Commentary: Stress, Conflict, and the Family System in Pediatric Cancer

Commentary: Stress, Conflict, and the Family System in Pediatric Cancer Family systems and family dynamics are of utmost importance in understanding both risk and resilience among families affected by pediatric cancer, as well as other medical conditions (Kazak, Alderfer, & Reader, 2017). Over three decades of work suggests that a consistent subset of youth with pediatric illness are at increased risk for negative psychosocial outcomes such as depression, anxiety, and posttraumatic stress, and this risk extends even beyond the affected children, to include their parents and siblings as well (Pinquart & Shen, 2011a, 2011b; Sharpe & Rossiter, 2002). Although it appears clear that family factors are important to individual adjustment, there is still a great need to understand precisely how these family systems dynamics change over time, as well as the underlying processes by which they change. Fladeboe and colleagues (2018) present interesting and compelling findings that add to our understanding of family functioning in the wake of a pediatric cancer diagnosis. Notably, Fladeboe and colleagues (2018) used a novel month-to-month data collection methodology to assess sibling conflict in conjunction with different sources or types of family stressors, which is especially commendable given the current underutilization of advanced methodologies pertinent to accurately understanding family systems (Berlin, Karazsia, & Klages, 2017). Fladeboe and colleagues (2018) found that parent perceptions of the severity of stressors did decrease across time. Mean levels of sibling conflict increased slightly, though levels of conflict were not elevated compared with the general population. Significant between-families effects were indeed found, such that families who indicated higher levels of cancer-related stress, general life stress, and financial stress experienced higher levels of sibling conflict than families reporting lower levels of these stressors. However, analyses revealed no within-families effects of stressors on sibling conflict, meaning changes in these stressors from month-to-month did not coincide with changes in sibling conflict. Thus, results suggest that the early presence and persistence of both cancer-specific and general stressors may result in more lasting impact on family functioning, especially as it pertains to sibling conflict. It is interesting, however, to consider other possible explanations for the findings presented by Fladeboe and colleagues (2018). In discussing these findings, the authors primarily focused on hypotheses in which increased perceptions of stressors are at the “root” of causality in the relationship between sibling conflict and stress. Their explanations included hypotheses such as the spill-over effect of stressors on a parent’s ability to provide effective and consistent parenting, as well as increased child reactivity to minor stressors. Alternatively, it is important to consider to what extent those families who are more prone to dysfunction premorbidly may be more likely to have a parent who perceives stressors as more severe and intrusive. For instance, parents who have a preexisting negative cognitive bias may be more likely to engage in negative parenting strategies such as using criticism, which may be related to an increased likelihood that their children have conflict following a significant life disruption such as pediatric cancer (Beck, 1987). Indeed, this alternative cognitive appraisal explanation may even be supported by the lack of within-families effects found in the study, suggesting that differences are indeed family-specific, rather than linked to levels of stressors at that given time. Although there is unfortunately no litmus test for either explanation, many well-established theories exist to suggest that indeed both explanations could be accurate (Kazak, 1989; Thompson & Gustafson, 1996; Wallander & Varni, 1998). Thus, it is possible that premorbid factors, such as a parent’s cognitive appraisal bias, and the presence of increased stressors that often accompany pediatric cancer can both result in increased family dysfunction. To further expand on the present findings, foundational models of family systems are also important to reconsider in a new historical context, as they are still pertinent to understanding the complex interactions within the family unit. For instance, Olson and colleagues’ (1979) Circumplex Model of Marital and Family Systems posits that factors such as flexibility and cohesion of the family system are necessary for understanding how families may be differentially vulnerable to stressors and conflict among family members. As such, it may be that family flexibility and cohesion could be salient predictors of both parent perceptions of stressors and sibling