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The effects of parents' meta-emotion philosophy on coping with pediatric oncology patients

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The effects of parents' meta-emotion philosophy on coping with pediatric oncology patients
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Cejka, Anna
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English
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xi, 71 leaves : ; 28 cm.

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Cancer in children -- Psychological aspects ( lcsh )
Adjustment (Psychology) in children ( lcsh )
Parenting ( lcsh )
Parent and child ( lcsh )
Adjustment (Psychology) in children ( fast )
Cancer in children -- Psychological aspects ( fast )
Parent and child ( fast )
Parenting ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Thesis:
Thesis (M. A.)--University of Colorado Denver, 2008.
Bibliography:
Includes bibliographical references (leaves 65-71).
Statement of Responsibility:
by Anna Cejka.

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University of Colorado Denver
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Auraria Library
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268657352 ( OCLC )
ocn268657352

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THE EFFECTS OF PARENT'S META-EMOTION PHILOSOPHY ON COPING IN PEDIATRIC ONCOLOGY PATIENTS by Anna Cejka B.A., University of Colorado, 2006 A thesis submitted to the University of Colorado Denver in partial fulfillment of the requirements for the degree of Master of Arts Clinical Psychology 2008

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This thesis for the Master of Arts degree by Anna Cejka has been approved by Eric Benotsch J I Date

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Cejka, Anna Claire (M.A., Clinical Psychology) The Effects of Parent's Meta-Emotion Philosophy on Coping in Pediatric Oncology Patients Thesis directed by Assistant Professor Jennifer Adams ABSTRACT Research on parenting style and the processes through which each style may affect various outcomes in children has become more specific in recent years. Gottman, Katz and Hooven (1996) proposed a new model of parenting using meta-emotion or parents' emotions about their own and their children's emotions, and meta-emotion philosophy which is a representation of the parents' thoughts and approaches to their own and their children's emotions that is personified in a particular parenting style. Although very impressive and comprehensive research has been done on parental meta-emotion philosophy and children's ability to regulate emotions and react appropriately in social situations both in normal child populations as well as those with conduct disorder and families with domestic violence histories, no research has been done on child populations faced with a serious illness like cancer. The current research investigated the link between parenting philosophy and the ability for children to cope with an uncontrollable situation such as being diagnosed with cancer. There was no significant relationship found between parenting philosophy and

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children's ability to cope, however parents of these children revealed valuable information about their parenting prior to and after their child's diagnosis of cancer. This abstract accurately represents the content of the candidate's thesis. I recommend its publication. Signed

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DEDICATION I dedicate this thesis to my husband, Nathan, who supplied nonstop caffeine, hugs, and taught me to recognize my own strength and talent. I would also like to dedicate this thesis to my family, in particular my mom, Sally, without whom I would never have believed that I could make it this far.

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ACKNOWLEDGEMENT I would like to thank Jennifer Adams for her unfailing support and patience and for our wonderful, inspirational conversations. I would also like to thank Eric Benotsch and Kristin Kilbourn for their support and help with this thesis. Finally, I would like to thank Edythe Albano and Jeanelle Sheeder for welcoming me into the Children's Hospital medical and research teams and for their continued assistance and support.

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TABLE OF CONTENTS Figures ... ........... .............................................. ..... .................... ..... ..... .......... x Tables .... ... .... ............ ........................................ ..... ....... ........... ........ .......... xi CHAPTER 1. INTRODUCTION .................. .... ... .... ................... ..................... ... ... Pediatric Cancer: Incidence Prevalence, and Psychological Effects ......... ... ... ........ ... ..................................... .......... ... ..... Pediatric Cancer Statistics ... ............ ........ .... ..................... ... ..... 1 Pediatric Cancer: Psychosocial Functioning and Research ............ 2 Current Directions ........................ ... ....... ... ....... ... ......... ............. 7 Parenting Style Research: History and Issues ... ... ..... ..... ....... ....... 8 Characteristics of the Parenting Philo sop hies ... ................ ...... ........ 14 Rationale for the Current Study ................ ................................. .... 17 2. METHOD ............... ..... .. ........ ............. ... ...... .... ... ............................... 20 Participants ...... .............. .............. .... ..... ..... ....................... ... ... ... 20 Measures ..... ....................... ... ........................ ... ............ .... ........... 21 The Parenting Style Survey ................ .... .... ....... ....... ............ ... 21 The Meta-Emotion Questionnaire ... .... ..... ....... ....... ........ .... ... ..... 22 Vll

