formed

of

remaining

items

explained

of

the

variation

Alpha

coefficients

from

the

other

dimensions

ranged

from

α

to

α

and

inter-item

correlations

ranged

from

r

to

r

-LRB-

Table

-RRB-

Table

's

alpha

EATQ-R

dimensions

of

children

in

the

current

study

and

a

control

studyDimensionsCurrent

studyControlCronbach

's

alphaMean

inter-item

correlationsCronbach

's

alphaMean

inter-item

correlationsNumber

of

itemsEffortful

Pleasure

Perceptual

Pleasure

Cross

validity

The

same

research

group

conducted

a

prospective

study

among

children

of

parents

recently

diagnosed

-LRB-

weeks

ago

-RRB-

with

cancer

using

a

similar

procedure

in

approaching

families

as

was

used

in

the

current

study

The

adapted

structure

was

tested

among

adolescent

children

-LRB-

daughters

mean

age

years

SD

years

-RRB-

that

participated

in

the

prospective

study

-LRB-

comparison

group

-RRB-

Results

of

PCA

among

children

in

the

prospective

study

were

similar

to

those

found

in

the

current

study

The

internal

consistency

and

mean

inter-item

correlations

of

the

two

groups

were

comparable

-LRB-

Table

-RRB-

Results

of

the

Principal

Components

Factor

Analysis

are

available

on

request

Internalising

and

externalising

problems

in

children

T

tests

revealed

no

significant

differences

in

prevalence

of

internalising

and

externalising

problems

between

sons

and

norm

group

boys

as

reported

by

themselves

and

their

ill

parents

Daughters

and

their

ill

parents

reported

significantly

more

internalising

problems

than

found

in

norm

group

girls

-LRB-

Table

-RRB-

Table

statistics

of

the

YSR

and

one

sample

t

tests

for

comparison

of

study

and

norm

group

SonsNorm

group

boystDaughtersNorm

group

girlstMeanSDMeanSDMeanSDMeanSDInternalising

problems

Externalising

problems

Internalising

problems

Externalising

problems

p

Children

's

problems

and

socio-demographics

illness-related

variables

and

life

events

Socio-demographics

Daughters

experienced

significantly

more

internalising

problems

than

sons

as

was

reported

by

ill

parents

and

self-reports

-LRB-

t

p

t

p

-RRB-

Neither

children

's

age

and

educational

level

nor

parent

's

age

gender

or

educational

level

were

significantly

related

to

the

prevalence

of

problems

reported

in

children

Illness-related

variables

Parents

and

children

reported

more

internalising

problems

in

case

of

recurrent

disease

than

in

case

of

primary

disease

Time

since

diagnosis

was

not

significantly

associated

with

reports

of

either

internalising

or

externalising

problems

-LRB-

even

after

controlling

for

recurrent

disease

-RRB-

Life

events

The

number

of

negative

life

events

children

or

parents

experienced

during

the

preceding

year

was

significantly

positively

correlated

with

internalising

-LRB-

r

p

r

p

respectively

-RRB-

and

externalising

problems

-LRB-

r

p

-RRB-

reported

by

or

in

children

Children

's

temperament

and

socio-demographics

illness-related

variables

and

life

events

Socio-demographics

Sons

had

significantly

higher

mean

scores

on

pleasure

intensity

-LRB-

t

p

-RRB-

and

significantly

lower

scores

on

shyness

-LRB-

t

p

-RRB-

than

daughters

did

Age

of

children

was

significantly

negatively

related

to

effortful

control

-LRB-

r

p

-RRB-

No

relationship

was

found

between

child

's

educational

level

and

temperament

Illness-related

variables

No

significant

relationships

were

found

between

length

of

time

since

diagnosis

and

children

's

temperament

Children

of

parents

who

had

recurrent

disease

differed

significantly

in

fear/worry

from

children

of

parents

with

primary

disease

-LRB-

t

p

-RRB-

Life

events

Number

of

negative

life

events

experienced

was

significantly

positively

correlated

with

pleasure

sensitivity

-LRB-

r

p

-RRB-

perceptual

sensitivity

-LRB-

r

p

-RRB-

and

fear/worry

-LRB-

r

p

-RRB-

and

negatively

with

effortful

control

-LRB-

r

p

-RRB-

Relationships

between

temperament

and

problems

in

children

All

temperament

dimensions

were

significantly

related

to

children

's

self-reported

internalising

problems

Shyness

pleasure

intensity

and

fear/worry

were

significantly

related

to

internalising

problems

as

reported

by

ill

parents

Effortful

control

frustration

and

fear/worry

were

significantly

associated

with

the

prevalence

of

externalising

problems

in

children

as

reported

by

children

and

parents

-LRB-

Table

-RRB-

Table

statistics

of

the

temperament

dimensions

and

correlations

of

these

variables

with

internalising

and

externalising

problemsTemperamentMeanSDChildrenIll

parentsInternalisingExternalisingInternalisingExternalisingrrrrEffortful

Pleasure

Perceptual

Pleasure

p

p

Predictors

of

internalising

and

externalising

problems

Internalising

problems

Child

's

gender

and

recurrent

disease

explained

a

significant

percentage

of

the

variance

in

the

prevalence

of

internalising

problems

in

child

's

-LRB-

-RRB-

and

parent

's

reports

-LRB-

-RRB-

Both

variables

appeared

to

have

a

significant

negative

independent

effect

Life

events

accounted

for

a

significant

increment

in

explained

variance

in

child

's

-LRB-

-RRB-

and

parent

's

reports

-LRB-

-RRB-

The

temperament

dimensions

predicted

a

significant

percentage

of

additional

variance

in

children

's

-LRB-

-RRB-

and

parent

's

reports

-LRB-

-RRB-

Shyness

frustration

perceptual

