Running Head: PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
Children Coping with Cancer: Cross-Sectional and Prospective Relations between
Parenting Behaviors and Children’s Coping
Psychology Honors Research Thesis
Jennifer Ragan
Vanderbilt University
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Abstract
Objective. Children diagnosed with cancer face numerous sources of stress and are at risk
for emotional problems such as anxiety and depression. Parenting behavior and children’s coping
are two important factors that may impact children’s adjustment to cancer. The purpose of the
current study is to examine cross-sectional and prospective relations between mothers’ parenting
behaviors and children’s coping in a sample of childhood cancer patients. Methods. Children
ages 5-17 who had recently been diagnosed with new or relapsed cancer (n=108) and their
parents were recruited from two hospitals in the Southern and Midwestern United States. Child
and parent reports of parenting behaviors and child’s coping were obtained at two time points:
near diagnosis (T1) and 12 months after diagnosis (T2). Results. Significant cross-sectional and
longitudinal associations of parental warmth and parental psychological control with children’s
coping were found near the time of child’s cancer diagnosis and one year later. These findings
have the potential to guide future intervention studies to enhance adjustment outcomes for
children with cancer by using parenting as an avenue to improve children’s coping.
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Introduction
Recent estimates reported by the American Cancer Society (2013) suggest that about
12,000 children in the United States are diagnosed with cancer every year. Although this
number is alarming, the 5-year survival rate for childhood cancer patients has been increasing
significantly over the past 40 years due to advancements in treatment methods. Estimates predict
the current 5-year survival rate for children with cancer to be 83% (American Cancer Society,
2013). While the increase in survival rates brings good news to childhood cancer patients and
their parents, living with an illness such as cancer introduces many stressors into the lives of
these children.
Sources of stress for pediatric cancer patients include uncertainty about cancer and its
outcomes, pain from medical procedures, side effects of treatment, separation from family, and
changes in daily roles and functioning (e.g., Rodriguez, Dunn, Zuckerman, Vannatta, Gerhardt,
& Compas, 2012; Rourke, Stuber, Hobbie, & Kazak, 1999). Many years after diagnosis, patients
may continue to experience side effects from treatment such as impaired organ functioning,
secondary cancers, and cognitive deficits (American Cancer Society, 2013). Making the
transition into young adulthood may bring about new stress for childhood cancer survivors as
they face the late effects of treatment and attempt to incorporate their traumatic past into their
developing identity (Rourke et al., 1999).
Because childhood cancer and progression into survivorship involve numerous sources of
stress, these children are a vulnerable population for emotional problems. Children with cancer
tend to report elevated levels of anxiety, depression, and symptoms of post-traumatic stress (e.g.,
Kazak, Alderfer, Rourke, Simms, Streisand, & Grossman, 2004; Sawyer, Antoniou, Toogood, &
Rice, 1997; Schultz, Ness, Whitton, Recklitis, Zebrack, Robison, Zeltzer, & Mertens, 2007).
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Coping is one factor that has the potential to facilitate or impair children’s emotional adjustment
to cancer (Compas et al., in press). Furthermore, research indicates that certain parenting
behaviors are closely associated with children’s coping (Gaylord-Harden, Campbell, &
Kesselring, 2010; Watson et al., in press). Therefore, parenting behaviors and children’s coping
are two important factors to analyze in the context of children’s emotional adjustment to cancer.
The purpose of the present study is to examine the relationship between mothers’ parenting
behaviors and children’s coping in a sample of pediatric cancer patients. It is important to
understand the specific associations between parenting and children’s coping, as findings may
help clarify how to develop interventions that enhance emotional adjustment in children with
cancer.
Coping and Adjustment to Cancer
The way a child copes with the stress of having cancer may affect emotional adjustment.
Compas et al. (2001) define coping as conscious, volitional efforts to regulate oneself or the
environment in response to stressful events or circumstances. Past research on the relationship
between coping strategies and emotional adjustment for children with cancer has been
summarized in a meta-analysis conducted by Aldridge and Roesch (2007). The researchers
summarized the relationship between coping and emotional problems for pediatric cancer
patients based on a synthesis of 26 past studies. Among these studies, a variety of coping
measures and taxonomies were used. In their analysis, Aldridge and Roesch classified coping
strategies from the 26 past studies based on two major dichotomous coping taxonomies: (a)
approach (e.g., seeking information, positive reappraisal) vs. avoidance (e.g., denial, self-blame);
and (b) problem-focused (e.g., problem solving, seeking support) vs. emotion-focused (e.g.,
acceptance, optimism). After assigning the coping strategies described in each study to the
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appropriate taxonomy, Aldridge and Roesch examined the associations between these 4 coping
strategies and 6 emotional problems (overall adjustment, physical problems, depression, overall
distress, overall anxiety, overall pain).
For example, a study by Frank, Blount, and Brown (1997) was included in Aldridge and
Roesch’s (2007) meta-analysis. In their study, Frank et al. used a brief 10-item self-report
measure to assess the coping strategies of 86 children being treated for cancer. Coping strategies
were classified as positive/approach or negative/avoidance. The researchers used the Child
Behavior Checklist to measure participants’ internalizing and externalizing problems. Frank and
colleagues found that children’s use of avoidance coping accounted for part of the variance in
both depression and anxiety scores. They concluded that avoidance coping is a negative coping
style that can result in emotional problems for children with cancer.
Another study included in Aldridge and Roesch’s meta-analysis was by Tyc, Mulhern,
Jayawardene, and Fairclough (1995). Tyc and colleagues assessed coping strategies and distress
levels among 57 pediatric cancer patients undergoing chemotherapy. The researchers found that
the children who reported low levels of distress about chemotherapy treatment were more likely
to problem solve and seek social support as coping strategies (Tyc et al., 1995). These strategies
fit into both the approach and problem-focused categories of coping. Tyc and colleagues also
found that children who reported high levels of distress about chemotherapy treatment did not
employ problem solving as a coping strategy. Together, these findings suggest that approach and
problem-focused coping styles are associated with more positive emotional adjustment in
children with cancer.