conflict, or it may be that family structure moderates the relationship between parent-perceived stress and sibling conflict. Thus, future research in this area may benefit from assessing family systems factors with measures such as the Family Adaptability and Cohesion Evaluation Scale IV, the McMaster Family Assessment Device, and the Family Environment Scale (Miller, Epstein, Bishop, & Keitner, 1985; Moos & Moos, 1994; Olson, 2011). In sum, these findings provide insight into potentially overlooked impact that pediatric cancer-related stress has on the family system as a whole and provide us with valuable directions for future research. Regardless of the exact mechanisms operative in these complex interrelationships, these results speak to the importance of evaluating family functioning in families affected by pediatric cancer using longitudinal designs and contemporary statistical approaches. As such, pediatric psychologists should continue expanding research to better understand specific novel aspects of family functioning (such as sibling conflict), as it is related to the many challenges that accompany pediatric cancer. In addition, although extant data suggest that there is “transmission” of stress from parent to child, we do not necessarily know how this occurs. Thus, to further understand the clinical implications of this finding, it will be important to evaluate modifiable mediating factors, such as parent–child verbal and nonverbal communication patterns that may operate to transmit stress (Murphy, Murray, & Compas, 2017). In addition, these approaches should ideally assess multiple dimensions of family functioning, especially in families who identify multiple significant stressors following a pediatric cancer diagnosis. Conflicts of interest: None declared. References Beck A. T. ( 1987). Cognitive models of depression. Journal of Cognitive Psychotherapy , 1, 5– 37. Berlin K. S., Karazsia B. T., Klages K. L. ( 2017). Research design in pediatric psychology. In Handbook of Pediatric Psychology  ( 5th ed., pp. 38– 55). New York: The Guilford Press. Fladeboe K., King K., Kawamura J., Gurtovenko K., Stettler N., Compas B., Friedman D., Lengua L., Breiger D., Katz L. F. ( 2018). Caregiver perceptions of stress and sibling conflict during pediatric cancer treatment. Journal of Pediatric Psychology , jsy008, https://doi.org/10.1093/jpepsy/jsy008. Kazak A. E. ( 1989). Families of chronically ill children: A systems and social-ecological model of adaptation and challenge. Journal of Consulting and Clinical Psychology , 57, 25– 30. Kazak A. E., Alderfer M. A., Reader S. K. ( 2017). Families and other systems in pediatric psychology. In Handbook of pediatric psychology  ( 5th ed., pp. 566– 579). New York: The Guilford Press. Miller I. W., Epstein N. B., Bishop D. S., Keitner G. I. ( 1985). The McMaster family assessment device: reliability and validity. Journal of Marital and Family Therapy , 11, 345– 356. Moos R. H., Moos B. S. ( 1994). Family environment scale manual . Palo Alto, CA: Consulting Psychologists Press. Murphy L. K., Murray C. B., Compas B. E. ( 2017). Topical review: Integrating findings on direct observation of family communication in studies comparing pediatric chronic illness and typically developing samples. Journal of Pediatric Psychology , 42, jsw051. http://doi.org/10.1093/jpepsy/jsw051 Olson D. ( 2011). FACES IV and the circumplex model: Validation study. Journal of Marital and Family Therapy , 37, 64– 80. Olson D. H., Sprenkle D. H., Russell C. S. ( 1979). Circumplex model of marital and family systems: I. Cohesion and adaptability dimensions, family types, and clinical applications. Family Process , 18, 3– 28. http://doi.org/10.1111/j.1545-5300.1979.00003.x Pinquart M., Shen Y. ( 2011a). Anxiety in children and adolescents with chronic physical illnesses: A meta-analysis. Acta Paediatrica , 100, 1069– 1076. http://doi.org/10.1111/j.1651-2227.2011.02223.x Pinquart M., Shen Y. ( 2011b). Behavior problems in children and adolescents with chronic physical illness: A meta-analysis. Journal of Pediatric Psychology , 36, 375– 384. http://doi.org/http://dx.doi.org/10.1093/jpepsy/jsq104 Sharpe D., Rossiter L. ( 2002). Siblings of children with a chronic illness: A meta-analysis. Journal of Pediatric Psychology , 27, 699– 710. http://doi.org/10.1093/jpepsy/27.8.699 Thompson R. J., Gustafson K. E. ( 1996). Adaptation to chronic childhood illness . Washington, DC: American Psychological Association. Wallander J. L., Varni J. W. ( 1998). Effects of pediatric chronic physical disorders on child and family adjustment. Journal of Child Psychology and Psychiatry , 39, 29– 46. http://doi.org/10.1111/1469-7610.00302 © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Pediatric Psychology Oxford University Press

Commentary: Stress, Conflict, and the Family System in Pediatric Cancer

