Journal of Pediatric Psychology, Vol. 25, No. 7, 2000, pp. 481-491
© 2000 Society of Pediatric Psychology
The Influence of Parent-Child Relatedness on Depressive Symptoms in Children With Asthma: Tests of Moderator and Mediator Models
The Children's Hospital of Buffalo, State University of New York at Buffalo
All correspondence should be sent to Beatrice L. Wood, Pediatric Psychiatry and Psychology, Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, New York 14222. E-mail: bwood{at}acsu.buffalo.edu .
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Abstract |
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Objective: To examine the influence of parent-child relationship quality on the association between illness-related functional status and depressive symptoms in children with asthma.
Methods: Questionnaire data were collected from the child, caregiver, and physician. Fifty-five children with asthma (8-17 years of age), their caregivers, and physicians participated.
Results: Regression analyses suggest that patterns of mother-child relatedness (secure vs. insecure) mediate the relationship between functional status and depressive symptoms.
Conclusions: The parent-child relationship may be an important pathway by which illness influences symptoms of depression in children with asthma. This study suggests that impaired functional status does not directly contribute to symptoms of depression, but rather influences the parent-child relationship in ways that may promote the development of depressive symptoms in the child.
Key words: asthma; asthma severity; depression; functional status; relatedness; attachment; parent-child relationship; family; mediator; moderator.
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Introduction |
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Asthma is the most prevalent chronic illness in childhood (Halfon & Newacheck, 1993
), affecting approximately 4.8 million children
(Adams & Marano, 1995;
Centers for Disease Control and Prevention
[CDC], 1995). Pediatric asthma is a growing phenomenon, as its
morbidity and mortality continue to escalate
(Weitzman, Gortmaker, Sobel, & Perrin,
1992). The National Heart, Lung, and Blood Institute
(NHLBI, 1997, p. xiv) defines
asthma as "a chronic inflammatory disorder of the airways in which
inflammation causes recurrent episodes of wheezing, breathlessness, chest
tightness, and cough. These episodes may be associated with airflow
obstruction that is reversible either spontaneously or with
treatment."
Children with asthma are more likely to experience psychological
difficulties than are healthy children
(Kashani, Konig, & Shepperd,
1988; MacLean, Perrin, &
Gortmaker, 1992) with estimates of psychopathology among these
children ranging from 25% to 42% (Mrazek,
1992). The psychological difficulties of these children most
commonly include symptoms of depression
(Gizynski & Shapiro, 1990;
Nelms, 1989). Bennett
(1994), in a meta-analytic
review of 60 studies, found that children with asthma were at greater risk for
developing depressive symptoms even when compared to children with other
chronic illnesses such as cancer, cystic fibrosis, and diabetes mellitus.
Moreover, depressive symptoms may be particularly problematic for children
with asthma because of a possible psychophysiological link between depressive
symptoms and asthma morbidity and mortality
(Miller, 1987;
Miller & Strunk, 1989;
Miller & Wood, 1997).
Despite numerous studies examining the association between asthma and
depression, pathways by which depressive symptoms arise in children with
asthma have not been identified. Current research has focused mainly on the
medically related aspects of asthma, investigating asthma severity as a
primary risk factor. Although some evidence suggests that asthma severity is
associated with depressive symptoms, overall, the findings have been
inconsistent and sometimes contradictory
(Kashani et al., 1988;
MacLean et al., 1992;
Padur et al., 1995). This
suggests that factors beyond the biological parameters of the illness may be
operating as well.
Family functioning has been implicated in the psychosocial outcomes of
children, including those children experiencing chronic illness
(Eiser, 1990), with 20%-25% of
children exhibiting a psychiatric disorder in poorly functioning families,
compared to 7% of children exhibiting a psychiatric disorder in well
functioning families (Rutter,
1981). Furthermore, Jessop and Stein
(1985), investigating the
familial environments of children with chronic illness, found that children
with high illness-related functional status came from higher functioning
families and exhibited fewer emotional problems. Functional status is defined
as the degree to which a child can function in his or her normal activities
despite current symptoms of asthma. Although functional status is inversely
related to disease severity, which refers to the intensity and frequency of
symptoms, other factors likely influence the degree to which a child actually
is impaired by the illness. Depression, for example, may lead a child to be
less motivated, or more pessimistic, about coping effectively with the
disease, even if it is not very severe. Conclusions from these studies
underscore the importance of family factors and suggest that the functional
impact of an illness may be more predictive than illness severity alone in the
psychological adjustment of children with chronic illness.
