original article Annals of Oncology 18: 1951–1956, 2007

doi:10.1093/annonc/mdm373
Published online 5 October 2007

Family functioning and adolescents’ emotional

and behavioral problems: when a parent has cancer
S. M. Gazendam-Donofrio1, H. J. Hoekstra2, W. T. A. van der Graaf5, H. B. M. van de Wiel1,
A. Visser3, G. A. Huizinga1 & J. E. H. M. Hoekstra-Weebers1,3,4*
1
Wenckebach Institute, University Medical Center Groningen, University of Groningen, The Netherlands; 2Department of Surgical Oncology, University Medical
Center Groningen, University of Groningen, The Netherlands; 3Department of Health Psychology, University Medical Center Groningen, University of Groningen,
The Netherlands; 4Comprehensive Cancer Center North-Netherlands, Groningen, The Netherlands; 5Department of Medical Oncology, Radboud University Nijmegen
Medical Center, Nijmegen, The Netherlands

Received 12 June 2007; revised 28 June 2007; accepted 28 June 2007

Background: This article focuses on possible relationships between functioning of adolescents with a parent
diagnosed with cancer 1–5 years earlier and family environment.
Patients and methods: In all, 138 patients, 114 spouses and 221 adolescents completed the Family Environment
Scale. Additionally, adolescents filled in the Impact of Event Scale and Youth Self-report and parents reported on the
adolescents’ functioning using the Child Behavior Checklist.
Results: Patients and spouses reported that their families differ from the norm; they are more expressive and social,
better organized, less controlling and have less conflict. Adolescents reported the same and additionally find their
family. Family environment was weakly to moderately strongly negatively related to the adolescents’ functioning; family
relationships related more strongly to the adolescents’ functioning than family structure did. No significant relationship

original
article
was found between family environment and the adolescents’ cancer-related distress. Discrepancy in reports of family
environment between parents and between parents and adolescents, in general, did not relate to the adolescents’
functioning or distress. Parent–adolescent discrepancy only correlated with adolescent self-reports of their
functioning.
Conclusion: Families with parental cancer functioned positively. Despite this, family functioning seems to be a risk
factor for behavioral and emotional problems in adolescents.
Key words: adolescents, distress, family environment, parental cancer

introduction
A parent’s cancer diagnosis impacts the entire family.
Literature has shown a number of psychological consequences
for patients and spouses, including diminished quality of life,
anxiety and depression [1, 2]. Also affected are the children.
A review on children of cancer patients found problems
being reported in various domains of child functioning,
e.g. behavioral problems and disturbed physical and cognitive
functioning [3]. Recent studies have found that adolescents
reported impaired emotional and behavioral functioning [4]
and that 35% of adolescent daughters and 21% of adolescent
sons reported post-traumatic stress symptoms (PTSS) levels
requiring professional care [5]. Adolescents are in
a developmental phase in which they are aware of physical
and emotional pain that a parent may be experiencing.
They understand what death is and that their parent’s
*Correspondence to: Dr J. E. H. M. Hoekstra-Weebers, Wenckebach Institute,
University Medical Center Groningen, University of Groningen, PO Box 30001, 9700 RB,
Groningen, The Netherlands. Tel: +31-50-361-4978; Fax: +31-50-361-9326;
E-mail: j.hoekstra-weebers@psb.umcg.nl
prognosis may be poor. This may place them at higher risk
of developing psychological problems than their younger
siblings [6, 7]. Furthermore, older children may take
on responsibilities or partly assume parental roles, which
may impair the normative development of establishing
personal identity [7–9]. Thankfully, not all adolescent children
of cancer patients develop psychological problems. Therefore,
it is important to identify factors that may place certain
adolescents at risk, thereby enabling mental health
professionals to help children at an early stage.
Research has suggested that the quality of the family
environment affects how family members make it through
cancer [10–14]. In these reports, family cohesion, in
particular, has been found to relate to how adults and
children cope with stressful events. High emotional
expressiveness and cohesion and low conflict in family
relationships have been shown to predict better psychological
adjustment to cancer [3, 10, 11, 15]. However, the number
of oncology studies focusing on family functioning is limited
and results sometimes conflict; for example, one study
reported interestingly that a positive family environment

