Journal of Pediatric Psychology, Vol. 17, No. 6, 1992, pp. 741-755

Psychological Adjustment of Children with Cystic Fibrosis: The Role of Child Cognitive Processes1 and Maternal Adjustment

Duke University Medical Center Received December 2, 1991; accepted February 7, 1992

Found 60% of children 7-12 years old with cystic fibrosis to have a parentreported behavior problem and 62% met the criteria for a DSM-III diagnosis based on a structured clinical interview with the child. Mixed internal and external behavior problem patterns and diagnoses of anxiety and oppositional disorder were most frequent. Support was provided for the hypothesized psychosocial/mediational roles of child perception of self-worth and maternal anxiety in child adjustment. Together, the variables of the transactional stress and coping model accounted for 39 and 43% of the variance in mother-reported internalizing and externalizing behavior problems andfor 68% of the variance in child-reported problems. Key Words: cystic fibrosis; child adjustment; stress and coping.

Cystic fibrosis (CF) has a prevalence of 1 in 2,000 live births and is the most common genetic disease that affects Caucasians. Advances in health care have increased the median survival age from 11 years in 1966 to 28 years in 1989 'This paper was accepted for the special issue by Michael C. Roberts. This research project was supported by National Institute of Health Grant R01 HL 37548 to Robert J. Thompson, Jr. We gratefully acknowledge the contributions of Elizabeth Harrell, David A. Johndrow, and Susanne Meghdadpour to data gathering and management and of Kay Hodges for the Child Assessment Schedule training. 2 A11 correspondence should be sent to Robert J. Thompson, Jr., Division of Medical Psychology, Duke University Medical Center, Box 3362, Durham, North Carolina 27710. 741 0146-8693/92/1200-0741SO6 30/0 19 1992 Plenum Publishing Corporation

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

Robert J. Thompson, Jr., 2 Kathryn E. Gustafson, Kim W. Hamlett, and Alexander Spock

742

Thompson, Gustafson, Hamlett, and Spock

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

(Fitzsimmons, 1990). Children with CF can now expect to assume an adult role in society (Lewiston, 1985) and there is an increased emphasis on their psychosocial adjustment (Drotar & Bush, 1985). The evidence regarding the psychological adjustment of patients with CF is similar to that found with other chronic childhood illness: There is an increased risk for maladjustment but the potential for good adjustment also exists (Thompson, 1985). To inform our efforts to foster psychological adjustment, there is a need for theoretically and conceptually driven studies to delineate the processes associated with good and poor adjustment to CF. A transactional stress and coping model (Thompson, 1985), within an ecological-systems theory perspective (Bronfrenbrenner, 1977), is demonstrating utility in guiding research, integrating findings, and informing clinical practice regarding adjustment to chronic illness. Chronic illness is viewed as a potential stressor to which the individual and family systems endeavor to adapt. The illness—outcome relationship is a function of the transactions of biomedical, developmental, and psychosocial processes. Illness parameters are those that reflect severity. Demographic parameters include gender, age, and SES. However, the focus is on patient and family processes that are hypothesized to further mediate the illness—outcome relationship over and above the contributions of illness and demographic parameters. Guided by the cognitive stress and coping model of Lazarus and Folkman (1984), the choice of psychosocial/mediational processes was based on two criteria: Empirical evidence that the process served to reduce the impact of stress and saliency as a potential intervention target. With regard to psychological adjustment of adults with chronic illness and of mothers of children with chronic illness, three types of psychosocial/mediational processes were included: Cognitive processes of appraisals of stress (Lazarus & Folkman, 1984) and expectations of locus of control (Strickland, 1978) and efficacy (Bandura, 1977); coping methods (Folkman & Lazarus, 1980); and family functioning (Kronenberger & Thompson, 1990; Moos & Moos, 1981). This transactional stress and coping model (reflected in the top portion of Figure 1) was used to delineate the processes associated with the psychological adjustment of 68 mothers of children and adolescents (age 7-17 years) with CF (Thompson, Gustafson, Hamlett, & Spock, 1992). Poor psychological adjustment was reported on the SCL-90-R by 34% of the mothers. Poor maternal adjustment was not associated with the illness parameter of clinical severity of their child's CF or the demographic parameters of age, gender, or socioeconomic status (SES). Together these parameters accounted for only 15% of the variance in maternal anxiety symptoms and 13% in maternal depressive symptoms. However, maternal adjustment was related to the hypothesized psychosocial/ mediational processes. Poor adjustment was associated with higher levels of perceived daily stress, more use of palliative coping methods, and family func-

