By Fiese, Barbara Winter, Marcia; Anbar, Ran; Howell, Kimberly; Poltrock, Scott
This preliminary report links the literatures on family asthma management practices and on the characteristics of family interaction patterns thought to influence children’s adjustment to a chronic physical illness. Specifically, this study of 60 families with a child with asthma examined the extent to which perceived burden of routine asthma care affected child mental health via its influence on parent-child interaction patterns. Mothers completed a measure of asthma management routine burden, mother and child were observed in a 15-minute interaction task, and children completed measures of child anxiety and asthma quality of life (QOL). Perceived routine burden significantly predicted child anxiety and QOL through its effect on mother-child rejection/criticism. The same pattern did not hold for mother intrusiveness/control. The results are discussed in terms of how overall family climate and regulation of routines affects child well-being. Implications for clinical practice and limitations of the study are provided. Keywords: Pediatric Asthma; Family Routines; Family Interaction; Family Burden
Fam Proc 47:63-79, 2008
There has been a long-standing tradition of examining distinct patterns of family interaction that may be linked to psychological functioning in children with asthma (Minuchin et al., 1975). More recently, researchers have begun to examine the role that family management practices may play in influencing child health and wellbeing (Fiese & Wamboldt, 2001; McQuaid, Walders, Kopel, Fritz, & Klinnert, 2005). To date, these two domains of family influence have not been integrated within one study, despite the promise in doing so. Thus, the purpose of this preliminary report is to join these literatures in a transactional framework that allows for an examination of indirect family influences on individual adaptation in the family context of a chronic health condition (Fiese, Spagnola, & Everhart, 2008). Our aim is to explore whether the effects of family disease management practices influence child emotional functioning by virtue of their effects on family interaction patterns. In doing so, we hope to take a step toward elucidating the complex relationship that exists between family process and emotional functioning for children with asthma.
FIGURE 1 Conceptual Model Depicting the Hypothesized Pathways from Asthma Burden to Mother-Child Interaction and from Mother- Child Interaction to Child Functioning
There are three specific aims of this study. First, we endeavor to extend existing knowledge by considering two distinct family interaction patterns that have been theorized to be important to child outcomes: intrusiveness and rejection. second, we conceptualize the stress of child asthma on families as manifesting in the family system as the burden that caregivers associate with managing a chronic disease. Third, we consider how perceived burden impacts child functioning (quality of life and anxiety) through mother-child interaction patterns (see Figure 1).
FAMILY INTERACTION PATTERNS
Theorists and researchers have long been interested in understanding how the family climate may affect the expression of symptoms for children with asthma. One of the earliest accounts of this was provided by Dr. Murray Peshkin in 1919. Peshkin observed that when his child asthmatic patients were removed from their homes, their symptoms “disappeared” under the care of sympathetic and nurturing nurses in a hospital setting. Given that this was evidenced even for children reared in thoroughly cleaned homes, Peshkin speculated that his child patients were in essence emotionally allergic to their parents and that by placing them in a convalescent environment, he had performed a “parentectomy” that alleviated the child’s symptoms (Robinson, 1972). While few would endorse Peshkin’s notion of an allergic response to parents, his observations ultimately prompted others to identify distinct patterns of interaction within families that are associated with children’s asthma.
Two dimensions of family interaction have been particularly identified in the literature as potential contributors to child symptoms. First, parents who were considered to be overprotective were thought to exacerbate their child’s symptoms (Lee, Murry, Brody, & Parker, 2002). The reasoning underlying this notion is that some parents’ reasonable concern for their children’s physical health may evolve into overinvolvement and overprotectiveness. Results have supported this conclusion, with some parents of children with asthma at times exhibiting overly controlling and intrusive patterns of interaction (Gustafsson, Kjellman, & Bjorksten, 1994). However, the links to child outcomes are inconclusive because most of the reports that have examined overprotective or intrusive interaction styles in relation to child symptoms have been clinical reports or naturalistic observations of parents in the home with few details about the coding scheme (Renne & Creer, 1985). Thus, the notion that overprotective patterns of interaction will be associated with greater child symptoms requires additional exploration.