sensitivity

and

fear/worry

appeared

to

have

a

significant

positive

independent

effect

in

children

's

reports

of

the

variables

appeared

to

have

a

significant

independent

effect

in

parent

's

reports

Interaction

terms

between

temperament

dimensions

and

child

's

gender

failed

to

contribute

significantly

to

the

prediction

of

internalising

problems

in

children

and

parent

's

reports

The

final

models

accounted

for

and

of

the

variance

in

child

's

and

parents

models

respectively

-LRB-

Table

-RRB-

VIFs

ranged

between

suggesting

that

there

was

no

problem

of

collinearity

Table

analyses

examining

temperament

as

a

predictor

of

internalising

problems

reported

by

children

an

ill

parents

ChildrenIll

parentsInternalising

problemsInternalising

Child

's

gender

Recurrent

Step

Negative

life

Step

Effortful

control

Pleasure

Perceptual

Pleasure

The

dashes

indicate

that

variables

were

not

entered

into

the

model

because

no

significant

univariate

relationship

was

found

p

p

Externalising

problems

Life

events

accounted

for

a

significant

percentage

of

the

explained

variance

in

children

's

reports

-LRB-

-RRB-

The

temperament

dimensions

accounted

for

a

significant

increment

in

children

's

-LRB-

-RRB-

and

parent

's

reports

-LRB-

-RRB-

Effortful

control

had

a

significant

unique

negative

effect

for

both

children

and

parent

and

frustration

also

for

children

's

reported

externalising

problems

The

interaction

terms

did

not

contribute

significantly

to

the

problems

reported

The

variables

entered

into

children

's

and

parents

models

explained

and

respectively

of

the

variance

-LRB-

Table

-RRB-

VIFs

in

both

models

were

acceptable

ranging

between

Table

analyses

examining

temperament

as

a

predictor

of

externalising

problems

as

reported

by

children

and

ill

parents

ChildrenIll

parentsExternalising

problemsExternalising

Negative

life

Step

Effortful

control

The

dash

indicates

that

the

variable

was

not

entered

into

the

model

because

no

significant

univariate

relationship

was

found

p

p

Discussion

and

conclusion

The

present

study

is

the

first

to

examine

the

contribution

of

temperament

to

prevalence

of

problems

among

adolescent

children

of

parents

diagnosed

with

cancer

The

findings

suggest

that

temperament

predicted

internalising

and

externalising

problems

beyond

the

effects

of

socio-demographics

-LRB-

child

gender

-RRB-

illness-related

variables

-LRB-

recurrent

disease

-RRB-

and

number

of

negative

life-events

The

most

powerful

temperament

dimensions

for

internalising

problems

were

shyness

and

fear/worry

-LRB-

reactive

factor

-RRB-

To

a

lesser

extent

frustration

and

perceptual

sensitivity

-LRB-

children

's

reports

only

-RRB-

heighten

the

risk

for

internalising

problems

It

was

argued

that

shy

and

anxious

children

generally

have

a

tendency

to

withdraw

and

are

hesitant

to

seek

support

from

their

surroundings

-LSB-

-RSB-

whereas

seeking

support

might

be

important

especially

in

situations

in

which

a

parent

had

cancer

High

levels

of

frustration

are

related

to

reduced

ability

to

regulate

attention

and

emotions

whereby

children

are

less

able

to

relax

and

direct

themselves

toward

matters

other

than

the

stressor

-LSB-

-RSB-

Withdrawn

behaviour

anxiety

and

depression

might

be

consequences

of

these

tendencies

Internalising

problems

reported

by

the

child

also

increase

when

they

were

highly

sensitive

to

things

and

people

around

them

-LRB-

perceptual

sensitivity

-RRB-

Although

Rothbart

and

Bates

-LRB-

-RRB-

hypothesised

that

children

with

this

kind

of

sensitivity

are

more

vulnerable

for

internalising

and

externalising

problems

research

on

these

dimensions

is

lacking

-LSB-

-RSB-

The

relationships

between

shyness

anxiety

and

frustration

and

internalising

problems

found

in

children

reports

have

also

been

found

in

studies

among

the

general

population

-LSB-

-RSB-

Those

who

have

a

temperament

characterised

by

a

low

level

of

effortful

control

-LRB-

regulative

factor

-RRB-

and

a

high

level

of

frustration

are

more

at

risk

to

develop

externalising

problems

The

relationship

between

effortful

control

and

externalising

problems

has

been

found

in

other

studies

as

well

-LSB-

-RSB-

Children

who

have

more

control

show

more

initiative

in

undertaking

activities

have

more

ability

to

shift

their

attention

and

to

focus

and

are

less

easily

distracted

by

circumstances

-LSB-

-RSB-

The

control

that

children

have

over

their

behaviour

in

this

regard

decreases

the

chance

of

externalising

problems

As

mentioned

above

frustration

decreases

emotional

regulation

and

can

lead

to

externalising

problems

in

addition

to

manifesting

itself

in

internalising

problems

-LSB-

-RSB-

No

effect

was

found

for

pleasure

intensity

which

was

in

contrast

to

the

results

of

a

recent

study

among

children

in

the

general

population

That

study

found

that

children

who

scored

high

on

pleasure

intensity

experienced

more

externalising

problems

-LSB-

-RSB-

Whether

the

relationship

between

temperament

and

problems

is

specific

for

situations

in

which

children

are

exposed

to

a

parent

with

cancer

is

not

clear

It

is

argued

that

reactive

and

regulative

temperament

factors

really

are

important

when

the

child

experienced

stressful

events