The developmental literature indicates that, within the family context,
parent-child relationships specifically may influence the emotional well-being
of children. Positive parent-child relationships may be particularly important
for children facing adversities related to chronic illness, potentially
lessening the risk of depression in these children
(Gizynski & Shapiro,
1990). Attachment theory has guided the conceptualization of
parent-child relationships in this regard
(Huebner & Thomas, 1995;
Masten, Best, & Garmezy,
1990). Secure attachment relationships allow the child to regulate
his or her emotions in response to environmental challenges
(Cassidy, 1994), with the
disruption of attachment relationships leaving the child ill prepared to
negotiate such adversities (Cicchetti,
Ganiban, & Barnett, 1991). We propose that the quality of
children's attachment relationships with their caregivers will be implicated
in the extent to which asthma-related functional impairment evokes depressive
symptoms.
Although few well-validated and widely accepted instruments for assessing
attachment in school-age children exist, Lynch and Cicchetti
(1991,
1997) have approached the role
of attachment in studies of emotional well-being in children by using an
adapted version of Connell's
(1990) concept and measure of
"relatedness." Relatedness describes the quality of the child's
self-reported relationship patterns with his or her caregivers
(Connell, 1990). It
encompasses dimensions of emotional proximity seeking and emotional quality,
which together yield five categories of relatedness (two secure and three
insecure) (Lynch & Cicchetti,
1991,
1997). These relatedness
patterns parallel attachment patterns
(Cicchetti, Toth, & Lynch,
1995), representing a profile of parent-child interactions that
typify qualitatively distinct positive and negative relationship types.
This study investigates the possible association and specific pathways by which parent-child relatedness may influence the relationship between illness-related functional status and depressive symptoms in children with asthma. We conceptualize two possible ways in which this influence may take place: (1) secure relatedness will buffer, and insecure relatedness exacerbate, the impact of poor functional status on depressive symptoms (relatedness moderates the relationship between functional status and depressive symptoms); (2) functional status will influence parent-child relatedness in ways that influence the child's level of depression (relatedness mediates the relationship between functional status and depressive symptoms).
In the first case, the conceptualization of relatedness as a moderator is
consistent with the Biobehavioral Family Model
(Wood, 1993), proposing that
family process and biological factors interact in their influence on the
well-being of children with chronic illness. In the second case, the
conceptualization of relatedness as a mediator is consistent with Nelms's
(1989) suggestion that the
presence of a chronic illness may negatively alter the parentchild
relationship so as to render the child more vulnerable to psychological
problems. Thus, the study reported herein tests two competing models:
hypothesis 1 (relatedness as a moderator) and hypothesis 2 (relatedness as a
mediator), each proposing different pathways by which relatedness may
influence the impact of functional status on depressive symptoms in children
with asthma (see figure 1).
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Method |
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Participants
Fifty-five children with asthma (ages 8-17, M = 11.8) participated in this study. Twenty-three (41.8%) participants were girls and 32 (58.2%) were boys. Thirty-eight (69.1%) were Caucasian, 10 (18.2%) African American, 1 (1.8%) Hispanic, 1 (1.8%) Native American, and 5 (9.1%) other. Six (10.9%) mothers attended some high school, 16 (29.1%) graduated from high school, 16 (29.1%) attended some college, 12 (21.8%) graduated from college, and 5 (9.1%) attended graduate school.
Children were serially recruited over a 3-month period from the allergy and immunology clinic of a children's hospital located in the northeast United States and from an allergist's private practice. Recruitment criteria included (1) diagnosis of asthma prior to the clinic visit; (2) age between 8 and 17 years; (3) accompaniment to the clinic by a parent/legal guardian; and (4) absence of other major medical illnesses.
Fifty-five (93%) of 59 families agreed to participate. Two families declined because of time constraints, one declined for the protection of the child, and one declined because they do not participate in formal research projects. Families who participated were not compensated.
Measures
The Asthma Severity Rating Form. This form, completed by the
physician, identifies the child's asthma severity according to criteria
established by the NHLBI
(1997). Severity
classifications include mild intermittent, mild persistent, moderate
persistent, and severe persistent. Reliability and validity data are not
available for these criteria as they are considered the guidelines by which
other measures are constructed and validated. Asthma severity is included to
inform the functional status measure, investigating whether the child's
functional status is, in fact, associated with illness severity.