A second dimension of family interaction that has been identified as a contributor to child functioning is parental criticism and rejection. Parent criticism has been found to be related to hospitalization rates and response to treatment (F. S. Wamboldt, Wamboldt, Gavin, Roesler, & Brugman, 1995) and problematic child behaviors (Christiannse, Lavigne, & Lerner, 1989). At its most extreme influence, high levels of parental criticism have been linked to increased risk for death due to severe asthma (Strunk, 1987). Rejection has also been associated with higher rates of hospitalization for children with asthma (Chen, Bloomberg, Fisher, & Strunk, 2003). Thus, in addition to further exploring the potential role of intrusiveness, we also consider the role of parent rejection and criticism in children’s functioning.
There are a variety of ways in which non-supportive family interaction patterns may affect children’s mental health. It is well recognized that families who exhibit negative emotional interaction patterns (e.g., conflict) and exhibit rejecting attitudes toward their children place children at increased risk for poor behavioral outcomes (e.g., Repetti, Taylor, & seeman, 2002). We chose to focus specifically on two aspects of child functioning-child anxiety and quality of life. Children with asthma are at increased risk for developing internalizing symptoms as compared with externalizing symptoms (McQuaid, 2001; Ortega, Huertas, Canino, Ramirez, & Rubio- Stipec, 2002). While it may not be surprising that feelings of panic, somatic complaints, and worry would be associated with an illness that is characterized by shortness of breath and frightening attacks that can lead to hospitalization, the long-term consequences of anxiety symptoms in childhood have been associated with increased risk for depression in adolescence and for asthma morbidity (Cole, Peeke, Martin, Truglio, & Seroczynski, 1998; Wamboldt, Fritz, Mansell, McQuaid, & Klein, 1998). Whereas the link between family interaction and child mental health has been fairly well established in the literature, outcomes associated with disease management strategies have tended to focus on functional morbidity and the extent to which optimal practices are related to fewer health symptoms (McQuaid et al., 2005). Thus, we included a measure of child quality of Ufe that assesses the degree to which children’s asthma affected their daily activities, caused them to worry, and the extent of overall disease symptom expression. We expected child report of anxiety and quality of life to be moderately related to each other. However, given that they are often considered as distinct outcomes for family interaction and family management, we tested both in our separate models.
THE PERCEIVED BURDEN OFASTHMA MANAGEMENT
Caring for a child with persistent asthma requires a daily investment of energy including regular house cleaning, filling prescriptions, avoiding allergens, and reminding the child to take his or her medications, typically twice a day (NIH, 1997). The family’s ability to manage these daily tasks has been found to be related not only to adherence to medical regimens but also to quality of life for child and caregiver (Fiese, Wamboldt, & Anbar, 2005; McQuaid et al., 2005). In an interview-based assessment of family asthma management, McQuaid and colleagues report that daily practices such as symptom monitoring and balancing attention to disease management and other developmental and family issues were related to disease morbidity above and beyond the effects of disease severity and medical adherence. In a questionnaire study of 153 families, Fiese and colleagues identified two aspects of family management associated with children’s outcomes. First, the implementation of regular routines around medication use was associated with medical adherence and health care utilization. A second aspect of family management, identified as the burden associated with daily care, was associated with quality of life for child and caregiver. Routine burden can best be conceptualized as the amount of strain that the parent perceives as associated with the daily demands of care. It can be distinguished from the actual practice of carrying out the routine itself, and thus it may reflect more of the emotional commitment often noted in the study of family rituals (Fiese, Tomcho et al., 2002). FAMILY INTERACTION PATTERNS AS AN INTERVENING VARIABLE
In the case of pediatric asthma, the added demands of daily care may manifest in parent’s resentment and feelings of burden, which affects how parent and child interact with each other (Wamboldt, Wamboldt, & Gavin, 2001). Adopting a contextual approach, we propose that parent-child interaction patterns are embedded in the overall climate of daily disease management. Specifically, we expect that the perceived burden of asthma management will lead to less adaptive caregiver-child interactions, which in turn will impact child functioning (see Figure 1). Thus, in this report we examine the extent to which family interaction patterns act as an intervening variable in the path between family burden of asthma management practices and child emotional functioning.