-LSB-

-RSB-

A

stressful

event

such

as

illness

in

the

parent

brings

forth

negative

emotions

specifically

in

children

high

in

emotionality

Children

with

low

levels

of

effortful

control

may

have

difficulties

to

deal

with

these

emotions

and

may

develop

as

a

consequence

emotional

or

behavioural

problems

-LSB-

-RSB-

Although

the

sons

and

daughters

differed

in

the

problems

experienced

and

in

their

temperament

the

relationship

between

temperament

and

problems

were

similar

for

both

genders

as

was

found

in

a

previous

study

-LSB-

-RSB-

Similar

patterns

were

found

for

parent

's

and

self

reported

problems

and

temperament

in

the

current

study

according

to

a

previous

study

-LSB-

-RSB-

Our

results

showed

however

a

stronger

relationship

between

temperament

and

the

problems

reported

by

children

than

parents

reports

of

problems

whilst

Oldehinkel

and

colleagues

found

the

opposite

This

inconsistency

may

be

attributed

to

the

informant

Oldehinkel

and

colleagues

used

parents

reports

to

examine

temperament

whereas

the

current

study

used

self-reports

from

children

A

number

of

studies

found

that

parents

and

children

perceived

the

level

of

problems

of

children

under

these

circumstances

different

-LSB-

-RSB-

The

differences

in

perception

may

have

caused

also

the

differences

between

parents

and

children

found

in

the

present

study

Another

interesting

result

from

this

study

is

that

four

of

the

seven

temperament

dimensions

were

related

to

the

number

of

negative

life

events

experienced

This

is

consistent

with

Rothbert

's

theory

which

suggests

that

despite

its

biological

base

temperament

is

influenced

by

experiences

The

influence

of

stressful

environmental

factors

on

the

development

of

temperament

is

an

interesting

phenomenon

Because

the

current

study

uses

a

cross-sectional

design

no

causal

statements

can

be

derived

from

the

results

The

current

study

is

one

of

few

to

use

self-reports

of

temperament

from

a

large

number

of

children

to

examine

the

relationship

between

temperament

and

internalising

and

externalising

problems

It

is

generally

assumed

that

self-description

is

an

important

source

of

information

in

the

field

of

personality

research

Nonetheless

it

was

faced

with

some

difficulties

First

Rothbart

and

colleagues

paid

a

lot

of

attention

to

the

development

of

the

theory

around

temperament

The

empirical

implementation

of

the

EATQ-R

however

was

limited

The

original

structure

of

the

EATQ-R

seemed

not

applicable

for

the

Dutch

children

in

the

current

study

A

recent

study

among

Dutch

adolescents

reported

also

some

problems

with

the

self-reported

version

of

the

EATQ-R

-LSB-

-RSB-

and

used

therefore

the

parent

version

Furthermore

the

comparison

of

results

from

the

current

study

with

those

of

studies

that

used

other

theories

of

temperament

was

difficult

due

to

differences

in

conceptualizing

and

in

labelling

with

regard

to

corresponding

dimensions

More

research

using

reliable

validated

instruments

to

investigate

the

temperament

of

children

is

necessary

Second

some

of

the

items

used

to

measure

temperament

resemble

items

on

the

problem

scale

and

can

cause

item-overlap

Previous

studies

show

that

the

association

between

constructs

remains

essentially

the

same

when

correcting

for

possible

overlapping

items

-LSB-

-RSB-

indicating

that

they

are

separate

concepts

To

examine

whether

patterns

were

similar

among

different

informants

parent

's

reports

were

used

also

Fourth

the

current

study

is

cross-sectional

Longitudinal

designs

may

provide

more

insight

into

the

causality

of

relationships

Fifth

most

of

the

relations

between

temperament

and

problems

found

in

the

current

study

were

similar

to

those

found

in

other

studies

The

use

of

a

control

group

may

have

provided

more

detailed

information

about

whether

the

relationships

between

temperament

and

problems

differed

for

children

of

parents

with

cancer

and

those

of

children

in

the

general

population

Finally

the

current

study

did

not

pay

attention

to

the

interaction

between

children

's

temperament

and

other

potential

predictors

such

as

parenting

the

parent

child

relationship

and

coping

Thomas

and

Chess

introduced

the

goodness-of-fit

concept

which

means

that

problems

in

children

arise

only

when

temperament

and

the

expectations

of

the

surroundings

are

not

well

adjusted

to

each

other

-LSB-

-RSB-

The

fact

that

temperament

of

children

can

have

an

impact

on

the

prevention

of

problems

by

children

is

important

information

Health

care

providers

can

use

this

knowledge

to

assist

parents

to

take

the

individual

characteristics

of

the

child

into

account

and

by

means

of

this

to

understand

their

children

's

behaviour

better

Additionally

parents

might

be

supported

to

improve

the

fit

between

the

temperament

of

the

child

and

the

consequences

of

having

a

parent

with

cancer

B O O O O B I I I O O O O O O O O O O O O O O O B O B I I I O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I I O O O O O O O O O O O B I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O B O B I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B I O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B O B I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O