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The DASS21 ....... .... .... .................. ... .............. .......................... 23 Procedure ..... .... .... ...... ..... .............. . ... ... ..... ............... ..... .... 24 3. RESULTS ... .................. ........................... .............. ................ ... ... 25 Power Analysis ................................................. .... ........................... 25 Parentin g Style Questionnaire and Coping ... .................................... 25 The Meta-Emotion Questionnaire .................. ............... ........ ........ 29 Pre-Diagnosis Parenting Styles and Themes ....... ............... .......... .... 30 The Dismissing Parent.. ................................................................ 30 The Disapproving Parent. ....... .............. ... ..... .... ..... ...... ..... ......... 32 The Laissez-Faire Parent. ........................... ........ ......... ... ... ......... 34 The Emotion-Coaching Parent. .... ................ ................ .... ... ..... 35 Post-Diagnosis Parenting Styles and Themes .......... ... ........ .. ... ........ 38 The Dismissing Parent.. ................................ ..... ............... ...... ..... 38 The Disapproving Parent.. ........... ........ ...... ...... ................. ........ ... .40 The Laissez-Faire Parent. ....... .................................................... .40 The Emotion-Coaching Parent. .......... ................................... ...... .41 Positive Cognitive Restructuring ............. ........... .... .... ...... ........ .. .44 4. DISCUSSION .............. ......................................... ...... ...................... .... 46 Limitations ................ ..... .............. ..... ... ............... ................ ....... .... 51 Future Directions .......... ...... .......... ............................ .................... ... 52 Vlll

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APPENDIX A. Parenting Style Questionnaire ............. ........ .......... ..... ..... ..... .... .... 55 B. Questions Based on the Meta-Emotion Interview ............ .......... ... ..... 61 C The DASS21 .... ............... ...... .... ........ ... .... ............ .................. ............ 63 REFERENCES .... ...... ... .... ................ ... ..... ...... ..... .......... ....... ................... ........ 65 IX

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LIST OF FIGURES Figure 3 1 DASS21 means as a function of parenting style .... ...... ..... .... 27 3.2 Breakdown of parents in pre and post-diagnosis parenting styles based on the meta-emotion questionnaire ....... .............. ... ... .... .... .44 X

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LIST OF TABLES Table 1.1 Summary of psychosocial functioning in pediatric cancer patients .... .... ..... 3 3.1 DASS21 normative data vs. participant data .... ........... .............................. 29 XI

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CHAPTER 1 INTRODUCTION Pediatric Cancer : Incidence, Prevalence, and Psychological Effects Pediatric Cancer Statistic s In the 1960 s mo s t children with c ancer died and the 5year sur v i v al rate was a mere 28 % (Ries Harras Edward s & Blot 1996). Incidence of cancer has been increasing over the past 30 years howe v er the 5-year survival rate has also increased to a substantial 80 % today (Surveillance Epidemiology, and End Results 2007). Although 80 % of the children diagnosed with cancer will survive diagnosis and treatment the National Cancer Institute and the U.S National In s titute ofHealth estimate that amongst diseases not including accident s, cancer is the still leading cause of death in children from infancy to 15 years of a g e (Greenlee Murray Bolden & Wingo 2000; Surveillance Epidemiology, and End Results 2007). It is approximated that 10, 400 new cases of pediatric cancer are expected in 2007 and that the majority of these ca s es will be diagnoses of leukemia brain tumors and other central nervous system tumors Today it is estimated that 1 in 900 people is a survi vor of pediatric canc e r (Robinson 2003). Because s urvival rates have increased so substantially the focus of research on pediatric cancer has shifted to include 1

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interventions that will enhance the psychological social and behavioral functioning of children living with and surviving cancer. Pediatric Cancer: Psychosocial Functioning and Research Research has been done on the psychological sequelae of those children who are survivors of cancer which can include depression, anxiety and poor self-esteem. In addition to these residual symptoms these children may be prone to poor socialization and deficient self-help skills due to the effects of cancer and its treatment such as phys ical deformity and handicaps (Koocher et al., 1980) as well as stunted growth infertility and neurocognitive deficits (Oberfield & Sklar 2002). These residual effects can have a negative impact on social functioning and relationships especially considering the impact of treatment induced infertility on future romantic relationships (Boman & Bodegard, 2004; Byrne et al., 1989; Patenaude & Kupst 2005). Patenaude & Kupst (2005) (Table 1.1) summarized the results of the past twenty years of research that correlates a range ofvariables such as time since diagnosis age type of cancer and type of treatment with psychosocial functioning in pediatric cancer patients and survivors. Table 1.1 Summary of psychosocial functioning in pediatric cancer patients 2