ª 2007 European Society for Medical Oncology

original article Annals of Oncology

correlated to higher anxiety and depression in adolescents Table 1. Demographics

[16]. Some studies focus on either only adults or on children
with cancer. For these reasons and to bring more attention to Children Patient Spouse
this important subject, our team conducted the following Mean age in years 15.5 6 2.0 45.4 6 4.2 46.5 6 5.5
study. Gender N (%)
Our goal was to explore family functioning and possible Female 116 (52.5) 112 (81) 22 (19)
relationships between family environment and adolescents’ Male 105 (47.5) 26 (19) 92 (81)
functioning. We hypothesized that families confronted with Adolescents per family, N (%)
parental cancer would report functioning more positively than 1 72 (52)
a norm group [17]. Furthermore, we expected to find 2 53 (38)
a significant relationship between family environment and ‡3 13 (9)
the adolescents’ functioning and cancer-related distress. Marital status N (%)
Literature from studies examining families not confronted with Married/cohabitating 128 (93)
cancer has shown relationships between discrepancy in how Divorced/widowed/single 10 (7)
parents and adolescents viewed their family environment and Mean time since parent’s 2.8 6 1.2
lower self-competence [18], problem behavior [19], depression diagnosis in years
and anxiety [20] and poorer psychological well-being of Disease status N (%)
adolescents [21], particularly for girls. We, therefore, expected No evidence 102 (78)
that larger discrepancies would be related to more dysfunction Recurrence 36 (22)
and distress.

patients and methods

procedure
This study is part of a larger project examining how families function when
a parent has cancer [4, 5, 22]. During a 2-year period, cancer patients at
the University Medical Center Groningen undergoing treatment or seen
for a follow-up visit were approached by oncology specialists and nurses.
Patients were eligible if they had been diagnosed with cancer 1–5 years
before study entry, had children 4–18 years at time of parent’s diagnosis
and were fluent in Dutch. Written information was offered to all eligible
patients and their partners. An adapted brochure was provided for the
children. In accordance with Medical Ethical Committee policy, informed
consent was given by each family member separately. After obtaining
informed consent, researchers mailed packets to each family member
containing questionnaires and prepaid return envelopes. Cancer patients,
spouses, and children were instructed to fill in separate questionnaires
independently of each other and not discuss their answers.
sample
A total of 476 families were approached for the study; 209 agreed to
participate (44%). There were no significant differences between
participating and nonparticipating parents regarding the ill parent’s gender,
type of cancer or time since diagnosis. This study focused on families
with adolescent children (11–18 years). Demographic information is
summarized in Table 1. The vast majority of patients were married.
Patients were diagnosed with various types of cancer, including breast
(54%), gynecological (11%), skin (9%), hematological (8%), urological
(5%), soft tissue and bone tumors (5%), head/neck (3%),
gastrointestinal (3%) and central nervous system (2%). Thirty-six
patients indicated they had recurrent disease; remaining patients showed
no evidence of disease.
Many families who declined to participate provided a reason why.
Twenty-two percent gave an explanation directly related to the parents
(e.g. having moved on with their lives or being too emotionally distressed).
The children were named as the reason by 20% (e.g. lack of interest or
children not having been informed of parent’s illness). Twenty-five percent
gave a variety of explanations, including another illness in the family or the
busyness of parents or children. The remaining 33% did not explain their
refusal to participate.
instruments
Patients and spouses completed the Dutch version of the Child Behavior
Checklist (CBCL) [23, 24]; adolescents completed the Dutch version of
the Youth Self-Report (YSR), designed for children aged 11–18 [25, 26].
The CBCL and YSR consist, respectively, of 120 and 102 items and
normative data for both tests exists. The internalizing, externalizing and
total problem scales were used. The internalizing scale reflects the
internal mental state, i.e. withdrawal, somatic complaints and anxiety/
depression. The externalizing scales represent socially unacceptable
behavior, e.g. delinquency and aggressiveness. The total problem scale is
the sum of all scales: internalizing, externalizing, thought, social,
attention and other problems. Higher scores indicate more problems.
The reliability and validity of the CBCL/YSR has been supported in
a great number of studies. In this study, Cronbach’s alphas on the three
scales ranged from 0.84 to 0.94 for reports from the patients, spouses
and adolescent children.
The Dutch translation of the Impact of Event Scale (IES) [27, 28] was
used to measure adolescents’ cancer-related distress. The 15-item scale
measures intrusive experiences (seven items) and avoidance of thoughts
and images related to the event (eight items). The sum of the two
subscales is the total score, which can range from 0 to 75; higher scores
indicate more distress. The IES has been shown to be reliable [29] and
Cronbach’s alpha in this study was high (a = 0.95).
Patients, spouses and adolescents filled in the Dutch version of the
Family Environment Scale (FES) [30, 31], which consists of seven
11-item subscales: cohesion, expressiveness, conflict, organization, control,
family values and social orientation. Respondents are asked whether
statements about family environment apply to their family. Scores on
each subscale range from 0 to 11; higher scores denote a more positive
environment. Index scores can be calculated for Family Relationships
Index (FRI, sum of cohesion, expressiveness and conflict; scores range
from 0 to 33) and Family Structure Index (FSI, sum of organization and
control; scores range from 0 to 22). Higher scores on the indices reflect
more positive family relationships and more structure. The manual
provides norm scores based on a sample of 1707 adults and 551
adolescents from The Netherlands. The FES has good test–retest
reliability and an adequate internal consistency [30, 31]. Other
(psycho-oncology) studies [11, 15, 32] have reported alpha coefficients

