Adolescent Adjustment and Maternal Breast Cancer: A Test of the Faucet Hypothesis

Frances Marcus Lewis, PhD Emily L. Darby, MD

ABSTRACT. This study investigated the effects of parental functioning on adolescent adjustment during the acute phase of treatment for mothers diagnosed with breast cancer. Data from self- and parent-report questionnaires were obtained in the homes of 87 adolescents and 174 parents within six months of the mothers diagnosis. Associations between adolescent adjustment (self-esteem, behavioral problems, anxiety) and parental functioning (depressed mood, parenting quality, and marital adjustment) were examined when neither, one, or both parents were functioning at compromised levels. When both parents had depressed mood, adolescents tended to show increased behavioral problems; maternal depressed mood was the main source of influence. When the quality of the parenting relationship between the adolescent and both parents was poor, adolescents showed significantly lowered self-esteem and increased anxiety. Marital adjustment did not affect adolescent functioning significantly. Maternal depressed mood and the quality of
Dr. Lewis is Elizabeth Sterling Soule Distinguished Professor of Health Promotion & Nursing, School of Nursing, and Dr. Darby is a Resident in Internal Medicine, University of Washington, Seattle, WA. Address correspondence to: Dr. Frances Marcus Lewis, School of Nursing, University of Washington, Box 357262, Seattle, WA 98195 (E-mail: fmlewis@u.washington.edu). The research was supported by the following grants from the National Institutes of Health: Helping Mothers with Breast Cancer Support Their Child, R01-CA-78-424; Family Home Visitation Study, R01-CA-55-347; and Single Womens Breast Cancer Study, R01-NR-04-135 and by the Arlene Barrison Fellowship, American Cancer Society. Journal of Psychosocial Oncology, Vol. 21(4) 2003 http://www.haworthpress.com/web/JPO 2003 by The Haworth Press, Inc. All rights reserved. Digital Object Identifier: 10.1300/J077v21n04_05

81

82

JOURNAL OF PSYCHOSOCIAL ONCOLOGY

the parent-child relationship significantly influenced adolescent adjustment during the acute phase of the mothers breast cancer. [Article
copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> 2003 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Breast cancer, adolescent, psychosocial adjustment, parenting behavior

Breast cancer is the most commonly diagnosed form of cancer in women in the United States. In 2003, an estimated 211,300 women in the country would be newly diagnosed with the disease (Jemal et al., 2003). Of these new cases, an estimated 22% would involve women of childbearing or child-rearing age. Although this rate reflects the enormity of the health problem for women, equally alarming are the potential ramifications of the disease on their childrens lives. Indeed, an estimated 1 of every 3 women diagnosed with the disease in 1997 was of child-rearing age (20 to 60 years) (ACS, 1999), one-third of whom were estimated to have one or more children living at home (Parker, Tong, & Bolden, 1996). REVIEW OF THE LITERATURE Despite these statistics, only four research programs have examined the childs response to a mothers breast cancer (Table 1). Initially, Lichtman, Taylor, and Wood (1992) examined the parent-child relationship through reports from mothers who had been diagnosed with early stage breast cancer an average of 25.5 months earlier. Asking each mother if a shift in the relationship with her children had been positive, negative, or mixed, the researchers found that a change in the parent-child relationship because of cancer was actually more likely to be favorable. Still, the authors reported that the mother-daughter relationship was at greater risk for a negative shift than was the mother-son relationship. They also hypothesized that the worsened mother-daughter relationship might be related to the daughters own concerns about being diagnosed with the illness later in life. Unclear was whether these study results reflected the personal views of the daughters and sons.

Frances Marcus Lewis and Emily L. Darby

83

TABLE 1. Summary of the Literature on Adolescent Functioning and Parental Cancer

Compas et al., 1994. Sample: 117 patients (total), 76 spouses, 34 young adults, 50 adolescents, 26 preadolescents. Patients' diagnoses: Varied32% breast cancer: Stages I (33%), II (28%), III (22%), IV (17%). Study design: Cross-sectional. Measures: YSR, BSI, and IES, a 4-point Likert scale measuring control, seriousness, and stressfulness. Goal. To examine anxiety/depression and stress response in patients and their children. Compas et al., 1996. Sample: 134 patients (total), 45 young adults, 59 adolescents. Patients' diagnoses: Varied28% breast cancer, mean 9.8 weeks postdiagnosis: Stages I (36%), II (24%), III (21%), IV (19%). Study design: Cross-sectional. Measures: YSR, IES, and open-ended question about coping. Goal: To examine coping styles in children, adolescents, and young adult children of parents with cancer. Grant & Compas, 1995. Sample: 55 adolescents (21 girls and 12 boys with mother's cancer; 12 girls and 10 boys with father's cancer). Patients' diagnoses: Varied, 2 months postdiagnosis, Stages I (36%), II (24%), III (21%), IV (19%). Study design: Cross-sectional. Measures: YSR, open-ended question about coping, and APES. Goals: To examine the mechanisms responsible for the risk to adolescents of parents with cancer and to study coping styles and family responsibilities. Lewis & Hammond, 1996. Sample: 70 patients, 70 partners, 70 adolescents (mean age, 16.3 years). Diagnosis: Early stage breast cancer. Study design: Cross-sectional. Measures: CES-D, DAS, F-COPES, Rosenberg Self-Esteem Scale, Relationships Scale-Child Parent Attachment subscale. Goal: To use path analysis to examine the impact of maternal breast cancer on adolescents and the family. Lewis et al., 1989. Sample: 48 mothers, 48 fathers, children aged 6 to 12 years. Patients' diagnoses: Type II diabetes (13), nonmetastatic breast cancer (19), fibrocystic breast disease (16); mean length of illness 39.63 months. Study design: Cross-sectional. Measures: CES-D, DAS, Relationships Scale-Child Parent Attachment subscale. Goal: To use path analysis to examine the effects of maternal illness on the spouse and children. Lewis et al., 1996. Sample: 23 single women and 25 school-aged children; 101 couples and 106 school-aged children. Patients' diagnosis. Early stage breast cancer; mean time 18 months since diagnosis. Study design: Longitudinal. Measures: CES-D, Rosenberg SelfEsteem Scale, Relationships Scale-Child Parent Attachment subscale. Goals: To examine the functioning of adolescent and younger school-aged children of single women with breast cancer on 3 occasions and to compare the results with adolescents and younger children of married women. Lichtman et al., 1984. Sample: 67 women and 156 children (30 living at home at time of diagnosis). Diagnosis: Breast cancer; Stages I (31%), II (55%), IV (14%). Mean time since diagnosis, 25.5 months. Study design: Cross-sectional. Measures: Index of Well-Being, Marital Adjustment Scale, POMS, Rosenberg Self-Esteen Scale, and interview questions (How has the relationship changed? Is the change better, worse, or mixed?). Goal: To examine how the breast cancer diagnosis may change the relationship between mother and children.