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I I Variab l es II R es ult s of P revio u s R esea r c h II R e f e r e n ces Disease a nd t rea tm e n t Diagnosis involving CNS Lower cognitive and academic Armstrong & Mulhern 2000 review functioning Boman & Bodegard 2000; Mulhern et More difficu l ties i n al., 1994; Van n atta et al. 1998 psychosocial functioning Bone-tumors More difficulties in adjustment Eiser et al. 1998 ; Langeveld et al. 2002 Type o f trea tm e n t CNS lrradiation Lower cognitive and academic Armstrong & Mulhern, 2000 review Chemotherapy functioning Zebrack & Zeltzer, 2002 review More intensive lower adjustment P hysica l se qu e lae/fu nctio n a l Elkin et al., 1997 ; Fritz et al,. 1988; imp ai rm e nt More severe associated with Greenberg et al., 1989 ; Koocher & lower psychological O Malley 1981 functioning Time since diagnosis Longer associated with better Cella & Tross 1986; Koocher & adjustment O Malley, 1981; Kupst& Shulman, 1988 Duration of treatment Shorter, leads to better Koocher & O Malley 1981 adjustment P e r so n a l Age at diagnosis Older better adjustment Cella et al., 1987; Mulhern et al., 1989 Younger, better adjustment Barakat et al., 1997; Elkin et al. 1997; Slavin et al. 1982 Previous functioning Previous adjustment related to Kupst & Sh u lman 1988 ; Kupst et l ong-term adjustment al. 1995 Degree of perceived stress Lower, better adjustment Last & Grootenhuis, 1 998 ; Varni et al., 1994 Level of cognitive functioning Higher better adjustment Boman & Bodegard, 2000 ; Kupst et al., 1995; Mackie et al., 2000 ; Levin Newby etal.,2002 Fa mil y/E nvironm e n ta l Adaptability / cohesiveness Higher, better adjustment Kazak & Meadows 1989 ; Levin Newby et al. 2002 ; Rait et al., 1992 Open communication More open better adjustment Fritz et al., 1988; Koocher & O Malley, 198 1 ; Kupst & Schulman 1988 Family and social support More support better Fritz et al., 1988; Kupst & Schulman adjustment 1988 ; Trask et al., 2003 Coping/adjustment/family Hig her level, better adjustment Carlson-Greene et al. 1995 ; Kupst & Schulman 1988 ; Kupst et al. 1995; Sahler et al., 1997 Socioeconomic resources I Higher better adjustment Koocher & O'Malley, 1981; Kupst et al., 1995 Patenaude, A. F. & Kupst, M. J (2005). Psychosocia l Functioning in Pediatric Cancer". Journal of Pediatric Psychology, 30(1), 9 27. 3 I

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Although this res e arch shows that children diagnosed with cancer can have significantly increased psychological distress as well as significantly increased behavioral and social problems both during treatment and as survivors results over the years have varied (e.g. Koocher and O Malley 1981; Lavigne and Faier Routman, 1992). Elkin et al. (1997) identified several common methodological inconsistencies in studies of psychosocial outcomes of pediatric cancer patients that may account for the discrepancies in this research. These include methodological differences such as differences in outcome variables di f ferences in the types of mea s ures used as well as differences in the respondent (i.e. teacher parent, or patient) sample size and population and the time at which the assessment was done (i.e. early middle or late stages of treatment or survivors) (Elkin et al., 1997 ; Noll et al., 1998 ; Patenaude & Kupst, 2005; Worchel et al., 1988) There are also discrepancies in regards to the psychological outcomes with v ariables like age at diagnosis gender and time elapsed since their diagnosis. Whether they were measured during early or late stages of treatment or during initial remission may make a difference in terms of expression ofpsychological distress (Elkin et al., 1997). Research in this area has so far been conflictual and inconclusive and further investigation into specific factors that lead to these inconsistencies is necessary. A moderate amount of distress can be expected in all pediatric cancer patients but there may be differences in families and children that predict in adaptive coping among children with cancer or those who have survived cancer. A meta analysis of 4

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60 studies of depression among children with chronic medical problems showed that these children had slightly more risk for depression but most were not clinically depressed (Bennett, 1994). Children with chronic illnesses face similar challenges to those with cancer include painful procedures and procedural distress frequent trips to the hospital or long inpatient stays, increased anxiety and stress within the family and general trauma associated with treatment. In terms of pediatric cancer patients specifically other studies (e g Jay eta!., 1983; Dahlquist eta!. 1985) from the 1980s showed that a child's coping doesn't necessarily increase over time and adjustment to cancer is predicted by the child's previous experiences, age and developmental level the parents' level of anxiety and distress the amount of social support the utilization of coping skills and perceived control (Patenaude & Kupst 2005) Koocher and O'Malley (1981) were the first to study a large number of survivors using both clinical interviews and standardized measures. They found that although many of the participants were able to lead relatively normal lives in terms of social and academic functioning, nearly half of the survivors showed significant distress. Cella et a!. (1987) conducted interviews and staff ratings of survivors of childhood Hodgkin's disease and found that one third of their participants showed evidence of psychosocial maladjustment associated with increases in avoidant thinking about their illness when using interviews and staff ratings. Other studies, like Mulhern eta!. (1989) utilized a parent-report questionnaire to examine adjustment in pediatric cancer survivors. They reported two to four times the incidence of social and 5

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behavioral problems in children that were s urvivors of cancer compared to a non cancer s ample As compelling as the previously mentioned research is, there are almost an equal number of studie s that show evidence that significant distress associated with cancer diagnosis and treatment is rare (Fritz Williams & Amylon 1988 ; Kupst & Schulman 1988). In fact Lavigne and Faier-Routman ( 1992) found that among childr e n with chronic illnesses children with cancer were at significantly lower risk for p s ychological distress Other studies have found that pediatric canc e r survivors adjustment is not s ignificantly different from controls or norms and rates of depression and anxiety may be at or lower than the rates throughout the general population (Boman & Bodegard 1995 ; Elkin et al., 1997 ; Gray et al., 1992; Kazak 1994 ; Kazak et al., 1997; Kupst et al., 1995; Mackie et al., 2000; Madan-Swain et al., 1994 ; Radcliffe, Bennett Kazak Foley & Phillips 1996 ; Simms Kazak, Golomb Goldwein & Bunin 2002). Although many studies have found that the average level of adjustment in pediatric cancer patients and survivors is close to the level of the general population there is still a significant percentage (25-30 % ) of families and children who exhibit high psychological social and family distress and a number of research studies suggest that 50 % of pediatric cancer patients and their families experience maladjustment (Boman & Bodegard 1995 ; Friedman & Meadows 2002; Koocher & O'Malley 1981; Kupst et al., 1995). 6

