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© 2003 American Society for Clinical Oncology Maternal Preoccupation and Parenting as Predictors of Emotional and Behavioral Problems in Children of Women With Breast Cancer
From the Department of Psychiatry, Institute of Community and Family Psychiatry, Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Quebec, Canada; and the Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AK. Address reprint requests to John Sigal, PhD, Department of Psychiatry (ICFP), 4333 Cote St Catherine Rd, Montreal, Quebec, H3T 1E4, Canada; email: cdovick{at}icfp.jgh.mcgill.ca.
Purpose: To test the hypothesis that differences between sicker and not-so-sick women in their preoccupation with their illness and parenting behavior can explain why some investigators find that children of breast cancer patients fare better than controls and other investigators find the reverse. Patients and Methods: Forty-two women with metastasized breast cancer (sicker mothers) and 45 women with a first occurrence of nonmetastasized breast cancer (not-so-sick mothers) rated the degree of their preoccupation with the disease, their parenting behavior, mood, and social supports and the emotional and behavioral symptoms in one of their children. Their 12- to 18-year-old children rated their mothers’ parenting behavior, their own emotional and behavioral symptoms, and their self-esteem. Results: Sicker mothers reported relatively less preoccupation. They, and their children, reported less poor parenting and fewer externalizing symptoms in the children. Regression analyses revealed further differences between the groups. Conclusion: Less preoccupation with their illness and less poor parenting behavior by sicker mothers may explain why their children seem to fare better then those of not-so-sick mothers. Formulations concerning families of breast cancer patients should include consideration of the effect of the mothers’ perception of the severity of their illness.
STUDIES OF the psychosocial effect of cancer on the family refer primarily to the functioning of the family unit as a whole or to the effects on the spouse.1–5 The emotional and behavioral consequences for children of parents with cancer have rarely been studied. Studies of children of mothers with breast cancer are even rarer. The studies that have been performed generally find more emotional and behavioral problems in these children,5–7 both of the internalizing (eg, sadness and anxiety) and of the externalizing (eg, disobedience and aggression) types. Adverse effects extending into adulthood, particularly in the area of sexuality, have also been documented.8 A number of variables have been found to mediate the effect of the mothers’ illness on their children. Some of these variables include the severity of the illness,4–7 the mothers’ psychosocial adjustment to the illness,6,7,9,10 social supports, the marital relationship, the family’s coping behavior, the relationship of the spouse to the children,11 and children’s coping style.10 Surprisingly, greater severity of the illness in mothers with breast cancer has been found to be associated with better psychosocial functioning in the children in two studies.7,12 However, no such relationship was found in a study of children of patients with a variety of cancers.13 The discrepancy may be a result of the difference in severity of the mothers’ illness in the two sets of studies, but the description of the samples does not permit verification of this hypothesis. Lewis et al11 provide an explanatory model of the relationship between the mothers’ illness and their children’s behavior. They point out that the mothers’ depressed mood may result in their being emotionally and physically inaccessible, which, in turn, can have negative effects on the quality of the parent-child relationship. Much research supports the argument that maternal depressed mood adversely affects children’s behavior.14,15 Wahler and Dumas,16 however, proposed a more general model. They proposed that stressors of any kind may result in a narrowing of a parent’s attention to the behavior of their children. This reduction of parental attention can result in disruptive behavior on the part of the children or in their becoming saddened by the loss of their parent’s psychologic presence. On the basis of the assumption that parental preoccupation, defined by Bowlby17 as physical presence but psychologic absence, would result in problematic behavior in their children, studies by Sigal et al18–20 of families from a variety of stressful situations support Whaler and Dumas’ proposal. The reader will note that preoccupation may be of a cognitive or an affective nature. The term, therefore, includes a broader set of variables than was proposed by Lewis et al,11 who refer only to the affective component of the mothers’ state. In brief, there is an empirically supported theoretical model to explain the clinical observation of dysfunctional behavior in children of mothers with breast cancer. In addition, the model suggests that because sicker mothers are likely to be more preoccupied with their illness than mothers who are not so sick, their children are likely to have more psychologic symptoms. To summarize, on the basis of the model, we hypothesize that children of the less ill mothers with breast cancer will have fewer psychologic symptoms than children of sicker mothers and that the severity of children’s psychologic symptoms will be directly proportional to the degree of their mothers’ preoccupation with their illness and the quality of their parenting.