1952 | Gazendam-Donofrio et al. Volume 18 | No. 12 | December 2007

Annals of Oncology
similar to those in the present study, which ranged from 0.42 (cohesion) to
0.69 (conflict). However, these alpha coefficients are lower than those listed
in the manual. We, therefore, followed the test creator’s
recommendation not to over-rely on internal consistency values [33].
Lastly, demographic data were gathered from parents on date of
diagnosis, type of cancer, treatment and disease status. Parents also
reported children’s ages and gender.
analysis
The t-tests were carried out to compare all family members’ reports of
family environment with the norm. Effect sizes were calculated to assess
clinical significance [34]. Effect sizes ‡0.50 indicate a clinically
significant difference; those <0.49 were considered small [35]. In
addition, t-tests were carried out to compare patients’ reports of family
functioning with spouses’, parents’ reports with adolescents’ and differences
between boys’ and girls’ reports. A variable creating subgroups of
adolescents was made to explore differences between those in early (11–13),
middle (14–16) and late adolescence (17–18) in how children viewed
family functioning. An analysis of variance tested differences between
these subgroups. A variable was created to measure discrepancy between
family members’ picture of the family environment [30] by subtracting
the adolescent’s score from the parent’s (parent–adolescent discrepancy).
This variable was used in correlational analyses. Pearson’s product-
moment correlations were calculated to explore relationships between
adolescent functioning and adolescent reports of cancer-related distress
and each family member’s perception of the family environment and
parent–adolescent discrepancy. Correlation coefficients <0.30 were
considered weak, 0.30–0.50 moderately strong and >0.50 strong [34].
results
comparisons with norm and family members
In comparison with the norm group, parents found their family
more expressive, less conflictual, better organized, less
controlling and more social than the norm group (Table 2).
The FRI was significantly higher than the norm. Cohesion
and the FSI were similar to the norm. According to patients
but not spouses, the family was less strict in their values.
original article
Effect sizes were small, with one medium effect size on
spouses’ report of conflicts.
No significant differences were found between patients’
and spouses’ reports of family functioning. Inter-parent
correlation coefficients ranged from moderately strong to
strong: cohesion, r = 0.43; expressiveness, r = 0.46; conflict,
r = 0.50; organization, r = 0.56; control, r = 0.53; family
values, r = 0.38; social orientation, r = 0.57; FRI, r = 0.54;
FSI, r = 0.56.
Adolescents’ reported that their family was more cohesive,
expressive, organized and social and had fewer conflicts than
the norm group (Table 2). The FRI and FSI were significantly
higher. Adolescents reported no significant differences on
control or family values. Medium effect sizes were found on
conflict, social orientation and the FRI; small effect sizes
were found on cohesion, expressiveness, organization and the
FSI. No differences were found between boys and girls or
between children in early, middle or late adolescence.
Since no significant differences were found between patient
and spouses’ scores, a mean parent score was used in t-tests
examining differences between parents’ and adolescents’
views of the family. Significant differences were found on all
but one subscale, family values. Adolescents described their
family as less cohesive, expressive, organized, controlling and
socially oriented than their parents. The adolescents’ FRI and
FSI scores were also significantly lower than the parents’ scores.
Medium effect sizes were found for control, social
orientation and the FSI and small effect sizes were found for
cohesion, expressiveness, conflict, organization and the FRI.
adolescents’ functioning and family environment
To keep analyses manageable, the parents’ mean score on the
FRI and FSI were used in correlational analyses (see Table 3).
Time since diagnosis, treatment intensity and disease status
were not significantly related to family environment or
children’s functioning. Intra-family relationships according to
parents correlated significantly to both patient and spouse