In this preliminary study, we focused our observations on mother- child interactions. Recognizing that fathers, siblings, and grandparents are influential members of a child’s life and that all may affect disease management, we are also cognizant that mothers and fathers may differ in their interactive styles in significant ways (Holmbeck, Coakley, Hommeyer, Shapera, & Westhoven, 2002; Parke, 2004); we limited our analysis to mother-child pairs. This necessarily limits the generalizability of our study but due to the complexity of our proposed model we opted for a strategy that would allow for the greatest number of observations and adequate statistical power.
We expand on previous research that has been methodologically limited in several aspects. First, the observational studies examining the role of overprotectiveness and control have been limited to primarily case studies and small sample sizes. Thus, we aim to consider how intrusiveness and control may be related to children’s mental health in a larger sample under a semi-structured laboratory task. second, measures of family interaction and criticism have relied primarily on the use of self-report measures or interview techniques (Chen et al., 2003; Wamboldt et al., 1995). In response, we aim to observe directly the extent to which mothers express criticism or rejection during an emotionally neutral interaction task. Third, we endeavor to test an indirect pathway whereby the effects of perceived burden of care on child functioning are through mother-child interaction patterns. We reason that mothers who perceive more burden associated with daily management routines will engage in more rejecting and perhaps more intrusive interaction patterns (Figure 1, Path A) with their children and that these negative interaction patterns will in turn increase children’s anxiety and decrease their quality of life (Path B).
METHOD
Participants
Participants for this study were recruited from two pediatric clinics in a mid-size city in central New York State. Families who expressed interest in participating in the project were included in the study if, at the time of recruitment, the target child: (1) was between the age of 5 and 13, (2) had an asthma diagnosis (of at least 6 months duration) confirmed by their physician, (3) had experienced asthma symptoms at least twice per month for the previous 6 months, (4) was prescribed daily asthma medication, and (5) was not diagnosed with a chronic medical condition other than asthma.
Participants included 60 children (19 girls and 41 boys; mean age 8.69 years, SD = 2.42) and their primary caregivers (62% female [mothers or grandmothers], 31% mothers and fathers, and 7% fathers). In all but the 7% of families in which only the father participated, the female (mother or grandmother) was identified by the family as the primary caregiver for the child. Therefore, and because our sample size did not allow enough power to compare families based on primary caregiver gender, we focused on the female primary caregiver in this study.
Primary caregiver-reported child ethnicity was 67% Caucasian, 26% African-American, 4% Hispanic, 2% Asian, and 2% other. Socioeconomic status of the sample, indexed by the mean total score on the Hollingshead Index (Hollingshead, 1975), ranged from 6 to 66, with a mean of 35.18 (SD = 17.88), indicating that on average, families were in group three of the five social strata groups of the Hollingshead Index. Sixty percent of primary caregivers reported being married, 20% single, 6% remarried after divorce, 2% remarried after widowed, 7% separated, 2% divorced, and 4% widowed.
Procedure
Children and their primary caregivers were recruited through two pediatric clinics in a medical school/teaching hospital: a specialty pulmonary pediatric clinic and a general pediatric practice. Following a description of the study by the physician or respiratory therapist during a routine visit to the office, interested primary caregivers were contacted by phone to discuss and schedule study participation. In this Institutional Review Board-approved study, children and caregivers were interviewed in a laboratory setting where caregiver written consent and child verbal assent to participate were obtained. During the lab visit, caregivers and children completed questionnaires, were interviewed about the effects of asthma on their daily lives, and participated in a family interaction task. The family lab visit lasted approximately 2 hours, for which caregivers were paid $50 and children received prizes for participating.
Measures
Functional symptom severity
Primary caregivers completed the Functional Symptom Severity of Asthma scale, which consists of six items assessing the extent of wheezing, nighttime waking, activity limitation, and speech limitation (Rosier et al., 1994). The validity of this measure has been demonstrated by its theoretically meaningful ties to school days missed, functional impairment, and medical care visits. For this study, we used mother report on four items pertaining to the last year: wheezing frequency, along a 4-point scale from 4 = daily to 0 = never; frequency of nighttime waking, rated along a 4-point scale from 4 = most nights to 0 = never; and two items pertaining to frequency of activity limitations and sports limitations due to asthma symptoms, rated along 4-point scales from 4 = daily to 0 = never. Items were standardized and, consistent with previous research, a total score was derived by summing responses across items; internal consistency as indexed by intraclass correlation was .82 in this sample.