internalising and externalising problems


Response shift due to diagnosis and primary treatment of localized prostate cancer : a then-test and a vignette study Aim Whether a prostate cancer diagnosis induces response shift has not been established so far . Therefore , we assessed response shift in men who were diagnosed with localized prostate cancer . Introduction Response shift , defined as an adaptation to changing health -LSB- 1 -RSB- , is a beneficial process for patients because it can help in adapting to a new situation . However , it may complicate the correct interpretation of change in health-related quality of life -LRB- QoL -RRB- scores over time in intervention studies , and therefore needs to be understood . Response shift refers to a change in the meaning of QoL over time -LSB- 2 -RSB- and can result from a change in one 's internal standards of measurement -LRB- i.e. recalibration -RRB- , a change in the importance attributed to the domains constituting QoL -LRB- i.e. change in values or reprioritization -RRB- , or a change in the definition of the concept of QoL -LRB- i.e. reconceptualization -RRB- -LSB- 3 , 4 -RSB- . These three forms of response shift are illustrated in the following example . Imagine a woman X . When asked to rate her QoL she thought of her -LRB- 50-h a week -RRB- job , her partner and playing volleyball with friends , and rated her QoL as very good . Unfortunately she fell ill . For some months she was not able to work . Her partner and relatives supported her a great deal , which she appreciated enormously . Gradually she recovered and started working again for 20 h a week , but was no longer able to play volleyball . She rated her new QoL again as very good , but this time the main aspects of her QoL consisted of her partner , her family and work . Her ratings did not change , i.e. twice ` very good ' , but in fact three forms of response shift had occurred . ` Work ' changed from a 50-h a week job to 20 h a week -LRB- recalibration -RRB- , her partner became more important -LRB- reprioritization -RRB- , and her concept of QoL has changed : no more sports , but relatives instead -LRB- reconceptualization -RRB- . This paper focuses on the assessment of response shift induced by a prostate cancer diagnosis . Schwartz and colleagues systematically addressed the state-of-the-art in the assessment and interpretation of response shift -LSB- 5 -RSB- . In a meta-analysis , following Cochrane guidelines , the magnitude and clinical relevance of response shifts across 19 longitudinal studies were evaluated . Most studies addressed global QoL and specific QoL domains such as fatigue , well-being , and pain , usually by conducting the then-test . Effect sizes , defined as the mean difference between tests divided by the standard deviation -LRB- SD -RRB- of the first assessment , were computed by the authors . These were generally small according to Cohen 's criteria -LSB- 6 -RSB- , with the largest effect sizes found for fatigue , followed by global QoL , physical role limitation , physical well-being , and pain . Effect sizes varied in direction , which complicated their interpretation . Schwartz et al. concluded with recommendations for future response shift publications , such as explaining the meaning of the study results in terms of recalibration , reprioritization , and reconceptualization -LSB- 5 -RSB- . Response shift is more likely to occur when an intense and pervasive change in health is experienced -LSB- 7 -RSB- . A cancer diagnosis may have a large impact on a person 's experienced health . Our group previously described the process of being diagnosed with prostate cancer through a screening process consisting of a Prostate Specific Antigen -LRB- PSA -RRB- test and , if indicated , a biopsy . Typically , localized prostate cancer diagnosed through screening is not associated with any physical symptoms . Men 's mental health and the valuation of their own health decreased significantly after they received their diagnosis , and we concluded that being diagnosed with prostate cancer was a deeply felt change in health -LSB- 8 -RSB- . We started the present study because we expected that a prostate cancer diagnosis induces response shift . We hypothesized that the pre-diagnosis health state would be rated more positively in retrospect -LRB- i.e. if assessed after diagnosis -RRB- than at the reference point itself -LRB- i.e. pre-diagnosis -RRB- . Collecting data on QoL before a cancer diagnosis is usually not feasible , since it is unknown who will develop cancer and when , so that the inclusion of a very large cohort would be required . However , the context of the European Randomized study for Screening on Prostate Cancer -LRB- ERSPC -RRB- -LSB- 9 -RSB- enabled us to include a cohort of men shortly before they were screened and subsequently diagnosed . We aimed at assessing the magnitude and direction of response shift effects after diagnosis and again after primary treatment . We employed two methods : the common then-test and a novel approach including rating of vignettes related to side effects of prostate cancer treatment -LRB- urinary , bowel , and erectile dysfunction -RRB- . Patients and methods Ethics approval and informed consent The Ethics Committee of the Erasmus MC approved the research protocol . All participants gave additional written informed consent to be interviewed for the study . Parent study Inclusion of the ERSPC participants was initiated in 1994 among all male inhabitants of the Rotterdam region aged between 55 and 74 years . The only exclusion criterion was a previous prostate cancer diagnosis . Details on study recruitment for the ERSPC have been reported earlier -LSB- 9 -RSB- . Respondents Randomly selected participants from the parent study were approached . All men who were due for the second -LRB- n = 2,798 -RRB- or third screening round -LRB- n = 2,024 -RRB- between January 2003 and