Despite the findings of individual studies included in the meta-analysis, Aldridge and
Roesch (2007) were unable to reach a significant consensus about coping and emotional
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adjustment. In their synthesis of the 26 studies, Aldridge and Roesch calculated effect sizes
relating the four coping classifications to the six emotional problems. Of the 24 mean effect
sizes, only one revealed a significant association between coping and emotional problems,
indicating a small, positive association between emotion-focused coping and depression.
Overall, the results of Aldridge and Roesch’s synthesis reveal that past studies have failed to
provide evidence of a significant or meaningful association between coping strategies and
emotional adjustment.
Since Aldridge and Roesch (2007), little research has been added to the literature
regarding children coping with cancer and emotional adjustment. Several researchers have
reported on types of coping strategies used by childhood cancer patients (Engvall et al., 2011;
Hildebrand et al., 2011; Li et al., 2010; Rollins, 2009; Smorti, 2012). However, the association
between coping and emotional adjustment has not been a focus of analyses in these studies. One
exception is Maurice-Stam, Oort, Last, Brons, Caron, and Grootenhuis (2009), who reported on
coping strategies and quality of life of childhood cancer patients after the end of treatment.
Maurice-Stam et al. (2009) found a small, negative correlation between the use of interpretative
control coping (seeking more information about the disease) and quality of life after treatment
ended. Results also revealed a small, positive correlation between the use of vicarious control
coping (relying on expertise of physician and attributing power to cancer treatment) and quality
of life. Despite the individual findings of Maurice-Stam and colleagues, however, there is still
wide variation among researchers regarding the conceptualization and categorization of coping.
Overall, recent literature still indicates a lack of consensus about the association between
coping and emotional adjustment for children with cancer. It is possible that this discrepancy is
due to the lack of consistency in the way researchers have measured and categorized coping. The
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present study is a part of a 5- to 6- year longitudinal study designed to overcome these
limitations. The first goal is to use a valid measure of coping. Many measures of coping rely on
brief methods of assessment. For example, the KIDCOPE is a widely used checklist developed
by Spirito (1988) that uses 10 items to measure coping styles. Although a brief checklist is an
efficient way conduct research, more detailed information about coping mechanisms can be
captured with the use of longer questionnaires. In the current study, we use the Responses to
Stress Questionnaire (RSQ), a valid and adaptable 57-item questionnaire created by ConnorSmith, Compas, Wadsworth, Thomsen, and Saltzman (2000) to evaluate a wide range of coping
responses.
Another limitation we aim to overcome is the wide variety in the categorization of coping
styles. In the past, researchers have used dichotomous classifications such as approach versus
avoidance responses or problem-focused versus emotion-focused coping. Based on the idea that
there are actually multiple dimensions of coping to take into consideration, the RSQ was
designed to evaluate coping according to three main dimensions of coping: primary control
coping, secondary control coping, and disengagement coping (Connor-Smith et al., 2000).
Primary control coping is an engagement strategy that involves controlling and changing the
objective condition, such as altering the source of stress or one’s reaction to the stress (e.g.,
problem solving, emotional modulation). Secondary control coping is an engagement strategy
that involves changing oneself to adapt to the stressor (e.g., acceptance, cognitive reappraisal).
Disengagement responses involve active orientation away from a stressor (e.g., avoidance,
denial). The RSQ and these three dimensions of coping are becoming more widely recognized in
research and establish a strong basis for measuring coping (Hamill 2005; Silk et al., 2003;
Wadsworth et al., 2004, 2005; Yao 2010). By using a valid measure and categorization of
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coping, the current study aims to resolve the discrepancy in past research and uncover an
accurate relationship between coping styles and emotional adjustment for children with cancer.
In baseline analyses with the sample that is the focus of the current study, Compas et al. (in
press) found significant correlations of secondary control coping and disengagement coping with
anxiety/depression within and across informants. Primary control coping was associated with
anxiety/depression within informants. Further, linear multiple regression analyses indicated that
secondary control coping accounted for unique variance in symptoms of anxiety/depression both
within and across reports from children and their mothers.
Parenting and Children’s Coping
Findings from past research reveal that parenting behaviors, including parental warmth,
psychological control, and behavioral control are associated with children’s coping (GaylordHarden et al., 2010; Kliewer, Fearnow, & Miller, 1996; McIntyre & Dusek, 1994; Watson et al.,
in press). Warm parenting is characterized by variations of responsiveness, acceptance, support,
and sympathy (Morris, Silk, Steinberg, Myers, & Robinson, 2007). Parents who convey a sense
of warmth and available support to their child provide a safe and secure environment for the
child to develop. According to attachment theory, children in this environment tend to seek
social support more often and engage problems more actively (Kliewer et al., 1996; McIntyre &
Dusek, 1994). There have been several studies designed to examine the association between
warm parenting and coping. For example, children’s perceptions of maternal acceptance are
related to higher levels of active coping and support seeking in children (Gaylord-Harden et al.,
2010; Kliewer et al., 1996). Observed maternal responsiveness is associated with an increased
use of problem-focused coping in preadolescents with spina bifida (McKernon et al., 2001).
Family social support has been associated with less wishful thinking, and more problem-focused
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coping and resiliency among children in rural, low-income populations (Markstrom, Marshall, &
Tryon, 2000).
Watson et al. (in press) examined the effects of a preventive intervention to improve
parenting skills among a sample of mothers with a history of depression and to increase their
children’s use of secondary control coping. From baseline to the 6-month follow-up, parents
exhibited a significant increase in observed parental warmth and responsiveness, and from
baseline to the 18-month follow-up, children showed a significant increase in use of secondary
control coping strategies. Furthermore, increases in parental warmth and responsiveness
significantly accounted for (mediated) the effects of the intervention on increases in children’s
use of secondary control coping strategies over time. The findings of this intervention highlight
the importance of the effects of warm and responsive parenting on children’s coping.