Table 2. FES descriptives and comparisons with norm group

Patients Spouses Norm Adolescents Norm Comparison of parents’

(parents) (adolescents) mean score with
adolescents
Mean t ES Mean t ES Mean Mean t ES Mean t ES
(SD) (SD) (SD) (SD)
Cohesion 8.6 (1.4) 0.0 0.00 8.6 (1.5) 0.0 0.00 8.6 (2.0) 8.0 (1.8) 5.9** 0.39 7.1 (2.7) 3.1** 0.33
Expressiveness 8.5 (2.1) 2.4* 0.14 8.5 (1.9) 2.5** 0.14 8.2 (2.2) 7.5 (2.5) 5.1** 0.37 6.6 (2.4) 5.2** 0.41
Conflict 3.6 (2.3) 28.5** 0.46 3.4 (2.2) 29.4** 0.55 4.7 (2.5) 4.2 (2.4) 28.3** 0.63 5.7 (2.4) 24.9** 0.32
Organization 8.5 (1.0) 4.3** 0.27 8.3 (2.2) 2.2* 0.13 8.0 (2.4) 7.9 (2.2) 5.9** 0.42 6.9 (2.5) 3.5** 0.24
Control 8.1 (1.9) 23.7** 0.19 7.9 (1.7) 25.4** 0.31 8.5 (2.2) 6.5 (2.2) 20.1 0.00 6.5 (2.4) 9.4** 0.73
Family values 7.2 (2.2) 24.3** 0.21 7.5 (2.1) 21.3 0.09 7.7 (2.5) 7.5 (2.1) 0.8 0.04 7.4 (3.4) 0.3 0.05
Social orientation 7.9 (2.1) 7.5** 0.40 7.9 (1.9) 7.1** 0.42 7.0 (2.4) 6.8 (1.9) 7.2** 0.53 5.8 (1.9) 8.7** 0.65
FRI 24.5 (3.9) 5.9** 0.30 24.7 (3.9) 6.4** 0.35 23.1 (5.2) 22.4 (5.1) 8.4** 0.63 19.0 (5.8) 6.6** 0.47
FSI 16.6 (2.9) 0.6 0.00 16.3 (3.0) 21.1 0.09 16.6 (3.8) 14.4 (3.5) 3.5** 0.26 13.4 (4.2) 8.1** 0.64

SD, standard deviation; FES, Family Environment Scale; FRI, Family Relationships Index; FSI, Family Structure Index.
*P £ 0.05; **P £ 0.01.

Volume 18 | No. 12 | December 2007 doi:10.1093/annonc/mdm373 | 1953

original article Annals of Oncology

reports of the adolescents’ problems and with the adolescent

self-reports. Two correlations with patient reports were

Adolescent IES
moderately strong; the others were weak. Family structure as
viewed by the parents related significantly, though weakly, to

20.16*
20.07
20.04

20.02
0.13

20.02
all three scales of the patient reports of adolescents’
functioning, while only one weak correlation was found with
spouse reports of the adolescents’ externalizing of problems.
The adolescents’ cancer-related distress was not significantly
Externalizing

correlated with the parents’ view of the family environment.