Asthma Symptom Questionnaire. The ASQ, an 8-item questionnaire
completed by the parent, measures the frequency and intensity of the child's
current asthma symptoms. This questionnaire was constructed by the
investigators according to the NHLBI
(1997) criteria for the
classification of asthma severity. Higher scores reflect more severe asthma
symptoms. Cronbach's alpha coefficient for the ASQ in the current sample of
children is.83. The ASQ was correlated with the physician's asthma severity
rating (r =.522, p <.001), providing evidence of
convergent validity for the two ratings (see
Table I).
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Play Performance Scale for Children. The PPSC
(Lansky, List, Lansky, 1987)
indexes functional status by measuring how restricted the child is in his or
her activities as the result of asthma. The parent chooses the one description
(from a continuum of 11 possibilities) that best describes the child's ability
to function in the past week. The range of descriptions include 0 =
unresponsive; 10 = no play, does not get out of bed; 90 = minor restrictions
in physically strenuous activity; 100 = fully active, normal. Although this
instrument has been administered in samples of children with asthma
(Padur et al., 1995),
reliability and validity data have only been reported in samples of children
with cancer with the interrater reliability between mother and father reports
(r =.71, p <.0001)
(Lansky et al., 1987). The
validity of the PPSC is demonstrated by its ability to discriminate between
inpatient and outpatient samples of children
(Lansky et al., 1987).
We selected the PPSC over other measures of quality of life and asthma functional status because it was the most behaviorally oriented, thus minimizing subjective judgment on the part of the parent. Furthermore, unlike most quality of life measures, the PPSC clearly differentiates functional status from asthma severity, excluding items that more properly reflect asthma severity. (Similarly, the asthma severity measures used in this study included no items of functional status.)
Relatedness Questionnaire. The Relatedness Questionnaire (Lynch
& Cicchetti, 1991,
1997), a 17-item questionnaire
completed by the child, measures the child's relationship patterns with an
adult caregiver. The questionnaire is completed once for each target
caregiver. The instrument has two subscales: Psychological Proximity Seeking
and Emotional Quality. Psychological Proximity Seeking refers to the child's
desire to be "closer" to the person about whom the child is
answering the questionnaire. For example, the child may endorse items stating
that he or she wishes to be better understood by the caregiver or spend more
time with the caregiver. It is assumed that endorsing proximity-seeking items
reflects insufficiency of attachment connection. Emotional Quality refers to
the positive and negative emotions that the child feels in the presence of the
caregiver.
The configurational combination of scores on each dimension yields five
qualitatively distinct patterns of relatedness (two secure and three
insecure). Children with optimal patterns of relatedness report
higher than average levels of positive emotions and lower than average amounts
of psychological proximity-seeking. Average children report levels of
emotional quality and psychological proximity-seeking within one standard
deviation of the mean for each dimension. These children feel positive and
secure in their relationships, and they are satisfied with existing degrees of
closeness. Children with deprived (ambivalent) patterns of
relatedness report lower than average levels of emotional quality, but higher
than average amounts of psychological proximity seeking. These children desire
to feel closer to others, but their relationships are characterized by
feelings of negativity and insecurity. Children with disengaged
(avoidant) patterns of relatedness report lower than average levels of
emotional quality and lower than average amounts of psychological
proximity-seeking. These children have predominantly negative feelings about
others and do not want to be any closer to them. Confused children
report high levels of emotional quality as well as extremely high amounts of
psychological proximity-seeking. In order to increase power, and consistent
with the way in which relatedness has been treated in past research
(Cicchetti et al., 1995), we
combined these categories into a secure relatedness group and an insecure
relatedness group for the purposes of this study.
This questionnaire has been used with children ages 8 to 13. Cronbach's
alpha coefficient for psychological proximity seeking ranges from.83 to.93 and
for emotional quality from.67 to.83. In the current sample of children,
Cronbach's alpha for psychological proximity seeking is.89 and for emotional
quality is.87. The validity of the Relatedness Questionnaire is supported by
its ability to differentiate maltreated from nonmaltreated children and to
predict psychosocial outcomes in these children
(Toth & Cicchettti,
1996).