Cystic Fibrosis

743

CogDltlV*

Hctaoda of

Frociases

Health Locus or Control Child Pajoho.ool.l/H.dlitlon.l rrooaaaaa | Cognlt1 v fHethoda or| I | Frooaaaa |

Self-eateea

Fig. 1. Conceptual transactional stress and coping model for chronic childhood illness.

tioning characterized by low levels of supportiveness. The psychosocial/ mediational processes accounted for an additional 35 and 40% of the variance in maternal anxiety and depressive symptoms, respectively. The next step in this line of research is to expand the model to delineate the processes associated with the psychological adjustment of children with CF. Appropriate measures currently exist to assess two cognitive processes of the child: Expectations of health locus of control and efficacy in terms of self-worth (Rutter, 1987). The bottom portion of Figure 1 reflects the addition of these child cognitive processes to the model. Figure 1 also depicts another process, children's coping methods, that is hypothesized to mediate child adjustment. Children's coping methods are incorporated into the model once the development of an adequate measure has been completed. Within an ecological-systems theory perspective, it is hypothesized that the psychological adjustment of children is affected by levels of stress and symptoms experienced by other family members (Compas, Howell, Phares, Williams, & Ledoux, 1989). In particular, there is considerable support for the role of parental depressive symptoms in parent-reported child behavioral/emotional problems (Compas, Howell, Phares, Williams, & Giunta, 1989; Daniels, Moos, Billings, & Miller, 1987; Hammen et al., 1987; Schaughency & Lahey, 1985). The hypothesized relationship of maternal adjustment to child adjustment is also depicted in Figure 1. Three lines of evidence converge to indicate that comprehensive assessment of the psychological adjustment of children requires multiple measures. First,

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

|CoplQ(

Child Ad Jll8tB«Bt

744

Thompson, Gustafson, Hamlett, and Spock

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

studies indicate a range in levels of agreement among alternative measurement strategies such as parent-completed checklists and clinical diagnoses (Kazdin & Heidish, 1984; Steinhausen & Gobel, 1987). Second, there is evidence for the differential sensitivity of methods. For example, behavior checklists may better reflect externalizing problems while structured clinical interviews may better reflect the phenomenological dimension of affective problems (Breslau, 1985). Third, as discussed above, parental distress can influence parental perceptions and reports of their child's adjustment. The utility of a structured clinical interview, the Child Assessment Schedule (CAS; Hodges, Kline, Stem, Cytryn, & McKnew, 1982), for assessing the psychological adjustment of children with CF was established recently in a study that compared children with CF (7-14 years old) with psychiatrically referred and nonreferred children (Thompson, Hodges, & Hamlett, 1990). The criteria for a major DSM-III (American Psychiatric Association [APA], 1980) diagnosis was met by 58% of the children with CF compared to 77% of the psychiatrically referred and 23% of the nonreferred children. The findings also suggested a framework within which to reconcile previous disparate findings regarding the psychosocial adjustment of children with CF (see Lavigne, 1983). School-age children with CF did not demonstrate, in general, more symptoms of behavioral disturbance than healthy children. Only in terms of the internalizing problems of worries, self-image, and anxiety did the children with CF demonstrate symptom levels comparable to that of psychiatrically referred children. The necessary next step is to utilize both behavior checklist and clinical interview methods to assess the adjustment of children with CF. This assessment strategy increases the comprehensiveness of the assessment of adjustment by capitalizing on the differential sensitivities of these parent-report and self-report methods. The current study addresses two questions regarding the psychological adjustment of children with CF. First, what types of adjustment problems are demonstrated by children with CF according to mother-report and child-report? Second, how do the parameters and psychosocial/mediational processes of the transactional stress and coping model act together to influence adjustment? Three hypotheses are assessed. One, poor adjustment will be predominantly of the internalizing type as reflected in higher frequencies of internalizing behavior problems and anxiety diagnoses than externalizing behavior problems and conduct disorder diagnoses. Two, good and poor adjustment subgroups will not differ significantly in terms of illness and demographic parameters but will differ significantly in terms of child cognitive processes and maternal adjustment. More specifically, in comparison to children with good adjustment, children with poor adjustment will have lower perceptions of self-worth, expectation of health locus of control that are higher on the chance dimension and lower on the internal

Cystic Fibrosis

745

and powerful others dimensions, and their mothers will have higher levels of anxiety and depression. Three, child cognitive processes and maternal psychological adjustment will account for independent and significant increments in the variance in child adjustment over and above that accounted for by illness and demographic parameters.