84

JOURNAL OF PSYCHOSOCIAL ONCOLOGY TABLE 1 (continued)

Welch, Wadsworth, & Compas, 1996. Sample: 54 patients, 36 spouses, 55 adolescents, 34 preadolescents. Diagnoses: Varied37% breast cancer, 10 weeks postdiagnosis: Stages I (29%), II (36%), III (22%), IV (13%). Study design: Longitudinal. Measures: CBCL, YSR. Goal: To examine the impact of parental cancer on preadolescent and adolescent children 10 weeks postdiagnosis and 4 weeks later. Wellisch et al., 1991, 1992. Sample: 60 daughters aged 18-65 years with history of mother's breast cancer; age at mother's diagnosis: 1 to 10 years (9), 11-20 years (15), adult (36); 60 matched controls. Mothers' diagnosis: Breast cancer. Study design: Cross-sectional and retrospective. Measures: A structured questionnaire, BSI, Derogatis Sexual Function Inventory, Sexual Arousability Inventory, Ways of Coping Checklist. Goals: To examine the effects of a mother's breast cancer on her daughters and to compare the daughters of mothers with no history of breast cancer.
NOTE: APES = Adolescent Perceived Events Scale, BSI = Brief Symptom Inventory, CBCL = Child Behavior Checklist, CES-D = Center for Epidemiological Studies-Depression Scale, DAS = Dyadic Adjustment Scale, IES = Impact of Events Scale, POMS = Profile of Mood States, YSR = Youth Self Report.

Wellisch et al. (1991, 1992) were first to report on the childs response to the mothers breast cancer. Data were obtained from 60 daughters of women with breast cancer, but only 12 of the daughters (15%) were children at the time of the mothers diagnosis. The authors concluded that the daughters who were aged 11 to 20 years at the time of their mothers diagnosis were more uncomfortable with the illnessrelated effects than were those who were adults at the time of diagnosis, but evidence for this claim is unclear from their reported data. The use of a retrospective design also suggests that the results were likely to have been affected by recall bias. The third body of research comes from Compass team (Compas et al., 1994, 1996; Grant & Compas, 1995; Welch, Wadsworth, & Compas, 1996). Unlike prior studies, which relied on open-ended interviews to measure the impact of different types of cancer on the child, Compass team used standardized measures of adolescent adjustment to describe the effects of parental cancer on children and adolescents. In the first in a series of studies, Compas et al. (1994) examined the impact of parental cancer on adolescents close to the time of diagnosisan average of two monthsusing two standardized measures of adolescent morbidity: the Child Behavior Checklist and the Youth Self Report. Although they did not focus exclusively on the effects of breast cancer, patients with the disease made up almost one-third of the sample. The results showed that adolescents of parents with cancer were at high risk for both anxiety and depression compared with normative samples. Increased anxiety and depression were greatest in girls whose mothers had cancer. Further

Frances Marcus Lewis and Emily L. Darby

85

studies by Compass team concluded that adolescents whose parents had cancer showed greater morbidity than did preadolescents. In addition, later research supported their initial finding that girls whose mothers had cancer were at greater risk for anxiety and depression than were girls whose fathers had cancer or boys when either parent had cancer (Grant & Compas, 1995; Welch et al., 1996). In addition to describing the level of psychosocial functioning of the children, Compas et al. (1994) also examined the relationship between parental disturbance and child functioning. Contrary to expectation, no statistically significant relation was found between parental mood and adolescent disturbance. The fourth body of research on maternal breast cancer and adolescent functioning was conducted by Lewiss team. Their work expanded on previous studies by examining mediators of adolescent adjustment within a theoretical model, not just by describing levels of adolescent adjustment to parental cancer (Lewis & Hammond, 1996; Moyer & Salovey, 1996). These models included three variables as hypothesized predictors of adolescent functioning: maternal depression, marital adjustment, and parenting quality (Lewis, 1998; Lewis & Hammond, 1992, 1996; Lewis, Hammond, & Woods, 1993; Lewis et al., 1989, 1996). The concepts of maternal depression, marital adjustment, and parenting quality are examined below in more detail. Maternal Depressed Mood A substantial literature links maternal depressed mood with problems in child adjustment. Depression with its sadness, pessimism and negative self and world-perception has a significant negative impact on the intra-psychic processes of the child (Tyra, 1997, p. 335). Almost one-third of children from families with parental clinical depression have documented symptoms of depression themselves during or before adolescence (Beardslee & Podorefsky, 1988). Rates of clinical depression with breast cancer differ across studies and appear to be significantly lower than rates of depressed mood (Dean, 1986; Hughson et al., 1988). Dean (1986) found that rates for clinical depression for postmastectomy patients did not differ significantly from rates in the control samples at either 3 or 12 months after surgery. However, using the Center for Epidemiological Studies-Depression Scale (CES-D), Rijken, de Kruif, and Komproe (1995) found that 28% to 30% of patients six weeks after mastectomy or lumpectomy were clinically depressed.

86

JOURNAL OF PSYCHOSOCIAL ONCOLOGY

Using the criteria in the Diagnostic and Statistical Manual of Mental Disorders (3rd edition), Fallowfield, Baum, and Maguire (1986) found that up to 21% of mastectomy patients whose mean time since surgery was well over a year were clinically depressed. Despite conflicting data on rates for depression, almost all the longitudinal studies on depression and breast cancer demonstrate a time main effect in which depression and depressed mood decline since time of diagnosis (Bloom, Cook, & Foutopolis, 1987; Dean, 1986; Fallowfield, Baum, & Maguire, 1986; Gottshchalk & Hoigard, 1986; Hughson et al., 1986, 1988; Lewis & Hammond, 1996; Lewis et al., 1996; Maguire et al., 1978; Neuling & Winefield, 1988; Rijken, de Kruif, & Komproe, 1995; Stanton & Snider, 1993). Numerous studies have shown that women with breast cancer have depressed mood at higher rates than nondiseased women do. An estimated 25% to 33% or more of women with breast cancer score in the clinical range on measures of depressed mood, anxiety, or both (Lewis, 1997). However, some investigators have documented the proportion of women with depressed mood to be as low as 16% at any time between 3 and 26 months after diagnosis or surgery (Dean, 1986; Holmberg et al., 1989; Maguire et al., 1978; Morris, Greer, & White, 1977). The full effects of depressed mood on families with mothers diagnosed with breast cancer are unclear, especially on adolescent children. In the studies of mothers with breast cancer by Lewiss team, there have been inconsistent associations between depressed maternal mood and adolescent functioning. One study with adolescent children of mothers with breast cancer showed a significant negative relationship between maternal depressed mood and adolescents self-esteem and quality of peer relationships (Lewis, 1996). However, another study found no statistically significant relationship between maternal depression and adolescent functioning (Lewis & Hammond, 1996). The results from these studies are not only inconsistent but also have relied on data obtained from study samples that were far from time of diagnosis. Still to be examined is the relation between parental depressed mood and adolescent functioning during the acute phase of the mothers treatment. Parenting Quality The quality of the parent-adolescent relationship is considered to be a major protective factor regarding adolescents psychosocial functioning (Lewis et al., 2000). Some scientists would argue that the quality of the parent-child relationship, more than parental depressed mood, pre-