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So what might account for these large discrepancies in fmdings other than differences in measurement technique and variations in the study populations? Elkin et al. (1997) posited that pediatric oncology patients and survivors minimize their displays of emotional distress and attempt to present in a positive way. They call this tendency a repressive adaptive style. Children who are repressors tend to score lower than those who are not repressors on anxiety depression and anger expression Elkin and his colleagues also found that childhood cancer survivors scores on the SCL-90R were significantly lower than the published norms This supports their hypothesis that these repressive tendencies may decrease the reporting of negative symptoms and this may in tum explain the discrepancies from previous studies of cancer survivors (Elkin et al., 1997). Current Directions Research in the pediatric psycho-onco logy field recently has attempted to investigate questions about how parents and children are able to cope with all of the psychological stressors and physiological challenges that come with cancer. What is lacking in the research is an understanding ofthe qualities of the parents and child that may protect them from having clinically significant levels of distress during the treatment process. Rather the research has focused on the specific aspects of the pediatric oncology population as a whole and made generalizations about how they respond to self-report measures. As Elkin and his colleagues posited, some children 7

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with cancer may have a desire to repress and minimize their distress and present themselves in a favorable light. However, there may be more specific protective factors that increase the child's and parents' ability to cope with and adapt to the child s cancer diagnosis and treatment. The current research attempts to understand how parenting style and parents' understanding and reactions to their own emotions and their children's emotions may increase or decrease the child's ability to cope with the diagnosis and treatment of cancer. Parenting Style Research: History and Issues The debate about which parenting style best serves children seems to have been laid to rest with Diana Baurnrind s revolutionary research on various parenting styles and their effects on children s well -being (1978 1996) Parenting style in general is defmed as a p sy chological construct that represents the strategies that parents generally use to raise their children Baumrind's assumption in all four of her parenting styles is that the main goal of parenting is to influence teach and control their children, but that there are continuum of parenting behaviors associated with each of these factors. Therefore the variation in parenting style is the extent to which a parent demands control with or without warmth and explanation, or as Baurnrind put it balancing responsiveness with demandingness (1978, 1991) Baurnrind (1967 1971 1987) distinguished three parenting styles authoritarian (restricti ve and cold), authoritative (restrictive and 8

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warm) and p e rmi ss i ve Baurnrind identified that authoritarian parents had conflicted irritable children (fearful apprehensive moody unhappy easily annoyed pa s sively hostile vuh1erable to stress, aimless sulky and unfriendly) and authoritative parents had energetic-friendly children (self-reliant self-controlled cheerful friendly able to cope w ell with stress cooperative with adults curious purpo s ive, and achievement oriented). Finally permissive parents had impulsive-aggressive children (rebellious low in self-reliance and self-control impul s ive aggressive domineering aimless and low in achievement). Other research has found that the permi s sive and rejecting style is a good predictor of delinquent and antisocial behavior whereas the restrictive and rejecting style is predictive ofwithdrawn and inhibited beha v ior and other internalizing disorders (Patterson 1982). Before Baurnrind s research Becker (1964) designed a 2x2 table of permissive versus restricti v e parenting as one factor and w armth v ersus hostility as the other factor. Parents who approached their children with a warm and restrictive style tended to have children who exhibited more confidence had increased self esteem and had appropriate social skills Parents who approached their children with a hostile and restrictive style tended to have children who exhibited social withdrawal were more argumentative and had limited social skills The warm and permissive cell was omitted or deleted from Becker s model. Finally parents who approached their children with a hostile and permissi v e style tended to have children who exhibited delinquent behavior were noncompliant and aggressive 9

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However a caveat to Becker and Baumrind's research is that although they defined some parenting characteristics they failed to operationalize the characteristics in a meaningful way that would help parents improve their approach to managing their childrens' behavior. Instructing parents to be warm and structuring when their child is having a tantrum does not dictatate to parents how exactly to respond to their child s emotions and w hat boundaries to set in terms of behavior. Recent research on emotion-coaching however, does indicate specific parental responses to children s emotions and behavior. Haim Ginott ( 1956 1971 1975) was the first to study how parents how parents dealt with their child s expression of emotions thoughts and actions. Gin ott felt ( 1956) that it was important for parents to relate to their children with empathy and caring without derogation and described effective parenting as being affectionate enthusiastic engaged and responsive to the child (Ginott 1956 as cited in Gottman 1996). In essence Ginott believed that parents should accept all feelings from their children using a language of acceptance "; acknowledging and reflecting feelings and complaints back to their children so their children could feel validated. In addition Ginott believed that it was important to teach parents how to express their own anger and sadness in order to foster healthy emotional communication. However Ginott made an important distinction between emotions and behavior such that all emotions were accepted all behavior was not. Out ofGinott's research John Gottman and his colleagues developed the concept of m e tae motion or feelings and thoughts about one s own emotions and 10