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© The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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Abstract

Family systems and family dynamics are of utmost importance in understanding both risk and resilience among families affected by pediatric cancer, as well as other medical conditions (Kazak, Alderfer, & Reader, 2017). Over three decades of work suggests that a consistent subset of youth with pediatric illness are at increased risk for negative psychosocial outcomes such as depression, anxiety, and posttraumatic stress, and this risk extends even beyond the affected children, to include their parents and siblings as well (Pinquart & Shen, 2011a, 2011b; Sharpe & Rossiter, 2002). Although it appears clear that family factors are important to individual adjustment, there is still a great need to understand precisely how these family systems dynamics change over time, as well as the underlying processes by which they change. Fladeboe and colleagues (2018) present interesting and compelling findings that add to our understanding of family functioning in the wake of a pediatric cancer diagnosis. Notably, Fladeboe and colleagues (2018) used a novel month-to-month data collection methodology to assess sibling conflict in conjunction with different sources or types of family stressors, which is especially commendable given the current underutilization of advanced methodologies pertinent to accurately understanding family systems (Berlin, Karazsia, & Klages, 2017). Fladeboe and colleagues (2018) found that parent perceptions of the severity of stressors did decrease across time. Mean levels of sibling conflict increased slightly, though levels of conflict were not elevated compared with the general population. Significant between-families effects were indeed found, such that families who indicated higher levels of cancer-related stress, general life stress, and financial stress experienced higher levels of sibling conflict than families reporting lower levels of these stressors. However, analyses revealed no within-families effects of stressors on sibling conflict, meaning changes in these stressors from month-to-month did not coincide with changes in sibling conflict. Thus, results suggest that the early presence and persistence of both cancer-specific and general stressors may result in more lasting impact on family functioning, especially as it pertains to sibling conflict. It is interesting, however, to consider other possible explanations for the findings presented by Fladeboe and colleagues (2018). In discussing these findings, the authors primarily focused on hypotheses in which increased perceptions of stressors are at the “root” of causality in the relationship between sibling conflict and stress. Their explanations included hypotheses such as the spill-over effect of stressors on a parent’s ability to provide effective and consistent parenting, as well as increased child reactivity to minor stressors. Alternatively, it is important to consider to what extent those families who are more prone to dysfunction premorbidly may be more likely to have a parent who perceives stressors as more severe and intrusive. For instance, parents who have a preexisting negative cognitive bias may be more likely to engage in negative parenting strategies such as using criticism, which may be related to an increased likelihood that their children have conflict following a significant life disruption such as pediatric cancer (Beck, 1987). Indeed, this alternative cognitive appraisal explanation may even be supported by the lack of within-families effects found in the study, suggesting that differences are indeed family-specific, rather than linked to levels of stressors at that given time. Although there is unfortunately no litmus test for either explanation, many well-established theories exist to suggest that indeed both explanations could be accurate (Kazak, 1989; Thompson & Gustafson, 1996; Wallander & Varni, 1998). Thus, it is possible that premorbid factors, such as a parent’s cognitive appraisal bias, and the presence of increased stressors that often accompany pediatric cancer can both result in increased family dysfunction. To further expand on the present findings, foundational models of family systems are also important to reconsider in a new historical context, as they are still pertinent to understanding the complex interactions within the family unit. For instance, Olson and colleagues’ (1979) Circumplex Model of Marital and Family Systems posits that factors such as flexibility and cohesion of the family system are necessary for understanding how families may be differentially vulnerable to stressors and conflict among family members. As such, it may be that family flexibility and cohesion could be salient predictors of both parent perceptions of stressors and sibling