Patients We obtained a list of 474 women between the ages 35 to 55 years who were told at least 6 months before the interview that they had breast cancer, who were currently in treatment, or who were not off treatment for more than 4 years. This age range was chosen because these women were more likely to have children in the age range of interest (6 to 18 years). The 6-month to 4-year limits were chosen, respectively, to get at longer-lasting psychologic effects of the illness and to limit the effect of other potentially preoccupying events. The women’s oncologists were shown the list of their patients and asked to indicate if there were any whom they did not wish us to contact. They refused permission to contact 52 women, primarily because they were too ill. Of the remaining 422 women, 44 (10.4%) refused to be interviewed or declined to give some information. Thus, we had an 89.6% acceptance rate. Among the 378 that accepted, 174 had no children ages 6 to 18 years. Of the remaining 204 women, 51 (25%) reported a recent illness, 37 (18.1%) had comprehension problems, and 29 (10%) were excluded for other reasons, leaving 87 (42.7%) of those who accepted and had children in the eligible age range for our study These 87 women were divided into two groups. The first group, labeled the not-so-sick mothers, consisted of 45 women who had been in treatment for nonmetastatic breast cancer. Their axillary lymph node dissections were free of disease. The second group, labeled sicker mothers, consisted of 42 women who were being treated for metastatic breast cancer (distal sites). For 31 of these women (73.8%), it was the first occurrence. In each group, 90% of the women had their last treatment for cancer within the 36 months of the time of their interview. The mean time lapsed since that last treatment was 19.8 months (SD = 1.89 months) for the first group and 17.6 months (SD = 2.54 months) for the second group, a nonsignificant difference (t = 0.70, P = .45). The two groups did not differ in any demographic variables. The mean age of the mothers was 44.7 years (SD = 4.7 years), 64% were Roman Catholic, 13% were Jewish, and 12% were Protestant. The remainder professed no allegiance. Fifty-five percent spoke French at home, 27% spoke English, and the remainder spoke another language. (In Quebec, most French-speaking people are Catholic, and most English speakers are Protestant or Jewish.) The group did not differ in years of schooling (approximately 14 years), household income (approximately $60,000), average number of children (2.2), or employment status (approximately 65% were working full-time and approximately 15% were housewives). In the 6-to-11 age group, the mean (± SD) age of the 16 sons was 8.81 years (± 1.80 years), and the mean age of the 11 daughters was 8.47 years (± 1.45 years). In the 12-to-18 age group, the mean age of the 30 sons was 15.0 years (± 1.83 years), and the mean age of the 30 daughters was 15.3 years (± 1.70 years).
Procedure Before proceeding with the interviews, informed consent was obtained from all participants. The mothers also gave signed permission to interview their 12- to 18-year-old children. (We did not request permission to interview the younger children because the validity of their responses to questionnaires is questionable.) If there was more than one child in the appropriate age range, the children were numbered in order of their ages, and one was selected using a table of random numbers. The interviews with the mothers and most of the children were conducted face-to-face in the parental home. The children were interviewed immediately after the mothers, if they were available. The children who were not available then were interviewed over the phone.
Measures We used the Self-Perception Profile for Children23,24 instrument to measure self-esteem or self-worth. This instrument has 36 items to measure four factors labeled Cognitive Competence, Social Competence, Physical Competence, and General Self-Esteem. Respondents are given a positive and negative description of a characteristic (eg, "some kids are kind of hard to like BUT other kids are really easy to like"). They are first asked to choose which alternative describes them best. They are then asked to note their choice as either "Really True For Me" or "Sort Of True For Me". The instrument has good reliability and validity24 for children ages 8 years and older.25 We chose to ask only the children aged 12 to 18 years to respond to this questionnaire for the reason given above. Independent variables. The disease and treatment status of the mothers were identified by a series of questions answered by the respondents. Two scales were used to measure maternal preoccupation. The first is the Impact of Events Scale (IES).26 The IES measures the degree to which intrusive or distracting thoughts about a stressor are experienced and whether ideas, feelings, or situations related to the experienced stress are consciously avoided.26–28 Following the methodology of Davidson and Baum,27 we worded the introduction to the IES to instruct them to respond with reference to their illness. The second measure of maternal preoccupation was the Cognitive Intrusive Questionnaire (CIQ).29 The CIQ measures the subjective negative experience associated with intrusive thoughts. It has been used to study styles of responding to unpleasant cognitive intrusions29 and the association of cognitive intrusions with depression and anxiety.30 Factor-based subscales measure severity of negative feelings generated by a thought ("How often does this thought enter your mind?" "How sad or unhappy does this thought make you feel?"), responsibility for the thought ("How guilty does this thought make you feel?"), and success in removing the thought ("How effective are the strategies that you use for getting rid of the thought?"). Reliability of the total score is adequate (alpha = 0.78 to 0.85). In our use of the CIQ, we asked patients to respond with reference to their thoughts about their breast cancer. The Parent’s Report Questionnaire (PRQ)31–33 scale was constructed for a study of parenting with twins. It consists of 48 items describing typical parenting behaviors. Each is rated on a seven-point scale. Factor analysis revealed the following five behavioral dimensions: respect for autonomy, control through guilt and anxiety, consistency, child centeredness, and parental temper and detachment. To limit the length of what promised to be a long interview, we selected the four items that loaded highest on each factor. The sole exceptions to this rule were the items of the consistency factor, from which we included all nine items. We did this because these items came closest to describing the good limit-setting behavior that we had, clinically, found to be an important discriminator between good and poor parenting behavior. Mothers and 7- to 12-year-old children completed this scale independently.
