Running Head: CANCER-RELATED COMMUNICATION STYLES
Associations of Maternal Macro- and Micro-Level Communication Styles and Child Emotions
During Parent-Child Discussions About Children’s Cancer
Leighann Hughart
Thesis completed in partial fulfillment of the requirements of the
Honors Program in Psychological Sciences
Under the Direction of Dr. Bruce Compas
Vanderbilt University
April, 2011
CANCER-RELATED COMMUNICATION STYLES
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Acknowledgements
I would like to extend my appreciation to those who graciously and selflessly contributed
to my thesis-writing experience. In particular, I would like to recognize the efforts of all
individuals on the Coping and Communication team at Vanderbilt, whose tireless and diligent
work have enabled the study to function beyond its potential. I am sincerely grateful to have had
the opportunity to work with such an intelligent group of individuals. Their motivation to help
others is evident in their continual production of excellent work, which is always met with great
enthusiasm. I am especially grateful to Dr. Bruce Compas, whose immense knowledge of and
unequivocal passion for research granted me the privilege of having an invaluable source of
information, advice and support towards my efforts. His wisdom of and dedication to his work
are truly inspiring. Finally, I would like to thank my family and friends for their endless
encouragement and support throughout this process.
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Abstract
Previous research indicates that children with pediatric cancer may be at risk for both
short-term and long-term emotional difficulties including anxiety and depression. Parent
communication may guide a child in successfully coping with stressful experiences related to the
diagnosis and treatment of cancer, which can ultimately influence the child’s ability to cope and
adjust to challenges posed by the illness. The current study aims to identify what aspects of
maternal parent communication patterns may heighten or relieve child pediatric cancer patients’
anxiety about cancer. Sixty-two mother-child dyads of families with children diagnosed with
cancer were recruited to participate in this two-site study. Mothers and children 10 years of age
or older were asked to complete questionnaire packets pertaining to their experience with the
illness. All families who completed the packets were then recruited to participate in a videorecorded observation including a communication task that involved a cancer-related discussion.
Parent communication techniques and child emotions evident in the conversation were coded.
Results indicate that mothers’ linguistic structures of their responses were related to their general
communication styles and that these ultimately predicted their child’s mood.
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Introduction
Parent-child communication is essential to providing children with examples and
information of how to effectively cope with life stressors, including the challenges and stresses
associated with chronic or potentially fatal illnesses. Effective communication about stressful
events is difficult, as parents must not only adjust to the situation but also formulate and execute
their explanations comprehensibly to their child. Families with children diagnosed with cancer
face numerous stressors that are further complicated by the treatment and uncertainty of the
illness. Previous findings indicate that parental full disclosure to a child about his or her
diagnosis, prognosis, and information regarding treatment may play a role in reducing anxiety or
distress in pediatric patients (e.g., Chesler et al., 1986; Slavin et al., 1982). The current study
utilized recorded mother-child discussions about cancer to examine specific components of
parent-child communication from a broad perspective of parenting style and a more micro-level
of linguistic responses to child utterances with the aims of understanding the relationships
between parenting style, parent communication, and child emotions during these interactions.
Parent-Child Communication
Socialization is fundamental for a child’s psychological development and ability to
function in society. Previous studies have led developmental psychologists to recognize that
parents are among the strongest determinants of this process (Maccoby et al., 1992).
Furthermore, a parent’s communicative abilities significantly affect the quality of their
relationship and influence on their child. Maccoby et al. (1992) argue the “initial phases of
parent—child bonding […] are based on affectively charged parent-child exchanges,” suggesting
that these effects begin early in the child’s development and continue throughout their
maturation.
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One active area of research on parental socialization and parent-child communication has
focused on adolescents’ risk for substance use and abuse. For example, considering the parent’s
role as teacher, Kelly et al. (2002) conducted a study exploring the relationship between youth
drug involvement and parent-child communication. Examining whether parental influence is the
most effective tool in preventing drug use, this study examined how parent communication of
values regarding drug abuse affected their child’s abuse rate. Previous studies indicate that
youth from families who practice frequent, open (bidirectional), and positive communication are
less likely to become involved in drugs (Kelly et al., 2002). This form of communication
encourages expressions of both parent and child perspectives and fosters the reinforcement of
conventional standards of conduct. By exercising active involvement in conversations, children
feel engaged in understanding behavioral norms (Kelly et al., 2002). Results of the Kelly et al.
(2002) study indicate that children who experienced more parental sanctions were less likely to
experiment with drugs (Kelly et al., 2002).
Because children view their parents as important and credible sources of information,
frequent and deliberate conversations about the dangers of substance abuse are essential in
lessening the likelihood of drug experimentation. Therefore, open communication encourages
children to ask more questions and increases child involvement in decisions, which previous
studies suggest affects their psychological adjustment (Kelly et al., 2002). Thus, it is the
parent’s responsibility to socialize their child, which heavily relies upon communicative abilities.
Through communication, the parent can successfully teach the child how to effectively respond
to the inevitable challenges encountered throughout maturation.
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Parent-Child Communication about an Illness
The dual parental role as an information source and an influential factor in their child’s
emotional and psychological development reinforces parental communication as an essential
agent in mediating potential life stressors a child may experience in his or her lifetime. One
major stressor a child may face is a chronic or potentially fatal illness. Because parents are the
gatekeepers of information between their children and physicians, appropriate communication
techniques about a child’s illness have remained an important but still under studied issue in the
medical realm, as reflected in two opposing views on the optimal way for parents to
communicate with their children about illness.
Previously, in the 1950s and 1960s, advocates of the protective approach prevailed
arguing that detailed knowledge about an illness and its prognosis, including the possibility of
death, would heighten a child’s anxiety or fear and potentially inhibit their coping abilities
(Chesler et al., 1986). Furthermore, supporters of this view argued that young children were
concrete thinkers, cognitively incapable of understanding the medical information associated
with their illness, therefore deeming disclosure unnecessary. However, by hiding information
about their child’s illness, parents risk the possibility that children will learn about their illness
from other sources, such as siblings, teachers, hospital staff, and peers. A child who is unable to
discuss or receive information pertaining to their illness is not necessarily protected from
heightened anxiety or fear; their discovery of the diagnosis and prognosis of their illness from
sources other than parents is potentially detrimental to their psychological adjustment. Rather,
they may view their illness as a subject of secrecy or a forbidden topic for discussion (Clarke et
al., 1986). Chesler et al. (1986) discuss reports of children who were aware of the prognosis of
their illness but who had parents unwilling to disclose information pertaining to the condition
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and consequentially experienced loneliness and isolation (Chesler et al., 1986). Hidden or
guarded disclosure may deny instrumental tools necessary to establish an honest relationship
with a child, which ultimately denies him opportunities for hope, as “an air of mystery implies
reason for despair” (Chesler et al., 1986).