METHOD Subjects

Procedure The Institutional Review Board-approved protocol included structured interviews conducted by psychologists with children and mothers separately and selfreport inventories that were also completed separately during a regular visit to the Center. Children were monitored by study staff while completing their inventories and reading assistance was provided if needed. The clinical interviews were conducted independently of, and blind to, the results of the self-report inventories. Consent/assent was obtained from both the mother and child.

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

The subjects were participants in a stress and coping project of the Cystic Fibrosis Center. There were 83 children (7-12 years of age) on the active clinic roster who were invited to participate. Of these, 13 children/parents declined to participate and another 16 children/parents did not respond. Of the 54 who enrolled in the study, 1 child was excluded because of multiple congenital anomalies. The study sample comprised 45 children (M age = 9.25 years, SD = 1.8) and their mothers with a completed protocol. There were 15 (33%) girls and 30 (66%) boys and all were Caucasian. There were no significant differences between the study sample (n = 45) and the 7-12 year old nonparticipants [n = 37 (13 declined and 16 nonresponders and 8 incomplete)] in sex distribution, x2U> A' = 82) = 3.56; ns) or age, F(l, 80) = 0.01; ns. Pulmonary functioning testing was routinely done at each clinic visit in accordance with the American Thoracic Society (1987) statement on the standardization of spirometry. This enabled a contrast between the study sample and nonparticipants (35 of 37) on pulmonary functioning as an indicator of illness severity. There was no significant difference (Wilks's lambda = .979) F(3, 76) = 0.55, ns, between the study sample and nonparticipants in the three measures of pulmonary functioning: Forced Vital Capacity, Forced Expiratory Volume at 1 second, and Forced Expiratory Flow.

746

Thompson, Gustafson, Hamlett, and Spock

Measures Illness Parameter

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

The Shwachman Clinical Evaluation System (Shwachman & Kulczycki, 1958) is a standard index of CF status used in clinical practice and reported in the medical literature. It assesses child functioning in four areas: activity, pulmonary physical findings and cough, growth and nutrition, and chest X-ray film findings. Patients are classified based on total score that ranges from 20 to 100 with higher scores indicating better functioning and less disease severity. This rating system was completed by the medical staff based on findings from the clinic visit. The Shwachman scores of the study sample resulted in the following classification of illness status: Very good (n = 25; 56%), good (n = 17; 38%), mild (n = 3; 7%), moderate (n = 0), and severe (n = 0). Demographic Parameters SES was assessed using the two-factor index of social position (Hollingshead, 1957). There was a relatively normal distribution of the five SES levels: I (high), n = 6 (13.3%); II, n = 9 (20.0%); III, n = 15 (33.3%); IV, n = 9 (20.0%); V, n = 6 (13.3%). Child PsychosociallMediatorial Processes Children's expectations regarding control over health were assessed with the Children's Health Locus of Control Scales (Parcel & Meyer, 1979). Children completed this 20-item scale with yielded three subscales: Internal, Powerful Others, and Chance with Cronbach alphas of .67, .52, and .78, respectively. Children also completed the 28-item Self-Perception Profile for Children (Harter, 1982). The scores on the 28-item Self-worth subscale was adopted as the measure of children's self-esteem. Maternal Psychological Adjustment Symptom Checklist 90-Revised. The SCL-90-R (Derogatis, 1983) is a 90item self-report measure of psychological distress along nine symptom dimensions: depression, anxiety, somatization, obsessive-compulsive, interpersonal sensitivity, hostility, phobic anxiety, paranoid ideation, and psychoticism. Raw scores on the nine symptom dimensions and the GSI were converted to t scores

Cystic Fibrosis

747

using nonpatient norms for girls. Maternal psychological distress was reflected in terms of the depression and anxiety symptom dimensions. Child Psychological Adjustment