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one s children's emotions (Gottman, Katz & Hooven 1996) They also refer to a parental metae motion philosophy which they describe as an organized set of thoughts and metaphors a philosophy and an approach to one s own emotions and to one's children's emotions (Gottman Katz & Hooven 1996). Gottman believed that a parent s interactions with a child influences the child s ability to selfregulate focus their attention and form bonds with family and friends. Also Gottman belie v ed that a child s emotion-regulation abilities are directly influenced by parenting and the way parents talk to their children about their emotions (Gottman et al 1996). With these concepts in mind Gottman et al (1996) established the Meta Emotion Interview (Katz & Gottman 1986). Gottman (1986) and his colleagues used the Meta-Emotion Interview to initially interview fifty-six parents of 4-to 5year-old children individually about their personal experiences of emotions especially sadness and anger their philosophy of expressing and controlling emotions and their attitudes and behavior about their children s anger and sadness (Gottman, Katz & Hooven 1996) Through this research it was discovered that there was a large variety in the experiences philosophies and attitudes that parents had about their own emotions and their children's emotions (Gottman Katz & Hooven, 1996) For example some parents saw anger as evil or even dangerous and they would not allow their children to express anger and other parents reported that they would punish their children for expressing anger e v en if they had not behaved inappropriately Some parents believed that anger was natural but would ignore it in their children while other parents 11

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encouraged the expression of anger in their children. There was a similar amount of variety in parents responses to sadness in their children as welL Some parents would minimize expressions of sadness in their children and in themselves whilst other parents saw s adness in their children and in themselves as an opportunity for learning and for being emotion coaches to their children about the world of emotion and how to respond to emotions Gottman and his colleagues (1996) also found that there was an interestin g gender differences among s t the parents responses Fathers were less likely to be aware of their own sadne s s or to console their children when they were sad while mothers consoled their children more when they expressed sadness (Gottman Katz & Hooven 1996). Gottman Katz and Hooven (1996) developed two variables from the intitial 12 constructs in their research A ware n es s measures the level of the awareness ofthe parent s own emotions and their children's emotions. Gottman (1996) found that only parents who were aware of emotion and emotion intensity found the expressions of emotions acceptable. Parents who were low on awareness saw negati v e emotions as toxic and dangerous and they tend to minimize these emotions or not notice them at all in order to not have to deal with them. For example a parent low in awareness might say "He s not sad much. It hurts me to see him sad though. I have to go out for a run These parents have difficulty describing how they could tell when they or their children experienced certain emotions and were unsure ofwhat would make their child feel a negative emotion or even what to do about it (Gottman Katz & 12

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Hooven, 1996). The second variable, coaching, analyzed the sum ofthe parental coaching. Parents high on coaching said things like, "I feel close to my child when he is sad," or "When my child is sad I let her know that I understand," in previous research. Parents low on coaching were either disapproving or dismissing of their child's emotion. Examples of a comment they made include, "I think that sadness is OK as long as it's under control," or I warn him about not developing a bad character" (Gottman, Katz, & Hooven, 1996). Combining these variables creates the parenting styles that Gottman describes in detail in Raising an Emotionally Intelligent Child: The Heart of Parenting (1997). From their pilot work and early research, Gottman, Katz and Hooven ( 1996) realized that there were some parents who were aware of their own emotions and how they worked in their lives and who could differentiate emotions as well as recognize these emotions in their children and help their children deal with their emotions. These parents acted as emotion coaches to their children and were therefore labeled as having an Emotion-Coaching parenting style. These are parents both high in awareness and high in coaching. Parents low on awareness and low on coaching have either Dismissing or Disapproving parenting styles. Finally, parents high on awareness and low on coaching have a Laissez-Faire parenting style. Characteristics of the Parenting Philosophies During a meta-emotion interview parents describe how they react to their 13

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child's emotions, what they think of their child's emotions (in particular the negative ones), and their own feelings about their children's emotions. A Dismissing parent, for example, will view their child's feelings as unimportant and will often ignore the child's feelings. These parents will want negative emotions to go away as quickly as possible and will distract the child from their negative emotions. They may also ridicule their children's emotions and believe that their children's emotions are irrational and therefore are not interested in listening to what the child is trying to communicate. They themselves may lack awareness into their own emotions and feel uncomfortable or overwhelmed by the child's emotions The Dismissing parent focuses more on getting over the emotion because they believe that negative emotions are dangerous, so focusing on the emotions wi 11 make the emotion worse. They lack confidence in their ability to deal with negative emotions and will react by trying to "fix things." These parents believe that their child's displays of negative emotions make them look bad and shows that their children are not behaving appropriately Gottman (1997) hypothesized that children who have Dismissing parents learn that their feelings are wrong because they are constantly being invalidated. They also may have issues regulating their own emotions since their parents were not able to teach them how to handle negative emotions. The Disapproving parent shares many of the same characteristics as the Dismissing parent but more negatively (Gottman, 1997). Instead of ignoring their child's negative emotions, they will judge and criticize their child's emotions. They 14