20.38**
20.16**
0.28**
Intra-family relationships according to the adolescents
20.17*
20.07

0.11
related moderately strongly to weakly to patient reports of
adolescents’ problems and spouse reports of externalizing and
total problems and related moderately strongly to the
adolescent self-reports on problems. Furthermore, the
Internalizing

FRI weakly, negatively correlated with the adolescents’

20.23**

20.32**
20.17**

cancer-related distress. Family structure according to the

0.17*
20.07

0.13

adolescents related only to their self-reports and not to

Adolescent YSR

CBCL, Child Behavior Checklist; YSR, Youth Self-report; IES, Impact of Event Scale; FRI, Family Relationships Index; FSI, Family Structure Index.
either the patient or spouse reports.
20.21**

20.39**
20.21**
0.27**

0.16*
20.07

adolescents’ functioning and parent–adolescent

Total

discrepancy
The amount of discrepancy between parents and adolescents
did not vary depending on the adolescent’s gender or stage
Externalizing

of adolescence. Parent–adolescent discrepancies on the FRI

correlated significantly with spouse reports of externalizing
20.21**

20.32**
20.16*

0.20*
20.04

20.04

and with all three scales of the adolescent self-reports

(Table 3). Parent–adolescent discrepancies on the FSI
related significantly to only the YSR total score. All
correlations with parent–adolescent discrepancy were weak.
Internalizing

No significant relationships were found between the

adolescents’ cancer-related distress and parent–adolescent
20.18*
20.09
0.01
0.08
20.11

20.11

discrepancy.
Spouse CBCL

20.24**

discussion
20.19*
20.12

0.04
0.04

20.09
Total
Table 3. Correlations between family environment and adolescents’ functioning

Our findings support our first and second hypotheses. First,

families with parental cancer function more positively
according to parents and adolescents. All family members
Externalizing

indicated that their family was more expressive, organized

and social and had less conflict than the norm. Additionally,
20.28**

20.33**
20.18*

20.13
0.16

0.02

parents described their family as less controlling, while

adolescents found their family more cohesive. Patients
additionally reported stronger family values. Our results
indicate that following cancer, family members perceive the
Internalizing

family as functioning more positively in different domains.

20.37**
20.21**
20.19**

Secondly, family environment and adolescent functioning are

20.05
20.09

20.13

related. Higher scores on family functioning are related to

lower problem scores. It seems that intra-family relationships,
Patient CBCL

how family member relate to each other, are strongly associated

20.34**
20.19**
20.25**

with adolescents’ functioning. Family structure seems to play

20.07
0.00

20.08
Total

a less important role; structure was weakly related to

adolescents’ functioning.
*P £ 0.05; **P £ 0.01.

In regard to the first hypothesis, higher levels of

Parents–adolescent

Parents–adolescent
Parents’ mean FRI

discrepancy FRI
Parents’ mean FSI

discrepancy FSI

expressiveness and lower levels of conflict may imply that

Adolescent FRI
Adolescent FSI

families with parental cancer communicate more openly and

that exchange is constructive rather than negative. It would
seem that family members are close. They talk frequently and
harmoniously. Communication is considered important for