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

The Missouri Children's Behavior Checklist. The MCBC (Sines, Pauker, Sines, & Owen, 1969) consists of 77 items that describe the behavior of children and form seven scales: aggression, inhibition, activity level, sleep disturbance, somatization, sociability, and depression. Parents indicate (yes-no for each item) whether their child demonstrated the described behavior during the previous 6 to 12 months. Factor analysis (Thompson, Kronenberger, & Curry, 1989) of MCBC standard scores of a large sample of children with medical, developmental, and psychiatric problems identified three factors: Internalizing Behavior Problem, Externalizing Behavior Problem, and Sociable. Hierarchical cluster analysis of the three factor scores yielded four behavior problem patterns: Internal Profile, External Profile, Mixed Internal and External Profile, and Undifferentiated Disturbance; and three behavior problem-free patterns: Low Social Skills Profile, Problem-Free Profile, and Sociable Profile. Evidence pertaining to the validity of this behavior classification system was provided in the finding of different frequencies of behavior profiles among children with developmental, psychiatric, and medical problems and nonreferred controls (Thompson et al., 1989). The yield from the MCBC in this study included the internalizing and externalizing behavior problem factor scores and the seven behavior patterns. In addition, a good adjustment subgroup, comprising those with a Problem-Free Profile or a Sociable Profile and a poor adjustment subgroup, comprising those with one of the four behavior problem patterns or the Low Social Skills Profile, were formed. The Child Assessment Schedule. The CAS (Hodges et al., 1982) is a semistructured, diagnostic, child interview. Based on the child's self-report, the interviewer scores each item as "yes," "no," "ambiguous," or "nonscorable." Subsequent scoring does not involve clinical judgment. A computer program matches the CAS items to specific DSM-III diagnostic criteria (APA, 1980). Matching for adjustment disorders is not undertaken because of the lack of sufficiently specified criteria in DSM-III. Satisfactory test-retest and interrater reliability and data relevant to validity and parent-child concordance have been reported (Hodges & Cools, 1990; Hodges, Cools, & McKnew, 1989; Hodges, Gordon, & Lennon, 1990). The CAS interviews were accomplished by two female clinical child psychologists (K.H. & K.G.) who were trained to a criterion of a kappa of .70 or greater for five consecutive interviews. The yield from the CAS in this study was the Total Symptom Score and whether the symptom, onset, and duration criteria were met for the major, common, DSM-III diag-

748

Thompson, Gustafson, Hamlett, and Spock

noses. Good and poor adjustment subgroups were formed on the basis of the presence or absence of CAS DSM-II1 diagnosis.

RESULTS Psychological Adjustment

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

The findings from the mother-completed MCBC are presented in Table I. Good adjustment was demonstrated by 18 (40%) children in terms of the Problem-free Profile and the Sociable Profile. Poor adjustment was demonstrated by 27 (60%) children in terms of a behavior problem pattern or the Low Social Skills Profile. The most frequent behavior problem patterns were the Mixed Internal and External Behavior Problem Profile (n = 10; 22%) and Undifferentiated Disturbance (n = 8; 18%). The findings from the CAS interview are presented in Table II. Good adjustment was demonstrated by 17 (38%) children while 28 (62%) children met the criteria for one or more DSM-III diagnoses. Diagnoses of anxiety (« = 20; 44%) and oppositional disorder (« = 11; 24%) were most frequent. Among the 28 children with a CAS diagnosis, internalizing types (anxiety, phobic, obsessive compulsive, and depression) were more frequent (n = 13; 28%) than externalizing types (ADDH, conduct disorder, and oppositional disorder) (n = 6; 13%). However, 9 (20%) children had both internalizing and externalizing types of diagnoses with anxiety disorder and either oppositional disorder (n - 6) or conduct disorder (n = 2) as the most frequent specific combination. There were 10 (22%) children who demonstrated good adjustment on both the MCBC and CAS, 20 (44%) children who demonstrated poor adjustment on both measures, and a total of 35 (78%) children who were identified as having poor adjustment by at least one measure. Of the 20 children with both a parentTable I. Frequency of Mother-Completed MCBC Behavior Patterns of Children with Cystic Fibrosis MCBC pattern

Poor adjustment Behavior problem pattern Internal profile External profile Mixed internal and external profile Undifferentiated disturbance Low social skills profile Good adjustment Problem-free profile Sociable profile