Parental control is another parenting behavior associated with children’s coping. Control
is commonly categorized into psychological control and behavioral control (Bean, Barber, &
Crane, 2006; Schaefer, 1965). Psychological control refers to parental intrusion and manipulation
of the child’s psychological world (Bean et al., 2006). Common characteristics of psychological
control, including poor communication and parental intrusiveness, have been linked to more
avoidant and disengagement coping strategies in children (Jackson, Bijstra, Oostra, & Bosma,
1998; Langrock, Compas, Keller, Merchant, & Copeland, 2002). Past research has also shown
that psychological control leads to more avoidant coping strategies specifically among children
in high stress environments (Gaylord-Harden et al., 2010). Therefore children who face the
stressors of cancer diagnosis may be more vulnerable to the negative impact that psychological
control has on coping.
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Behavioral control, sometimes referred to as firm control, is the extent of parental
regulation and structure imposed upon the child’s behavioral world (Bean et al., 2006). The
association between behavioral control and children’s coping is less straightforward. McIntyre
and Dusek (1994) found that parental behavioral control was associated with increased problemfocused coping and reduced emotion-focused coping. Power and Manire (1992) found that
behavioral control has a curvilinear relationship with children’s coping. That is, mothers using
moderate levels of behavioral control provide sufficient guidelines for their children without
being over- or under-controlling, providing a more positive context for learning (Hardy, Power,
& Jaedicke, 1993).
Present Study
The purpose of the present study was to examine the relationship between mothers’
parenting behaviors (e.g., warmth, psychological control, and behavioral control) and children’s
coping (e.g., primary control coping, secondary control coping, and disengagement coping) in a
sample of pediatric cancer patients. Children diagnosed with cancer are exposed to numerous
sources of stress, making them an important population of focus for adjustment interventions. No
studies to date have examined the specific relationship between parenting behaviors and coping
among pediatric cancer patients. There are several methodological strengths of the present study.
Past researchers have often relied on single informants to gather data. In the current study, we
used multiple sources to gather data, including the child and his or her mother. This allowed us
to identify correlations using cross-informant reports and gain a more accurate depiction of
possible associations. Furthermore, the design of the current study is longitudinal, whereas the
majority of past studies have been cross-sectional. By using a longitudinal design, we were able
to examine if changes occur over time in the association between parenting and children’s
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coping. By learning about the association across time, we will be better prepared to develop
effective interventions that are relative to a child’s specific cancer timeline. Finally, the current
study has the largest sample size to date for a longitudinal study following children from
diagnosis to survivorship. Together, the strengths of the current study provided an opportunity to
examine the relationship between parenting behaviors and coping styles in children with cancer.
At this time, all of the participants enrolled in the current longitudinal study have been
assessed at baseline (near the time of diagnosis) and 12 months after diagnosis. As noted above,
baseline data on children’s coping and emotional problems (anxiety, depression) have been
analyzed (Compas et al., in press). Significant baseline results suggest that at diagnosis, children
who use primary control coping and secondary control coping tend to report less anxiety and
depression. Disengagement coping, on the other hand, is associated with higher levels of anxiety
and depression. These findings near diagnosis provide the rationale for the present study
examining parenting behaviors and children’s coping. Now that we know children’s coping
styles are related to symptoms of anxiety and depression, it is important to know what factors
might impact children’s coping. Thus the goal of the present study was to examine the impact of
parenting behaviors on children’s coping at baseline and at the 12-month follow-up.
Hypotheses
In this study we examined cross-sectional and prospective relations between mothers’
parenting behaviors and children’s coping among a sample of childhood cancer patients. Data
was collected from mothers and children near the time of the child’s diagnosis (T1), and 12
months after diagnosis (T2). We tested the following hypotheses:
Hypothesis 1: In bivariate correlation analyses, maternal warmth will be correlated with
more primary control coping and secondary control coping and less disengagement coping.
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Maternal psychological control and behavioral control will be correlated with less primary
control coping and secondary control coping and more disengagement coping. These results will
apply cross-sectionally at T1 and T2, as well as prospectively from T1 to T2.
Hypothesis 2: In linear multiple regression analyses, maternal warmth, psychological
control, and behavioral control will have unique effects as predictors of children’s coping crosssectionally at both T1 and at T2.
Hypothesis 3: In linear multiple regression analyses, maternal warmth, psychological
control, and behavioral control will have unique effects as predictors of children’s coping
prospectively from T1 to T2.
Exploratory analyses were also conducted to examine the effect of age as a covariate with
our parenting and coping variables, as well as a predictor of children’s coping.
Method
Participants
Families who were eligible for enrollment in the study had a child that was: (1) age 5-17
years old at study entry, (b) had been recently diagnosed with a new or relapsed cancer, (c) was
receiving treatment through the oncology division, and (d) had no pre-existing developmental
disability. In the initial sample, participants included 336 children with cancer and their parents.
Only mothers and children who completed reports on parenting behaviors and children’s coping
were included in the analysis. Mother reports on parenting behaviors and their child’s coping
were obtained near diagnosis (T1; n = 240) and 12 months after diagnosis (T2; n = 163). Child
reports of parenting behaviors and children’s coping were also obtained from children who were
old enough to complete the self-report measures at T1 (n = 114) and T2 (n = 81). Therefore, the
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final sample for this study included 240 mothers and 114 children at T1. Due to participant
attrition in the sample, 163 mothers and 81 children remained in the study at T2.
The children included in the present sample at T1 (near diagnosis) were on average 10.38
years old (SD = 3.89). In this group, 52.1% of the children were male and 47.9% were female.
Race of the children included 83.3% White, 10.8% Black/African American, and 5.9% other.
Children had diagnoses of leukemia (38.8%), lymphoma (22.1%), brain tumor (6.7%), or other
solid tumor (32.5%). Annual family income levels varied: 30.4% earned $25,000 or less, 24.6%
earned $25,001-$50,000, 13.8% earned $50,001-$75,000, 10.4% earned $75,001-$100,000, and
17.9% earned $100,001 or more.
The children who remained in the sample at T2 (12 months after diagnosis) were on
average 10.22 years old (SD = 3.94). In this group, 54% of the children were male and 46%
were female. Race of the children included 85.9% White, 9.2% Black/African American, and
4.9% other. Children had diagnoses of leukemia (38.7%), lymphoma (22.7%), brain tumor
(6.7%), or other solid tumor (31.9%). Annual family income levels varied from: 28.2% earned
$25,000 or less, 26.4% earned $25,001-$50,000, 16.0% earned $50,001-$75,000, 11.7% earned
$75,001-$100,000, and 15.3 % earned $100,001 or more.