Due to the inconsistency of the guarded or closed method of communication, the open
approach to communication about a child’s illness gained popularity, as advocates assert that
honest discussion of diagnosis and prognosis will lead to better psychosocial adjustment in both
the patient and the family members (Slavin et al., 1982). Additionally, previous research credits
open communication with enhancing the coping skills of both the child facing the illness as well
as the general mental health of the family (Chesler et al., 1986). Psychological adjustment to an
illness may be more successful if a patient and his or her family are able to exercise effective
coping skills with the stressors and instability familiar to the illness experience.
Beyond the qualitative and quantitative aspects of disclosure about an illness to a child,
parental communication is further examined on at least two different levels; i.e., analysis of
parent-child interactions can involve both macro- and micro-level perspectives. Macro-level
approaches measure the general style of parent-child conversations, such as parents’ overall
levels of warmth and responsive listening to their child during a discussion about an illness.
This level of analysis provides a broad measure of communication patterns and styles within an
observed interaction. Macro- level analyses focus on moment-to-moment exchanges between
parents and children and are important to understanding parent-child interactions, as parent-child
discussions not only affect the child’s psychological adjustment to their illness but also may
influence aspects of their health. For example, in a study by Miller and Drotar (2007) analyzing
diabetic children and their decision-making and treatment adherence, findings measuring macro-
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level communicative patterns indicate that higher levels of positive parent communication were
associated with better treatment adherence. Negative communication was associated with
family decisions characterized by pessimism, inability to consider all options and perspectives,
and failure to take responsibility (Miller & Drotar, 2007).
Furthermore, previous studies suggest that during problem-solving tasks, negative
statements made between children with diabetes and their parents were associated with increased
problem-solving difficulty (Miller & Drotar, 2007). Therefore, higher levels of negative parent
communication increase the risk that adolescents are less likely to ask for help or engage in
conversations that require decision-making. Miller and Drotar (2007) note that this failure to
seek help and participate in joint decision-making with parents is potentially harmful to a child’s
well-being, as active input from the child is associated with positive psychological adjustment.
Similarly, Martin et al. (1998) also studied children with diabetes and found that the illness was
better maintained when parents were “more emotionally supportive, had better resolved their
grief about their child’s diabetes, were less sad and angry, and in parent-child dyads were better
able to resolve conflicts” (Martin et al., 1998). Ultimately, frequent, open and positive
communication regarding a child’s illness is associated with increased positive psychological
adjustment and better maintenance of the illness.
To measure communication styles during parent-child interactions about an illness,
global communication patterns have been examined. These patterns can be assessed through a
number of constructed observational coding systems, such as the Iowa Family Interaction Rating
Scale (IFIRS; Melby & Conger, 2001), the System for Coding Interaction and Family
Functioning (SCIFF; Lindahl & Malik, 2001), the Interaction Behavior Code (IBC; Prinz, Foster,
Kent, & O’Leary, 1979), and the McMaster Interaction Coding System (MICS; Dickstein,
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Hayden, Schiller, Seifer, & San Antonio, 1994), which are geared towards communication in
pediatric populations (Dunn et al., in press).
The current study utilized the Iowa Family Interaction Rating Scales (IFIRS; Melby &
Conger, 2001), which is a macro-level coding scheme constructed to evaluate non-verbal and
verbal behavioral and emotional elements during parent-child interactions. This coding system
has been designed and validated by parent-child dyads, which included children of various ages
(Melby & Conger, 2001). The range of ages facilitates applicability to a wide span of pediatric
patients. Additionally, the IFIRS system has been applied to a variety of different samples of
parent-child dyads (Melby &Conger, 2001), which establishes support for its use in the current
study. Rather than recording a bifurcated decision of whether or not a behavior occurred
throughout the observed interaction, this model uses a global rating scale for each code, ranging
from 1-9, to assess each code’s presence in the communication style of the focal. This design
allows for parametric statistical analyses and the potential to capture wider ranges of individual
differences in parent-child communication and parenting styles.
The second perspective of analysis of parent-child expressions during an interaction is on
a micro-level. Micro-level analyses include detailed and comprehensive analysis of both the
content of parent-child utterances and their linguistic and syntactic structures. For example,
following a child’s utterance, micro-level evaluation of a parent utterance may consider whether
they maintained or changed the topic of their child’s statement, and whether they expanded upon
it or repeated it. Previous language studies define particular responses to child utterances in
micro-level contingency categories (e.g., Saxton, 2005; Lasky & Klopp, 1982; Hart & Risley,
1992).
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The current study focuses on two types of micro-level parental responses to their
children: parental reflections and expansions of child utterances (Hart & Risley, 1992). Parents’
repeating of a child’s utterance has been a frequent component in micro-level analysis of parent
communication and several terms have been utilized to describe this communication mechanism.
While the current study refers to parents’ repeated content of child utterance as reflections,
Saxton (2005) identifies these responses as “recasts,” noting its common use in parent-child
conversations. Other terms refer to recasts as repeats, repetitions, and imitations (e.g., Lasky &
Klopp, 1982; Fey et al., 1999). The broad category term used by Saxton (2005) is characterized
as a response that “expands, deletes, permutes, or otherwise changes the [child utterance] while
maintaining significant overlap in meaning” (Saxton, 2005). This response provides numerous
advantages to the parent in executing effective communication with the child. Because the
parent is discussing a topic of interest to the child, parental recasts allow the parent to be more
confident in receiving and maintaining the child’s attention (Saxton, 2005). Saxton (2005) also
asserts that recasts ensure “a strong likelihood that the child will comprehend at least part of
what is being said to them, since lexical items are being reflected back to them from their own
utterance” (Saxton, 2005). Lasky and Klopp (1982), whose study classifies recasts as imitations,
defines this category as a “repetition of a preceding utterance,” which includes an exact
imitation, or “word for word repetition of utterance”; additionally, the term extends to
circumstances involving expanded imitations, or utterances that are “[repetitions] with additions”
(Lasky &Klopp, 1982).