Frances Marcus Lewis and Emily L. Darby

87

dicts adolescent adjustment (Lewis, Hammond, & Woods, 1993). In fact, Hirsch, Moos, and Reischl (1985) found an elevated risk of lowered self-esteem and increased behavior problems in children of both arthritic and depressed parents, leading the authors to question whether it was depressed mood or impaired parenting that affected adolescent functioning. Armsden and Lewis (1994) also speculated that breast cancer could result in lower quality of parenting even apart from maternal depression. Although better parenting tends to have a positive effect on adolescent adjustment (Armsden, 1986; Cassidy, 1988; Kobak & Sceery, 1988; White, 1979), poor parenting is known to result in increased behavior problems and lowered self-esteem in children (Maccoby & Martin, 1983). A few studies have demonstrated a significant relationship between parenting quality and adolescent adjustment in families where the mother had breast cancer (Lewis, 1996; Lewis & Hammond, 1996). Specifically, more attentive parenting was associated with an increase in adolescents positive self-appraisal (Lewis, 1996). Nonetheless, these studies focused on the parent-child relationship at a time far from diagnosis; the magnitude of the impact of parenting quality on adolescent adjustment during the acute phase is unknown. Furthermore, the impact of parenting quality by the well parent has largely been ignored in prior studies. Marital Adjustment Marital discord related to breast cancer could create an environment of uncertainty and tension for the adolescent (Buehler et al., 1994). Although marital tension alone may be inadequate to affect adolescent behavior or self-image (Emery & OLeary, 1984), Armsden and Lewis (1994) postulated that the interplay of maternal disease and marital tension may be sufficient to have discernible negative effects on the adolescent. Research on families with breast cancer has yet to test this hypothesis. In a study of child-rearing mothers with insulin-dependent diabetes, fibrocystic breast disease, or early stage breast cancer, lower marital adjustment significantly predicted lower psychosocial functioning and worsened parent-child relations among children aged 8 to 12 years (Lewis et al., 1989). Yet, data obtained exclusively from studies involving participants with breast cancer revealed no such association. Furthermore, in a study involving only patients with breast cancer, Lewis and Hammond (1996) determined that lower levels of marital adjust-

88

JOURNAL OF PSYCHOSOCIAL ONCOLOGY

ment failed to predict either the quality of the parent-child relation or the adolescents self-image. However, both studies involved participants whose mean time since diagnosis exceeded 23 months. The relationship between marital discord and adolescent adjustment during the acute phase of a mothers breast cancer is unknown. Compensatory Parenting With so many women with breast cancer suffering from depressed mood, why is there an inconsistent relationship between maternal mood and adolescent functioning? One clue might lie in the relation between the adolescent and the father. In Lewis and Hammonds study (1996) of adolescent-rearing mothers with breast cancer, although the adolescents view of the parent-child relationship was strongly related to self-esteem, both parents, not just the mother, contributed to the adolescents self-reports of parenting quality. Indeed, Amato and Ochiltree (1986) examined childrens development of competence and found that fathers contributed equally to childrens self-esteem. Furthermore, the childrens reports on the fathers parenting behavior in that study positively correlated with adolescent self-esteem. In contrast, the adolescents reports of their mothers parenting behavior was not associated with the adolescents self-appraisal. Thus, it would be no surprise to family systems theorists if fathers had a central role in shaping adolescent responses to the mothers cancer. As Hill (1972, p. 762) asserted: Modern systems theory would make room for the frequent empirical observation that the marital sub-system within the family is often quite insulated from the perturbations in the sibling sub-system and the parent-child sub-system. There is room . . . for the development of mechanisms which buffer between contending units to delay and even nullify the impacts of role changes in one position on other positions. The fathers parenting behavior in the presence of the mothers medical illness may compensate for the mothers behavior. To illustrate, consider a sink with two faucets as a metaphor for compensatory parenting behavior. If just one faucet is on, the drain may perform adequately. However, if both faucets are on, the drain could be overwhelmed, causing the sink to overflow. Extending this metaphor to families experiencing breast cancer, the greatest threat to the adolescents level of functioning exists when the behavior or functioning of

Frances Marcus Lewis and Emily L. Darby

89

both parents is compromised concurrently. This might occur when both parents have depressed mood or elevated marital tension. It also might occur when the quality of the relationship between the adolescent and both parents is compromised. On the basis of a compensatory model of parenting, one would hypothesize that the lowest levels of adolescent functioning would occur, not at either the peak of either maternal or paternal depressed mood or marital discord or the nadir of the adolescents report of the quality of relationship with each parent, but when both parents depressed mood or marital tension was elevated or when the adolescents evaluation of both parents parenting relationship with the adolescent was low. The purpose of the present study was to examine three compensatory parenting hypotheses that derive from the faucet metaphor: Adolescent functioning will be lowest when both parents have depressed mood. Adolescent functioning will be lowest when the adolescent reports a poor relationship with both parents. Adolescent functioning will be lowest when both parents report poor marital adjustment. METHODS The sample consisted of 87 adolescents and 174 parents who participated in a larger intervention study titled the Family Home Visitation Study (Lewis, 1992-1996). Data analyzed for the present study are limited to the baseline data obtained on adolescent and parental functioning at entry into the larger study and before they participated in the intervention. Signed informed consents were obtained before their participation. Characteristics of the Sample The average ages of the mothers and fathers were 44.15 years (SD = 4.31 years) and 46.41 (SD = 6.05 years), respectively. Couples were involved in long-term marriages (M = 19.35 years, SD = 6.87 years). Most participants were Caucasian: Only 8 mothers (9.2%) and 9 fathers (10.3%) were non-Caucasian. The parents were well educated: The mothers averaged more than two years of education after high school (M = 14.82 years, SD = 1.79 years), and the fathers averaged more than