n

%

27

60

5 2 10 g 2 18 9 9

11 4 22 18 4 40 20 20

Cystic Fibrosis

749 Table II. Frequency of CAS DSM-III Diagnoses of Children with Cystic Fibrosis %

28

62

4 20 15 9 2 5 2 4 11 6 0

9 44 33 20 4 11 4 9 24 13 0

reported behavior problem and a CAS diagnosis, 15 children had a mixture of internalizing and externalizing types. Only 5 had congruence in type of problem across measures: 3 had internalizing patterns and 2 had externalizing patterns. There were 15 children who were identified as poorly adjusted by one but not the other measure. In these situations, differences in types of problems reported were also evident. Children reported internalizing (n = 4) or mixed internalizing and externalizing problems (« = 3) while mothers reported externalizing (n = 4) or mixed internalizing and externalizing (n = 3) problems. Good Versus Poor Adjustment Differences between poor versus good psychological adjustment subgroups of children, based on the MCBC and/or the CAS, were assessed on each of the demographic and illness parameters, child cognitive processes, and maternal adjustment. ANOVA was used for metric data and chi-square was used for categorical data. MCBC good and poor adjustment subgroups did not differ significantly on the illness parameter of Shwachman medical status nor on the demographic parameters of sex, SES class, or age. There were no significant subgroup differences in the psychosocial/mediational process of health locus of control but there was a trend for the poor adjustment subgroup to have lower General Selfworth scores (M = 3.07 vs. 3.46), F(l, 42) = 3.34, p < .08, than the good adjustment subgroup. There were no significant (p < .05) MCBC subgroup differences in maternal adjustment as reflected in SCl^90-R depression or anxiety symptom scores.

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

DSM-III diagnosis Specific diagnoses Depression Anxiety (any) Separation anxiety Overanxious disorder Obsessive compulsive Phobic Attention deficit disorder Conduct disorder Oppositional disorder Enuresis Encopresis

n

750

Thompson, Gustafson, Hamlett, and Spock

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

CAS good and poor adjustment subgroups did not differ significantly on the illness parameter of Shwachman medical status or the demographic parameters of SES class or age. The frequency of CAS diagnosis was higher among female patients (87%) than male patients (50%), x 2 0 , N = 45) = 5.72, p < .02. However, there were no significant gender differences in terms of specific diagnoses. There were no significant subgroup differences on the psychosocial/ mediational processes of health locus of control. However, those with poor adjustment had lower General Self-worth scores than those with good adjustment (M = 3.03 vs. 3.55), F ( l , 42) = 6.10, p < .02. There were no significant CAS subgroups differences in maternal depression or anxiety symptom scores. Those with poor adjustment (n = 20) on both the MCBC and CAS did not differ significantly from those with good adjustment (n = 10) on the illness parameters of Shwachman medical status. While not differing in the demographic parameters of gender or age, those with poor adjustment on both measures had lower SES, x 2 (2, N = 30) = 6.88 p < .03, than those with good adjustment. In terms of psychosocial/mediational processes, there were no significant subgroup differences in health locus of control, but the poor adjustment subgroup had lower levels of child General Self-worth (M = 2.88 vs. 3.52), F(l, 27) = 5.91, p < .02, than those with good adjustment. There were no significant MCBC/CAS subgroups differences in maternal depression or anxiety symptom scores. Mediation of Adjustment Multiple regression analyses were undertaken to assess the unique and combined contributions of variables of the stress and coping model to child psychosocial adjustment in terms of MCBC Internalizing and Externalizing factor scores and CAS Total Symptom Score. Order of entry between sets of variables was determined a priori, in accordance with the stress and coping model, to reflect the increment in adjustment accounted for by the incorporation of psychosocial/mediational processes over and above that accounted for by demographic and illness parameters. Order of entry within sets of parameters and psychosocial/mediational processes was determined on the basis of a forward stepwise procedure. The illness parameters of Shwachman medical status was entered first followed by the demographic parameters of child gender, age, and SES. Order of entry among the demographic parameters was determined by magnitude of variance accounted for. Then the psychosocial/mediational processes and maternal psychological adjustment measures were allowed to enter if they met the criteria for accounting for a significant increment {p < .05) in variance. Thus, the regression analysis was hierarchical between sets and stepwise within sets (Cohen & Cohen, 1983). The final steps are depicted in Table III. The standardized regression coefficients show the association of each variable with adjustment.

Cystic Fibrosis

751

Table m . Summary of the Hierarchical Multiple Regression Scores Variables

R2 change





Cumulative R2

MCBC Internalizing Factor -.150 .09 .08 .109 -.037 .01 .00 -.199 -.405 .11 .355 .10

1.24 0.58 0.08 1.96 8.06' 6.I5*

.09 .17 .18 18 .29 .39

Shwachman SES Gender Child's age SCL-90-anxiety General self-worth

MCBC Externalizing Factor .088 .01 .11 .102 .004 .01 .00 -.225 .16 .517 -.406 .14

0.45 0.55 0.00 2.70 13.92/ 8.67'

.01 .12 .13 .13 .29 .43

Shwachman SES Child's age Gender General self-worth SCL-90 anxiety CHLOC-Chance'