Childhood Depression Inventory. The CDI
(Kovacs, 1985), a 27-item
questionnaire completed by the child, measures the child's symptoms of
depression. Scores range from 0 to 54, with higher scores indicating more
depressive symptoms. The CDI is appropriate for children ages 8 to 17. The
reported Cronbach's alpha coefficients for this instrument range from.83 to.89
(Smucker, Craighead, Craighead, &
Green, 1986). Cronbach's alpha coefficient for the current sample
of children is.90.
Childhood Depression Inventory-Parent Version. The CDI-P
(Kovacs, 1985), a 27-item
questionnaire completed by the parent, measures the child's symptoms of
depression as perceived by the parent. Scores range from 0 to 54, with higher
scores indicating more depressive symptoms. Cronbach's alpha coefficient
reported for this instrument is.85
(Wierzbicki, 1987), and for
the current sample of children is.82. In this study, the CDI-P was correlated
with the child's report of depressive symptoms (CDI) (r =.376,
p <.01), providing evidence of convergent validity for both
measures (see Table I).
Childhood Social Desirability Scale. Experience in the pilot phase of the study indicated that the questions posed to the child in the Relatedness Questionnaire and the CDI tended to elicit socially desirable answers in some children. Therefore, the modified CSD was included in this study. The CSD (Crandell, Crandell, & Katkovsky, 1965), a 16-item questionnaire completed by the child, measures the child's tendency to report socially desirable answers. Socially desirable answers are those responses the child provides that are not true, but that the child thinks reflect the "right" way to behave and think (e.g., a child's assertion that he or she "always washes his or her hands before meals"). Higher scores on the CSD indicate a greater tendency to report socially desirable answers. Test-retest reliability for this instrument ranges from.82 to.95. Cronbach's alpha coefficient in the current sample of children is.72.
Procedure
Children meeting recruitment criteria were invited to participate in the
study at the time of their regularly scheduled clinic appointments. Informed
written consent was obtained from the parent and informed written assent was
obtained from the child. If the child was 12 years old or younger, the assent
form was read aloud by the investigator. Copies of the consent forms were
provided to the families. The Institutional Review Boards of the hospital and
the affiliated university granted approval for the study.
The parent completed three questionnaires in reference to his or her child.
Instructions for each questionnaire were explained to the parent by the
investigator. The questionnaires were administered in a consistent order: (1)
ASQ; (2) PPSC (Lansky et al.,
1987); and (3) CDI-P (Kovacs,
1985). Experience in the pilot phase of the study demonstrated
that this order made the most sense to the research participants in completing
the questionnaires.
The child completed three questionnaires. Instructions for each
questionnaire were explained to the child by the investigator. The
investigator asked each child to read aloud sample questions from the
questionnaires to ensure that the child's reading ability was adequate. The
questionnaires were administered in a consistent order: (1) The Relatedness
Questionnaire (Lynch & Cicchetti,
1991,
1997), completed in reference
to the child's mother and father (if the child did not have a mother or
father, the investigator prompted the child to identify a primary caregiver
and a secondary caregiver); (2) CDI
(Kovacs, 1985); and (3) CSD
(Crandall et al., 1965).
The physician was asked to complete a form identifying the child's asthma
severity according to the NHLBI
(1997) classifications for
asthma severity.
While the child and parent were completing the questionnaires, the investigator remained in the room to answer questions that arose and to ensure that the child and parent completed their questionnaires independently.
Data Analysis
Relatedness as a Moderator (Hypothesis 1). When a variable acts as
a moderator, it specifies the conditions under which one variable is
related to another variable. Specifically, a moderator variable can
"affect the relationship between two variables, so that the nature of
the impact of the predictor variable on the dependent variable varies
according the level or value of the moderator"
(Holmbeck, 1997, p. 599). That
is, the moderator variable interacts with the predictor variable in
determining the dependent variable. In our model, the child's pattern of
relatedness (secure vs. insecure) with his or her caregiver is predicted to
moderate (buffer or exacerbate) the relationship between functional status and
depressive symptoms.
Regression analyses were conducted to test this hypothesis. All variables
were centered, a procedure recommended to reduce the problem of
multicollinearity (Aiken & West,
1991). The interaction term was computed by multiplying functional
status and relatedness. On the first step of the regression equation,
functional status and relatedness were entered simultaneously. On the second
step, the interaction term was entered. Moderation is demonstrated if the
interaction term is significant. Moderation analyses for mother and father
relatedness were conducted separately.