Measures
Demographics and Medical Data. Parents provided demographic information including
age, education level, race, family income, and marital status. Participants gave permission for
the research staff to access medical data, where data regarding the child’s diagnosis/relapse
status was extracted.
Children’s Coping. The Responses to Stress Questionnaire-Pediatric Cancer version
(RSQ-PC; Compas et al., in press; Connor-Smith et al., 2000; Miller et al., 2009; Rodriguez et
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al., 2012) was used to obtain adolescents’ self-reports and mothers’ reports of their children’s
coping with cancer. The RSQ-PC version includes a list of 12 cancer-related stressors (e.g.,
missing school, frequent hospital or clinic visits, changes in personal appearance), and 57 items
reflecting voluntary (coping) and involuntary (automatic) stress responses of
children/adolescents in response to cancer-related stressors. For the purpose of this study, only
the three voluntary coping scales are reported. The coping scales include: primary control
coping (i.e., problem solving, emotional modulation, emotional expression), secondary control
coping (i.e., acceptance, cognitive restructuring, positive thinking, distraction), and
disengagement coping (i.e., avoidance, denial, wishful thinking). The factor structure of the RSQ
has been supported in confirmatory factor analytic studies with children and adolescents from a
wide range of ethnic and cultural backgrounds coping with a variety of stressors (Benson et al.,
2011; Compas et al., 2006; Connor-Smith et al., 2000; Connor-Smith & Calvete, 2004;
Wadsworth et al., 2004; Yao et al., 2011).
Parenting Behaviors. The Children’s Report of Parent Behavior Inventory-30 (CRPBI30; Schludermann & Schludermann, 1988) was used to obtain children’s perceptions of their
mothers’ parenting behavior. Mothers provided self-reports of their own parenting behavior
using the Parent Behavior Inventory-30 (PBI-30), a first-person, but otherwise identical, version
of the CRPBI-30. Children and mothers responded to 30 items that evaluate parenting behaviors
using a 3-point scale (1 = “not like,” 2 = “somewhat like,” 3 = “a lot like”). The 30 items yielded
three categories of parenting behaviors: Warmth, Psychological Control, and Behavioral Control.
The CRPBI-30 and PBI-30 are shortened versions of an original instrument developed by
Schaefer (1965) that included over 260 items but yielded the same three factors of Warmth,
Psychological Control, and Behavioral Control. The factor structure has been supported through
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various modifications of the original instrument and in culturally diverse studies (Renson,
Schaefer, & Levy, 1968; Schludermann & Schludermann, 1971, 1983).
Procedure
The Institutional Review Boards at two hospitals in the Southern and Midwestern United
States approved the study protocol. Children were identified from cancer registries at two
pediatric oncology centers, and a member of the research team approached parents in the clinic
or hospital to introduce the study. Parents who were willing to participate completed an
informed consent form, and children (ages 10-17 years) completed an assent form. In the case
that only one parent was present, consent forms were sent home for the other parent. For both
the T1 (near diagnosis) and T2 (approximately 12 months after diagnosis) assessments,
questionnaire packets were either given to participants at the hospital or mailed to their home.
For T1, families in this sample were enrolled between several weeks and months after the child’s
first diagnosis or relapse (M = 39.94 days, SD = 23.58). Parents and children returned the T1
questionnaires between several weeks and months after the child’s first diagnosis or relapse (M =
64.75 days, SD = 35.35). For T2, follow-up questionnaire packets were given to families once
they were 12-months past first diagnosis or relapse. Parents and children returned the T2
questionnaires approximately one year after first diagnosis or relapse (M = 407.96 days, SD =
60.71). Families received compensation at each assessment when at least one parent or child
completed the measures.
Results
Data Analytic Strategy
Using SPSS (21st ed.), we ran three main sets of analyses. First, in our preliminary
analyses section, we ran descriptive analyses to examine the mean levels of reported parenting
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behaviors and children’s coping among children and mother reports. We also ran correlations to
examine child age as a possible covariate among parenting behaviors and children’s coping.
Next, to test Hypothesis 1, we ran bivariate Pearson correlation analyses to examine crosssectional and prospective associations between parenting behaviors and children’s coping.
Finally, to test Hypotheses 2 and 3, we used linear multiple regression analyses to examine the
unique cross-sectional and prospective associations of parenting behaviors as predictors of
children’s coping. Child age was also entered into each regression equation to control for its
possible unique effects as a predictor of children’s coping.
Preliminary Analyses
Descriptive Statistics. Means and standard deviations of parenting behaviors and
children’s coping are shown in Table 1 for T1 and T2 using mother and child reports. Parenting
behaviors are reported as means of a 3-point rating scale. At both time points, mothers and
children consistently rated parental warmth the highest, suggesting that mothers in the current
sample use high levels of parental warmth (M = 2.62 to 2.85). Behavioral control was
consistently rated the second highest (M = 1.49 to 1.70), followed by psychological control as the
lowest (M = 1.35 to 1.55). Paired samples t-tests showed that parental warmth was significantly
higher than both behavioral control and psychological control. Furthermore, psychological
control was significantly higher than behavioral control. These differences hold true for both
mother self-reports and children’s reports about their mothers. Children’s coping scores are
presented as ratio scores. At both time points, mothers and children consistently reported that
children use secondary control coping the most often (M = .28 to .29). Primary control coping
was the next coping style most often used by children (M = .18 to .19), while disengagement was
consistently reported as the least used coping style (M = .14 to .15).
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Possible Covariate: Child age. Bivariate correlations were used to assess possible
associations between the mother and child reports of all our parenting behavior variables and
children’s coping variables with child age. Some significant differences emerged. Child age was
negatively correlated with maternal warmth consistently across the T1 mother reports (r = -.14; p
< .05), T2 mother reports (r = -.24; p < .01), and T2 child reports (r = -.29; p < .01). Child age
was also correlated negatively with primary control coping according to the T2 mother reports (r
= -.21; p < .01), positively with secondary control coping according to the T1 mother reports (r =
.17; p < .01), and positively with disengagement coping according to the T2 mother reports (r =
.18; p < .01).