Routine burden
Burden associated with asthma management was measured using mother reports on the asthma routines subscale of the Family Routines Questionnaire-Asthma Version (Fiese et al., 2005). The asthma routines subscale consists of eight forcedchoice items that pertain to roles, routines, cleaning, remembering to take medication, timing of medication, and so on. The validity of the FRQ- A has been evidenced by its meaningful ties to general family functioning as well as adherence to medication regimens. Previous research with the full FRQ has found it to be unrelated to social desirability and socioeconomic status in community-based samples and for families with a child with asthma (Fiese & Kline, 1993; Markson & Fiese, 2000). Three items were used to assess caregiver report of burden associated with asthma: how much of a chore asthma management is perceived to be, the degree to which cleaning to avoid allergens is haphazard as opposed to routinized, and the extent to which asthma is perceived as no big deal as opposed to an opportunity for family growth. Items were reverse scored so that higher scores indicated higher burden. A principal components analysis indicated that the three items cohered together on one overall factor (loadings .66, .81., and .75) and therefore scores were averaged to form an overall burden score. Internal consistency for this sample was a = .60. Although slightly lower than recommended (Nunnally, 1978), the overall internal consistency is likely underestimated due to the relatively few number of items that comprise the scale, and therefore we deemed it acceptable for this early stage research (Henson, 2001; Onwuegbuzie & Daniel, 2002; Osburn, 2000; Streiner, 2003).
Mother rejection and intrusiveness
Mother rejection and intrusiveness were coded from observations of caregiver-child interactions. More specifically, caregivers and children were given 15 minutes to complete a drawing of a family crest/coat of arms with symbols and activities that represent their family. This crest task was chosen specifically for this study as it was consistent with the overall design of the project’s focus on family routines and family activities.
Caregivers and children were alone during the videotaped task, which was later coded for the extent to which female primary caregivers were rejecting and intrusive during the interaction. First, we assessed mother rejection using the System for Coding Interactions and Family Functioning (SCIFF; Lindahl & Malik, 1996). The SCIFF codes were designed to capture family interaction patterns and highlight both adaptive and maladaptive aspects of family relationships. Codes are rated along a 5-point Likert scale ranging from 1 = very low to 5 = high. For this study, we used the Rejection and Invalidation code, which captures the extent to which parent behaviors or verbalizations are rude, dismissive, insensitive, critical, blaming, or insulting to the child, ranging from not at all rejecting or invalidating to several instances of overt rejection, criticism, etc.
Second, to measure Intrusiveness, we drew from the SCIFF format as well as common theoretical conceptualizations of autonomy (e.g., Hauser et al., 1984; Mattanah, 2005; see Cowan, Cowan, Ablow, Johnson, & Measelle, 2005) to develop a code assessing the extent to which the mother allowed the child to direct the task and valued the child’s opinion. Ratings ranged from 1= Intrusive I Controlling, in which the mother did not seem to recognize the child’s needs, perspective, or competence and instead controlled the task him/ herself and/or devalued the child’s contribution, to 5= High Autonomy, where the mother solicited and reinforced the child’s opinion, initiative, and problem solving during the task. Ratings were reverse scored such that higher scores indicate higher intrusiveness. All videotaped interactions were coded by a rater who was extensively trained on the appropriate application of the rating systems. In addition, 25% of the interactions were coded by a second trained rater. Interrater reliability, indexed by Cronbach’s a, was .83 for Rejection and .82 for Intrusiveness.
Child quality of life
Children completed the Pediatric Asthma Quality of Life Questionnaire (PAQLQ; Juniper, Guyatt, Ferrie, & Griffith, 1993). The PAQLQ is designed to measure child emotional, physical, and social impairments experienced by children with asthma. Children ages 8 years and older were asked questions pertaining to how much they were bothered by various symptoms or situations associated with asthma during the past week, on a scale ranging from 1 = all of the time to 7 = none of the time. For the first three items, children were asked to choose activities (both spontaneously and via a list) that were limited by asthma during the past week; of the endorsed activities, children were asked to choose the three that bothered them the most and then asked how much they were bothered. The remaining 20 items were presented in question and answer format. Consistent with PAQLQ procedures, items were averaged to form three subscales: emotional functioning (8 items, e.g., “How often did your asthma make you feel angry during the past week?”); physical symptoms (10 items, e.g., “How much did coughing bother you in the past week?”); and social activity limitations (5 items, e.g., “How often did you feel you couldn’t keep up with others because of your asthma during the past week?”). Internal consistency in this sample, as indexed by intraclass correlation, was .90, .90, and .76 for the emotional functioning, physical symptoms, and social activity limitations subscales, respectively.