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may tend to set more limits than needed and will punish their child for expression of negati v e emotions r e gardle s s of whether they are beha v ing badly or not. The s e parents believe that expression of negative emotions s hould be time-limited and controlled. In addition to their criticism oftheir child s emotions these parents believe that their children use their emotions to manipulate others and that displays of emotion show that their children are weak. Ultimately these parents want their children to obey their authority and be "emotionally tough ". Gottman believes that the effects ofthis p a renting style on children are the same as the Dismissi n g style (Gottman 1997). The Lai ssez -Fair e parent falls at the other end of the s pectrum and is extremely accepting of emotional expression in their children and will comfort their children when they are experiencing negative emotions However although they comfort their children they fail to give their children much behavioral direction and do not set behavioral limits. In addition to their over-acceptance ofbehavioral problems, they do not help their children problem-solve or teach their children about their emotions Ultimately they belie v e that their job is to help their children release their emotions since there is nothing they can do about the emotion itself. Children who have parents who are Lai ssez -Fair e might have difficulty learning how to regulate their emotions and may have trouble forming relationships or getting along with other children (Gottman 1997). Finally, the Emotion Coa c hing parent interprets a child's expression of 15

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negative emotions as a learning opportunity and a time to develop an intimate connection. They do not try to make their child's emotions go away but are comfortable spending time with a child who is expressing sadness, anger or fear. These parents are aware of how their own emotions work in their lives and value their own emotions and their children's emotions. In contrast to the other parenting styles, the Emotion-Coaching parent does not feel that they have to fix their children's problems and does not invalidate the child's feelings. In essence the Emotion Coaching parent uses times when their children are expressing emotion to "coach" their children about their emotionshelping the child label their emotion, learn problem-solving skills and emotion regulation. These parents will accept and validate the emotion with empathy but they do not accept all behavior that results from their child's emotion. It is important to note that these parents are not just displaying warmth to their children, since a parent can be warm but oblivious to emotion and emotion-coaching. The Emotion-Coaching type of positive parenting is called scaffolding-praising. Gottman and his colleagues found that when they presented parents and children with a teaching task where parents had to help their children that parents that were high on the scaffolding-praising dimension gave their children structure and stated the goals and directions of the game simply while remaining relaxed and then they waited for their child to act and made comments when their child did well. Parents that were low on the scaffolding-praising dimension did not provide structure for their children or they provided their children with too much 16

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information at once which confused the child. These parents also tended to mention only their child s mistakes instead ofbeing their child s "cheerleaders" (Gottman Katz & Hooven, 1996) The Emotion-Coa c hing parenting style works, as Gottman describes by inhibiting parental derogation since parents who react empathically and validate their child s emotions cannot be critical and show contempt at the same time (Gottman Katz & Hooven 1996). Because children with Emotion-Coa c hin g parents learn to re g ulate their emotions and problem-solve during times of stress these children are more likely able to cope with anger and sadness than children whose parents have other parenting styles Rationale for the Current Study Although research has been done on "normal child and adolescent populations in terms of the effects of an Emotion Coa c hing parenting style on their ability to regulate emotions problem-solve, and interact with peers the literature related to meta-emotion parenting styles and how they relate to a child s ability to cope with a major illness is limited One of the unique aspects of a chronic illness is that it is mostly an uncontrollable situation. In an uncontrollable situation a parent has fewer opportunities to model problem-solving skills for their children. Eisenberg (1996) mentions that positive cognitive restructuring in uncontrollable situations may be a necessary added coping technique parents use in order to reduce stress in their children Cognitive restructuring a proce s s of recognizing challenging and changing 17

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cognitive distortions and negative thought patterns can improve a person s mood and mental state (Beck 1995). For example a parent might say "Let's look at the positives in this situation and focus on the future," or "Even though this is happening, look at all the great things you've accomplished." It will be interesting to see if in the current study parents use cognitive restructuring as a part of their emotion-coaching strategy, and if they used this before their child was diagnosed with cancer. lfhaving a particular parenting style could increase a child s ability to regulate their emotions and cope with cancer and thereby increasing the strength of their immune system, this research would have implications for the development of family interventions and/or brief coping skills training or information on validating, problem-solving skills and accepting their child's emotions. Based on results from previous research on pediatric cancer patients and children of parents with an Emotion-Coa c hing philosophy the current study proposes one main hypothesis and one exploratory hypothesis. The main hypothesis is that children whose parents utilized an Emotion-Coa c hing parenting style will demonstrate better psychosocial functioning and coping skills as compared to peers whose parents utilized Dismissing Disapproving or Laissez-Faire parenting styles. The exploratory hypothesis is that parents who reported utilizing an Emotion Coaching parenting style before their children were diagnosed with cancer will continue this strategy after their children s diagnosis and will add positive cognitive 18

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restructuring to their coping as measured by responses to the post-cancer diagnosis qualitative questions. 19

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CHAPTER2 METHOD Participants Participants included 39 pediatric oncology patients (23 females, 16 males) and one parent from each family (32 mothers, 7 fathers) from The Children's Hospital Hematology / Oncology clinic (TCH-HOC) in Denver, Colorado. 7.5% (2) ofthe participants identified as Hispanic, 88% (24) identified as White, and 3% (1) identified as White and Hispanic. Participants were recruited for this study as part of a larger pilot program called The Futures in Fertility Program. The goals of this larger program were to identify the psychosocial support, educational and health care needs surrounding reproductive health issues for adolescent cancer patients and their families. The Futures in F e rtility Program is currently at the beginning of a three-phase study which includes education and psychological support for the patients and their families fertility monitoring for females and enhancing protocols for referring males to sperm banks, and fmally the development of cutting-edge medical treatments, such as oocyte and ovarian cryopreservation for adolescent females. 20