Correlation Analyses
Hypothesis 1: Maternal warmth would be correlated with more primary control coping
and secondary control coping and less disengagement coping. Maternal psychological control
and behavioral control would be correlated with less primary control coping and secondary
control coping and more disengagement coping. These results would apply cross-sectionally at
T1 and T2, as well as prospectively from T1 to T2. Cross-sectional correlations between child
and mother reports of parenting behaviors and children’s coping at T1 are presented in Table 2.
Three of the nine correlations within the children’s reports of parenting and coping were
significant (p < .05). Five of nine correlations within mothers’ reports of parenting and coping
were significant (p < .05). Four of the eighteen cross-informant correlations were significant (p <
.05). Correlations ranged from small to medium in magnitude (r = .15 to .30). Significant
correlations followed the expected pattern. Mothers’ warmth was associated with children’s
increased use of primary control coping and secondary control coping, and decreased use of
disengagement coping. Maternal psychological control was associated with children’s decreased
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use of primary control coping and secondary control coping, and increased use of disengagement
coping. Maternal behavioral control was associated with children’s decreased use of secondary
control coping and increased use of disengagement coping. At T1, there were no significant
correlations between behavioral control and children’s primary control coping.
Cross-sectional correlations between child and mother reports of parenting behaviors and
children’s coping at T2 are presented in Table 3. At T2, seven of the nine correlations within the
children’s reports of parenting and coping were significant, four of nine correlations within
mothers’ reports of parenting and coping were significant, and eight of the eighteen crossinformant correlations were significant (all p < .05). Correlations ranged from small to medium
in magnitude (r = .22 to .47). As with T1, the significant correlations at T2 followed the expected
patterns. Maternal warmth was positively associated with children’s primary control coping and
secondary control coping, and was negatively associated with disengagement coping. Maternal
psychological control was negatively associated with children’s primary control coping and
secondary control coping, and was positively associated with disengagement coping. Maternal
behavioral control was negatively associated with children’s primary control coping. At T2,
behavioral control was not significantly associated with secondary control coping or
disengagement coping.
Prospective correlations between child and mother reports of parenting behaviors at T1
and children’s coping at T2 are presented in Table 4. Significant correlations followed the
expected pattern and ranged from small to medium in magnitude (r = .18 to .32). Within the
children’s reports, only one of nine correlations was significant over time (p < .05). Maternal
warmth at T1 was associated with decreased use of children’s disengagement coping at T2.
Within the mother’s report, three of nine correlations were significant (p < .05). Maternal
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warmth at T1 was associated with increased use of children’s primary control coping at T2 and
decreased use of disengagement coping at T2. Maternal psychological control at T1 was
associated with decreased use of children’s secondary control coping at T2. Finally, only two of
eighteen cross-informant correlations were significant over time (p < .05). Maternal warmth at
T1 was positively associated with children’s primary control coping at T2, and maternal
psychological control at T1 was negatively associated with primary control coping at T2.
Maternal behavioral control at T1 was not significant with children’s coping at T2 among withinor cross-informant reports.
In summary, Hypothesis 1 was partially supported. Several significant correlations
emerged in the expected pattern between maternal warmth and psychological control with
children’s coping, cross-sectionally and prospectively. Behavioral control, however, had very
few significant associations with children’s coping cross-sectionally, and no significant
associations over time.
Multiple Linear Regression Analyses
Hypothesis 2: Maternal warmth, psychological control, and behavioral control would
have unique effects as predictors of children’s coping cross-sectionally at both T1 and at T2.
Linear multiple regression analyses were conducted to predict children’s coping from parenting
behaviors using mothers’ reports for both measures. Table 5 shows three regression equations
predicting the three types of children’s coping at T1 using maternal warmth, psychological
control, and behavioral control at T1 as predictors. Maternal warmth at T1 was a significant
predictor of children’s primary control coping ( = .14, p < .05), secondary control coping ( =
.18, p < .01), and disengagement coping ( = -.14, p < .05) at T1. Maternal psychological
control at T1 was a significant predictor of children’s secondary control coping ( = -.20, p <
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
20
.01) and disengagement coping ( = .21, p < .01) at T1. Maternal behavioral control did not
have any unique effects as a predictor of children’s coping at T1. In each regression equation, R2
values ranged from .037 to .085.
Table 6 shows three regression equations predicting the three types of children’s coping
at T2 using maternal warmth, psychological control, and behavioral control at T2 as predictors.
Maternal warmth at T2 was a significant predictor of children’s primary control coping ( = .18,
p < .05) and disengagement coping ( = -.20, p < .05) at T2. Psychological control at T2 was a
significant predictor of children’s primary control coping ( = -.31, p < .01) and secondary
control coping ( = -.19, p < .05) at T2. Behavioral control had no unique effects as a predictor
of children’s coping at T2. In each regression equation, R2 values ranged from .063 to .155.
In summary, Hypothesis 2 was partially supported. At T1 and T2, maternal warmth and
psychological control had unique effects as predictors of children’s coping. Behavioral control
had no unique effects as a predictor of children’s coping at either T1 or T2.
Hypothesis 3: Maternal warmth, psychological control, and behavioral control would
have unique effects as predictors of children’s coping prospectively from T1 to T2. Linear
multiple regression analyses were conducted to predict children’s coping at T2 from parenting
behaviors at T1, accounting for children’s coping at T1. Mothers’ reports were used for both
measures. Table 7 shows three regression equations predicting the three types of children’s
coping at T2 using maternal warmth, psychological control, behavioral control, and children’s
coping at T1 as predictors. As expected, children’s coping from T1 was a strong predictor of
children’s coping at T2 for primary control coping ( = .48, p < .01), secondary control coping
( = .56, p < .01), and disengagement coping ( = .48, p < .01). Maternal warmth at T1 was a
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
21
significant predictor of primary control coping ( = .19, p < .01) and disengagement coping (
= -.14, p < .05) at T2. In each regression equation, R2 values ranged from .314 to .373.