Saxton (2005) and Lasky and Klopp’s (1982) definitions of recast and imitation introduce
a supplemental code to recasts. Referred to in the current study as expansions, this code has
been defined as a response to an utterance that “[retains] the [child’s] words in the order given,
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and [adds] those functions that will result in well-formed simple sentence that is appropriate to
the circumstances” (DePaulo & Bonvillian, 1978). In expansions, the parent preserves the
child’s meaning while also altering grammar and adding words or content.
Previous studies suggest that expansions and reflections may promote conversation
among parent-child dyads (Nelson et al., 1996; Hart & Risley, 1992). Classifying these terms as
“repetitions, expansions, and extensions,” Hart and Risley (1992) viewed these types of
responses as measures of the parent’s positive feedback to the child. Nelson et al. (1996) argue
that recasts are natural and conversational, thus promoting the continuation of a conversation.
Similarly, Saxton (2005) notes “that parents do not need to be prompted or trained to recast their
children’s speech. Instead, recasting seems to fall out naturally from the constraints imposed by
the challenge of talking to a linguistically naïve interlocutor,” which indicates its facilitation of
flowing conversation (Saxton, 2005).
Micro-level analysis of parental communication also includes measuring the length and
complexity of the parent’s utterance, which have shown to depend on child age (Snow, 1972).
DePaulo and Bonvillian (1978) suggest the importance of expansions pertaining to a child’s age
in their review of studies examining micro-level communication patterns between parents and
children. For example, Nelson et al. (1973) found that children exposed to expansions involving
both grammatically incomplete and complete utterances performed better than the control group
on imitating sentences and level of predicate complexity. Similar findings from a study
performed by Fey et al. (1999) regarding recasts (reflections) suggest that this mechanism
facilitates language learning and more complex syntax in children (Fey et al., 1999). Recasts
may simplify child-processing demands and allow the child to compare the adult’s grammar with
child’s own grammar, which may resolve discrepancies in their grammar. Because expansions
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and reflections may potentially assist in language development and comprehensibility of parental
utterances, their frequency of use by the parent may differ with age, as parental language
changes with their gauging of their child’s capability of understanding.
Current literature recommends open communication between parents and children who
are battling a chronic or potentially fatal illness; additionally, parental communicative
approaches utilizing reflections and expansions may promote more conversation from the child
and assist in their understanding of complex content. However, understanding the potential link
between micro-analytic communication styles and child emotions about certain significant
childhood illnesses, such as cancer, remains unanswered. Additionally, no research exists in
these populations examining the relationship between macro- and micro-levels of
communication, such as whether the parent’s parenting style and communicative approach will
direct them to use particular linguistic styles during discussions about stressful situations.
Parent-Child Communication about Cancer
Because pediatric cancer remains the leading cause of death by disease among children
ages 1-14 years-old in the United States, psychological adjustment to this illness, its treatment,
and the overall experience has been the focus of considerable research. In 2007, 10,400 children
between one and fourteen years old were diagnosed with cancer, and it is predicted that 1,545 of
these children will die from the illness (Edwards, 2009). However, death rates have declined
dramatically in the past 20 years, as the 5-year survival rates for all pediatric cancers increased
from 58.1 percent in 1975-1977 to 79.6% in 1996-2003 (Edwards, 2009). The increase in
survival rates and treatment options has led to research on the adjustment of current pediatric
cancer patients as well as long-term survivors. Adjustment entails measuring the child’s
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externalizing and internalizing behavior problems, fear, anxiety, self-esteem, global functioning,
family functioning, and their determinant factors.
Parent-child communication about cancer arises as an important process of interest, as the
uncertainty of cancer and its treatment and prognosis affect what the parent will ultimately
communicate to the child about their illness. Clarke et al. (2005) assert that parents’ planning
and strategizing about parent-child discussions concerning cancer is crucial; their findings
indicate, “good psychosocial adjustment is related to a child’s early knowledge of the diagnosis,”
as children who were informed about their illness at diagnosis exhibited better adjustment
compared to those who were either misinformed initially or notified at a later stage (Clarke et al.,
2005). Clarke et al. (2005) also suggested that parents who practiced open communication and
provided more information to the child about his or her illness may better equip their child with
effective coping abilities; these children “understand the importance of taking medication, feel
able to discuss their worries and concerns with parents, and trust their family and health
professionals” (Clarke et al, 2005).
However, while parents must consider the quality and amount of information about
cancer they disclose, previous studies address the importance of parents to exercise ageappropriate communication when providing information about an illness. Parents are then left
with the difficult task of gauging their child’s capacity for understanding the information they
provide (Chesler et al., 1986). The age of the child is significantly related to the amount of
information about the illness, its treatment and prognosis disclosed by the parent, with younger
children given less information than older children (Chesler et al., 1986). Snow (1972)
conducted a study measuring the length of parent utterances and the quantity of speech and
found that mothers spoke to younger children in shorter, less elaborate statements (Snow 1972).
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Additionally, parents report that the amount of information they disclosed depends on what they
feel their child is cognitively able to understand and absorb (Chesler et al., 1986). Child
comprehensive evaluation by the parent is essential. For example, Clarke et al. (2005) found
that refusal and lack of adherence to treatment in children with cancer were associated “with a
lack of understanding, and poor communication regarding diagnosis and treatment,” suggesting
that parents must find effective forms of communication to successfully explain the complexities
of cancer (Clarke et al., 2005). Because cancer treatments and the terms used to describe them
are complex, the task of determining an age-appropriate approach to these discussions becomes
further complicated. Little research has focused specifically on parent-child interactions about
cancer; however, because children rely heavily on parental explanations, close examination of
parental utterances is crucial in understanding how to avoid disconnect during these
conversations.