A modified, picture-based version of the PAQLQ was developed for children under the age of eight, in which they were asked to respond to questions by drawing an X anywhere along a line anchored by three depicted thermometers: empty (“not at all”), half full, and full (“a lot”). For these younger children, the first three activity questions along with four other items (e.g., “How often did your asthma make you feel frustrated during the past week?”) from the original scale were eliminated due to difficulty level/ developmental considerations, resulting in 16 questions, one pertaining to activities, 10 averaged to form the symptoms subscale, and five averaged into the emotional functioning subscale. In this sample, intraclass correlation indexing internal consistency was .83 and .74 for the physical symptoms and emotional functioning subscales, respectively. Next, they were standardized and then combined across age. Consistent with previous research (e.g., Juniper et al., 1993), subscale scores were averaged to form an overall index of child quality of life (QOL) that demonstrated high internal consistency (alpha = .91).
Child anxiety
Children completed the Multidimensional Anxiety Scale for Children (MASC; March, 1997), a measure of anxiety problems including physical symptoms, harm avoidance, social anxiety, separation/panic, and total anxiety. The MASC is intended for children aged 8 and above, and therefore data are only available for older children in this sample. The 39 items of the MASC were read aloud to children, and children were asked to respond along a 4- point scale ranging from 0 = Never true about me to 3 = Often true about me. Following the MASC scoring procedure, an age- and gender- specific T-score was derived for each child based on the total score and MASC norms derived from a diverse group. The MASC has adequate psychometric properties, as evidenced by an internal consistency of .88 and a three month test-retest of .93; in addition, the MASC has been found to distinguish between children with and without anxiety disorders (March, Sullivan, & Parker, 1999).
Demographics
To assess mother and father occupation and education levels, mothers completed questions from the Hollingshead Index (Hollingshead, 1975). More specifically, mothers reported on their own and fathers’ education level along a 7-point scale ranging from 1 = less than seventh grade completed to 7= graduate or professional degree. Similarly, they reported occupations along a 9-point scale from 0 = not employed to 9 = high executives, large business owners, etc.
RESULTS
Preliminary Analyses
The means, standard deviations, and intercorrelation of the main study variables are presented in Table 1. First, given the broad age range of the children in this study, we verified that no main study variables were significantly correlated with child age (see Table 1). Next, we conducted a series of preliminary regression analyses in which the demographic variables (occupation and education for both parents) were simultaneously entered in predicting each of the child functioning outcome variables. Because no variables uniquely predicted the child functioning variables, the demographic variables were dropped from subsequent models.
For descriptive purposes, we also examined whether child asthma symptom severity was significantly related to the main study variables. Burden necessarily includes aspects of asthma severity, and while we did not wish to taint the measure of routine burden by removing (i.e., controlling for) asthma severity in the main analyses, we did want to ensure that our measure of burden was not simply a marker of asthma severity. Therefore, we conducted regression analyses to consider whether parent report of functional severity and burden of care accounted for significant unique variance in the observed interaction patterns. In a regression analysis predicting mother intrusiveness, we found that only burden of care was a significant predictor when also simultaneously considering symptom severity, F(1,44) = 5.06, p
TABLE 1
Means, Standard Deviations, and Correlation Among the Main Study Variables
Primary Analyses
A series of linear regression analyses were conducted to address whether greater burden would impact child functioning through mother- child interaction. As discussed previously, our interest was less in whether there was mediation, per se, which would describe a direct effect of burden on child anxiety and QOL through mother rejection or intrusiveness. Instead, we were concerned with whether burden would impact mother-child interaction, and in turn, whether mother- child interaction would impact child anxiety and QOL. Theoretically, mother-child interactions characterized by intrusiveness or rejection serve the same function in mediator and indirect effects models by linking burden to child functioning (MacKinnon, Krull, & Lockwood, 2000; MacKinnon, Lockwood, Hoffman, West, & Sheets, 2002). However, the two models are substantively distinguishable: a mediator explanation uses an intervening variable to address why a given predictor variable relates to an outcome, while