In summary, Hypothesis 3 was partially supported. After accounting for children’s
coping at T1, warmth was the only parenting behavior at T1 that had a unique effect on
children’s coping at T2. Maternal psychological control and behavioral control did not have
unique effects as predictors of children’s coping over time.
Exploratory Analysis: Child age. Child age was entered into each regression equation to
control for its possible unique associations with children’s coping. Child age was a significant
predictor of children’s coping in five of the nine regression equations included in the analyses
(see Tables 5-7). Cross-sectionally near diagnosis (T1), child age predicted more secondary
control coping and less disengagement coping (Table 5). Cross-sectionally 12 months after
diagnosis (T2), child age predicted less primary control coping (Table 6). Additionally, in our
prospective regression equation predicting children’s coping at T2, child age predicted less
primary control coping and more disengagement coping (Table 7).
Discussion
Childhood cancer patients face numerous sources of stress that may lead to increased
levels of emotional problems including anxiety and depression (e.g., Kazak et al., 2004; Sawyer
et al., 1997; Schultz et al., 2007). The way a child copes with the stress of having cancer has a
significant impact on such emotional problems. When children use more primary control coping
and secondary control coping, they tend to have lower levels of anxiety and depression. When
they use more disengagement coping, they tend to have higher levels of anxiety and depression
(Compas et al., in press). Therefore, healthy and adaptive coping is an important concern in the
context of childhood cancer. Past research suggests that parenting behaviors influence children’s
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
22
coping, but no studies to date have examined the relationship with childhood cancer patients
coping (Gaylord-et al., 2010; McIntyre and Dusek, 1994; Watson et al., in press). The present
study addresses this gap in existing literature by analyzing cross-sectional and prospective
relations between parenting and children’s coping in a sample of childhood cancer patients.
We found partial support for our first hypothesis when we tested cross-sectional and
prospective correlations between parenting behaviors and children’s coping with cancer.
Specifically, warmth and psychological control emerged as parenting behaviors that are
significantly associated with children’s coping. As predicted, our findings suggest that higher
levels of maternal warmth are associated with more positive styles of children’s coping. In crosssectional analyses at both T1 and T2, maternal warmth was significantly associated with more
primary control coping, more secondary control coping, and less disengagement coping among
children. Prospectively, maternal warmth near diagnosis was correlated with more primary
control coping and less disengagement coping among children 12 months later.
Our correlation analyses also suggest that higher levels of maternal psychological control,
as predicted, are associated with more negative styles of children’s coping. Cross-sectionally at
T1 and T2, maternal psychological control was significantly associated with less primary control
coping, less secondary control coping, and more disengagement coping among children.
Prospectively, psychological control near diagnosis was associated with less primary control
coping and less secondary control coping among children 12 months later.
Overall, correlation analyses indicated fairly consistent associations between maternal
warmth with positive children’s coping styles, and maternal psychological control with negative
children’s coping styles. Correlations between maternal behavioral control and children’s coping
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
23
were less consistent cross-sectionally, and were nonexistent prospectively, indicating a weak
association that was not expected. We address this issue further below.
Regression analyses were used to examine more comprehensive associations between
parenting behavior and children’s coping, by assessing the unique effects of parenting behaviors
as predictors of children’s coping. Maternal warmth emerged as a very consistent predictor of
children’s positive coping styles. Maternal warmth consistently predicted more primary control
coping and less disengagement coping in cross-sectional regressions and in prospective
regressions after controlling for initial levels of each type of coping. Warmth also predicted
more secondary control in cross-sectional analyses near diagnosis. Maternal psychological
control was a fairly consistent predictor of children’s negative coping styles, but only from a
cross-sectional standpoint. Psychological control predicted less secondary control coping at T1
and at T2. Psychological control also predicted more disengagement coping at T1 and less
primary control coping at T2. Finally, maternal behavioral control had no significant effects as a
predictor of children’s coping cross-sectionally or over time.
Overall, the pattern of findings from this study is consistent with past research on
parental warmth. Maternal warmth was a consistent predictor of children’s coping, particularly
of increases in children’s use of primary control coping and decreases in use of disengagement
coping. It was also the only parenting behavior that predicted children’s coping over time from
diagnosis to 12-months. It is possible that parents who exhibit high levels of warmth towards
their children provide a sense of safety and support for the child (Kliewer et al., 1996; McIntyre
& Dusek, 1994; Watson et al., in press). Researchers have found that children in this
environment tend to use more engagement coping strategies, such as seeking social support and
problem solving. They tend to use disengagement strategies, such as wishful thinking, less often
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
24
(Gaylord-Harden et al., 2010; Markstrom, et al., 2000). The associations between maternal
warmth and children’s primary control coping and disengagement coping that emerged in the
present study match these findings from past research.
It is important to note that maternal warmth only had a significant effect as a predictor of
children’s secondary control coping cross-sectionally at T1. We expected a longitudinal
association to emerge as well. Watson et al. (in press) found that parental warmth and
responsiveness predicted increases in children’s use of secondary control coping in the context of
a longitudinal family intervention for mothers with a history of depression. Possible mechanisms
by which parental warmth may increase secondary control coping in children are parental
modeling of adaptive coping, direct coping coaching, or engaging children in positive distraction
activities (Watson et al., in press). It is possible that this relationship only emerged in the present
study at T1 because the time of diagnosis is the most emotionally intense point in time.
Furthermore, the stressors facing children near the time of their cancer diagnosis are mostly
beyond their control and are especially well suited to the use of secondary control coping.
Maternal warmth may serve to facilitate this type of coping at this crucial time. At 12 months
after the diagnosis, parents of children with cancer may engage less often in behaviors that
facilitate secondary control coping in their children, and instead use behaviors that tend to
facilitate primary control coping when children have more opportunity to exert control over the
stressors in their lives as they move into long-term survivorship.