90

JOURNAL OF PSYCHOSOCIAL ONCOLOGY

three years of post-high school education (M = 15.47 years, SD = 2.48 years). Seventy-seven percent of the mothers and 93% of the fathers were employed either full or part time outside the home. The average annual family income ranged between $40,000 and $50,000. The families had an average of 2.72 children (SD = 1.04 children) living in the home, and the adolescents average age was 15.51 years (SD = 1.83 years). Fifty-one of the 87 adolescents (58.6%) were male. The mothers were in the acute phase of diagnosis and treatment for early stage breast cancer, and the average time since their diagnosis was 4.87 months (SD = 2.57 months). The majority of mothers (61.1%) had non-breast conserving surgery and were treated with chemotherapy or a combination of chemotherapy and radiation therapy (80.5%). Instruments Standardized questionnaires with established reliability and validity were used to measure the study variables. Measures of parental mood, marital adjustment, and parenting quality were assessed with the Center for Epidemiological Studies-Depression Scale (CES-D), the Spanier Dyadic Adjustment Scale (DAS), and the Inventory of Parent and Peer Attachment (IPPA). Measures of adolescent functioning were the Child Behavior Checklist (CBCL), the State-Trait Anxiety Inventory, Form Y-2 (STAI Y-2), and the Rosenberg Self-Esteem Scale. Higher scores on all these scales denote more positive values, except for the Rosenberg Self-Esteem Scale and the STAI Y-2, on which higher scores denote lower functioning. Assessment of parents. The CES-D measures the frequency with which the respondent experiences symptoms of depressed mood (Radloff, 1977). The scale consists of 20 items representing the major symptoms in the clinical syndrome of depression and refers to feelings during the preceding week. The scale is commonly used to measure depressive symptomatology in cancer patients (Hann, Winter, & Jacobsen, 1999). Internal consistency reliabilities range between .84 and .85 for three samples in the general population and .90 for samples of patients (Radloff, 1977). Test-retest correlations at three months (n = 378) were moderate (r = .48), as expected because the CES-D was designed to measure current level of depression. CES-D scores are known to differ in the predicted direction across groups of acute depressives; recovered depressives; drug addicts, alcoholics, schizophrenics; and a presumably healthy community sample. CES-D scores correlate well with clinicians ratings on the Hamilton Depression Rating Scale and with the SCL-90 Depression scale

Frances Marcus Lewis and Emily L. Darby

91

(but not with the other SCL-90 scales) (Weissman & Myers, 1980). The scores are highly correlated with scores on the Zung Depression Scale (r = .90) and the Beck Depression Scale (r = .81) (Weissman & Myers, 1980). In studies of maternal breast cancer or other chronic medical illnesses, higher CES-D scores significantly predicted poorer marital adjustment in both wives and husbands (Lewis, Hammond, & Woods, 1993; Lewis et al., 1989). Marital adjustment was measured by the total score on the DAS (Schaefer & Burnett, 1987; Sharpley & Cross, 1982; Spanier, 1976). The DAS is a 32-item self-administered scale that measures the quality of marriage. Prior studies established the validity of the measure, including its significant positive association with higher levels of psychosocial functioning in households of mothers with chronic medical illness (Lewis et al., 1989) and of mothers with breast cancer (Lewis & Hammond, 1996). The initial internal consistency reliability reported by Spanier (1976) was .96 (Cronbachs alpha). Construct validity was established with the Locke-Wallace Marital Adjustment Scale; correlations between the measures were .86 for married respondents and .88 for divorced respondents (Spanier, 1976). The IPPA assesses adolescents perceptions of the positive and negative affective and cognitive dimensions of relationships with their parents, particularly how well the parents are sources of psychological security (Armsden & Greenberg, 1987). The instrument is a self-report questionnaire with a five-point ordinal scale containing 25 items in each of the mother and father sections. The alpha coefficients for internal consistency reliabilities are .87 for mother attachment and .89 for father attachment. Among late adolescents, parental attachment scores are moderately to highly correlated with family and social self-scores from the Tennessee Self-Concept Scale (Armsden & Greenberg, 1987). Parental attachment scores of 12- to 18-year-olds also are moderately correlated with scores on the Family Adaptation and Cohesion Scales (FACES II), a standardized measure of the households psychosocial functioning as well as with family coping behavior (Lewis, Ellison, & Woods, 1985). In a sample of 10- to 16-year-old psychiatric patients, less secure parent attachment was related to a clinical diagnosis of depression, parental rating of the adolescents depressive symptoms, and to the patients self-reported level of depression (Armsden et al., 1990). Armsden (1986) found that late adolescents who experienced more secure attachments to their mother and father reported less conflict between their parents and experienced less loneliness. Among early to middle adolescents, attachment with parents was associated with less

92

JOURNAL OF PSYCHOSOCIAL ONCOLOGY

hopelessness, less externally oriented locus of control, and greater self-management (coping) skills (Armsden et al., 1990). Assessment of adolescents. The form of the CBCL (Achenbach & Edelbrock, 1983) completed by parents measures a broad range of 4- to 16-year-old childrens behavior problems and social competencies of concern to mental health workers. The instrument also can be used with older adolescents still living at home. Children referred by clinics scored higher on the Behavior Problems Scale than did non-clinic-referred children (Achenbach & Edelbrock, 1978). The Behavior Problems portion of the CBCL reported in the present study consists of 118 items rated by a parent on a three-point response scale: 0 (Not true), 1 (Somewhat or sometimes true), and 2 (Very true or often true). From factor analyses conducted on data from clinic-referred children, eight or nine behavior problem scales (depending on age and sex) were constructed. Second-order factor analyses grouped the scales into an Internalizing and Externalizing dichotomy. The Externalizing broad-band scale measures aggressive, antisocial, and undercontrolled behavior; the Internalizing broad-band scale measures fearful, inhibited, and overcontrolled behavior (Webster-Stratton & Hammond, 1988). Three-month test-retest reliabilities from parents of inpatient children averaged .74, and six-month retest reliabilities were in the .60s range for outpatient children. CBCL scores were found to be significantly higher for children with psychiatric disorders according to the Research Diagnostic Criteria (Weissman, Orvaschel, & Padian, 1980). Internalizing and externalizing scores were moderately to highly correlated with scores on the Connors Abbreviated Rating Scale and the Werry-Weiss-Peters Activity Scale in a sample of 91 hyperactive and normal children (Mash & Johnston, 1983). The STAI Y-2 assesses individual differences in the tendency to react with anxiety (Spielberger, 1983). The scale used in the current study consists of 20 statements to which respondents indicate the extent to which the statement is generally true for them, from Almost never to Almost always (four-point scale). The instrument has been widely used to screen for anxiety problems and to evaluate the effects of psychotherapeutic interventions. Form Y-2 represents an attempt to provide a purer measure of anxiety, as opposed to depression, and has improved psychometric properties. Internal consistency reliabilities (Cronbachs alphas) were .90 or above for all high school age groups. Stability reliability coefficients at 60-day retest were .68 for highschool males and .65 for high-school females (Spielberger, 1983).