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Potential participants were identified by the staff of the TCH-HOC with the permission ofthe Clinical Director. The patients ranged in age from 13 to 23 (M = 16. 63). Participation in the study was optional and no compensation was offered to patients or their families. Participants were excluded due to incomplete surveys (4) and for the parents not being available to complete their portion of the survey (9) so that the final study population consisted of 14 female and 12 male pediatric oncology patients and 23 mothers and 3 fathers No Participants refused to participate This research has been reviewed and appro v ed by the Colorado Multiple Institution Review Board (07-1000). Measures The Parenting Style Survey One parent from each family with a child in treatment was given the parenting style survey from Rai s ing an Emotionall y Intelli ge nt Child (Gottman 1997) (Appendix A), a book developed on the findings of initial research on meta-emotion parenting philosophies (Gottman Katz & Hooven 1996) The measure was composed of 81 true / false questions referring to their "meta-emotion ", or feelings about their own emotions and their children s emotions as well as their reactions to or perceptions of their own and their children's emotions The number of" true" answers on certain items was added to determine the parent s parenting style. 21

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Previous research on Meta-Emotion p a renting styles h as been done e v aluating both parents parenting styles and then analyzing effects based on both parents (Gottman Katz & Hooven 1996) The atmosphere of the oncology floor, where usually only one parent will attend with their child made it extremely difficult to obtain parenting style surveys from both parents. In addition to this challenge, many families were non-nuclear so that the parents were no longer married and there was a step-parent involved or one parent had passed away The decision to only obtain one parenting style survey challenges the validity of the resulting data however Gottman and his colleagues reported that no main or interaction effects w ere found when they compared mothers and fathers except that mothers tended to be more aware and more coaching of emotion than fathers and that fathers were less aware of sadness than mothers (Gottman, Katz & Hooven 1996). Therefore we believe that analyzing a child's coping based on one parent s survey results to be a valid approach especially since 88% (23) of the parents surveyed were mothers The Meta-Emotion Questionnaire In addition to the true / false questions excerpts based on the Meta-Emotion Interview (Katz & Gottman 1996) were added to the survey (Appendix B) These questions were designed to get a qualitative perspective ofthe parent s meta-emotion and meta-emotion philosophy and to discern whether their philosophy changed after the child s diagnosis of cancer. For example one question asks about how the parent 22

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would react to their child's anger prior to their diagnosis of cancer and another question asks how the parent would respond to their child's anger after having been diagnosed with cancer. The DASS21 Each cancer patient and one parent were given the 21item version of the original42-item selfreport measure the Depression Anxiety Stress Scales (DASS21) (Appendix C). The DASS21 is composed ofthree scales designed to measure levels of depression anxiety and stress These scales have been shown to have high internal consistency in previous research however the lowest age used in initial trials was 17 although the authors claim efficacy in populations as young as 12 (Lovibond & Lovibond, 1995). Concurrent validity for the DASS21 was established using correlations with other depression and anxiety measures. The DASS21 Depression scale correlated highly with the BDI as well as moderately with the anxiety measures. The DASS21 Anxiety scale was also found to be correlated highly with the BAI and moderately with the STAI-T. Across groups the DASS21 was found to reliably identify major depressive disorder on the Depression and Stress subscales as well as individuals with panic disorder on the Anxiety subscale The nonclinical group scored significantly lower on the three subscales than the clinical groups (Lovibond & Lovibond, 1995). 23

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Procedure As noted above, patients were identified by the staff of the TCH-HOC with the permission of the Clinical Director using the demographic data from the TCH database (eg age gender treatment and treatment location). They were approached either in the inpatient or outpatient unit at an appropriate time deemed by their primary physician and/or their parent. After the patients and their parents listened to an initial introduction to the project by either their attending physician or the principal investigator, the principal investigator would read through the consent form. If the patients and their parent(s) agreed to participate in the study, assent I consent would be obtained and a copy of informed consent was given to them. The participants would then fill out the measures in a private exam room or infusion room The primary investigator was available for questions at any time while the participants were filling out the questionnaire. After the participants fmished the questionnaire, they received educational and referral information on fertility preservation and psychosocial support services. 24

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CHAPTER3 RESULTS Power Analysis The power of the study was 3 with an effect size of. 71, a low power value due to the small number of participants. Effect size estimates were not available in the Gottman literature and therefore a large effect size was calculated in order to obtain an estimate of the minimum appropriate sample size With a power of0.95 and alpha of .05, a sample size of 106 was needed to detect a large effect size (t = 1 98) for an independent samples t-test. For correlations a sample size of96 was needed to detect a large effect size (r= 50). This study had a sample size of24 for quantitative analyses and a subsample size of26 for qualitative analyses. The sample size was not large enough to detect large effect sizes when conducting independent samples t-tests or Pearson s correlations. Parenting Style Questionnaire and Coping It was hypothesized that parents with an Emotion-Coa c hing parenting style would have children who scored lower on the DASS21 than children of parents with Laissez-Faire Dismi s sing, or Disapproving parenting styles. We began by 25