an indirect effects explanation explains that a predictor variable impacts an intervening variable, which in turn impacts an outcome variable. In other words, the distinguishing characteristic of a test of indirect effects is the recognition of situations in which an independent variable impacts the outcome not directly, but through a third variable. Therefore, we allowed for the theoretical possibility of both mediation and indirect effects. Empirically, testing progressed the same way. Following the recommendations of Baron and Kenny (1986), we used multiple regression analysis to test for possible indirect effects (including mediation) in a series of three steps for each outcome and intervening variable combination. First, we checked whether burden was correlated with the child outcome variable (Figure 1, Path C) by specifying a regression equation in which the child functioning variable (QOL or anxiety) was regressed onto burden. second, we tested whether burden was associated with the intervening parent-child interaction variable (rejection or intrusiveness; Figure 1, Path A) by specifying a regression equation in which the intervening variable was regressed onto burden. Third, we checked that the intervening variable was associated with the child functioning outcome (Figure 1, Path B) over and above any effects of burden by specifying a regression equation in which the child functioning variable was regressed onto burden and an intervening variable simultaneously. To establish mediation, the results must support all three steps; to support indirect effects, the results must support steps two and three (Baron & Kenny, 1986; MacKinnon et al., 2002; also see Kenny, Kashy, & Bolger, 1998).
FIGURE 2 beta Coefficients of Significant Pathways within Models Testing the Indirect Effects of Asthma Burden on Child Quality of Life and Anxiety Through Mother Intrusiveness For each set of regressions, the results of the first equation were examined to address whether burden of asthma care would predict child QOL and anxiety directly. Burden was not significantly associated with child anxiety, F(1,33) = 1.39, ns. However, greater burden was associated with lower child QOL, beta = – .36; F(1,51) = 7.39, p
FIGURE 3 beta Coefficients of Significant Pathways within Models Testing the Indirect Effects of Asthma Burden on Child Quality of Life and Anxiety Through Mother Rejection/Criticism
Following the recommendations of MacKinnon et al. (2002), to determine whether the magnitude of the indirect effect was large enough to be statistically meaningful, each indirect effect was divided by its standard error and the result was tested for significance using the critical values presented by MacKinnon et al. (2002). Significant indirect effects of burden on child functioning through mother rejection were supported for both child QOL (z’ = – 1.48, p
DISCUSSION
We set out to examine whether perceived burden of family asthma management practices affect child well-being by virtue of its effects on mother-child interaction patterns. The results supported this indirect pathway for mother-child critical interactions but not for intrusive interactions. We structure our discussion to highlight the potential transactional nature of burdensome family management routines and interaction patterns in creating a climate of care as well as recognizing the limits of our study that suggest future lines of research.
We aimed to link variations in perceived burden of asthma routines with child well-being via their effects on mother-child interaction patterns. We reasoned that caregivers who perceived daily management to be more of a chore would engage in less supportive interactions with their child with asthma; in turn, these negative patterns of interaction would result in greater anxiety and lower QOL for children. The results support the hypothesized pathway for rejecting/critical patterns of interaction: the burden of routine asthma care was associated with critical mother-child interaction patterns, which in turn were associated with higher anxiety and lower QOL for children with asthma (see Figure 3). However, unlike the results indicated in case and clinical report findings, we did not find that overprotective or intrusive patterns of interaction were associated with compromised child functioning in this sample (see Figure 2).
Caring for a family member with a chronic illness presents a host of challenges for caregivers. The negative effects of tending to the needs of spouses and adult children with chronic mental and physical disorders have been recognized within diverse groups and developmental periods. For example, spouses of dementia patients have been shown to have compromised immune functioning (Kiecolt- Glaser, Dura, Speicher, Traske, & Glaser, 1991) and population- based studies have documented that individuals providing 20 or more hours per week in care for an ill family member are twice as likely to experience psychological distress (Hirst, 2005). Thus, in divergent populations, healthcare is a family process that affects not just the identified patient but multiple family members.