.003 .102 -.402 .099 -.809 .280 .218

Total Symptom .03 11 .00 .00 .44 .06 .04

0.00 0.92 13.48 1.02 56.79* 6.94* 4.33rf

.03 .14 .14 .14 .58 .64 .68

"Standardized regression coefficient. *F test on R2 change. Child's Health Locus of Control-Chance. d p < .05. 'p < .01. fp < 001. «D < .0001. c

The squared semipartial R2 correlation indicates the increment in the portion of variance accounted for by each variable. The corresponding F values indicate whether this increment was significant. The cumulative R2 indicates the total amount of variance accounted for by the variables in the model. In terms of the mother-reported internalizing and externalizing behavior problems scores, the illness and demographic parameters accounted for 18 and 13% of the variance, respectively. The psychosocial/mediational processes of maternal anxiety level and child's general self-worth accounted for an additional 21 and 30% of the respective variances. Together the variables of the stress and coping model accounted for 39% of the variance in internalizing behavior problems and 43% in externalizing behavior problems. In terms of the child's CAS Total Symptom Score, the illness and demo-

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

Shwachman SES Gender Child's age Child's general self-worth SCL-90 anxiety

752

Thompson, Gustafson, Hamlett, and Spock

graphic parameters accounted for 14% of the variance. The child's psychosocial/mediational processes of self-worth (44%) and chance health locus of control beliefs (4%) and maternal anxiety (6%) accounted for an additional 54% of the variance. Together the variables of the stress and coping model accounted for 68% of the variance in child's CAS Total Symptom Score.

DISCUSSION

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

The relatively high rate of mother-reported (60%) and child-reported (62%) adjustment problems (44% had poor adjustment on both measures) indicates that the study sample may have been overrepresented by children and families with high levels of stress and distress. Although the study sample did not differ significantly from eligible nonparticipants in age, gender distribution, or pulmonary functioning, it is possible that there was selective participation in this study that was described as a stress and coping project. However, the purpose of this study was not to generate estimates of the frequency of adjustment problems in children with CF. Rather, the focus was on examining the types of adjustment problems demonstrated by children with CF and how biomedical, demographic, and psychosocial processes act together to influence the within-group variability in adjustment. The preponderance of internalizing versus externalizing problems has been a consistent finding in children with developmental and chronic medical problems (Breslau, 1985; Thompson, 1986) including children with CF (Simmons et al., 1987; Thompson et al., 1990). However, the findings of the current study indicate that a combination of internalizing and externalizing problems was most frequent. These findings suggest that children with CF may be at risk for a constellation of anxiety-based internalizing problems and oppositional externalizing problems. This constellation is likely to be more "silent" and not as demanding of attention as externalizing-conduct disorder patterns that typically prompt referral of children for psychological services. Thus, there is a risk that the psychological distress and adjustment problems of children with CF could go unrecognized and unattended in the face of pressing medical problems. There was 66% congruence in classification of poor versus good adjustment based on the mother-reported MCBC and child-reported CAS DSM-III diagnoses. Where there was lack of congruence, children tended to report internalizing or mixed internalizing and externalizing types of problems while mothers tended to report externalizing or mixed internalizing and externalizing type problems. These findings provide further support for the differential sensitivity of mother-completed checklists and child interview methods (Hodges et al., 1990). Delineating the parameters and processes that mediated the adjustment of

Cystic Fibrosis

753

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

children confronted with CF was a primary focus of this study. The findings provide support for the inclusion of child cognitive processes and maternal psychological adjustment into the model as mediators of child adjustment to CF. In particular, support is provided for the psychosocial/mediational role of children's self-worth and mother's anxiety symptoms in child psychological adjustment determined through either mother-report or child interview. In terms of the contrast of good versus poor adjustment subgroups, no significant differences were found in illness severity or on the demographic parameters of gender, age, or SES with the exception that those with poor adjustment on both measures had lower SES. The major finding is that children's perception of self-worth was lower in children with poor adjustment. In terms of the unique and combined contributions of the parameters and processes of the model to the full range of adjustment, relatively small amounts of variance were accounted for by the illness (1 to 9%) and demographic parameters (9 to 12%). However, children's perceptions of self-worth accounted for an 11-14% increment in variance in mother-reported internalizing and externalizing behavior problems and a 44% increment in variance in Total Symptom Score from the child interview. Thus, although child self-worth was associated with child adjustment as reported by mothers, it was more strongly related to child-reported distress. In addition, maternal anxiety accounted for a 10-16% increase in variance in mother-reported internalizing and externalizing behavior problems and a 14% increment in CAS Total Symptom Score. These findings add to the body of evidence regarding the impact of maternal psychological adjustment on child adjustment. More importantly, these findings indicate that this impact is not merely due to the influence of maternal distress on their perceptions of their children's behavior. Maternal anxiety symptoms were just as strongly related to child adjustment reflected by child-report as by mother-report. The current study has several limitations. First, the conceptual model that guided this study could have incorporated other processes and different methods. While the variables of the model accounted for 39 to 68% of the variance in child psychological adjustment, it is evident that a considerable portion of variance remains unaccounted. Additional dimensions of child psychosocial/mediational processes, such as stress appraisal and coping methods, need to be included in the model. This model is viewed as a beginning point in the effort to delineate processes that mediate adjustment in relation to the stress of chronic childhood illness. As such, the model will evolve in relation to findings across specific chronic childhood illnesses. Second, the findings of this study reflect a cross-sectional report within a longitudinal study design. The next step in this line of research is to address the stability and change in psychosocial adjustment, psychosocial/mediational processes, and their interrelationship, over, time and in relation to developmental