Overall, the pattern of findings on parental psychological control from this study is also
fairly consistent with past research. Parental psychological control emerged as a predictor of
children’s coping cross-sectionally, but not prospectively. Past research suggests that parental
psychological control is associated with parenting characteristics such as intrusiveness and poor
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
25
communication, which often lead to more avoidant coping strategies among children (Jackson et
al., 1998; Langrock et al., 2002). Our results on psychological control are consistent with these
past findings. Maternal psychological control was associated with higher levels of
disengagement coping and lower levels of primary and secondary control coping. In fact,
parental psychological control had the most consistent impact on secondary control coping. It is
possible that psychological control, defined as intrusion and manipulation of the child’s
psychological world, leads to a greater difficulty with secondary control coping strategies (e.g.,
acceptance, cognitive restructuring, positive thinking, distraction). These types of coping
strategies require cognitive and psychological command over one’s thoughts and emotions. High
levels of parental psychological control may thwart these types of abilities. Because maternal
psychological control did not predict children’s coping prospectively from T1 to T2, our results
suggest that the impact of psychological control on children’s coping is not as permanent as
maternal warmth was found to be.
Finally, the overall pattern of findings for maternal behavioral control did not emerge as
we had predicted. Regression analyses showed no significant effects of behavioral control as a
predictor of children’s coping cross-sectionally or prospectively. This lack of support for our
hypothesis, however, does reflect the mixed findings past research has shown. Behavioral control
has a complex relationship with children’s coping and adjustment, and findings in the past have
been less consistent (McIntyre and Dusek, 1994; Power and Manire, 1992). It is possible that our
lack of significant associations is due to an issue with the measure used to evaluate behavioral
control. It is also possible that in the specific context of children with cancer, maternal
behavioral control (i.e., regulation and structure of child’s behavior) is an expected parental
behavior. A highly protective environment and a very structured and scheduled routine may be
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
26
normal for a child newly diagnosed with cancer. Thus, children may accept behavioral control as
a normal part of life, leading it to have little impact on their ability to cope.
Overall, the significant findings of the present study supported and extended relevant
findings from past research. This study was the first to evaluate the association between
parenting behaviors and children’s coping in the context of childhood cancer patients, which may
explain why some of our findings diverge from past research. The most important result that
emerged was the relationship between maternal warmth and children’s coping. The consistent
and long-term association between these two factors suggests that parental warmth is a strong
and positive parenting behavior that has important implications for children coping with cancer.
There were strengths as well as limitations to the present study. One strength was the
longitudinal design of the study, which allowed for prospective analyses between parenting
behaviors and children’s coping. The novel context of childhood cancer patients and their
mothers is another strength that contributes to the expanding body of knowledge on children’s
adjustment to cancer. Additional strengths include the relatively large sample size for a
longitudinal study on children with cancer and a wide age range. The primary limitation on this
study is attrition. Between the initial assessment near diagnosis and the 12-month follow up
assessment, we lost about 30% of the mothers and children included in this sample. Some of the
attrition in our sample is due to families choosing to drop out of the study, and unfortunately,
part of the attrition is due to the death of a patient. In the future, emphasis should be placed on
reducing the number of families who leave the study based on choice. Another limitation is the
ethnic and racial homogeneity. Future studies will benefit from a more diverse sample to
generalize findings to a wider population of children.
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
27
The findings from the present study have important implications. First, they replicated
past findings on the association between parenting behaviors and children’s coping. Second, they
extended those findings to a new context, children with cancer and their mothers. This is key
because this population of children is an important target group for interventions that reduce
emotional distress. The findings from the present study can be used as an impetus to conduct
parenting interventions to enhance children’s coping. We found that maternal warmth
consistently predicts more primary control coping and less disengagement coping, and those
effects extend through one year after diagnosis. Maternal psychological control also has crosssectional effects on children’s coping. These results suggest that improving parenting can be
used as an avenue to enhance children’s coping. An important next step for future research is to
examine the relationship between parenting behaviors and children’s coping with children’s
symptoms of anxiety and depression. This extended analysis will give a greater picture of how a
potential intervention will work for children with cancer and their families.
One noteworthy finding from the present study that has important implications for future
interventions is the set of associations between child age, parenting, and children’s coping. In the
preliminary analyses of this study, we found that child age was negatively correlated with
maternal warmth. This association was significant in mother reports at both T1 and T2 as well as
child reports at T1. As children get older, mothers tend to exhibit less parental warmth. This is
concerning in light of the positive impact that parental warmth has on children’s coping.
Furthermore, when child age was included in the regression analyses, we found that 12 months
after diagnosis, child age predicted less primary control coping and more disengagement coping
(Tables 6 and 7). As children get older, they are using more negative styles of coping. Age is
therefore an important factor to consider in the consideration of future interventions. Emphasis
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
28
should be placed on teaching mothers’ to continue using warmth even as their child ages. Such
an intervention has the potential to offset the reduction in children’s primary control coping and
the increase in disengagement coping, and ultimately enhance coping.
In conclusion, the findings from this study have the potential to guide future intervention
studies to enhance adjustment outcomes for children with cancer by using parenting as an avenue
to improve children’s coping. Past research has shown that parenting has significant associations
with children’s coping. Further research is needed to confirm this association in the context of
childhood cancer patients and to explore the function of age further, so that preventative
interventions can be developed to reduce the emotional distress these children face during their
diagnosis and recovery.
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
29
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Table 1. Means and standard deviations for mothers’ parenting behaviors and children’s coping.
Child Reports
(T1; n=114)
Parenting Behaviors (T1)
Warmth
Psychological Control
Behavioral Control
Children’s Coping (T1)
Primary Control Coping
Secondary Control Coping
Disengagement Coping
Mother Reports
(T1; n=240)
M
SD
M
SD
2.70
1.55
1.70
.34
.41
.26
2.85
1.36
1.54
.22
.31
.26
.18
.29
.15
.04
.06
.03
.19
.28
.14
.03
.06
.03
Child Reports
(T2; n=81)
Mother Reports
(T2; n=163)
M
SD
M
SD
Parenting Behaviors (T2)
Warmth
2.62
.39
2.83
.27
Psychological Control
1.47
.37
1.35
.28
Behavioral Control
1.68
.28
1.49
.23
Children’s Coping (T2)
Primary Control Coping
.18
.04
.19
.03
Secondary Control Coping
.29
.06
.28
.06
Disengagement Coping
.15
.03
.15
.03
Note. T1: near diagnosis; T2: 12 months after diagnosis. Scores for parenting behavior are
presented as means of a 3-point scale on the CRPBI and PBI. Scores for children’s coping are
presented as proportion scores on the RSQ.