1954 | Gazendam-Donofrio et al. Volume 18 | No. 12 | December 2007

Annals of Oncology
family functioning and is particularly important during
adolescence [36, 37]. Families that express emotions openly
have lower levels of distress [11]. A previous study
conducted by our team found that open communication
was related to fewer PTSS in adolescent daughters, while
more problem communication was related to more
PTSS [5].
Interestingly, adolescents reported their family to be more
cohesive than the norm group, while their parents did not. A
characteristic of adolescence is an increase in autonomy—the
child breaks away from the family unit and forms his own
identity. Families with younger children are naturally more
cohesive because small children are less able to take care of
themselves [9]. In families with a chronically ill parent,
adolescents often assume additional tasks or more
responsibilities. They give up some autonomy and spend
more time with the family. Adolescents may interpret this as
more cohesive, while parents may view their family’s
cohesiveness as normal. However, considering that patients in
our sample had been diagnosed an average of 2.8 years
previously, it may be that adolescents confronted with
parental cancer delay their disengagement from the family.
Our findings seem to illustrate that adolescents display
less emotional and behavioral problems when cohesiveness is
higher. This would mean that while adolescents in our
families may have less autonomy than their peers, it does
not necessarily bother them. Interestingly, we did not find
any differences between how boys or girls viewed the
family’s functioning, in contrast to other studies [20, 38].
Family environment and children’s functioning were not
significantly related to illness-related variables, in line with
research reporting that cancer-related variables are unrelated to
emotional functioning [39]. The amount of time since the
patient’s diagnosis, disease status and treatment intensity
all appeared unrelated to family functioning. It would seem
that the positive affect on family environment after cancer is
more permanent. Cancer’s effects are not all negative;
positive effects have also been found [40]. Family environment
may also be positively affected.
With regard to the findings for the second hypothesis, each
parent was asked to report on the family’s and the adolescents’
functioning separately. Relationships with patient-perceived
adolescent functioning were more often significant and
stronger than relationships with spouse-perceived adolescent
functioning. Being that the majority of our patients were
women, our findings may imply that mothers and fathers
view their relationship with their children differently or
have different views on the relationship between family
environment and how the children function. This is
supported by two recent studies reporting that mothers’
reports of children’s functioning correlated more often
significantly with the children’s functioning than the
fathers’[4, 41].
Intra-family relationships correlated weakly with adolescents’
cancer-related distress, but their view of family structure and
the parents’ view of the family environment were not at all
related to adolescents’ distress. It would seem that family
environment does not offer much protection for, nor does it
aggravate, cancer-related distress. Other factors, such as the
Volume 18 | No. 12 | December 2007
original article
adolescent’s personality traits, may be more strongly related to
whether a child develops PTSS [5].
Adolescents viewed their family environment significantly
differently than their parents, which is in line with research
with the FES [30]. Our third hypothesis was that parent–
adolescent discrepancies would relate to the adolescents’
functioning. This was unsupported. Incongruity in parents’
and adolescents’ views related only weakly to the adolescents’
self-reports and to spouses’ reports on externalizing of
problems. More problems were reported when discrepancies
were larger and externalization related more strongly to the
size of the discrepancy than internalization did. This is
consistent with a study reporting an association between
parent–adolescent discrepancies and externalizing [18].
However, another study also reported a significant
relationship between discrepancies and internalizing [20],
something our study did not show. It is believed that
discrepancies and disagreements between parents and
adolescents serve to help the adolescent develop
autonomy. However, in the short term this may be
associated with higher stress in the family and maladaptive
behavior.
One of our study’s limitations is the low response rate. While
no differences were found between participants and
nonparticipants regarding demographic and illness-related