754

Thompson, Gustafson, Hamlett, and Spock

tasks and periods of risk or resiliency (Thompson, 1986). This information is necessary to guide efforts to derive intervention programs to enhance adjustment to the stress associated with CF. Finally, one criterion for inclusion of variables as hypothesized psychosocial/mediational processes was potential saliency as an intervention target. These initial findings suggest the psychological adjustment of children with CF could be enhanced by preserving self-esteem which may serve to increase the child's resiliency in the face of the stresses associated with CF. Fostering maternal adjustment, while important in its own right, could also reduce the potentially deleterious impact of maternal anxiety on mother-child interactions and child psychosocial functioning. However, the findings of this study are largely correlational and evidence for the causal contribution of maternal adjustment and child self-esteem needs to be determined through empirical intervention studies. Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

REFERENCES American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Thoracic Society. (1987). Standardization of spirometry. American Review of Respiratory Diseases, 136. 1285-1298. Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall. Breslau, N. (1985). Psychiatric disorder in children with physical disabilities. Journal of the American Academy of Child Psychiatry, 24, 87-94. Bronfrenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist, 32, 513-531. Cohen, J., & Cohen, P., (1983). Applied multiple regression!correlation analyses for the behavioral sciences. Hillsdale, NJ: Erlbaum. Compas, B. E., Howell, D. C , Phares, V., Williams, R. A., & Ledoux, N. (1989). Parent and child stress and symptoms: An integrative analysis. Developmental Psychology, 25, 550-559. Compas, B. E., Howell, D. C , Phares, V., Williams, R. A., & Giunta, C. T. (1989). Risk factors for emotional/behavioral problems in young adolescents: A prospective analysis of adolescent and parental stress and symptoms. Journal of Consulting and Clinical Psychology, 57, 732-740. Daniels, D., Moos, R. H., Billings, A. G., & Miller, J. J., III. (1987). Psychosocial risk and resistance factors among children with chronic illness, healthy siblings, and healthy controls. Journal of Abnormal Child Psychology, 15, 295-308. Derogatis, L. R. (1983). SCL-90-R: Administration, Scoring, and Procedures Manual 11. Baltimore, MD: Clinical Psychometric Research. Drotar, D., & Bush, M. (1985). Mental health issues and service. In N. Hobbs & J. M. Perrin (Eds.), Issues in the care of children with chronic illness (pp. 514-550). San Francisco: Jossey-Bass. Fitzsimmons, S. C. (1990, September 12). Cystic fibrosis patient registry, 1989; preliminary data. Bethesda, MD: Cystic Fibrosis Foundation. Folkman, S., & Lazarus, R. S. (1980). An analysis of coping in a middle-aged community sample. Journal of Health and Social Behavior, 21, 219. Hammen, C , Adrian, C , Gordon, D., Burge, D., Jaenicke, L., & Hiroto, D. (1987). Children of depressed mothers: Maternal strain and symptom predictors of dysfunction. Journal of Abnormal Psychology, 96, 190-198. Harter, S. (1982). The Perceived Competency Scale for Children. Child Development, 53, 87-97. Hodges, K., & Cools, J. N. (1990). Structured diagnostic interviews. In A. M. La Greca (Ed.), Through the eyes of the child: Obtaining self-report from children and adolescents. Boston, MA: Allyn and Bacon.