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
37
Table 2. Correlations between child and mother reports of parenting behaviors at T1 with
children’s coping at T1.
Child Self Report
Child
Report
Mother
SelfReport
Warmth T1
Psychological
Control T1
Behavioral
Control T1
Warmth T1
Mother Report
Primary
Control
Coping T1
Secondary
Control
Coping T1
Disengage
-ment
Coping T1
Primary
Control
Coping T1
Secondary
Control
Coping T1
Disengage
-ment
Coping T1
.30**
.14
-.03
.07
.06
-.07
-.24**
-.22*
.13
-.03
-.26**
.14
-.09
-.15
.06
-.15
-.26**
.20*
.23*
.09
.10
.15*
.18**
-.15*
-.15*
.17**
.00
.02
Psychological
-.17
-.11
.01
-.09
Control T1
Behavioral
-.13
-.09
.03
.04
Control T1
Note. Sample sizes: n = 108 children; n = 240 mothers. T1: near diagnosis.
Note. * p<.05; ** p<.01.
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
38
Table 3. Correlations between child and mother reports of parenting behaviors at T2 with
children’s coping at T2.
Child Self Report
Child
Report
Mother
SelfReport
Warmth T2
Psychological
Control T2
Behavioral
Control T2
Warmth T2
Mother Report
Primary
Control
Coping T2
Secondary
Control
Coping T2
Disengage
-ment
Coping T2
Primary
Control
Coping T2
Secondary
Control
Coping T2
Disengage
-ment
Coping T2
.36**
.23*
-.25*
.09
.24*
.03
-.43**
-.47**
.24*
-.45**
-.25*
.34**
-.24*
-.15
.10
-.31**
-.04
.19
.16
.14
-.24*
.25**
.14
-.23**
Psychological
-.46**
-.11
.30**
-.26**
-.22**
Control T2
Behavioral
-.17
-.01
.08
-.01
-.12
Control T2
Note. Sample sizes: n = 74 children; n = 163 mothers. T2: 12 months after diagnosis.
Note. * p<.05; ** p<.01.
.13
.05
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
39
Table 4. Correlations between child and mother reports of parenting behaviors at T1 with
children’s coping at T2.
Child Self Report
Child
Report
Mother
SelfReport
Warmth T1
Psychological
Control T1
Behavioral
Control T1
Warmth T1
Mother Report
Primary
Control
Coping T2
Secondary
Control
Coping T2
Disengage
-ment
Coping T2
Primary
Control
Coping T2
Secondary
Control
Coping T2
Disengage
-ment
Coping T2
.20
.15
-.26*
.13
.11
.00
.00
-.19
.04
.00
-.17
.12
-.18
-.10
.15
-.05
-.09
.02
.23*
-.01
-.17
.32**
.11
-.26**
Psychological
-.25*
-.07
.22
-.15
-.18*
.11
Control T1
Behavioral
-.10
-.02
.10
.03
.01
-.05
Control T1
Note. Sample sizes: n = 78 children; n = 163 mothers. T1: near diagnosis; T2: 12 months after
diagnosis.
Note. * p<.05; ** p<.01.
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
40
Table 5. Linear multiple regression analyses predicting children’s coping at T1 from parenting
behaviors at T1 using mother reports.
Primary Control Coping (T1)
Variable
β
t
R2
F
Child Age
.02
.23
.037
2.28
Warmth T1
.14
2.11*
Psychological Control T1
-.14
-1.84
Behavioral Control T1
.12
1.51
Secondary Control Coping (T1)
Variable
β
t
R2
F
Child Age
.16
2.60*
.085
5.50
Warmth T1
.18
2.86**
Psychological Control T1
-.20
-2.68**
Behavioral Control T1
.13
1.72
Disengagement Coping (T1)
Variable
β
t
R2
F
Child Age
-.14
-2.22*
.075
4.80
Warmth T1
-.16
-2.44*
Psychological Control T1
.21
2.83**
Behavioral Control T1
-.11
-1.49
Note. * p<.05; ** p<.01.
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
41
Table 6. Linear multiple regression analyses predicting children’s coping at T2 from parenting
behaviors at T2 using mother reports.
Primary Control Coping (T2)
Variable
β
t
R2
F
Child Age
-.16
-2.07*
.155
7.28
Warmth T2
.18
2.33*
Psychological Control T2
-.31
-3.61**
Behavioral Control T2
.12
1.39
Secondary Control Coping (T2)
Variable
β
t
R2
F
Child Age
.02
.22
.063
2.70
Warmth T2
.14
1.69
Psychological Control T2
-.19
-2.06*
Behavioral Control T2
-.04
-.39
Disengagement Coping (T2)
Variable
β
t
R2
F
Child Age
.13
1.66
.083
3.64
Warmth T2
-.20
-2.52*
Psychological Control T2
.10
1.13
Behavioral Control T2
.04
.35
Note. * p<.05; ** p<.01.
PARENTING BEHAVIORS AND CHILDREN COPING WITH CANCER
42
Table 7. Linear multiple regression analyses predicting children’s coping at T2 from parenting
behaviors at T1 using mother reports, accounting for children’s coping at T1.
Primary Control Coping (T2)
Variable
β
t
R2
F
Child Age
-.15
-2.33*
.373
18.83
PC-Coping T1
.48
7.24**
Warmth T1
.19
2.93**
Psychological Control T1
-.10
-1.29
Behavioral Control T1
.03
.37
Secondary Control Coping (T2)
Variable
β
t
R2
F
Child Age
-.08
-1.23
.332
15.73
SC-Coping T1
.56
8.10**
Warmth T1
-.04
-.52
Psychological Control T1
-.12
-1.47
Behavioral Control T1
.07
.83
Disengagement Coping (T2)
Variable
β
t
R2
F
Child Age
.20
2.95**
.314
14.53
D-Coping T1
.48
6.93**
Warmth T1
-.14
-2.04*
Psychological Control T1
.05
.57
Behavioral Control T1
-.05
-.61
Note. * p<.05; ** p<.01.