conflict, or it may be that family structure moderates the relationship between parent-perceived stress and sibling conflict. Thus, future research in this area may benefit from assessing family systems factors with measures such as the Family Adaptability and Cohesion Evaluation Scale IV, the McMaster Family Assessment Device, and the Family Environment Scale (Miller, Epstein, Bishop, & Keitner, 1985; Moos & Moos, 1994; Olson, 2011). In sum, these findings provide insight into potentially overlooked impact that pediatric cancer-related stress has on the family system as a whole and provide us with valuable directions for future research. Regardless of the exact mechanisms operative in these complex interrelationships, these results speak to the importance of evaluating family functioning in families affected by pediatric cancer using longitudinal designs and contemporary statistical approaches. As such, pediatric psychologists should continue expanding research to better understand specific novel aspects of family functioning (such as sibling conflict), as it is related to the many challenges that accompany pediatric cancer. In addition, although extant data suggest that there is “transmission” of stress from parent to child, we do not necessarily know how this occurs. Thus, to further understand the clinical implications of this finding, it will be important to evaluate modifiable mediating factors, such as parent–child verbal and nonverbal communication patterns that may operate to transmit stress (Murphy, Murray, & Compas, 2017). In addition, these approaches should ideally assess multiple dimensions of family functioning, especially in families who identify multiple significant stressors following a pediatric cancer diagnosis. Conflicts of interest: None declared. References Beck A. T. ( 1987). Cognitive models of depression. Journal of Cognitive Psychotherapy , 1, 5– 37. Berlin K. S., Karazsia B. T., Klages K. L. ( 2017). Research design in pediatric psychology. In Handbook of Pediatric Psychology  ( 5th ed., pp. 38– 55). New York: The Guilford Press. Fladeboe K., King K., Kawamura J., Gurtovenko K., Stettler N., Compas B., Friedman D., Lengua L., Breiger D., Katz L. F. ( 2018). Caregiver perceptions of stress and sibling conflict during pediatric cancer treatment. Journal of Pediatric Psychology , jsy008, https://doi.org/10.1093/jpepsy/jsy008. Kazak A. E. ( 1989). Families of chronically ill children: A systems and social-ecological model of adaptation and challenge. Journal of Consulting and Clinical Psychology , 57, 25– 30. Kazak A. E., Alderfer M. A., Reader S. K. ( 2017). Families and other systems in pediatric psychology. In Handbook of pediatric psychology  ( 5th ed., pp. 566– 579). New York: The Guilford Press. Miller I. W., Epstein N. B., Bishop D. S., Keitner G. I. ( 1985). The McMaster family assessment device: reliability and validity. Journal of Marital and Family Therapy , 11, 345– 356. Moos R. H., Moos B. S. ( 1994). Family environment scale manual . Palo Alto, CA: Consulting Psychologists Press. Murphy L. K., Murray C. B., Compas B. E. ( 2017). Topical review: Integrating findings on direct observation of family communication in studies comparing pediatric chronic illness and typically developing samples. Journal of Pediatric Psychology , 42, jsw051. http://doi.org/10.1093/jpepsy/jsw051 Olson D. ( 2011). FACES IV and the circumplex model: Validation study. Journal of Marital and Family Therapy , 37, 64– 80. Olson D. H., Sprenkle D. H., Russell C. S. ( 1979). Circumplex model of marital and family systems: I. Cohesion and adaptability dimensions, family types, and clinical applications. Family Process , 18, 3– 28. http://doi.org/10.1111/j.1545-5300.1979.00003.x Pinquart M., Shen Y. ( 2011a). Anxiety in children and adolescents with chronic physical illnesses: A meta-analysis. Acta Paediatrica , 100, 1069– 1076. http://doi.org/10.1111/j.1651-2227.2011.02223.x Pinquart M., Shen Y. ( 2011b). Behavior problems in children and adolescents with chronic physical illness: A meta-analysis. Journal of Pediatric Psychology , 36, 375– 384. http://doi.org/http://dx.doi.org/10.1093/jpepsy/jsq104 Sharpe D., Rossiter L. ( 2002). Siblings of children with a chronic illness: A meta-analysis. Journal of Pediatric Psychology , 27, 699– 710. http://doi.org/10.1093/jpepsy/27.8.699 Thompson R. J., Gustafson K. E. ( 1996). Adaptation to chronic childhood illness . Washington, DC: American Psychological Association. Wallander J. L., Varni J. W. ( 1998). Effects of pediatric chronic physical disorders on child and family adjustment. Journal of Child Psychology and Psychiatry , 39, 29– 46. http://doi.org/10.1111/1469-7610.00302 © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Journal of Pediatric PsychologyOxford University Press

Published: Apr 19, 2018

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