Frances Marcus Lewis and Emily L. Darby

93

The Rosenberg Self-Esteem Scale is a 10-item self-report scale that measures the self-acceptance (liking or approval) component of self-esteem (Rosenberg, 1965). Respondents are asked to rate each item on a four-point Likert scale ranging from Strongly agree to Strongly disagree, with lower scores denoting higher self-esteem (Rosenberg, 1962). Silber and Tippett (1965) reported a two-week stability reliability coefficient of .85. Internal consistency reliability coefficients of .74, .86, and .89 also were reported for children aged 13 to 19 years over three different data collections at four-month intervals; stability coefficients over the same periods were .73 between Times 1 and 2 and .79 between Times 2 and 3 (Lewis, Woods, & Ellison, 1986). Silber and Tippett (1965) documented scale correlations ranging from .56 to .83 with similar measures and with clinical judgment. Crandall (1974) reported an interscale correlation of .60 with Coopersmiths Self-Esteem Inventory. In a study of 70 adolescents whose mothers had breast cancer, the standardized internal consistency reliability coefficient (Cronbachs alpha) was .88 (Lewis & Hammond, 1996). RESULTS Parental Depression and Adolescent Adjustment For analytic purposes, the parents were stratified into three groups according to their scores on the CES-D: (1) neither parent reported depressed mood (a score lower than 10), (2) only one parent reported depressed mood (score of 10 or higher), and (3) both parents reported depressed mood. A three-group ANOVA was calculated to examine differences between the three parent groups on five measures of adolescent functioning: the CBCL Total Behavior Problems Scale and the Externalizing and Internalizing subscales, the STAI Y-2, and the Rosenberg Self-Esteem Scale (see Table 2). The results revealed a statistical tendency for adolescents Total Behavior Problems scores to be affected by parental depressed mood (F[2,84] = 2.91, p = .06). The Newman-Keuls range test revealed that the Total Behavior Problem scores were significantly greater when both parents were depressed than when neither parent was depressed (p < .05). No other comparisons were significant. Hypothesis 1 was not rejected. Additional analyses were calculated to examine further the contribution of maternal and paternal depressed mood to adolescent functioning.

94

JOURNAL OF PSYCHOSOCIAL ONCOLOGY

TABLE 2. Parents CES-Da Scores and Measures of Adolescent Adjustment: Means (SDs)
Measure of Adolescent Adjustment Child Behavior Checklist Total Behavior Problems Externalizing Internalizing Rosenberg Self-Esteem Scale STAI Y-2c: Trait anxiety Neither Parent Depressed (n = 29) 44.28 (12.25) 46.14 (10.52) 47.31 (11.50) 1.73 (.32) 37.10 (6.47) One Parent Depressed (n = 37) 47.38 (11.38) 48.16 (9.60) 48.86 (11.04) 1.66 (.44) 36.30 (8.33) Both Parents Depressed (n = 21) 52.10 (9.34)ab 52.10 (9.19) 53.48 (9.52) 1.50 (.48) 34.76 (11.69)

aCenter for Epidemiological Studies-Depression Scale. bF[2,84] = 2.91, p < .06; Newman-Keuls range test, groups significantly different at p < .05: Both Parents >

Neither Parent. cState-Trait Anxiety Inventory, Form Y-2.

Maternal depressed mood was significantly associated with three measures of adolescent functioning (Table 3): Total Behavior Problems, externalizing problems, and internalizing problems. Maternal depressed mood did not account significantly for the adolescents self-esteem or anxiety scores. Paternal depressed mood was not significantly related to any measure of adolescent functioning (Table 4). Quality of the Parenting Relationship and Adolescent Adjustment The adolescents also were stratified into three groups for analytic purposes: (1) those with a poor relationship with neither parent, (2) those with a poor relationship with one parent, and (3) those with a poor relationship with both parents. The cutoff for poor parenting quality was set at .5 standard deviations below the mean. A three-group ANOVA was calculated on measures of adolescent adjustment (Table 5). The results revealed that the quality of the parenting relationship significantly affected both adolescent self-esteem and adolescent anxiety (F[2,84] = 8.55, p < .001, and (F[2,84] = 10.45, p = .001, respectively). Group comparisons showed that when one parents or both parents relationship with the adolescent was poor, the adolescents self-esteem was significantly lower than when both parents relationship with the adolescent was positive.

Frances Marcus Lewis and Emily L. Darby

95

TABLE 3. Mothers CES-Da Scores and Measures of Adolescent Adjustment: Means (SDs)
Measure of Adolescent Adjustment CES-D Scores Less Than 10 (n = 44) 44.00 (11.52) 46.02 (10.18) 46.14 (10.97) 1.70 (.39) 10 or Higher (n = 43) 51.05 (10.58) 50.91 (9.22) 52.86 (10.04) 1.59 (.45)

t-test

Child Behavior Checklist Total Behavior Problems Externalizing Internalizing Rosenberg Self-Esteem Scale STAI Y-2b: Trait Anxiety

t[85] = 2.97** t[85] = 2.34* t[85] = 2.98**

NS

36.95 (7.38)

35.42 (9.85)

NS

aCenter for Epidemiological Studies-Depression Scale. bState-Trait Anxiety Inventory, Form Y-2.

*p < .05. **p < .01.

TABLE 4. Fathers CES-Da Scores and Measures of Adolescent Adjustment: Means (SDs)
Measure of Adolescent Adjustment Mean CES-D Scores Less Than 10 (n = 51) 46.76 (12.38) 47.71 (10.09) 49.45 (11.33) 1.71 (.36) 10 or Higher (n = 36) 48.50 (10.37) 49.47 (9.84) 49.47 (10.66) 1.56 (.48) NS NS NS

t-test

Child Behavior Checklist Total Behavior Problems Externalizing Internalizing Rosenberg Self-Esteem Scale STAI Y-2b: Trait Anxiety

t[85] = 1.73

36.65 (7.08)

35.56 (10.61)

NS

aCenter for Epidemiological Studies-Depression Scale. bState-Trait Anxiety Inventory, Form Y-2. p < .10.

Group comparisons revealed that adolescent anxiety was highest when both parents had a poor relationship with the adolescent (Table 5). When the quality of the relationship with one parent was high, the adolescents anxiety was lower than when the adolescents relationship with both parents was poor. Hypothesis 2 was not rejected. Additional analyses were conducted to examine the contribution of the parenting relationship for each parent calculated separately. A poor

96

JOURNAL OF PSYCHOSOCIAL ONCOLOGY

TABLE 5. Adolescents IPPAa Scores and Measures of Adolescent Adjustment: Means (SDs)
Measure of Adolescent Adjustment Child Behavior Checklist Total Behavior Problems Externalizing Internalizing Rosenberg Self-Esteem Scale STAI Y-2c: Trait Anxiety Poor Relationship With Neither Parent (n = 66) 46.27 (10.86) 47.24 (9.27) 48.58 (10.57) 1.56 (.40) 34.27 (7.78) Poor Relationship With One Parent (n = 13) 49.15 (12.99) 50.46 (10.17) 50.00 (12.29) 1.80 (.30) 39.38 (8.66) Poor Relationship With Both Parents (n = 8) 54.75 (13.36)a 55.00 (13.23) 55.88 (11.54) 2.11 (.35)b 46.88 (7.02)d

aInventory of Parent and Peer Attachment. bF[2,84] = 8.55, p < .001; Newman-Keuls range test, groups significantly different at p < .05: Both Parents

and One Parent > Neither Parent. cStait-Trait Anxiety Inventory, Form Y-2. dF[2,84] = 10.45, p < .001; Newman-Keuls range test, groups significantly different at p < .05: Both Parents > One Parent > Neither Parent.