Unfortunately, research on the psychological adjustment of pediatric cancer patients has
had a number of limitations, and major inconsistencies exist in the findings. Bennett (1994)
stated that while 9 to 14% of children suffer from chronic illnesses, “considerable disagreement
exists […] as to whether children with such disorders are at increased risk for adjustment
problems” (Bennett 1994). Arguments concerning psychological adjustment among children
with illnesses are complicated, as studies must determine whether children with differing chronic
illnesses are equally at risk of poor psychosocial adjustment. Furthermore, Bennett (1994)
asserts, “children with chronic medical problems have been found to have increased rates of
behavioral and emotional problems in some but not all studies” (Bennett 1994). For example,
Clarke et al. (2005) reported that 84.1% of the children in their study “showed negative
behavioral (temper tantrums, feeling agitated, immature, boisterous, uncooperative, and
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manipulative) or mood (anxious, needy, withdrawn) changes” (Clarke et al., 2005). However,
Eiser et al. (2000) found that survivors of pediatric cancer showed no signs of problems as
reflected in measures of anxiety, depression or self-esteem when compared to the normative
population (Eiser et al., 2000).
To strengthen the understanding of psychological adjustment among pediatric cancer
patients, Bruce (2005) suggests further investigation should include “assessment of discrete
cancer populations, [assessment of] coping styles and life-threatening illness, [assessment of]
parent-child interactions, and [the profiling of] trauma-related symptoms over time” (Bruce
2005). For example, by measuring time since diagnosis, researchers can determine if pediatric
patients exhibit different behaviors throughout their experience with the illness. Without
controlling these variables, findings will remain limited and ambiguous about cancer patients’
adjustment patterns.
Finally, studies analyzing psychosocial adjustment in pediatric cancer patients have
utilized different measures via questionnaire packets and surveys. Without standardized
measures, results remain difficult to synthesize and interpret. Most studies merely assess data
from questionnaires, but do not integrate any form of observational data or interviews, which
would enable thorough analysis of linguistic and syntactic structure within a conversation.
Furthermore, no research has been conducted examining the relationship between parental
communication styles, parental linguistic structure, and emotions of pediatric cancer patient
when discussing the illness. Literature considering parent child communication on a broad
macro-level and a meticulous micro-level and whether this in turn affects emotions of children
with cancer is nonexistent.
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Current Study
As noted above, parent-child communication can be measured on macro and micro
levels. Because mothers are typically the primary caregivers and the source of communication
and emotional support, the current study considered parent-child interactions about cancer from
each perspective. Currently, no literature exists examining parent communication and parenting
style. This study linked macro-level analysis of parenting style with a micro-level analysis of
parent communication and expected that parental expansions and reflections of child utterances
would be positively associated with a parent communicative style of higher warmth/support,
communication, and listener responsiveness. Furthermore, based on current literature, open and
honest communication is positively associated with better psychological adjustment. Because of
this evidence, I hypothesized that certain parental contingencies to child utterances affect their
child’s emotions during discussions about cancer. The current study examined whether a
relationship exists between the linguistic and syntactic structure of maternal utterances and a
child’s emotions during these interactions. I hypothesized that use of maternal expansions and
reflections would associate with scores of maternal warmth, listener responsiveness, and
communication. Additionally, I hypothesized that these parental communicative approaches
would associate with higher levels of child positive mood and less anxiety and sadness from the
child during these discussions about cancer.
Method
Participants
In this two-site study, mothers were recruited from the Pediatric Hematology/Oncology
units of the Vanderbilt Children’s Hospital and the Columbus Children’s Hospital-Ohio State
University. Potential participants included families with children between the ages of 5 and 17
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years-old who had recently been diagnosed with cancer. Because in the study is focused on
learning whether a relationship exists between cancer-related stress and time of diagnosis,
families recruited as soon as possible following initial diagnosis. Mothers and children were
approached 3 to 6 weeks post diagnosis and were considered eligible to participate if the child
did not exhibit any learning deficits or have any additional serious medical condition separate
from cancer.
Currently, the study has data available for 62 mother and child interactions coded on both
the macro- and micro levels, which provides information about the mothers’ general
communicative styles as well as the specific linguistic and syntactic structure of their utterances.
Additionally, these coded interactions account for the child’s mood throughout the dyad’s
observed interaction. Thus, the current sample available for analysis includes 62 mothers
between the ages of 24 and 72 (M = 38.37 SD = 8.43) and children with cancer ages 5 to 17 (M
= 10.44, SD = 3.97). Within this sample of children with cancer, the distribution of diagnoses is
generally representative. Leukemia represents the majority (40.0%) of the sample, with
diagnoses of Lymphoma (17.6%), brain tumors (8.0%) and other solid tumors (e.g.,
osteosarcoma, neuroblastoma, Wilm’s tumor) (33.6%) following. Table 1 provides demographic
information for both mothers and children. Demographic information for one remaining
mother-child dyad is not available. All mothers and children participated during the initial
weeks or months of the active phase of the child’s treatment.
Measures
Parental Responses and Contingency. To measure parental responses and contingency
to child utterances, our research team developed a coding system assessing numerous aspects
regarding micro-level analysis of linguistic and syntactic structure. During an interaction,
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following a child’s utterance, the parent’s next two utterances are coded on the basis of two
factors: (1) their topic and conversation maintenance, and (2) their contingency to the child’s
utterance. For example, following a child’s utterance, does a parent maintain or change the topic
of conversation? Because mothers constituted the majority of our sample and are typically the
primary caregiver and source of information for a child, the current study analyzed segments of
discussions about cancer among mother-child dyads and coded maternal responses to child
utterances.
Data analyses specifically examined maternal reflections and expansions, which comprise
two of the ten micro-analytic contingency codes defined in the coding system developed for this
study. Maternal reflections include those utterances that strictly repeat the content of the child’s
utterance. Similarly, maternal expansions qualify as repetitions to the child’s utterance, but with
added semantic or syntactic content. Codes in the coding system not represented in the current
analyses consider other components of parental utterances, such as whether their responses to a
child cause the child to reevaluate or reframe his or her emotions and perspective surrounding
the topic of conversation. This coding system allowed our team to quantify the degree of
parental contingency to a child’s response and allow us to measure whether certain methods of
communication (e.g., reflecting or expanding upon a statement) are associated with
communicative abilities among the mother-child dyad and the child’s emotions during the
interaction.