variables, 56% of those asked declined to participate. We
cannot be sure whether the high nonresponse rate affected
our findings or whether the prevalence of problems may have
been underreported or overreported. Families gave reasons on
both sides of the spectrum: some were too distressed and others
reported having adjusted and moved on. Additionally, our
population only included families with patients who survived.
It is possible that these two factors may have led to a sample
bias in our data. Our dataset included a number of families
(48%) with more than one adolescent, which may mean
that subjects are not independent of each other. However, all
of our analyses were conducted at the child level and not the
family level; we focused on individuals, not the family system.
Furthermore, a multilevel study in this project reported that
only a small percentage of the variation in children’s
functioning could be explained on the family level [42].
A further limitation is the cross-sectional nature of our data
which prevents us from drawing conclusions about causal
relationships. Another point may be the low alpha
coefficients for the FES. However, Moos [33] argued that
one should not focus on the internal consistency statistic,
which may be lower in homogenous groups. Nevertheless, this
may be a source of unreliability in our study. Finally, the
majority of our patients were female. This may seem
skewed, but a majority of cancer patients in this age group
are female [43].
In summary, we found that the family environment of
families where a parent has cancer is different from the
environment in families not confronted with cancer.
Families seem to function more positively. This aside,
a negative relationship was found between family
environment and the children’s behavioral and emotional
functioning. Our findings indicate that it may be helpful for
health care professionals to pay attention to family
doi:10.1093/annonc/mdm373 | 1955
original article
functioning in order to target adolescents at risk for
developing problems.
funding
Dutch Cancer Society (2000-2333); IJsselmond Foundation for
Health Care Research.
references
1. Hodges LJ, Humphris G, Macfarlane G. A meta-analytic investigation of the
relationship between the psychological distress of cancer patients and their
carers. Soc Sci Med 2005; 60: 1–12.
2. Vachon M. Psychosocial distress and coping after cancer treatement. Can Nurs
2006; 106: 26–31.
3. Visser A, Huizinga G, van der Graaf W et al. The impact of parental cancer on
children and the family: a review of the literature. Cancer Treat Rev 2004; 30(8):
683–694.
4. Visser A, Huizinga G, Hoekstra H et al. Emotional and behavioural functioning of
children of a parent diagnosed with cancer: a cross-informant perspective.
Psychooncology 2005; 14: 1–12.
5. Huizinga GA, Visser A, Hoekstra H et al. Stress response symptoms in adolescent
and young adult children of parents diagnosed with cancer. Eur J Cancer 2005;
41: 288–295.
6. Compas BE, Worsham N, Epping-Jorden J et al. When mom or dad has cancer:
II. Coping, cognitive appraisals, and psychological distress in children of cancer
patients. Health Psychol 1996; 15(3): 167–175.
7. Pedersen S, Revenson T. Parental illness, family functioning, and adolescent
well-being: a family ecology framework to guide research. J Fam Psychol 2005;
19(3): 404–409.
8. Patenaude A. A different normal: reactions of the children and adolescents to the
diagnosis of cancer in a parent. In Baider L, Cooper C, Kaplan De-Nour A (eds):
Cancer and the Family, 2nd edition. John Wiley & Sons 2000; 239–272.
9. Rolland J. Cancer and the family: an integrative model. Cancer survivorship:
resilience across the lifespan. Cancer 2005; (Suppl): 2584–2595.
10. Barton M. Family Environment, Time Since Diagnosis, and Gender as Predictors
of Psychosocial Adaption in Oncology Patients. Ball State University 2001.
11. Edwards B, Clarke V. The psychological impact of a cancer diagnosis on families:
the influence of family functioning and patients’ illness characteristics on
depression and anxiety. Psychooncology 2004; 13: 562–576.
12. Varni J, Katz E, Colegrove R, Dolgin M. Family functioning predictors of
adjustment in children with newly diagnosed cancer: a prospective analysis.
J Child Psychol Psychiatr 1996; 37(3): 321–328.
13. Weihs K, Politi M. Family development in the face of cancer. In Crane D, Marshall E
(eds): Handbook of Families and Health. Interdisciplinary Perspectives. Sage
Publications 2005; 3–18.
14. Weihs K, Reiss D. Family reorganization in response to cancer: a developmental
perspective. In Baider L, Cooper C, Kaplan De-Nour A (eds): Cancer and the
Family, 2nd edition. John Wiley & Sons 2000; 19–39.
15. Giese-Davis J, Hermanson K, Koopman C. Quality of couples’ relationship and
adjustment to metastatic breast cancer. J Fam Psychol 2000; 14(2): 251–266.