May 2004 were sent a short questionnaire on health -LRB- see below -RRB- by mail . Men who were diagnosed through the screening process were interviewed twice by one of the authors -LRB- IK -RRB- ; one month post-diagnosis -LRB- but before treatment -RRB- and again 7 months post-diagnosis . Assessing response shift To assess the magnitude and direction of response shift effects two methods were used : the then-test , and vignettes -LRB- a novel method in response shift research -RRB- . For the resulting study scheme , see Fig. 1 . The then-test is a retrospective evaluation of an earlier assessment -LRB- retrospective pre-test-post-test design -RRB- . At post-test respondents are asked to remember how they were doing at the reference point and to retrospectively rate their level of functioning or QoL at that time . The then-test was originally developed to measure recalibration . The method assumes that respondents will use their post-test internal standards when providing a re-evaluation or ` then-test ' rating of their health at the reference point -LSB- 5 -RSB- . The comparison between the then-test and the post-test is thus assumed not to be confounded by recalibration and can be considered as an indication of true change -LSB- 2 -RSB- . The comparison of the mean pre-test , which is the assessment that was completed at the reference point , and then-test scores would reflect an estimate of the magnitude and direction of response shift -LSB- 2 -RSB- . Because respondents in our study were included before diagnosis , they could provide then-test scores relating to their health before diagnosis and to their health between diagnosis and treatment . Before completing the then-test , respondents were explicitly reminded about the period the then-test was referring to : e.g. the time when the respondents had not yet been diagnosed with prostate cancer and were unaware of having prostate cancer . Respondents were then asked to re-assess their health at that time . Three then-tests were conducted : two referencing pre-diagnosis health -LRB- measured at 1 month post-diagnosis and 7 months post-diagnosis -RRB- and one referencing 1-month post diagnosis health -LRB- measured at 7-months post-diagnosis -RRB- , see Figs. 2 , 3 , 4 . The respondents completed generic QoL measures , i.e. the Short-Form 36 -LRB- SF-36 -RRB- mental health and vitality , and the EQ-5D VAS for self-rated health , as a pre-test , post-test and then-test . The SF-36 consists of eight scales on physical and mental domains of health . We used the scales on mental health -LRB- five items on being nervous , down , peaceful , depressed and happy -RRB- and vitality -LRB- four items on being full of life , having a lot of energy , being worn out and tired -RRB- . Higher scores -LRB- 0 -- 100 -RRB- indicate better mental health and vitality -LSB- 10 -RSB- . The EuroQol -LRB- EQ -RRB- 5D valuation of own health is a visual analog scale on current overall health , anchored at the lower end -LRB- 0 -RRB- by ` worst imaginable health state ' and at the upper end -LRB- 100 -RRB- by ` best imaginable health state ' -LSB- 11 -RSB- . As a novel method to assess response shift we used vignettes that each described a health state relating to side effects of therapy for localized prostate cancer , i.e. urinary , bowel or erectile dysfunction . The vignettes contained items of the EQ-5D self-classifier complemented with items on dysfunction , for instance , ` Mr. A has no problems in walking about , has no problems washing or dressing himself , experiences urinary leakage daily , has no pain or discomfort , is not anxious or depressed ' . Respondents were asked to indicate how good or bad they evaluated these health states on visual analog scales anchored at the lower end -LRB- 0 -RRB- by ` very bad ' and at the upper end -LRB- 10 -RRB- by ` very good ' . We used the vignettes to explore reprioritization . We hypothesized that men would value the health states as less detrimental after diagnosis than before . After diagnosis they knew they might experience these dysfunctions themselves in the context of prostate cancer treatment.Additionally , information on respondents ' age and on the Gleason score -LRB- a clinical criterion for histological grading of the aggressiveness of the tumour -RRB- were obtained through the screening office . Fig. 1Study schemeFig . 2Original and then-test scores of the EuroQol valuation of own health by prostate cancer patients -LRB- n = 52 -RRB- . If we measure only EQ-VAS preceding diagnosis and at 1-month post-diagnosis , the difference between these scores is regarded the ` observed change ' . However , if the retrospective pre-diagnosis assessment provides a more valid comparison with the post-diagnosis assessment , the ` true change ' is reflected by the difference between the retrospective pre-diagnosis assessment and the post-diagnosis assessment . The difference between the pre-diagnosis assessment and the retrospective pre-diagnosis assessment provides an indication of the size and direction of the ` response shift ' induced by the diagnosis . Similar explanations are valid for the other data points in the figureFig . 