Transcripted versions of interactions were double-coded by a primary and a reliability
coder. To contingency code the interactions, coders were required to pass a detailed, written
exam with a 90%. Additionally, coders were required to practice on previously coded transcripts
and discuss them with experienced coders. All coded transcripts were subjected to double-
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coding, which were afterwards discussed by the primary and reliability coders, who resolved
discrepancies by providing examples and clarifications from the coding manual to support a
particular code. Mean percent agreement was calculated for each contingency code. For
reflections, percent agreement averaged at 90% while expansion percent agreement was at 69%.
Maternal parenting and communication style. Codes for emotions and communication
will be a subset of those included in the Iowa Family Interaction Rating Scales (IFIRS; Melby et
al., 1998) to assess levels of and styles of communication and emotions for parents and children.
The IFIRS is a global observational coding system that evaluates both verbal and non-verbal
behaviors during exchanges between parents and children, as well as affective aspects of each
participant in the interaction. Rated on a scale of 1 (not at all characteristic) to 9 (highly
characteristic), behaviors and emotions are assessed based on their frequency, intensity, and
proportions during the exchange. Behaviors and emotions that are absent are represented by a
score of 1 while prevalent behaviors are scored as a 9. For example, an individual rated 1 on
Positive Mood displayed “no examples or evidence of Positive Mood;” an individual rated 9
“frequently” was “happy, optimistic, content, positive about self and life in general” during the
interaction (Dunn et al., 2010).
Fifteen codes were rated for both children and mothers, with an additional 9 codes rated
for the mothers alone. Parent codes are organized into three categories: emotion, dyadic
interaction, and parenting. Maternal communication style was evaluated using selected IFIRS
codes measuring her expressiveness, listener responsiveness, and supportiveness throughout the
interaction. Expressiveness was indicated in the mother’s scores on communicative abilities
throughout the conversation (e.g., does she provide clear explanations and clarifications for her
statements and reasoning?). Listener responsiveness measured how attentive the mother is to
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the child’s utterances. Supportive communication was represented by the mother’s warmth and
encouragement extended to the child during the interaction.
The IFIRS has been validated against reports from self, sibling, and parent-report using
correlation analysis and confirmatory factor analysis (Melby & Conger, 2001) and previous
studies indicate the system’s strong inter-rater reliability, internal consistency, and test/retest
reliabilities (Melby & Conger, 2001; Ge et al., 1996; Melby et al., 1995). There is some
evidence that racial differences both in coders as well as subjects are important to consider in
observational coding (Melby et al., 2003) and the study took steps to monitor this possibility.
Videotapes of the interactions were coded by a primary coder and compared with the
codes of a reliability coder. Coders were required to pass an in-depth written assessment of the
IFIRS coding definitions and conventions with at least 90% correct. Additionally, coders must
have achieved at least 80% reliability on practice tapes that had previously been coded by
experienced coders. Each recorded interaction was independently coded by two trained
observers, who watched the interactions a total of five times: once to become familiar with the
interaction, twice more to code one participant (e.g., the mother) and finally two more times to
code the other participant. The focal coded first was determined by a coin flip. Codes were
then compared between the two coders: when ratings with a code were one point off from each
other, the higher score was documented as the consensus score. With codes that were two or
more points different, coders discussed the examples that led them to assign that score and
determined a consensus score by referring to specific examples and considering their intensity in
the interaction. Inter-rater reliability was 78%.
Observed child emotions. Observed child emotions during the interaction were
examined using a combination of the IFIRS system codes assessing their positive affect, anxiety,
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prosocial behavior, and sadness throughout the discussion. Sadness measures the degree of
despondence, unhappiness, sadness, regret and depressive symptoms evident in an individual
during the task. Anxiety conveys the prevalence of nervousness, fear, tension, stress, worry and
concern. Positive mood analyzes the frequency and intensity of positive, uplifting and
optimistic statements in an individual’s verbal and non-verbal (e.g., smiling, laughing) behavior.
Finally prosocial behavior indicates an individual’s cooperation, maturity and engagement in the
conversation, essentially indicating their ability to promote conversation in the exchange.
Procedure
In this two-site study, the Institutional Review Board approved the protocol for each site.
Eligible families included those with children between the ages of 5 and 17 who were recently
diagnosed with cancer. The families were typically approached 3 to 6 weeks post diagnosis.
Children with any significant learning deficits and additional serious medical conditions aside
from cancer were exempted from the study. Patients between the ages of 10 and 17 years-old
and all parents of participating families were recruited to participate in Phase I of the study,
which involved completion of a questionnaire battery. Participating children completed an
assent form while participating parents signed a consent form. The questionnaire battery
included measures for both children and the parents. These measures required the participant to
provide demographic information, medical information, reports of emotional and behavioral
problems, cancer-specific worries and fears, perceived stress, psychological distress (e.g.,
depression), information about coping methods, family environment information, and
information about their parent-child communication experiences. Following completion of
Phase I, families were approached and asked to participate in a videotaped observational session
(Phase II).
CANCER-RELATED COMMUNICATION STYLES
22
To address the limitations of previous studies, the second phase of the study provided a
valuable supplement to gaining insight on the effectiveness of strong parent-child
communication about cancer and its impact on the child’s psychological adjustment to the
illness. All observational sessions at the Vanderbilt site took place at the Vanderbilt Children’s
Hospital. During this phase, the patient and his or her parent were asked to participate in two
tasks measuring how they communicate. The first task was a puzzle task and was meant to
provide a sense of how the dyad communicates in general. The parent and child were placed at
a table and separated by a divider hindering visibility of one another. The parent was given a
completed version of a puzzle (which varied based on the child’s age) and told they must guide
their child to construct the same puzzle purely through verbal instruction. They were given 5
minutes to complete the task and were unable to view the result until 5 minutes has passed.