relationship with the mother, compared to a high-quality mother-child relationship, affected the adolescents externalizing problems, self-esteem, and anxiety to a significantly greater extent (Table 6). When the quality of the relationship between the father and the adolescent was poor, the adolescent experienced significantly lower self-esteem and higher anxiety (Table 7). Marital Adjustment and Adolescent Functioning When the couples were stratified according to level of marital adjustment assessed by the DAS for purposes of analysis, three groups were formed: (1) both spouses reported normal marital adjustment (score of 115 or greater), (2) one spouse reported poor marital adjustment (score less than 115), and (3) both spouses reported poor marital adjustment. A three-group ANOVA revealed that marital adjustment did not affect adolescent functioning significantly (Table 8). Hypothesis 3 was rejected. DISCUSSION The major assumption of our research was that adolescents would be more likely to show adjustment problems when both parents were func-

Frances Marcus Lewis and Emily L. Darby

97

TABLE 6. Adolescents IPPAa Scores for Relationship with the Mother and Measures of Adolescent Adjustment: Means (SDs)
Measure of Adolescent Adjustment Child Behavior Checklist Total Behavior Problems Externalizing Internalizing Rosenberg Self-Esteem Scale STAI Y-2b: Trait Anxiety High Quality (n = 75) 46.60 (11.31) 47.52 (9.45) 48.56 (10.94) 1.60 (.40) 35.00 (7.72) Poor Quality (n = 12) 53.00 (12.08) 54.17 (11.62) 55.08 (9.99) 1.93 (.41) 43.67 (10.78)

t-test

NS t[85] = 2.19* NS

t[85] = 2.65* t[85] = 3.41**

aInventory of Parent and Peer Attachment bState-Trait Anxiety Inventory, Form Y-2.

*p < .05. **p < .01.

TABLE 7. Adolescents IPPAa Scores for Relationship with the Father and Measures of Adolescent Adjustment: Means (SDs)
Measure of Adolescent Adjustment Child Behavior Checklist Total Behavior Problems Externalizing Internalizing Rosenberg Self-Esteem Scale STAI Y-2b: Trait Anxiety High Quality (n = 70) 44.46 (10.76) 47.54 (9.27) 48.86 (10.43) 1.56 (.40) 34.44 (8.21) Poor Quality (n = 17) 51.71 (13.99) 52.12 (12.06) 51.94 (13.13) 2.00 (.31) 43.41 (6.67)

t-test

NS NS NS

t[85] = 4.26*** t[85] = 4.17***

aInventory of Parent and Peer Attachment bState-Trait Anxiety Inventory, Form Y-2.

***p < .001.

tioning at compromised levels on depressed mood, parenting quality, or marital adjustment during the acute phase of the mothers breast cancer. The results offer conditional support for the faucet hypothesis in two areas: the parents depressed mood and the parent-adolescent relationship. The adolescent tended to show elevated levels of behavioral problems when both parents were depressed, as opposed to when neither parent was depressed. Additional analyses revealed that maternal, not paternal, depressed mood significantly contributed to the adolescents

98

JOURNAL OF PSYCHOSOCIAL ONCOLOGY

TABLE 8. Parents DASa Scores and Measures of Adolescent Adjustment: Means (SDs)
Measure of Adolescent Adjustment Child Behavior Checklist Total Behavior Problems Externalizing Internalizing Rosenberg Self-Esteem Scale STAI Y-2b: Trait Anxiety Both Parents: Normal Adjustment (n = 34) 47.97 (11.30) 48.85 (10.55) 50.15 (10.99) 1.70 (.39) 36.59 (9.08) One Parent: Poor Adjustment (n = 27) 45.19 (11.42) 46.56 (10.02) 48.22 (8.89) 1.61 (.48) 33.56 (9.28) Both Parents: Poor Adjustment (n = 26) 49.23 (12.10) 49.85 (9.19) 49.85 (13.10) 1.61 (.40) 38.42 (6.88)

aDyadic Adjustment Scale. bState-Trait Anxiety Inventory, Form Y-2.

behavioral problems. Specifically, the mothers depressed mood affected greater total, externalizing, and internalizing behavior problems in the adolescent. These data are inconsistent with Compas et al.s earlier findings (1994) that parental mood and adolescent disturbance were not significantly related. It is possible that the association of maternal depressed mood with adolescent functioning may reflect a shared variance problem. Recall that the mother was the reporter of both her own mood and her adolescents behavior. As such, her mood may have systematically caused her to view her adolescents behavior in more negative terms. (This potential bias also is reflected in the absence of effects of parental depressed mood on adolescent anxiety or self-esteem. In these latter results, the adolescent was the source of information about anxiety and self-esteem, not the mother.) Thus, a sad mother may have interpreted more behavior problems in the adolescent. However, it is equally plausible that maternal depressed mood resulted in behavior problems in the adolescent. At a minimum, the results suggest the need to assess maternal depressed mood clinically during the acute phase of treatment in child-rearing mothers with breast cancer. The strongest support for the faucet hypothesis comes from results on the parenting relationship. From a systems perspective, there were substantial adjustment problems when the parent-child subsystem was compromised. When adolescents reported a poor relationship with both parents, both self-esteem and anxiety were affected deleteriously. Sepa-

Frances Marcus Lewis and Emily L. Darby

99

rate analyses by individual parents revealed that the quality of the relationship with each parent significantly affected the adolescents selfesteem and anxiety. The mothers parenting relationship also was associated with increased externalizing problems. Despite the negative influence of compromised parenting, there was hopeful news in the study results. Compensatory parenting significantly diminished adolescent anxiety. Adolescents had lower anxiety when they reported a positive relationship with one parent compared to when they had a poor relationship with both parents. This latter result argues the importance of compensatory parenting during the mothers acute treatment phase. Even if both parents cannot be there for the adolescent during the acute phase of the mothers breast cancer, the adolescent benefits from a positive relationship with at least one parent. The phrase Parents matter has direct relevance to these results. Parents of adolescents need to know that their ways of relating to the adolescent, from the adolescents viewpoint, has documented positive consequences for the adolescent during the acute phase of the mothers breast cancer. Marital maladjustment did not affect adolescent functioning. This is clinically fortunate news. From a systems perspective, tension in the marital subsystem did not cross the boundaries of the adolescent subsystem. Given this evidence, clinicians and scientists can put primary emphasis on maternal depressed mood and the quality of the relationship between the adolescent and parents as determinants of adolescent functioning during the acute phase of the mothers breast cancer. LIMITATIONS OF THE STUDY Data from the present study were limited to cross-sectional data obtained from primarily middle-class, well-educated, White families in long-term marriages. Thus, the results may not generalize to fiscally challenged, less well-educated families, and shorter-term marriages. Although parental mood, parenting quality, and marital quality were tested as determinants of adolescent adjustment, it is always possible that other variables co-varied with these variables and produced study results. For example, prior parenting history, not current parenting, may have influenced adolescent functioning. Future studies using longitudinal designs are needed to test such alternative hypotheses (Woods & Lewis, 1992). From a family systems perspective, family environments are co-created by the adolescent and the parents, not unilaterally generated by the