3Original and then-test scores of the SF-36 mental health by prostate cancer patients -LRB- n = 52 -RRB- . ` Observed change ' , ` True change ' and ` Response shift ' refer to the differences in SF-36 mental health scores between the assessment at 2 months before diagnosis and post - and then-test at 1 month after diagnosis -LRB- for further explanation , see caption at Fig. 2 . -RRB- Fig. 4Original and then-test scores of the SF-36 vitality by prostate cancer patients -LRB- n = 52 -RRB- . ` Observed change ' , ` True change ' and ` Response shift ' refer to the differences in SF-36 vitality scores between the assessment at 2 months before diagnosis and post - and thentestthen-test at 1 month after diagnosis -LRB- for further explanation , see caption at Fig. 2 . -RRB- Statistical analysis Procedures concerning imputation of missing responses in the SF-36 items were conducted according to the guidelines of the SF-36 Health Survey Manual -LSB- 12 -RSB- . Differences between assessments were tested with paired-samples t-tests . P-values ≤ 0.05 were considered statistically significant . The type I error rate , i.e. the ratio of significant findings to the number of comparisons , was calculated . To assess the magnitude of the differences between the assessments we used Cohen 's effect sizes , defined as the mean difference between tests divided by the SD of the first assessment , and interpreted as follows : 0.2 < d < 0.5 indicates a small , 0.5 ≤ d < 0.8 a moderate , and d ≥ 0.8 a large effect size -LSB- 6 -RSB- . The minimal important difference -LRB- MID -RRB- , which is the smallest change in a patient-reported outcome that is perceived by patients as beneficial or that would result in a change of treatment , was operationalized as a difference of at least half a SD -LSB- 13 -RSB- . Non-response bias was analysed by testing differences between the respondents and the non-respondents with unpaired t-tests . Results Out of the 3,892 men who completed the initial questionnaire before screening on prostate cancer , 82 were subsequently diagnosed . Of these , 52 -LRB- response 63 % -RRB- consented to participate in two additional telephone interviews at 1 and at 7 months post-diagnosis . All 52 respondents participated in the first interview , which took place before treatment had been initiated . Due to personal circumstances one respondent later refused the second telephone interview . Average age at screening was 67.3 years -LRB- SD 4.4 -RRB- , ranging from 60 to 74 years . The Gleason score was favourable in 42 of the 52 patients , i.e. below seven -LRB- Table 1 -RRB- . In all respondents but one , treatment had been initiated at 7 months post-diagnosis , i.e. radical prostatectomy -LRB- n = 25 -RRB- , brachytherapy -LRB- n = 12 -RRB- , active surveillance -LRB- n = 10 -RRB- , external radiotherapy -LRB- n = 3 -RRB- , or hormonal treatment -LRB- n = 1 -RRB- , see Table 1 . Table 1Gleason scores and treatment modality of the respondents -LRB- n = 52 -RRB- Gleason score < 7 n = 42Gleason score ≥ 7 n = 10Total n = 52Radical prostatectomy18725External radiotherapy123Brachytherapy1313Active surveillance99Hormonal treatment 11No treatment choice yet11 Original scores , i.e. scores relating to the respondents ' health at the time of the assessment and interviews , and then-test scores relating to the two reference points are given in Table 2 . For example , ` 85.2 ' in the upper right corner of Table 2 reflects the ` EQ valuation of own health ' score of the then-test measured at 7 months post-diagnosis referencing 2 months pre-diagnosis . Mental and self-rated health scores worsened significantly from 2 months preceding diagnosis to 1 month post-diagnosis . The average mental health score , for instance , was 83.2 at 2 months pre-diagnosis , and 75.8 at 1-month post-diagnosis ; a decrease of 7.4 that exceeds the MID . At 7 months post-diagnosis mental and own health scores had increased again , but not to their original level . Table 2Mean health scores -LRB- standard deviation -RRB- of the respondents -LRB- n = 52 -RRB- before and after diagnosis , original and thentests scoresReferring toOriginal scores -LRB- n = 52 -RRB- P-value * Thentests1 month post-diagnosis -LRB- n = 52 -RRB- P-value : thentest vs. originalEffect size : thentest vs original 7 months post-diagnosis -LRB- n = 51 -RRB- P-value : thentest vs. originalEffect size : thentest vs. original2 months pre-diagnosisEuroQol own health80 .2 -LRB- 11.7 -RRB- 83.2 -LRB- 9.0 -RRB- 0.058 − 0.2685.2 -LRB- 7.6 -RRB- 0.002 a − 0.43SF-36 mental health83 .2 -LRB- 11.6 -RRB- 84.5 -LRB- 11.0 -RRB- 0.304 − 0.1083.2 -LRB- 10.9 -RRB- 1.000.01SF-36 vitality75 .3 -LRB- 15.6 -RRB- 79.6 -LRB- 12.0 -RRB- 0.008 − 0.2879.4 -LRB- 12.4 -RRB- 0.046 − 0.261 month post-diagnosis , before initiation of treatmentEuroQol own health74 .5 -LRB- 15.1 -RRB- 0.01074.1 -LRB- 14.5 -RRB- 0.6180.03SF-36 mental health75 .8 -LRB- 16.8 -RRB- 0.001 a72 .8 -LRB- 18.3 -RRB- 0.0420.17SF-36 vitality74 .7 -LRB- 14.2 -RRB- 0.77172.6 -LRB- 13.7 -RRB- 0.1110.157 months post-diagnosis , after intiation of treatment in 80 % of respondentsEuroQol own health77 .6 -LRB- 13.7 -RRB- 0.196SF-36 mental health80 .4 -LRB- 13.8 -RRB- 0.066SF-36 vitality73 .1 -LRB- 17.7 -RRB- 0.213 * P-value of difference with previous original score -LRB- P ≤ 0.05 are considered significant -RRB- aChange exceeds the minimal important difference -LRB- operationalised as 1/2 standard deviation -RRB- Original scores of pre-diagnosis health were lower , indicating worse health than on the then-test scores . For example , the original pre-diagnosis mental health score was 83.2 on average , but the then-test score measured at 1 month post-diagnosis was 84.5 , indicating a more positive judgement of pre-diagnosis mental health in retrospect . Original scores of health between diagnosis and treatment , on the other hand , were higher , indicating better health than on the then-test scores . The original vitality score , for instance , was 74.7 at 1 month post-diagnosis , but the then-test score measured at 7 months post-diagnosis was 72.6 . This means that vitality between diagnosis and treatment was judged worse when measured in retrospect than when measured at the reference point itself . Original and then-test scores are presented in Figs. 2 -- 4 , including estimates of the response shift effects , i.e. the difference between mean pre-test and then-test scores , and estimates of ` true ' change , i.e. the difference between the mean post-test and then-test scores . Effect sizes of the differences between then-test and original scores were small -LRB- Table 2 -RRB- . The vignettes describing urinary , bowel and erectile