The second task required that the parent and child engage in a conversation about cancer,
its treatments, and their personal experiences with the illness. The participants were given a
card with prompt questions and were asked to engage in discussion for fifteen minutes. Prior to
and following this discussion, both the parent and child were asked to complete pre- and postquestionnaires asking them how they were feeling and how much they talk about cancer with one
another. After the discussion, the participants were also debriefed and asked how they felt about
the conversation.
Phase III asked those parents and eligible children who completed the Phase I
questionnaire battery to complete a similar questionnaire packet twelve months after their
recruitment. Families received compensation for each completed phase of the study.
CANCER-RELATED COMMUNICATION STYLES
23
Data Analytic Approach
Means and standard deviations for mother communication and linguistic styles and child
emotions were calculated and are presented in Table 2. Analyses of the primary research
questions were conducted using Pearson correlations and linear multiple regression analyses.
Results
Preliminary Analyses
To examine the representativeness of the current sample of mothers who have children
with cancer, independent sample t-tests were run for mothers, with available demographic data,
who completed the observation phase (n = 54) and for those who only completed the
questionnaire packets (n = 155). Missing demographic data for 8 of the mothers account for the
discrepancy in the larger sample size reported for in the other subsequent data analyses.
Mothers’ available demographic data were used to examine mother age, education level, marital
status, annual family income, child age, and child gender as potential influential factors.
Furthermore, mother scores from scales in the questionnaire packets utilized to measure
posttraumatic stress disorder and anxiety were examined. Results indicated no significant
differences in either score of PTSD, t (151) = -1.51, ns, or of depression, t (153) = -1.38, ns, for
mothers who did and did not complete the observation. Likewise, there were no significant
differences for mother age, t (153) = 1.33, ns; annual family income, t (148) = 1.95, ns; marital
status, t (153) = 1.02, ns; age of child, t (155) = 0.35, ns; or child gender, t (155) = -1.45, ns.
However, analyses indicated a significant difference in the education status of mothers, t (153) =
2.85, p < .01, as those who chose to complete the observation were slightly more educated than
those who did not.
CANCER-RELATED COMMUNICATION STYLES
24
Descriptive Statistics
Means and standard deviations were calculated for IFIRS scores and total number of
expansions and reflections throughout each mother-child interaction about cancer. For
contingency codes, mothers’ mean use of reflections (M = 8.33, SD = 8.70) were higher than
mothers’ mean use of expansions (M = 5.03, SD = 3.78). Means for mother IFIRS codes were
highest for the communication code (M = 7.18, SD .89) and lowest for listener responsiveness (M
= 6.70, SD = 1.15). Additionally, means and standard deviations were calculated for child
IFIRS scores. These calculations for child emotions during discussions about cancer indicated
that the child sadness mean score was highest (M = 5.60, SD = 1.40), while the child listener
responsiveness mean score was lowest (M = 5.37, SD = 1.27). Table 2 presents all mother and
child variables for which means and standard deviations were calculated.
Maternal Macro- and Micro-level Communication styles
Correlations between mother communication style and contingency codes during
discussions about cancer. Correlations between maternal macro-level parenting and
communication styles and micro-level maternal utterances are represented in Table 2. During
the mother-child conversations about cancer, mothers’ use of total reflections was significantly
positively correlated with mother listener responsiveness (r = .47, p < .01) and communication
scores (r = .30, p < .05). Mothers’ use of total expansions throughout the interaction was
significantly positively correlated with all mother communication styles: mother listener
responsiveness (r = .38, p < .01), mother communication (r = .28, p < .05), and mother
warmth/support (r = .27, p < .05). Mothers’ use of reflections was not significant with mother
warmth/support (r = .24, ns).
CANCER-RELATED COMMUNICATION STYLES
25
Maternal Communication and Linguistic Styles and Child Emotion
Correlations between mother IFIRS and contingency scores and child emotions during a
discussion about cancer. Correlation analyses were conducted to consider all levels of maternal
communicative patterns and their associations with different child emotions during cancerrelated discussions. Mother expansions were significantly positively associated with child
positive mood (r = .36, p < .01). However, no significant associations were found for mother
expansions and child anxiety (r = -.08, ns) and child sadness (r = -.19, ns). Furthermore, mother
reflections were not significant with any of the child mood codes: child positive mood (r = .15,
ns), child anxiety (r = -.08, ns), and child sadness (r = -.04, ns). Regarding mother parenting
and general communicative style, mother warmth and supportiveness was significantly positively
correlated with child positive mood (r = .42, p < .05) but not for child anxiety (r = -.03, ns) or
child sadness (r = -.04, ns). Likewise, mother communication and listener responsiveness
showed similar results. Mother communication was significantly positively associated with
child positive mood (r = .42, p < .01), but showed no significant relationship with child anxiety
(r =
-.02, ns) or child sadness (r = -.16, ns). Correlations for mother listener responsiveness
indicated a significant positive association with child positive mood (r = .46, p < .01) and no
significant associations with child anxiety (r = -.07, ns) or child sadness (r = -.07, ns). These
correlations are available in Table 4.
Multiple Linear Regression Analyses
Because correlation analyses indicated child positive mood as the only child emotion
significantly associated with mother communication patterns, multiple linear regression analysis
was facilitated to examine their roles as predictors of child positive mood during parent-child
conversations about cancer. Furthermore, mothers’ use of expansions was the only contingency
CANCER-RELATED COMMUNICATION STYLES
26
code to significantly positively correlate with child positive mood. Thus, because the IFIRS
codes are highly inter-correlated, three separate multiple linear regression analyses were
conducted to measure mother IFIRS codes and mother expansions as predictors of child positive
mood. Standardized beta-weights and semi-partial correlations were calculated with mother
IFIRS codes held constant and child positive mood as the dependent variable. In the second step
of the regression analysis, results indicate that mothers’ use of expansions significantly predicted
child positive mood ( = .270, p < .05) when added to mother communication scores. Similarly,
second-step regression analysis revealed that mothers’ expansions significantly predicted child
positive mood ( = .321, p < .05) when added to mother warmth/support. However, the
magnitude of mothers’ use of expansions did not predict positive mood when added to listener
responsiveness but remained a small effect ( = .225) and approached significance (p < .074).