Relatedness as a Mediator (Hypothesis 2). A mediator can be
described as the mechanism by which one variable influences another variable
(Baron & Kenny, 1986). In
our model, relatedness is predicted to mediate the relationship between
functional status and depressive symptoms, transmitting the effect of
functional status on depressive symptoms. In other words, functional status
influences relatedness, and relatedness, in turn, influences depressive
symptoms. According to Baron and Kenny
(1986), several statistical
conditions must be met to infer support for a mediating model. First, the
predictor variable (functional status) must be significantly associated with
the mediator variable (relatedness). Second, the predictor variable
(functional status) must be significantly associated with the criterion
variable (depressive symptoms). Third, the mediator variable (relatedness)
must be significantly associated with the criterion variable (depressive
symptoms). Mediation is demonstrated if, after controlling for the effects of
the mediator variable (relatedness) on the criterion variable (depressive
symptoms), the relationship between the predictor variable (functional status)
and the criterion variable (depressive symptoms) is significantly reduced
(Baron & Kenny, 1986).
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Results |
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Descriptive Statistics
Demographics. Although demographic information (age, gender, race, and educational level) was collected, no a priori predictions were made regarding the impact that demographic variables may have on any of the variables of interest (asthma severity, functional status, relatedness, and depressive symptoms). Past research has found that demographic variables were not correlated with depression in children with chronic illnesses (Bennett, 1994
). Furthermore,
post hoc analyses found no significant patterns of associations between age,
race, and educational level and the variables of interest. For these reasons,
these demographic variables were not controlled for in any further analyses.
Gender, however, was associated with functional status (r =.468,
p <.001). See the exploratory analyses section for post hoc
analyses including age and gender. Social Desirability. Scores on the CSD revealed a mean of 6.51 (SD = 3.23). Prior to all statistical analyses, social desirability was partialed out of the Relatedness Questionnaire and the CDI. All relationships reported in this article that include either of these two measures reflect adjusted scores. The CSD was not significantly correlated with relatedness, but was correlated with the CDI (r = -.464, p <.001).
Asthma Severity. Physician report indicated the following distribution of asthma severity: 21 (38.2%) mild intermittent, 23 (41.8%) mild persistent, 10 (18.2%) moderate persistent, and 1 (1.8%) severe. The physician report was correlated with the parent report of asthma severity (ASQ) (r =.522, p <.001). Neither rating of asthma severity was associated with the relatedness or depressive symptom measures (see Table I).
Functional Status. Scores on the PPSC
(Lansky et al., 1987) revealed
a mean of 88.18 (SD = 14.15) and a range of 50-100. This instrument
was designed to measure a wide array of functioning, including being
bed-ridden (scores below 50). Because children in this outpatient sample would
not be bed-ridden, scores between 50 and 100 were expected and provided an
adequate range for this sample. Functional status was correlated (r =
-.426, p <.05), with asthma severity confirming that at least some
portion of functional status was associated with asthma severity (see
Table I).
Relatedness. Fifty-three (96.4%) children answered the mother
relatedness questionnaire (Lynch & Cicchetti,
1991,
1997) for their mothers, 1
(1.8%) for their grandmother, and 1 (1.8%) for their stepmother. All
caregivers referred to in the mother relatedness questionnaire were considered
primary caregivers and 100% lived in the same home with their children.
Thirty-seven (67.3%) children reported secure relatedness patterns with their
mothers and 18 (32.7%) children reported insecure relatedness patterns with
their mothers. This distribution is comparable to normative samples of
children, with 67.5% reporting secure and 32.5% insecure relatedness with
their mothers.
Thirty-seven (67.3%) children answered the father relatedness questionnaire
(Lynch & Cicchetti, 1991,
1997) for their fathers or
stepfathers with whom they lived, 11 (20%) for fathers or secondary caregivers
with whom they have regular contact, and 7 (12.7%) reported having no contact
with their fathers or other secondary caregivers. Twenty-seven (56.3%)
children reported secure relatedness patterns with their fathers or secondary
caregivers, whereas 21 (43.7%) reported insecure relatedness patterns their
fathers or secondary caregivers.