16. Harris C, Zakowski S. Comparisons of distress in adolescents of cancer patients
and controls. Psychooncology 2003; 12: 173–182.
17. Trask P, Paterson A, Trask C et al. Parent and adolescent adjustment to pediatric
cancer: associations with coping, social support, and family function. J Pediatr
Oncol Nurs 2003; 20(1): 36–47.
18. Ohannessian C, Lerner R, Lerner J, von Eye A. Adolescent-parent discrepancies
in perceptions of family functioning and early adolescent self-competence. Int J
Behav Dev 2000; 24(3): 362–372.
19. Xiaoyi F, Jingtao Z, Jie X, Ali Y. Adolescent-mother discrepancies in perceptions
of parental conflict and adolescent problem behaviors. Psychol Sci (China) 2004;
27(1): 21–25.
1956 | Gazendam-Donofrio et al.
Annals of Oncology
20. Ohannessian C, Lerner R, Lerner J, von Eye A. Discrepancies in adolescents’ and
parents’ perceptions of family functioning and adolescent emotional adjustment.
J Early Adolesc 1995; 15(4): 490–516.
21. Shek D. A longitudinal study of Hong Kong adolescents’ and parents’ perceptions
of family functioning and well-being. J Genet Psychol 1998; 159(4): 389–403.
22. Huizinga G, Visser A, van der Graaf W et al. The quality of communication
between parents and adolescent children in the case of parental cancer. Ann
Oncol 2005; 16: 1956–1961.
23. Achenbach T. Manual for the Child Behavior Checklist and 1991 profiles.
Burlington, VT: Department of Psychiatry, University of Vermont 1991.
24. Verhulst F, van der Ende J, Koot H. Manual for the Child Behavioral Checklist.
Rotterdam, The Netherlands: Department of Child and Adolescent Psychiatry,
Erasmus University 1996.
25. Achenbach T. Manual for the Youth Self Report and 1991 profiles. Burlington,
VT: Department of Psychiatry, University of Vermont 1991.
26. Verhulst F, van der Ende J, Koot H. Manual for the Youth Self Report. Rotterdam,
The Netherlands: Department of Child and Adolescent Psychiatry, Erasmus
University 1996.
27. Brom D, Kleber R. De schokverwerkingslijst (the impact of event scale). Ned
Tijdschr Psychol 1985; 40: 164–168.
28. Horowitz M, Wilner N, Alvarez W. Impact of event scale: a measure of subjective
stress. Psychosom Med 1979; 41: 209–218.
29. Sundin E, Horowitz M. Horowitz’s impact of event scale: evaluation of 20 years of
use. Psychosom Med 2003; 65: 870–876.
30. Jansma J, de Coole R. GKS-II. Gezinsklimaatschaal Handleiding. Lisse, The
Netherlands: Swets & Zeitlinger 1996.
31. Moos R. Family Environment Manual, 2nd edition. Palo Alto, CA: Consulting
Psychologists Press 1986.
32. Logan D, Scharff L. Relationships between family and parent characteristics and
functional abilities in children with recurrent pain syndromes: an investigation of
moderating effects on the pathway from pain to disability. J Pediatr Psychol
2005; 30(8): 689–707.
33. Moos R. Conceptual and empirical approaches to developing family-based
assessment procedures: resolving the case of the family environment scale. Fam
Process 1990; 29: 199–208.
34. Cohen J. Statistical Power Analysis for the Behavioral Sciences. [revised edition].
Hillsdale, NJ: Erlbaum, 1988.
35. Norman G, Sloan J, Wyrwich K. Interpretation of changes in health-related
quality of life: the remarkable universality of half a standard deviation. Med Care
2003; 41: 582–592.
36. Barnes H, Olson D. Parent-adolescent communication and the circumplex model.
Child Dev 1985; 56: 438–447.
37. Jackson S, Bijstra J, Oostra L, Bosma H. Adolescents’ perceptions of
communication with parents relative to specific aspects of relationships with
parents and personal development. J Adolesc 1998; 21: 305–322.
38. Rodrigo M, Garcia M, Maiquez M, Triana B. Discrepancias entre padres e hijos
adolescentes en la frecuencia percibida e intesidad emocional en los conflictos
familiares. (Discrepancies between parents and adolescent children in the
perceived frequency and emotional intensity in family conflicts). Estudios
Psicologica 2005; 26(1): 21–34.
39. Bardwell W, Natarajan L, Dimsdale J et al. Objective cancer-related variables are
not associated with depressive symptoms in women treated for early-stage
breast cancer. J Clin Oncol 2006; 24: 2420–2508.
40. McGrath P. Positive outcomes for survivors of haematological malignancies from
a spiritual perspective. Int J Nurs Pract 2004; 10(6): 280–291.
41. Watson M, St James-Roberts I, Ashley S et al. Factors associated with emotional
and behavioural problems among school age children of breast cancer patients.
Br J Cancer 2006; 94: 43–50.
42. Huizinga G. The Impact of Parental Cancer on Children. University of Groningen
2006.
43. Comprehensive Cancer Center. Cancer Incidence in The Netherlands by Gender;
http://wwwikcnet.nl/uploaded/FILES/Landelijk/cijfers/Incidentie%202003/
A4%201999-2003 xls (8 December 2006, date last accessed).
Volume 18 | No. 12 | December 2007