Semi-partial correlations were squared to indicate the percentage of variance in the child’s
positive mood by the following predictors: Mother Listener Responsiveness and Mother
Expansions (sr2 = .043); Mother Communication and Mother Expansions (sr2 = .067); and,
Mother Warmth/Support and Mother Expansions (sr2 = .067). These results are presented in
Table 5, which provides beta-weights for solely mother IFIRS scores and child positive moods,
as well as beta-weights with mother IFIRS scores and mothers expansions added as predictors in
child positive mood.
Discussion
Pediatric cancer can be an extremely stressful illness for both children and their parents.
For the parent, the loss of control over their child’s well-being challenges their role as caretaker.
This traumatic change occurs at a time when their duties to protect their child are most crucial.
Because children typically view their parents as a primary source of knowledge, they look to
CANCER-RELATED COMMUNICATION STYLES
27
their parents to provide information about a situation that is foreign and frightening. A child
with cancer is suddenly thrown into a chaotic world of doctor’s appointments, periods of
inpatient stays and prolonged painful procedures and treatments, which are masked by numerous
complex terms. Such complexities and uncertainties pertaining to treatment and prognosis
heighten the mystery and threatening nature of cancer. Thus, parent-child discussions about
cancer provide a vital opportunity to shape the child’s perception and understanding about the
illness.
The previous approach to provide the child with little information about the illness and its
treatments in an attempt to protect them from anxiety or distress is now being refuted in several
studies (e.g., Chesler et al., 1986). Rather, the current literature (i.e., Clarke et al., 2005; Cline et
al., 2006) promotes open and honest conversation that involves disclosure to the child about their
cancer. Because parent-child communication is essential during stressful experiences, the
current study meticulously examined specific aspects of maternal macro- and micro-level
communication styles and whether they associate with child mood throughout a cancer-related
discussion. In examining conversational mechanisms utilized by parents, the current study
aimed to shed light on the relationships between parenting style, parental communication, and
children’s emotional responses, as no research exists addressing the influence of these factors in
children’s experience with cancer. Furthermore, prevailing literature fails to investigate if
particular parenting styles will correlate with specific linguistic approaches. The current study
delves into a fraction of the several components that construct language and general
communication style and how these factors may influence child mood.
Results of the study provided valuable information pertaining to the relationship of parent
general communication approaches and the structural aspects of their language. These findings
CANCER-RELATED COMMUNICATION STYLES
28
supported the hypothesis that mother’s with pro-social communication styles would be positively
correlated with their use of expansions and reflections. Analyses revealed that mothers who
were better listeners and more effective communicators utilized more reflections of their child
utterances during the discussion about cancer. While the association between responsive
listening and repetition of content reveal the obvious conclusion that strong listening skills are
required to repeat an utterance verbatim, the relationship with higher communication scores
necessitates a more conceptual interpretation. Previous studies (i.e., Nelson et al., 1996) argue
that reflections are natural and conversational. They promote the continuation of a conversation
by receiving and maintaining their child’s attention and ensuring their comprehensibility, since it
is the same lexical items from the child’s own utterances that are used (Saxton, 2005).
Comprehensibility among participants in an interaction is a fundamental aspect of the
communication code in the IFIRS rating system (Melby and Conger, 2001). Thus, a parent
whose conversational style clarifies what the child is saying will receive a higher communication
score: the use of reflections may function as a clarification device.
Mothers whose contingent responses involved more expansions were also rated as better
listeners and more effective communicators. However, these mothers were additionally
perceived as warmer and more supportive towards their children during the interactions.
Expansions as communication mechanisms indicate that the parent has acknowledged the child’s
utterance by not only repeating their content, but also facilitating their own contributions relative
to the statement. This approach exemplifies strong communicative and listening skills, and also
may represent a mother’s attempt to connect with her child by conveying a sense of
understanding. Rather than refute or attempt to reframe a child’s utterance, an expanded response
relies upon both the mother’s preservation of her child’s meaning and her contribution to the
CANCER-RELATED COMMUNICATION STYLES
29
utterance, which may communicate supportiveness. The significant correlations between the
macro- and micro-levels of parent communication styles are crucial to interconnecting the
components of communication and to linking different parenting styles to deeply rooted levels of
linguistic structure. For example, correlations from the current study suggest that parents who
are warmer, better listeners and better communicators are more likely to use expansions, or,
conversely, that mothers who more frequently utilized expansions were perceived as warmer
with stronger listening and communication skills. To determine methods of easing the stress of
cancer, it is important to examine aspects of parent communicative approaches that affect child
mood. Results in the current study determined which general maternal communication styles
and contingent responses to child utterances would predict child mood during the cancer-related
discussion.
Among measures of child positive mood, anxiety, and sadness, child positive mood
emerged as the only emotion code to significantly correlate with mother communication styles.
Furthermore, between the two contingency codes, only mother expansions were associated with
child positive mood and mother communication styles. These correlations are essential in
implying that particular parental communicative approaches are related to child emotions. Such
implications are further supported by the regression analyses, which provide strong evidence that
mothers who are warm and effective communicators will more frequently expand on their child’s
utterances and will evoke higher positive emotions from their child throughout the conversation.
Although listener responsiveness and expansions were not significantly predictive of child
positive mood, it is noteworthy that they approached significance. As previously mentioned,
child participation in discussions about their illness is significantly positively associated with
their adjustment to the illness (Slavin et al., 1982). Thus, the current study’s findings suggest that
CANCER-RELATED COMMUNICATION STYLES
30
these parental linguistic and conversational techniques are effective communication skills
because they encourage, acknowledge and support active participation from their child, which
ultimately contributes to their child’s emotions in these discussions.
Despite several findings, various limitations exist in the current study. Similar to
previous literature, which fails to incorporate multiple forms of data collection, the data analyses
of the current study only utilized information obtained from the observation phase. To better
determine whether macro- and micro-level communication components affect child anxiety and
sadness, future analyses of this sample should incorporate data from scales in the questionnaire
packets, which measure PTSD and depression for parents and children. Furthermore, the current
study focused on maternal responses to child utterances. To generalize these relationships
among parental macro- and micro-level communication components, father responses and
communication styles must also be examined. Additionally, the total number of expansions and
reflections coded in the discussion were considered, rather than their percentages relative to other
contingency codes present in the conversation. Therefore, lengths of conversations were
unaccounted for, such as those with fewer parental utterances or sequences unavailable to code.