100

JOURNAL OF PSYCHOSOCIAL ONCOLOGY

parents (Maccoby & Martin, 1983). This means that two-way causality likely operated in which the behavior of the adolescent affected the behavior of the parents and vice versa. Future research on parenting practices needs to include nonrecursive models of adolescent functioning in families impacted by maternal breast cancer. In the present study, tests of the faucet hypothesis were based on an additive model of parenting behavior. It is always possible that a mediational model operated instead. For example, parenting quality might mediate the effects of parental depressed mood on adolescent adjustment. Future research should test such mediational models (Moyer & Salovey, 1996). REFERENCES
Achenbach, T. M., & Edelbrock, C. S. (1978). The classification of child psycho-pathology: A review and analysis of empirical efforts. Psychological Bulletin, 85, 1275-1301. Achenbach, T. M., & Edelbrock, C. S. (1983). Manual for the Child Behavior Checklist and revised Child Behavior Profile. Burlington, VT: University of Vermont, Department of Psychology. Amato, P. R., & Ochiltree, G. (1986). Family resources and the development of child competence. Journal of Marriage and the Family, 48(1), 47-56. American Cancer Society (ACS). (1999). Cancer facts and figures 1999. Atlanta, GA: Author. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. Armsden, G. C. (1986). Attachment to parents and peers in late adolescence: Relationships to affective status, self-esteem, and coping with loss, threat and challenges. Unpublished doctoral dissertation, University of Washington, Seattle. Armsden, G. C., & Greenberg, M. T. (1987). The Inventory of Parent and Peer Attachment: Relationships to well-being in adolescence. Journal of Youth and Adolescence, 16, 427-454. Armsden, G. C., & Lewis, F. M. (1994). Behavioral adjustment and self-esteem among school-aged children of mothers with breast cancer. Oncology Nursing Forum, 21, 39-45. Armsden, G. C., McCauley, E., Greenberg, M. T., Burke, P. M., & Mitchell, J. R. (1990). Parent and peer attachment in early adolescent depression. Journal of Abnormal Child Psychology, 18, 683-697. Beardslee, W. R., & Podorefsky, M. A. (1988). Resilient adolescents whose parents have serious affective and other psychiatric disorders: Importance of self-understanding and relationships. American Journal of Psychiatry, 145, 63-69. Bloom, J. R., Cook, M., & Fotopoulis, S. (1987). Psychological response to mastectomy: A prospective comparison study. Cancer, 58, 89-96.

Frances Marcus Lewis and Emily L. Darby

101

Buehler, C., Krishnakumar, A., Anthony, C., Tittsworth, C., & Stone, G. (1994). Hostile interparental conflict and youth maladjustment. Family Relations, 43, 409-416. Cassidy, J. (1988). Child-mother attachment and the self in six-year-olds. Child Development, 59, 121-134. Compas, B. E., Worsham, N. L., Epping-Jordan, J. E., Grant, K. E., Mireault, G., Howell, D. C., et al. (1994). When mom or dad has cancer: Markers of psychological distress in cancer patients, spouses and children. Health Psychology, 13, 507-515. Compas, B. E., Worsham, N. L., Ey, S., & Howell, D. C. (1996). When mom or dad has cancer II: Coping, cognitive appraisals, and psychological distress in children of cancer patients. Health Psychology, 15, 167-175. Crandall, R. (1974). On the relationship between self-esteem, coping and optimism. Psychological Reports, 30, 485-494. Dean, C. (1986). Psychiatric morbidity following mastectomy: Preoperative predictors and types of illness. Journal of Psychosomatic Research, 31, 385-392. Emery, R. E., & OLeary, K. D. (1984). Marital discord and child behavior problems in a non-clinical sample. Journal of Abnormal Child Psychology, 12, 411-420. Fallowfield, L. J., Baum, M., & Maguire, G. P. (1986). Effects of breast conservation on psychological morbidity associated with diagnosis and treatment of early breast cancer. British Medical Journal Clinical Research Edition, 29, 1331-1334. Gottshalk, L. A., & Hoigard, M. J. (1986). The emotional impact of mastectomy. Psychiatry Research, 17, 153-167. Grant, K. E., & Compas, B. E. (1995). Stress and anxious-depressed symptoms among adolescents: Searching for mechanisms of risk. Journal of Consulting and Clinical Psychology, 63, 1015-1021. Hahn, D., Winter, K., & Jacobsen, P. (1999). Measurement of depressive symptoms in cancer patients: Evaluation of the Center for Epidemiological Studies Depression Scale (CES-D). Journal of Psychosomatic Research, 46, 437-443. Hill, R. (1972). Modern systems theory and the family: A confrontation. Social Science and Information, 10, 7-26. Hirsch, B. J., Moos, R. H., & Reischl, T. M. (1985). Psychosocial adjustment of adolescent children of a depressed, arthritic, or normal parent. Journal of Abnormal Psychology, 94, 154-164. Holmberg, L., Omne-Ponten, M., Burns, T., Adami, H. O., & Bergstrom, R. (1989). Psychosocial adjustment after mastectomy and breast-conserving treatment. Cancer, 64, 969-974. Hughson, A. V., Cooper, A. F., McArdle, C. S., & Smith, D. C. (1986). Psychological impact of adjuvant chemotherapy in the first two years after mastectomy. British Medical Journal Clinical Research Edition, 293, 1267-1271. Hughson, A. V., Cooper, A. F., McArdle, C. S., & Smith, D. C. (1988). Psychosocial consequences of mastectomy: Levels of morbidity and associated factors. Journal of Psychosomatic Research, 32, 383-391. Jemal, A., Murray, T., Samuels, A., Ghafoor, A., Ward, E., & Thun, M. J. (2003). Cancer statistics, 2003. CA: A Cancer Journal for Clinicians, 53(1), 5-26. Kobak, R. R., & Sceery, A. M. (1988). Attachment in late adolescence: Working models, affect regulation and representations of self and others. Child Development, 59, 135-146.