In the present study, we focused on the burden of care that mothers perceived as associated with daily routines. Caring for a child involves not only all regular parenting tasks, but also tasks such as filling prescriptions, paying careful attention to household cleaning and avoiding environmental triggers, and remembering to take medications. While each aspect in and of itself may not be burdensome, it is the tedious and repetitive aspects of management that can be burdensome and set the stage for a negative emotional climate (Fisher & Weihs, 2000). Consistent with this notion, we found that mothers who felt more overwhelmed and burdened by these tedious chores were also more likely to engage in rejecting exchanges with their child.
The role of criticism and rejection in predicting child outcomes extends previous reports that have focused primarily on self-report accounts of family interaction (Chen et al., 2003) or used methods that are more distal to the child’s experience such as the Five Minute Speech Sample (Wamboldt, O’Connor, Wamboldt, Gavin, & Klinnert, 2000). Although based on a relatively small sample, we observed that mothers who felt overwhelmed or burdened were more likely to criticize or reject their child’s comments or suggestions while drawing a picture of their family crest. In reviewing the video tapes of these interactions, we were struck by the ways in which some mothers chose to make critical comments about their child’s selection of symbolic content to reflect what was meaningful to him or her as a member of their family. For example, one child wanted to include her cousins in the picture as important members of the family but this suggestion was rejected outright by her mother because “they don’t count.” This is in stark contrast to another mother-child pair where the daughter chose to include the grandparents as meaningful members of the family because they were the “first thing that came to my mind.” It is interesting to note that in the first example, the child was coughing throughout the 15- minute interaction period. We provide these examples to illustrate how even subtle forms of rejection may send a message to the child that his or her opinion is not valued and parents’ concerns may override child feelings. In the context of chronic health conditions such as asthma, systematic exclusion from family activities may exacerbate vulnerable feelings associated with anxiety. When family gatherings are marked by themes of exclusion, then there are typically greater threats to individual health and well-being (Fiese, 2006).
Despite the potentially informative nature of our findings, there are also several limitations of this preliminary study to consider. First, we had several pathways (e.g., direct pathways) that were not statistically significant. It is important to consider this finding in light of the small sample size and borderline internal consistency evidenced for asthma burden (which can lower effect size; e.g., see Onwuegbuzie & Daniel, 2002). However, we doubt this was problematic in this study, given that we did evidence several statistically significant findings. In addition, although tests of indirect pathways were originally intended to infer causal chains, they do so only to the extent that the study design allows. Here, for example, we relied on a single laboratory observation at one point in time; therefore, causality cannot be inferred from these results. Future research with longitudinal datasets and multiple indicators would provide more conclusive results.
Second, we are not able to rule out the possibility that perceptions of routine burden are affected by parental psychiatric distress or that psychiatric symptoms actually cause greater burden. Likewise, it may be that burden and psychiatric distress interact in a synergistic way, such that one increases the other, which in turn exacerbates the other. We know that caregiver burden and psychological distress cooccur at relatively high rates (Hirst, 2005). Further, there is fairly convincing evidence to suggest that mothers with depressive symptoms have a more difficult time following their child’s prescribed medical regimen (Bartlett et al., 2004). Thus, an alternative explanation for our findings is that mothers with pre-existing psychiatric symptoms also experience more burden of care and engage in more critical interactions with their children with asthma. Taken from the perspective of cumulative nature of family risk (Evans, 2003; Sameroff & Fiese, 2000), this is a plausible scenario that bears consideration in future studies.