dysfunction states were rated significantly higher -LRB- i.e. better -RRB- by respondents at 1 month post-diagnosis than at 2 months pre-diagnosis -LRB- P-values 0.038 , 0.011 , and < 0.001 , respectively -RRB- . The valuation of erectile dysfunction showed the largest increase ; i.e. from 5.3 to 6.7 on a 0 -- 10 scale , with a moderate effect size of 0.57 -LRB- Table 3 -RRB- . This implies that respondents considered especially erectile dysfunction less detrimental after diagnosis with prostate cancer than before diagnosis . The differences between pre - and post-diagnosis valuations of the vignettes exceeded the MID in 4 out of 6 cases -LRB- Table 3 -RRB- . Table 3Average valuation by VAS -LRB- SD -RRB- of prostate cancer specific vignettes , scale 0-10 , P-values ≤ 0.05 were considered significantHealth state descriptionPre-diagnosis -LRB- n = 52 -RRB- 1 month post-diagnosis -LRB- n = 52 -RRB- P-value pre-diagnosis vs. 1 month post-diagnosisEffect size pre-diagnosis vs. 1 month post-diagnosis7 months post diagnosis -LRB- n = 51 -RRB- P-value pre-diagnosis vs. 7 months post-diagnosisEffect size pre-diagnosis vs. 7 months post-diagnosisDaily urinary leakage5 .6 -LRB- 2.1 -RRB- 6.3 -LRB- 1.5 -RRB- a0 .038 − 0.325.9 -LRB- 1.5 -RRB- 0.348 − 0.14 Daily bowel cramps5 .3 -LRB- 2.0 -RRB- 6.0 -LRB- 1.6 -RRB- 0.011 − 0.416.2 -LRB- 1.4 -RRB- a0 .012 − 0.39 Serious erectile dysfunction5 .3 -LRB- 2.2 -RRB- 6.7 -LRB- 1.8 -RRB- a < 0.001 − 0.576.5 -LRB- 1.8 -RRB- a0 .005 − 0.47 achange compared to previous score exceeds minimal important difference The results of the then-test were significant in 4 out of 9 comparisons , the results of the vignettes in 5 out of 6 . The overall type I error rate , which is the ratio of significant findings to the number of comparisons , was 0.6 -LRB- 9 out of 15 -RRB- . Non-response analysis The baseline average age in men who were diagnosed with prostate cancer but did not respond to the questionnaire -LRB- n = 30 -RRB- was 66.7 -LRB- SD 4.3 , range 59 -- 73 -RRB- years . Respondents and non-respondents did not differ significantly in age or other health measures -LRB- data not shown -RRB- . Discussion Men diagnosed with prostate cancer evaluated their pre-diagnosis health in retrospect as better than at the reference point itself . Post-diagnosis -- pre-treatment health was rated worse in retrospect than at the reference point . This suggests that ` true ' changes in health between the first assessment before diagnosis and the second one at 1 month post-diagnosis were larger than the original scores disclosed , and that response shifts were induced by first , the diagnosis , and second , subsequent treatment . The sizes of the response shifts induced by the diagnosis were larger than those induced by the treatment . The negligible to small effect sizes indicated that only some recalibration occurred . The directions of the effect sizes were interpretable and consistent with our hypotheses . Additionally , men evaluated vignettes relating to side effects of prostate cancer treatment as less detrimental after they were diagnosed than before diagnosis . We interpreted this change as a reprioritization of respondents who became aware after being diagnosed with prostate cancer that they were at risk of experiencing these health states themselves as a consequence of being treated for prostate cancer . In this new context dysfunctional health states were evaluated as less bad than before . The effect sizes were moderate for erectile dysfunction and small in the two other ones , indicating that reprioritization also occurred . The directions of the effect sizes were interpretable and consistent with our hypotheses . The overall type I error rate was 0.6 , which indicated that the statistical significance is very unlikely to be caused by chance . This is an additional indication that our findings reflect real differences . We conclude that the results of the then-tests and the ratings of the vignettes both indicate the presence of a response shift and adaptation of the patients to their new situation . In the meta-analysis of Schwartz et al. , the largest effect sizes on response shift -LRB- although still small -RRB- were found for the dimensions global QoL and fatigue -LSB- 5 -RSB- . These dimensions , represented in our study by EQ-5D on own health and the SF-36 vitality scale respectively , also resulted in small effect sizes . An important criticism of the then-test approach is its susceptibility to recall bias . Respondents are supposed to be able to remember their previous health at the reference point , which is extremely difficult in case of a chronic disease with no obvious trend towards better or worse health -LSB- 14 -RSB- . However , in a study on response shift in cancer patients undergoing various forms of treatment , there was evidence that recall bias was absent -LSB- 2 -RSB- . We assume that in the case of a deeply felt change in health -LRB- such as being diagnosed with cancer or the initiation of cancer therapy -RRB- recall will not cause memory difficulties for most respondents . Therefore , in our study we expect that recall bias did not have a major influence on the results . The then-test results in a retrospective judgement that subsequently is used to construct ` real change ' since the reference point . This approach assumes that the information that was acquired after the original judgment was made leads to more accurate estimates of QoL than the original judgment itself . This assumption is , however , not always true ; for example in the case that the newly acquired information is not correct -LSB- 14 -RSB- . The valuation of disease-specific vignettes -LRB- the second method used to assess response shift -RRB- has to our knowledge not been described before . It resulted in a moderate effect size considering the vignette on erectile dysfunction . The directions of the effect sizes were consistent with our