Children reporting insecure relatedness with their mothers, also reported more depressive symptoms than children reporting secure relatedness (t [2] = 4.75, p <.001). Similarly, children reporting insecure relatedness with their fathers or secondary caregivers also reported more depressive symptoms than children reporting secure relatedness patterns (t [2] = 2.42, p <.05).
Depression. On average, the children included in this study sample
were within nonclinical ranges on the CDI (M = 6.51, SD =
5.79, range: 0-20) (Kovacs,
1992). However, 10 (18%) children scored above the clinical
cut-off score (12) on the CDI (Smucker et
al., 1986). This finding demonstrates that a modest, but
reasonable range of depressive symptoms was captured in the sample. One
child's score on the CDI, in excess of 4 standard deviations from the mean,
was identified as a univariate outlier. As recommended by Tabachnick and
Fidell (1996), this score was
conservatively transformed to reduce undue influence on the sample statistics.
Scores on the CDI-P revealed comparable levels of depressive symptoms
(M = 6.02, SD = 5.07). The CDI-P correlated with the child's
report of depressive symptoms (CDI) (r =.376, p <.01).
The CDI child version was selected for further analyses, addressing the
study's specific interest in the child's perceived experience of depressive
symptoms.
Results of Tests of Moderation and Mediation
Regression analyses testing the moderating role of maternal relatedness
indicated that the interaction term (functional status x maternal
relatedness) did not account for a significant portion of the variance of
depressive symptoms, beyond that accounted for by functional status and
maternal relatedness, Rchange2 =.012,
Fchange (1, 51) =.914, n.s. Similarly, for paternal
relatedness, the interaction term (functional status x paternal
relatedness) did not achieve significance,
Rchange2 =.030, Fchange (1,
44) = 1.649, n.s.
The steps for testing for mediation were followed
(Baron & Kenny, 1986).
First, partial correlations revealed a significant association between
functional status and maternal relatedness (r =.334, p
<.05); second, between functional status and depressive symptoms
(r = -.298, p <.05); third, between maternal relatedness
and depressive symptoms (r = -.546, p <.001). The
association between functional status and depressive symptoms (ß = -.298,
p <.05) was reduced to a nonsignificant level (ß = -.130,
p =.293) after controlling for maternal relatedness. Goodness of fit
(Tabachnick & Fidell,
1996) of the mediation model to the collected data was.967 (see
Table II).
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Father relatedness did not meet criteria for testing mediation and, therefore, was not examined.
Exploratory Analyses
Previous empirical and clinical findings did not suggest specific
hypotheses regarding the interaction of age and gender with the other
variables of interest. Furthermore, there were no significant zero order
correlations between the developmental variables and depressive symptoms in
this study. Nevertheless, post hoc exploratory analyses found that age and
gender may, in fact, play an important role. A significant three-way
interaction was found between functional status, relatedness, and age (ß
=.383, p <.01). Examination of the plotted slopes suggests that
maternal relatedness in older children (ages 13-17) may buffer the influence
of poor functional status on depressive symptoms. A significant three-way
interaction was also found between functional status, relatedness, and gender
(ß =.463, p <.05). Examination of the plotted slopes suggests
that girls who are very functionally impaired (scores 60 and below) may not
benefit from positive mother-child relatedness in preventing symptoms of
depression. Extreme caution must be taken in the interpretation of these
results as they were not theoretically predicted and are based on 19 teenagers
and on 6 children scoring 60 or below on the functional status measure.
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Discussion |
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The purpose of this study was to investigate parent-child relationship quality as a potential risk or protective factor for children with asthma who are at increased risk for depression because of the functional impairment they may experience as the result of their illness. We identified two specific pathways by which the parent-child relationship may be influential in the association between illness-related functional status and depressive symptoms. The first pathway suggested that parent-child relationship quality would have a moderating effect. This hypothesis, however, was not supported. Overall, secure patterns of parent-child relationship did not buffer nor did insecure patterns exacerbate the impact of poor functional status on depressive symptoms. Instead, the second pathway in which parent-child relationship quality (secure or insecure) was predicted to mediate the relationship between functional status and depressive symptoms was supported. Illness-related functional impairment may influence the child's relationship with his or her primary caregiver, which, in turn, influences the development of depressive symptoms in the child. Overall, findings in this study underscore the importance of investigating parent-child relationships among children with asthma, emphasizing that disease factors alone may not fully explain the development of emotional disturbances in these children.