102

JOURNAL OF PSYCHOSOCIAL ONCOLOGY

Lewis, F. M. (1992-1996). The Family Home Visitation Study. (R01-CA-55347). Bethesda, MD: National Cancer Institute. Lewis, F. M. (1996). The impact of breast cancer on the family: Lessons learned from the children and adolescents. In L. Baider, C. L. Cooper, & A. Kaplan De-Nour (Eds.), Cancer and the Family (pp. 271-287). New York: John Wiley & Sons. Lewis, F. M. (1997). Behavioral research to enhance adjustment and quality of life in adults with cancer. Preventive Medicine, 26(Suppl. 5), S19-S29. Lewis, F. M. (1998). Family-level services in oncology nursing: Facts, fallacies and realities revisited. Oncology Nursing Forum, 25, 1377-1388. Lewis, F. M., & Hammond, M. A. (1992). Psychosocial adjustment of the family to breast cancer: A longitudinal analysis. Journal of American Medical Womens Association, 47, 194-200. Lewis, F. M., & Hammond, M. A. (1996). The fathers, mothers and adolescents functioning with breast cancer. Family Relations, 45, 456-465. Lewis, F. M., Ellison, E. S., & Woods, N. F. (1985). The impact of breast cancer on the family. Seminars in Oncology Nursing, 1, 206-213. Lewis, F. M., Hammond, M. A., & Woods, N. F. (1993). The family functioning with newly diagnosed breast cancer in the mother: The development of an explanatory model. Journal of Behavioral Medicine, 16, 351-370. Lewis, F. M., Woods, N. F., & Ellison, E. S. (1986). Final Report. Family Impact Study: The Family and Cancer (Grant No. RO1 NU 01000). Bethesda, MD: National Cancer Institute, Division of Nursing. Lewis, F. M., Woods, N. F., Hough, E. E., & Bensley, L. S. (1989). The familys functioning with chronic illness in the mother: The spouses perspective. Social Science and Medicine, 29, 1261-1269. Lewis, F. M., Zahlis, E. H., Shands, M. E., Sinsheimer, J. A., & Hammond, M. A. (1996). The functioning of single women with breast cancer and their school-aged children. Cancer Practice, 4(1), 15-23. Lewis, F. M., Behar, L. C., Anderson, K. A., Shands, M. E., Zahlis, E. H., Darby, E., & Sinsheimer, J. A. (2000). Blowing away the myths of the childs experience with the mothers breast cancer. In L. Baider, C. L. Cooper, & A. Kaplan De-Nour (Eds.), Cancer and the Family, 2nd Ed. (pp. 201-221). New York: John Wiley & Sons, Ltd. Lichtman, R. R., Taylor, S. E., Wood, J. V., Bluming, A. Z., Dosik, G. M., & Leibowitz, R. L. (1984). Relations with children after breast cancer: The motherdaughter relationship at risk. Journal of Psychosocial Oncology, 2(3/4), 1-19. Maccoby, E. E., & Martin, J. A. (1983). Socialization in the context of the family: Parent-child interaction. In P. H. Musser (Ed.), Handbook of child psychology: Socialization, personality, and social development (Vol. 4, pp. 1-101). New York: John Wiley & Sons. Maguire, G. P., Lee, E. G., Bevington, D. J., Kucherman, C. S., Crabtree, R. J. & Cornell, C. E. (1978). Psychiatric problems in the first year after mastectomy. British Medical Journal, 1, 963-965. Mash, E. J., & Johnston, C. (1983). Parental perceptions of child behavior problems, parenting self-esteem, and mothers reported stress in younger and older hyperactive and normal children. Journal of Consulting and Clinical Psychology, 51, 86-99.

Frances Marcus Lewis and Emily L. Darby

103

Morris, T., Greer, S., & White, P. (1977). Psychological and social adjustment to mastectomy: A two year follow-up study. Cancer, 40, 2381-2387. Moyer, A., & Salovey, P. (1996). Psychosocial sequelae of breast cancer and its treatment. Annals of Behavioral Medicine, 18, 110-125. Neuling, S. J., & Winefield, H. R. (1988). Social support and recovery after surgery for breast cancer: Frequency and correlates of supportive behaviors by family, friends and surgeon. Social Science and Medicine, 27, 385-392. Parker, S. L., Tong, T., & Bolden, S. (1996). Cancer statistics. Cancer, 46, 5-27. Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401. Remschmidt, H. (1994). Psychosocial milestones in normal puberty and adolescence. Hormone Research, 41(Suppl. 2), 19-29. Rijken, M., de Kruif, A. T., & Komproe, I. H. (1995). Depressive symptomatology of post-menopausal breast cancer patients: A comparison of women recently treated by mastectomy or by breast-conserving therapy. European Journal of Surgical Oncology, 21, 498-503. Rosenberg, M. (1962). Self-esteem and concern with public affairs. Public Opinion Quarterly, 26, 201-211. Rosenberg, M. (1965). Society and adolescent self-image. Princeton, NJ: Princeton University Press. Schaefer, E. S., & Burnett, C. K. (1987). Stability and predictability of quality of womens marital relationships and demoralization. Journal of Personality and Social Psychology, 53, 1129-1136. Sharpley, C. F., & Cross, D. G. (1982). A psychometric evaluation of the Spanier Dyadic Adjustment Scale. Journal of Marriage and the Family, 46, 739-741. Silber, E., & Tippett, J. (1965). Self-esteem: Clinical assessment and measurement validation. Psychological Reports, 16, 1017-1071. Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38(1), 15-28. Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory (Form Y). Palo Alto, CA: Consulting Psychologists Press. Stanton, A. L., & Snider, P. R. (1993). Coping with a breast cancer diagnosis: A prospective study. Health Psychology, 12(1), 16-23. Tyra, T. L. (1997). Self-esteem of children from depressive families [Abstract]. Psychiatria Polska, 28, 335-344. Webster-Stratton, C., & Hammond, M. A. (1988). Maternal depression and its relationship to life stress, perceptions of child behavior problems, and child conduct problems. Journal of Abnormal Child Psychology, 16, 299-315. Weissman, M. M., Orvaschel, H., & Padian, N. (1980). Childrens symptom and social functioning self-report scales: Comparison of mothers and childrens reports. Journal of Nervous and Mental Disease, 168, 736-740. Weissman, W. M., & Myers, J. K. (1980). Psychiatric disorders in a U.S. community: The application of research diagnostic criteria to a resurveyed community sample. Archives of Psychiatry in Scandinavia, 62, 99-111.

104

JOURNAL OF PSYCHOSOCIAL ONCOLOGY

Welch, A. S., Wadsworth, M. E., & Compas, B. E. (1996). Adjustment of children and adolescents to parental cancer: Parents and childrens perspectives. Cancer, 77, 1409-1418. Wellisch, D. K., Gritz, E. R., Schain, W., Wang, H., & Siau, J. (1991). Psychological functioning of daughters of breast cancer patients. Part I: Daughters and comparison subjects. Psychosomatics, 32, 324-335. Wellisch, D. K., Gritz, E. R., Schain, W., Wang, H., & Siau, J. (1992). Psychological functioning of daughters of breast cancer patients. Part II: Characterizing the daughter of the breast cancer patient. Psychosomatics, 33, 171-179. White, B. L. (1979). The family: The major influence on the development of competence. In N. Stinnett, B. Chesser, & J. Defrain (Eds.), Building family strengths: Blueprint for action (pp. 175-193). Lincoln, NE: University of Nebraska. Woods, N. F., & Lewis, F. M. (1992). Design and measurement challenges in family research. Western Journal of Nursing Research, 14, 397-403.

Received: May 3, 2001 Revised: June 3, 2003 Accepted: June 19, 2003

To request single copies of articles from Haworth journals at only $18.00 each, visit the Haworth website at www.HaworthPress.com today!