hypotheses . Our results showed that response shift can be studied by using vignettes . We consider the valuation of vignettes as a useful addition to the already available collection of tools to assess response shift . Apart from this theoretical value , the results of the vignettes may also have implications for clinical practice . In case of a diagnosis of localized prostate cancer several treatment options are available . Since there is no consensus about which of these treatments has the best outcome in terms of survival and QoL , considerations of patient preferences regarding mode of treatment and side effects are an essential element in shared decision making on the choice of therapy . To elicit a patient 's preferences and his individual trade-offs between benefits and side effects of various modes of treatment , vignettes can be useful -LSB- 15 -RSB- . However , our study showed that patient preferences may change in the course of the diagnostic and treatment process , which illustrates how difficult it is for a patient to imagine the consequences of an intervention in advance . This finding confirms the point made by Cowen et al. to recommend the use of individual utilities -LRB- `` actually prefer '' -RRB- instead of population 's utilities -LRB- `` should prefer '' -RRB- to optimise the choice of treatment for patients with prostate cancer -LSB- 16 -RSB- . We recommend further investigation of the vignettes method . The fact that being diagnosed with prostate cancer was found to induce response shift may be seen as an indication that men regard a prostate cancer diagnosis as a major life event , and is additional evidence for earlier findings -LSB- 8 -RSB- . In another study , men with metastic or locally advanced prostate cancer completed assessments on prostate symptoms shortly after diagnosis , and 3 and 6 months thereafter . The second and third assessments included then-tests . The presence of a response shift was suggested in patients and their spouses -LSB- 17 , 18 -RSB- . The authors remarked that retrospective and prospective assessments can not be used interchangeably . Lepore and Eton tested two conceptual models of response shift among men newly diagnosed with prostate cancer to explain the frequently observed lack of association between health problems and QoL in cancer patients . No support was found for the suppressor model , according to which health change leads to response shift , which in turn leads to a change in QoL . Some evidence was found for the buffering model , according to which response shift effects moderate the negative association between health problems and QoL . Two aspects of response shift , recalibration and reprioritization , were assessed by then-tests and a measure of primary life goal changes , respectively . They were found to moderate the relation between negative changes in physical health and changes in QoL -LSB- 19 -RSB- . Indications of response shift were also found in an earlier study on men treated for localized prostate cancer . Men stated , for instance , that they accepted the side effects of treatment because ` If they had n't intervened , that operation , maybe I would n't be here anymore ' -LSB- 20 -RSB- . The present study has several strengths and limitations . The study design is one of its strengths ; the unique context of the ERSPC enabled the inclusion of respondents before they -LRB- or anyone else -RRB- were aware that they had prostate cancer , which is usually unfeasible . To our knowledge this is the first study to measure response shift in men who were diagnosed with cancer . An additional strength is the compliance of the respondents ; 51 of the 52 respondents completed the 7-month assessment . For the then-test we selected measures that are considered subjective -LRB- i.e. SF-36 mental health and vitality , and EQ-5D of own health -RRB- but no objective items , which can be considered a drawback of the study . Furthermore , we acknowledge that offering questionnaires in two different modes -LRB- self-administered questionnaires before diagnosis vs. telephone interviews afterwards -RRB- may have been less than optimal . This design was chosen based on practical considerations , because assessments by telephone in 3,892 screen participants was not feasible , and self-administered questionnaires at 1 month after diagnosis undesirable since we wanted these assessments to be completed before the initiation of treatment . The unavailability of information on marital status and education is also a drawback . Another potential limitation of our study is that the interval between the initiation of treatment and the assessment at 7-months post-diagnosis was not the same for all respondents ; it is possible that response shift may vary according to the length of time that elapsed since treatment . However , information on this interval had been of limited use . The most common therapies for localized prostate cancer nowadays are surgery , radiotherapy , and active surveillance . These therapies differ greatly -LRB- by nature -RRB- in duration , the onset of side effects and their course over time . It may be that particular groups may be more prone to response shift than others , e.g. depending on age or prognosis . We plan to address this issue further , preferably in a larger sample than used in the current study . Conclusions Using two complementary techniques we found that a diagnosis of prostate cancer induces response shift . From a methodology point of view , the vignette-method needs to be explored further .

B I O O O O O O O O B I O O O O O O O O O O B I O O B I O O O O O O O O O O O B I O O O O O O O B I O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O B I O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O B I O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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prostate cancer
quality of life
response shift