Although the child's relationship quality with his or her father did not
mediate the impact of functional status on depressive symptoms, the influence
of fathers in the lives of their children should not be discounted. A
nonsignificant trend was detected in an exploratory analysis assessing the
relationship between positive mother-child relationships and the presence of a
father figure in the household: 73.0% of children with fathers present versus
55.6% with fathers not present reported secure relatedness with their mothers,
2(1,55) = 1.669, p =.196. Although this trend must be
interpreted with extreme caution, it nonetheless suggests that fathers may
play a role in supporting the mother-child relationship. Current literature
supports the notion that fathers do play an important role in the lives of
their children and that positive father-child relationships are in general
associated with better psychosocial outcomes
(Akande, 1997). However, future
research is necessary to identify the pathways by which the presence of a
father or father figure may affect the emotional well-being of children with
asthma.
Results of the exploratory analyses suggest that within the proposed mediational model, relatedness may also play a moderating role for certain subgroups of children. Post hoc analyses revealed that the developmental variables (age and gender) may interact with functional status and relatedness in predicting depressive symptoms in children with asthma. Specifically, positive maternal relatedness may buffer older children (ages 13-17) from depressive symptoms, but girls who are very functionally impaired (scores 60 and below on the functional status measure) may not be similarly protected. Firm conclusions, however, cannot be drawn because of the small sample size on which these analyses were based, with only 19 children in the 13 to 17 age range and 6 children scoring 60 or below on the functional status measure. These findings suggest areas of future research in which larger sample sizes are provided in the investigation of complex interactions between developmental and relationship variables, as well as the exploration of models of relationships including both mediating and moderating pathways.
Although this study supports a model that implies a linear direction of
effect from functional status through relatedness to depressive states in
children, the model does not exclude the possibility that some of the factors
may mutually influence one another. For example, Miller
(Miller, 1987;
Miller & Wood, 1997)
suggests that depressive symptoms may actually exacerbate airways dysfunction
in asthma via a psychophysiological (autonomic nervous system) pathway.
Furthermore, depressive symptoms may have a mediating influence on the
relationship between functional status and relationship quality. Functional
impairment may influence feelings of depression, and depressive symptoms may,
in turn, hamper the child's ability to experience or maintain positive
parent-child relationships. Clearly various possible inter-pretations of the
current data exist, and alternative models must be investigated before the
proposed mediational model can be fully accepted.
Future research must test causal direction, eliminate shared method variance, and more clearly define parent-child interactions relevant to the emotional well-being of children with asthma. A longitudinal study measuring parent-child relationship patterns and symptoms of depression, both before and after the onset of asthma, would help to confirm causal direction as would testing the impact of each variable on each other through controlled clinical intervention trials. Implementing observation and interview measures would prevent a limitation of this study in which the child's self-report was used for both relatedness and depressive symptoms. Shared method variance in this study may have accounted for the association between relatedness and depression, as the parental report of depression was not very highly correlated with the child's report and did not meet criteria for testing for mediation. Finally, distinguishing between the child's perception and more objective measures of relationship quality, as well as identifying coping strategies and communication patterns of the child, would provide useful information about the kinds of behaviors that support or undermine parent-child relationships.
This study suggests that the parent-child relationship between children
with asthma and their primary caregivers may be an important point of
intervention for the treatment and prevention of depressive symptoms.
Crittenden (1992) suggests
that parent-child attachment relationships may be improved by intervening with
the parent or the child directly. Furthermore, Campbell and Patterson
(1995), in a review of
family-centered intervention studies, suggest that family therapy approaches
in treating children with chronic illness may be the most efficacious. More
research is needed, however, to investigate the impact of these treatments and
ways in which traditional approaches to therapy may or may not apply to groups
of depressed children with different chronic illnesses.
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Acknowledgments |
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Support for this work was provided by a Research Scientist Development Award from NIMH awarded to Beatrice L. Wood (K01 MH01291). We thank John Parker and Chris Cox for their assistance with the data analyses, Jutta Helm and Jeffrey Rockoff for their help with participant recruitment, as well as all the families who participated in the study. In addition, we thank the members of David Reiss's Research Seminar and the anonymous reviewers for their critical reviews of this manuscript.
Received September 15, 1998; revision received February 17, 1999; revision received July 26, 1999; accepted October 29, 1999
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