Intervening Variables and Potential Confounders
Data Analysis and Statistical Methods We used linear stepwise regression models to examine the relative importance of our independent and intervening variables for predicting internalizing and externalizing symptoms in the children. Only the mothers’ ratings were used for these analyses.
The findings are presented in the following sequence: (1) factor analyses; (2) comparison of the two groups on the dependent and independent variables; (3) correlation between the time lapsed since the last hospital treatment and the mothers’ preoccupation with their illness, their parenting behavior, and the CBCL scores (we also calculated the correlations between that time lapse and the children’s ratings of their mothers’ parenting behavior and their rating of themselves on the Youth Self-Report); (4) regression analyses (these analyses were performed using the CBCL scores, the dependent measure, as an interval measure). Only statistically significant findings are reported.
Factor Analysis The preoccupation measures consistently yielded three factors, accounting for 73% of the variance. The first factor we labeled Preoccupation Salience. Loadings high on it were the Intrusion scales from the IES and Severity scale from the CIQ, with positive loadings, and the Removal Success scale from the CIQ, with a negative loading. When the IES Avoidance scale had a high loading on this factor, it was positive. Alphas were 0.92 for each of the groups. The scale based on this factor consisted of 21 items with a positive loading and two with a negative loading. The second preoccupation factor we labeled Preoccupation Avoidance. The CIQ scales Minimal Attention and Escape/Avoidance loaded high on it. The standardized alphas for these factors were 0.90 for the groups. The scale based on this factor consisted of four items with a positive loading and two with a negative loading. The third factor we labeled Preoccupation Attention. Scales loading high on it were Continued Attention and Avoidance from the CIQ, the latter with a negative loading. The alpha for sicker mothers was 0.68 but was only 0.39 for not-so-sick mothers. As a result, we have not included this factor in any of the subsequent analyses. To determine the factor structure of the parenting scales, we performed separate principal components of analyses for the ratings of the mothers in each of the groups. Two factors emerged consistently, accounting for 63% of the variance in each group for mothers’ ratings and 65% for the children’s ratings. The first factor we labeled Poor Parenting. PRQ subscales with high positive loadings on this factor were Control through Guilt and Anxiety and Parental Temper and Detachment. Respect for Autonomy had a high negative loading on this factor. Standardized alphas were 0.71 for each of the groups. The scale based on this factor consisted of eight items with a positive loading and four with a negative loading. The second parenting factor we labeled Good Parenting. Scales with a high loading on this factor were PRQ subscales Parenting Consistency and Child Centeredness. Standardized alphas were 0.69 for each group. The scale based on this factor consisted of 13 items, all with a positive loading. The physical health measures of the Medical Outcome Study Health Survey Short Form-36 yielded one factor, Physical Health. It accounted for approximately 60% of the variance in the two groups. The measures that comprised this factor were Physical Impairment, Physical Functioning, Role-Physical, Body Pain, and General Health. All items were rated so that high ratings indicated better physical health. Standardized alphas were 0.90 for each group. The scale based on this factor consisted of 21 items, all with a positive loading. The subscales of the Profile of Mood States yielded only one factor, accounting for 68% of the variance. All subscales (Tense/Anxious, Depressed, Anger/Hostility, Fatigue, and Confused), except Vigor, loaded high on this factor. Because of the items and direction of their loadings on this factor, we labeled it Negative Affectivity,37 a term that refers to negative, obsessive states such as anxiety, depression, isolation, and so on. Standardized alphas were 0.70 for each group. The scale based on this factor consisted of 40 items with a positive loading and eight with a negative loading. The items of the Social Supports Survey (that assess emotional/informational, affectionate, and positive social interactions) yielded one social support factor, explaining 80% of the variance. The standardized alphas for this factor were 0.75 for each group. The scale based on this factor consisted of 14 items, all with a positive loading. The four subscales of the Self-Perception Profile for Children yielded one factor labeled Self-Worth accounting for 51% of the variance, with a standardized alpha of 0.64. The scale based on this factor consisted of 15 items, all with a positive loading.