Cystic Fibrosis

755

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

Hodges, K., Cools, J. N., & McKnew, D. (1989). Test-retest reliability of a clinical research interview for children. The Child Assessment Schedule. Psychological Assessment, 1(4), 317-322. Hodges, K., Gordon, Y., & Lennon, M. P. (1990). Parent-child agreement on symptoms assessed via a clinical research interview for children: The Child Assessment Schedule (CAS). Journal of Child Psychology and Psychiatry, 31. 427-436. Hodges, K., Kline, J., Stem, L., Cytryn, L., & McKnew, D. (1982). The development of a child assessment interview for research and clinical use. Journal of Abnormal Child Psychology, 10, 173-189. Hollingshead, A. B. (1957). Two-factor index of social position. New Haven, CT: Department of Sociology, Yale University. Kazdin, A. E., & Heidish, I. E. (1984). Convergence of clinically derived diagnoses and parent checklists among inpatient children. Journal of Abnormal Child Psychology, 12, 421-436. Kronenberger, W., & Thompson, R. J., Jr. (1990). Dimensions of family functioning in families with chronically ill children: A higher order factor analysis of the Family Environment Scale. Journal of Clinical Child Psychology. 19, 380-388. Lavigne, J. (1983). Psychological functioning of cystic fibrosis patients. In J. Lloyd-Still (Ed.), Textbook of cystic fibrosis. Boston: John Wright/PSG. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Lewiston, N. J. (1985). Psychosocial impact of cystic fibrosis. Seminars in Respiratory Medicine, 6, 321-332. Moos, R. H., & Moos, B. S. (1981). Family Environment Scale Manual. Palo Alto, CA: Consulting Psychologists Press. Parcel, G. S., & Meyer, M. P. (1979). Development of an instrument to measure children's health locus of control. Health Education Monographs, 6, 149-159. Rutter, M. (1987). The role of cognition in child development and disorders. British Journal of Medical Psychology, 60, 1-16. Schaughency, E. A., & Lahey, B. (1985). Mothers' and fathers' perceptions of child defiance: Roles of child behavior, parental depression, and marital satisfaction. Journal of Consulting and Clinical Psychology, 53, 718-723. Shwachman, H., & Kulczycki, L. L. (1958). Long-term study of one hundred five patients with cystic fibrosis: Studies made over a 5-to-14 year period. American Journal of Diseases in Children, 96, 6-15. Simmons, R. J., Corey, M., Cowen, L., Keenan, N., Robertson, J., & Levison, H. (1987). Behavioral adjustment of latency age children with cystic fibrosis. Psychosomatic Medicine, 49, 291-301. Sines, J. O., Pauker, J. D., Sines, L. K., & Owen, D. R. (1969). Identification of clinically relevant dimensions of children's behavior. Journal of Consulting and Clinical Psychology, 33, 728-734. Steinhausen, H., & Gobel, D. (1987). Convergence of parent checklists and child psychiatric diagnoses. Journal of Abnormal Child Psychology, 15, 147-151. Strickland, B. R. (1978). Internal-external expectancies and health-related behaviors. Journal of Consulting and Clinical Psychology, 46, 1192-1211. Thompson, R. J., Jr. (1985). Coping with the stress of chronic childhood illness. In A. N. O'Quinn (Ed.), Management of chronic disorders of childhood (pp. 11-41). Boston: G. K. Hall. Thompson, R. J., Jr. (1986). Behavior problems in children with developmental and learning disabilities. International Academy for Research in Learning Disabilities Monograph Series (No. 3). Ann Arbor University of Michigan Press. Thompson, R. J., Jr., Gustafson, K. E., Hamlett, K. W., & Spock, A. (1992). Stress, coping and family functioning in the psychological adjustment of mothers of children and adolescents with cystic fibrosis. Journal of Pediatric Psychology, 17, 573-585. Thompson, R. J., Jr., Hodges, V. K., & Hamlett, K. W. (1990). A matched comparison of adjustment in children with cystic fibrosis and psychiatrically referred and nonreferred children. Journal of Pediatric Psychology, 15, 745-759. Thompson, R. J., Jr., Kronenberger, W., & Curry, J. F. (1989). Behavior classification system for children with developmental, psychiatric, and chronic medical problems. Journal of Pediatric Psychology, 14, 559-575.

Downloaded from http://jpepsy.oxfordjournals.org/ at Cambridge University on December 22, 2014

Psychological adjustment of children with cystic fibrosis: the role of child cognitive processes and maternal adjustment.

Found 60% of children 7-12 years old with cystic fibrosis to have a parent-reported behavior problem and 62% met the criteria for a DSM-III diagnosis ...
765KB Sizes 0 Downloads 0 Views