Third, the nature of our small preliminary study only allowed focus on female primary caregivers. It was predominantly mothers who tended to represent the family and identify themselves as the primary caregivers during medical appointments and in signing up and participating in our study. Is this a reflection that mothers carry much of the burden of caring for a child with asthma? Perhaps, but it is also likely that childrearing involves one or more other significant caregivers (e.g., Drotar et al., 1985). Thus, it is unfortunate that fathers are often not included in psychological and pediatric research despite the importance and promise in doing so (e.g., Drotar, 2005; Fiese, 2005; Parke, 2000; Phares, Lopez, Fields, Kamboukos, & Duhig, 2005). This limits the generalizability of findings to fathers, particularly given findings that suggest that the subjective experience of a chronic illness can differ among family members, including mothers, fathers, and siblings (e.g., Kazak et al., 2004). Inclusion of multiple family members is therefore an important future direction for this line of investigation. Chronic illness affects everyone in the family and greater attention to family-system-wide effects in addition to dyadic processes will be most likely to advance this area substantitively. Indeed, our ongoing studies are integrating this focus (Fiese, Foley, & Spagnola, 2006). Our findings may also be somewhat complicated by the complex association between symptoms of asthma severity and perception of routine burden. Although we could demonstrate that our measure of burden is not a simple marker for severity, we did not have standard measures of lung functioning and so we could not evaluate burden in light of a more objective assessment. The assessment of asthma symptom severity in and of itself is a complicated issue, as adherence to prescribed protocols should reduce most disease symptoms (NIH, 1997). For instance, in a previous report we found that adherence to medical protocols was related to parent report, of medication routines but not to perception of routine burden (Fiese et al., 2005). It could be argued that parents feel more burdened by care when their children experience more symptoms. On the other hand, when care is routinized and regimens are regularly followed, children are less likely to experience asthma symptoms. Clearly, longitudinal evidence with more precise measurement of disease severity is warranted. However, our findings are consistent with others that disease severity alone does not account for significant variations in family management practices (McQuaid et al., 2005).
Nonetheless, despite the limitations of this study that render results preliminary, we remain encouraged that our evidenced path from routine burden to child wellbeing through mother-child interaction patterns held for both child anxiety symptoms and QOL. To date, most studies considered either child mental health or QOL health symptoms as indicators of child well-being. Co-morbidity of health symptoms and psychological distress in children with asthma is quite high with children with more severe expressions of asthma at greater risk for behavioral and psychiatric disturbances (McQuaid, 2001; Ortega et al., 2002; M. Z. Wamboldt et al., 1998).
Also noteworthy is that our simple bivariate correlations revealed a direct relationship between perceived burden and child QOL but not anxiety. This may be due to the fact that we had to rely on a smaller number of respondents to the anxiety measure. It may also be that the link between routine burden and QOL is more direct. Yet, when we considered the indirect path, we found that even with the smaller sample effects of routine burden were garnered through its influence on elevated levels of criticism. Family climate characterized by a sense of daily life as a chore and interactions as critical and belittling bodes poorly for children’s physical and mental well-being.
We believe that these findings, with replication, have important implications for clinical practice. There are existing programs that aim to reduce negative interactions and increase supportive interactions between parents and children with chronic health conditions that have had some success in improving children’s health status (Wysocki et al., 2000). We propose that attention to family routines, including those associated with asthma care, may act as a starting point in addressing the family climate of children with a chronic health condition such as asthma (Fiese & Wamboldt, 2001). For some families, interventions aimed at getting routines back on track may be sufficient and little further assistance would be warranted. However, as we have demonstrated in this report, when daily routines turn into a burdensome affair, then there is a cost to mother-child functioning and ultimately to child health. Thus, prior to addressing criticism between parent and child, it may be helpful to assess whether healthy family routines have been disrupted, displaced, or neglected due to a focus on disease management that in turn has overwhelmed family life. As is often the case, a disruption in a family’s routines can indicate that the family is stressed (Steinglass, Bennett, Wolin, & Reiss, 1987).
When Peshkin conducted his “parentectomies” nearly a century ago, asthma was thought to be affected by a host of climatic features. Patients could be observed in hospital verandahs, breathing the fresh mountain air, hoping to improve their lung function. Children were removed from their homes to ameliorate the effects of these “smothering parents.” As has been noted in most areas of contemporary family research (Cox & Paley, 1997; Wood, 1993), families are complex systems that require complex methods to unravel their effects on individual health and well-being. Given that the family climate of pediatric asthma may be stormy at times, the future health of these children will require greater attention to the multiple influences on family well-being.
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BARBARA FIESE,PH.D.
MARCIA WINTER, PH.D.
RAN ANBAR, M.D. *
KIMBERLY HOWELL, PH.D.
SCOTT POLTROCK, PH.D.
Department of Psychology, Syracuse University, Syracuse, NY
* Department of Pediatrics, Upstate Medical University, Syracuse, NY.
Correspondence concerning this article should be addressed to Barbara Fiese, Department of Psychology, Syracuse University, 430 Huntington Hall, Syracuse, NY 13244. E-mail: bhfiese@ syr.edu
Copyright Blackwell Publishing Ltd. Mar 2008
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