Comparison of Groups on Principal Independent Variables and Dependent Variables
Effect of Time Lapsed
Regression Analyses
This study was designed to examine the hypothesis that physically ill mothers’ preoccupation with their illness and their parenting behavior can result in psychologic disturbances in their children. Our findings demonstrate, first, that the effect of the mothers’ preoccupation with their illness on their children’s symptoms is limited to the families in which the mothers are very ill (sicker mothers). Second, for the not-so-sick mothers, internalizing symptoms in their children are predicted by their mood and not by their preoccupation with their illness or by their parenting behavior. Third, consistent with the findings of others,38,39 our findings demonstrate a ubiquitous effect of poor parenting on externalizing symptoms in children. Finally, the results of the regression analyses also indicate that the effects of the mothers’ social supports, mood, and even her physical health on the children’s externalizing symptoms are negligible or at least secondary to the effects of poor parenting and, for sicker mothers, also secondary to the effects of the mothers’ attempts to avoid thoughts about their illness (Preoccupation Avoidance). Relative to the not-so-sick mothers and their children, the sicker mothers and their 12- to 18-year-old children reported fewer poor parenting behaviors on the part of the mothers, and the mothers reported fewer externalizing symptoms in the children. These findings may explain why some investigators7–9,11 found less psychologic symptomatology in children of mothers with breast cancer than in comparison groups, whereas others5,6 found more; the two groups of investigators may have been dealing with families in which the mothers had different stages of the disease. The association of the findings with time elapsed since their last hospital treatment suggest a possible explanation for the apparent paradox that the sicker mothers should manifest less poor parenting behaviors and that their children should have fewer psychologic symptoms. For the sicker mothers, greater elapsed time since their last hospital treatment was associated with reporting marginally better physical health, comparatively lower levels of preoccupation with illness, and comparatively lower levels of their children’s psychologic symptoms. On the other hand, for not-so-sick mothers, greater elapsed times since their last hospital treatment was associated with reports of even higher physical heath scores and higher levels of avoiding thinking about their illness, accompanied by a lower level of psychologic symptoms in their children. Without evidence of further disease, the longer the not-so-sick mothers remained well, the more they put thoughts about the disease out of their minds. For the sicker mothers, the more advanced stage of their disease made this harder to do. Based on these reports and our clinical observations, we propose that when the mothers in the sicker group begin to sense that they may die, they begin to feel that caring for their children is more important than scolding them. Such a reappraisal of priorities and values, termed cognitive processing by Taylor et al,40 has been found in breast cancer patients by other investigators.41–43 The children, for their part, become preoccupied with the seriousness of their mothers’ condition.44 Clinically, we observed that, as a result, they attempt to control what might otherwise be disruptive behavior. These dynamics do not change over time. The recurrence or spread of the cancer continues to reinforce the mothers’ fear of dying, with the positive consequences for their parenting behavior. For their part, the children continue to suppress any inclination to disruptive behavior. For the not-so-sick mothers and their children, the dynamic is different. Here, the correlations we obtained between the time lapsed from the last hospital treatment provide a more solid footing for our description of these dynamics. As time passes, the mothers in this group begin to feel better physically. It probably becomes apparent to them and to their children that the threat of death is diminished. As a result, they are able to increasingly push aside their thoughts about cancer. They return to their usual parenting behavior and are once again able to control the children who have become disruptive. The children, who had become more withdrawn, perceiving their mothers’ improving health, no longer feel the need to protect them and resume their usual behavior. The preceding arguments are, in part, based on the findings of the present study and, in part, based on our clinical observations.18 It is possible that the progressively higher level of avoidance of thoughts about their illness by the not-so-sick mothers is based on an illusion, on their minimization of the seriousness of their physical condition, or on increased hope with the passage of time. Even if this is so, it may have some positive consequences. Taylor et al42,45 have demonstrated in a variety of situations, including illness with cancer, that positive illusions (the conviction that things