Ultimately, as open and honest discussions appear to lessen child anxiety about an illness
(Chesler et al., 1986) and parental emotional support correlates with better maintenance of a
child’s illness (Martin et al., 1998), the current study indicates that effective communication
skills and warmth will predict positive emotions from children during conversations about
cancer. Furthermore, it suggests that expansions, which are also predictors of child positive
mood, appear to be a mechanism that conveys these general communication techniques. Since
parents are expected to be their child’s source of comfort and protection, these findings reveal
the potential to ease their stress with cancer-related discussions by utilizing certain linguistic
CANCER-RELATED COMMUNICATION STYLES
31
structures to better communicate and convey support. Subsequent analyses should evaluate
whether other parent communication styles and contingent responses to child utterances are
related and if they are significant predictors of child mood. Teaching parents which linguistic
structures will translate to a particular parenting style (i.e., responsive listening, supportiveness,
etc.) and will benefit their child’s mood may influence their child’s overall psychological
adjustment to the illness. Finally, because previous studies (i.e., Chesler et al., 1986; Snow,
1972) suggest that parents formulate their syntactic structures on their beliefs of their child’s
language capabilities, future research examining whether parent macro- and micro-level
communication techniques differ with children’s age would likely be beneficial.
CANCER-RELATED COMMUNICATION STYLES
32
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Table 1. Demographic Information for Mother and Child Participants
Mother
Age [mean (SD)]
38.37 (8.43)
Race [n (%)]
White
85.5
African-American
9.7
Other
3.2
Ethnicity [n (%)]
Hispanic/Latino
Not Hispanic/Latino
1.6
77.4
Annual Family Income [n (%)]
< $25,000
25.8
$25,001 – $50,000
21.0
$50,001 – $75,000
9.7
$75,001 – $100,000
12.9
> $100,000
29.0
Education [n (%)]
Some high school
Graduated high school
Graduated technical school
4.8
21.0
3.2
Some college
24.3
Graduated college
32.3
One or more years graduate
school
14.5
CANCER-RELATED COMMUNICATION STYLES
38
Marital Status [n (%)]
Single
4.8
Married
66.1
Divorced
8.1
Separated
4.8
Remarried
3.2
Widowed
4.8
Living with someone
8.1
Gender [n (%)]
Child
Male
58.1
Female
41.9
Age [mean (SD)]
10.44 (3.97)
Diagnosis Type [n (%)]
Leukemia
Lymphoma
Brain Tumor
Other Solid Tumors
40.0
17.6
8.0
33.6
CANCER-RELATED COMMUNICATION STYLES
39
Table 2. Means and Standard Deviations for Variables.
M
(SD)
Mother Expansions
5.03
(3.78)
Mother Reflections
8.33
(8.70)
Mother WM
5.96
(1.59)
Mother LR
6.70
(1.15)
Mother CO
7.18
(0.89)
Child PM
5.32
(1.65)
Child SD
5.60
(1.40)
Child AX
5.37
(1.27)
Note: Mother EXP = Mother Total Expansions; Mother REFL = Mother Total Reflections;
Mother WM = Mother Warmth/Supportiveness; Mother LR = Mother Listener Responsiveness;
Mother CO = Mother Communication; Child PM = Chile Positive Mood; Child AX = Child
Anxiety; Child SD = Child Sadness.
CANCER-RELATED COMMUNICATION STYLES
40
Table 3. Correlations among Mother Communication Styles and Linguistic Structure of
Utterances.
Mother Total Reflections Mother Total Expansions
Mother Listener Responsiveness .47**
.38**
Mother Communication
.30*
.28*
Mother Warm/Support
.24
.27*
** p < .01
* p < .05
CANCER-RELATED COMMUNICATION STYLES
41
Table 4. Correlations among mother communication styles and linguistic structures of
utterances, and child emotions during discussions about cancer.
Mother EXP
Mother REFL
Mother WM
Mother CO
Mother LR
Mother EXP
1
Mother REFL
.54*
1
Mother WM
.27*
.24
1
Mother CO
.28**
.30*
.63**
1
Mother LR
.38*
.47*
.55**
.76**
1
Child PM
.36**
.15
.42*
.42**
.46**
Child AX
-.08
-.08
-.03
-.02
-.07
Child SD
-.19
-.04
-.04
-.16
-.07
** p < .01
* p < .05
Note: Mother EXP = Mother Total Expansions; Mother REFL = Mother Total Reflections;
Mother WM = Mother Warmth/Supportiveness; Mother CO = Mother Communication; Mother
LR = Mother Listener Responsiveness; Child PM = Chile Positive Mood; Child AX = Child
Anxiety; Child SD = Child Sadness.
CANCER-RELATED COMMUNICATION STYLES
42
Table 5. Multiple linear regression analysis of mother macro- and micro- level communication
styles and child emotions during parent-child conversations about cancer.
Child PM
Standardized 
t
sr2
.447
3.840
.200
Mother LR
.362**
2.926
.112
Mother EXP
.225
1.819
.043
.322
2.667
.095
Mother CO
.322**
2.667
.095
Mother EXP
.270*
2.242
.067
.398
3.337
.158
Mother WM
.321**
2.661
.094
Mother EXP
.270*
2.242
.067
Block 1 R2  .200
Mother LR
Block 2 R2  .043*
Block 1 R2  .159
Mother CO
Block 2 R2  .067
Block 1 R2  .159
Mother WM
Block 2 R2  .067
**p < .01
*p < .05
Note: Mother EXP = Mother Total Expansions; Mother REFL = Mother Total Reflections;
Mother WM = Mother Warmth/Supportiveness; Mother CO = Mother Communication; Mother
CANCER-RELATED COMMUNICATION STYLES
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LR = Mother Listener Responsiveness; Child PM = Chile Positive Mood. Child PM is the
dependent variable. Each Mother IFIRS code was tested as a significant predictor of Child PM
with Mother EXP partialled out and added as a second step; part correlations were then
calculated for Mother EXP and squared to show percentage of variance of the predictors on
Child PM.