are better than they are objectively) are associated with, and may even be a necessary condition for, mental health. Another possibility is that these mothers accepted their illness and were, thus, able to use healthier defenses like suppression, anticipation, and affiliation. We will address this issue further in an article in which we will examine the role of defense mechanisms, broadly defined, in the context of the present study, as well as in a study of coping styles of stage I and II cancer patients compared with those of stage III and IV patients. Before adequate measures of preoccupation were available, Sigal18 used worry as an indicator of preoccupation. In a series of studies, he and his colleagues found that parental worry correlated with psychologic symptoms in their children. "Worry" is defined as "giving way to anxiety".46 Because coping devices used by cancer patients play an important role in determining the level of cancer patients’ anxiety and depression,47,48 they should be included in future studies as potential mediators between the mother’s illness and the degree of their preoccupation. The spouses’ avoidance of the patients and criticism of them affect the psychologic distress of cancer patients.49 Measurement of the spouses’ defense or coping mechanisms and their preoccupations should, therefore, also be incorporated in future studies. Our findings do offer some guidance to clinicians interested in averting potential long-term negative effects in the children of their breast cancer patients. For all of these people, a careful evaluation of the mothers’ thoughts about the consequences of their illness, their affective state, and parenting behavior is essential. For families in which the mother has metastases or a recurrence, clinicians should pay particular attention to the possible presence of internalizing symptoms in the children, because they are most easily concealed. For both groups of families, encouraging mutual disclosure of fears, anxieties, and hopes between the mothers and the children in families that appear to be in trouble may have beneficial effects for both50,51. Fortunately, cancer patients’ affective state, an important source of the preoccupation of these patients, is modifiable by a number of psychosocial methods (Anderson52 reviews the relevant studies). For clinical depressions, a combination of psychotherapy and antidepressant medication is efficacious.53 Intervention in the family is particularly important when the children manifest problems of the externalizing type because problems of this type are more likely to persist.54 Parenting style with at least some of these children is modifiable.55 Unfortunately, despite the importance of addressing communication problems between cancer patients and their children,56 the effectiveness of techniques for modifying them has yet to be demonstrated. Limitations of this study indicate that caution should be exercised with respect to our conclusions. First, we did not confirm the mothers’ reports of their disease status. This is a minor reservation because their perception of it may be a more important determinant of their psychologic state. Second, because 20% of the women in this study were separated or divorced and because of the already limited sample size, we did not include a measure of the marital relationship in our analyses. That relationship is known to affect the mothers’ psychologic state.11 Our measure of social supports would only indirectly compensate for this shortcoming. Finally, our findings may be valid only for families of women with breast cancer and not for families in which a parent has some other type of cancer. Because parental preoccupation has been shown to correlate with psychologic problems in such a variety of situations,15–17 however, it seems likely that our findings are generalizable to families in which a parent has some other form of cancer.
This study could not have been completed without the collaboration of the following physicians: R. Margolese, MD, L. Panasci, MD, and M. Pollock, MD, Jewish General Hospital; and D. Fleiszer, Montreal General Hospital, Montreal, Quebec; R. Moralejo, St Mary’s Hospital; J. Zidulka, A. Hood, and D. Stern, Queen Elizabeth Hospital; and H. Shibbata and A. Langleben, Royal Victoria Hospital. We gratefully acknowledge the help of the following people: Phyllis Brockhouse, BA, Denise Cadieux, Nettie Harris, BA, Lynn Blauer, BA, and Mildred Kaminsky, MSW, for conducting the interviews; Ruth Stilman, MLS, and Judy Grossman, BA, for bibliographic assistance; Michael Buonvino, BA, for statistical work; Diana D’Angelo and André-Marie Boucher, BA, for facilitating our access to eligible patients; Caroline Dovick, MSW, Suzanne Morin, Laura Rose, BA, and Eva Dolenszky, MA, for their secretarial assistance; and Marie Claude Ouimet, BSc, Goldie Sigal, MLS, Laurence Panasci, MD, and the anonymous reviewers for their invaluable comments on earlier versions of this article.
Supported by grant no. RS-2286-093 from the Conseil Québécois de la Recherche Sociale (Quebec Social Science Research Council), Quebec, Canada.
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