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establishing each parent's parenting style by adding the number of"true" answers to questions divided into the parenting subscales. These four numbers were then divided by the number of "true" answers in each subscale and the fmal scores were compared. The highest subscale score was the parent's determined parenting style. We found based on the parenting style survey that parents fell into only two of the four parenting styles, Lai ssez -Faire (6 parents) and Emotion-Coaching (18 parents) To assess for the effect of the two parenting styles on the children's coping independent samples t-tests were performed. It was found that there was no significant difference between Laiss ez -Faire and Emotion-Coaching parenting styles and the children's DASS21 total or scores (t(22)=. 594, ns). There was also no significant difference between Laiss ez -Faire and Emotion-Coaching parenting styles on the Depression, Anxiety or Stress subscales ofthe DASS21 (t(22)=-.459, ns) (t(22)=-.811 ns) (t(22) = -.599, ns). 26

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DASS21 Means by Parenting Style 14 1 2 1 0 Mean 8 Score 6 Laissez-Faire Emotion-Coa c h 4 2 0 Total Score Depression Anxiety Stress Scale Figure 3.1 DASS21 means as a function ofparenting style Figure 3 1 displays the mean scores for the DASS21 as a function ofparenting style. As evident in the graph, the difference between the Depression scale scores of children with the 6 Laissez-Faire parents (M = 2 83, SD = 3.82) and those with the 18 Emotion-Coaching parents (M = 3 89 SD = 3 81) is not significant. No significant differences were found on the children with Laissez-Fa ire parents scores (M = 2.5, SD = 1.64) and the chi l dren with Emotion-Coaching parents scores (M = 3.76, SD = 1 64) on the Anxiety scale. The scores on the Stress scale between the children with Laisse z -Faire parents (M = 4.33 SD = 4.37) and Emotion-Coaching parents (M = 5.56 SD = 4.31) were also not significantly different. However the scores of the 27

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children with Laisse z -Faire parents were consistently lower than those of the children with Emotion-Coa c hing parents. Pearson's correlations were done to further the investigation ofthe relationship between the two parenting styles and the children's scores on the DASS21. As expected the total DASS21 score was significantly correlated to the Anxiety scale (r =.88, p < .01), Depression scale (r =.92, p < .01), and the Stress scale (r =.89 p < .01) The scales were all inter-correlated with each other as well, supporting previous research that shows that the symptoms of anxiety depression and stress are often comorbid (Hirschfield 2001). When comparing the mean scores on the DASS21 of the participants they were very close to the published normative data for the DASS21 and did not indicate that the participants had significant clinical distress (Table 3.1). The total participants' mean for the total DASS21 score (M = 11.21, SD = 9.49) is slightly above the mean ofthe normative sample (M = 9.43 SD = 9.66), however it is far below the clinically significant total score of28. Similarly the participants' total mean for the Depression scale (M = 3.36 SD = 4.48) was slightly higher than the mean of the normative sample (M = 2.83 SD = 3.87) but far below the clinically significant score of 11. The Anxiety scale mean scores for the participants (M = 3 .13, SD = 2 64) were also slightly higher than the means ofthe normative sample (M = 1.88 SD = 2.95) as was the participants' mean for the Stress scale (M = 4.95 SD = 28

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8.681) compared to the normative sample (M = 4.73 SD = 4 .2) however both scores were much lower than the clinically significant scores of8 (Anxiety) and 13 (Stress). Table 3 1 DASS21 nom1ative data vs. participant data DASS21 Scale Total Mean SD Depression Mean SD Anxiety Mean SD Stress Mean SD Normative Data 9.43 9 66 2.83 3.87 1.88 2.95 4 .73 4.2 Participant Data 11.21 9.49 3.36 4.48 3 .13 2.64 4.95 8.68 Clinically Significant Score 28 I 1 8 13 The Meta-Emotion Questionnaire Qualitative data collected from the parents responses to the Meta-Emotion questionnaire was analyzed by hand using highlighters to divide the reports into themes based on the qualities ofthe parenting styles from Gottman and his colleagues' previous research and books (Gottman Katz & Hooven, 1996 ; Gottman 1997). Two groups of variables, awareness and coaching, were analyzed based on the original two variables from Gottman's first publication (1996). It is important to note 29

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that the most parents regardless of their dominant parenting style, reported occasional use of statements consistent with other parenting styles In other words an Emotion-Coachin g parent may use a dismissing statement occasionally as a Disapp r oving parent may use a Lai ssez -Fair e type statement. Pre-Diagnosis Parenting Styles and Themes The Dismissing Parent It was found that 12 out of the 26 parents ( 46 % ) responded to the pre diagnosis questions consistent with a Dismi ss ing parenting style. These parents displayed low awareness of their own and their children s emotions and low coaching when asked how they felt about negative emotions such as sadness and anger and how they responded to these emotions in their children prior to their child's diagnosis of cancer. These parents tended to say things like : "[I would try] not to dwell on it. To fmd something that makes me happy" and "I m not usually sad in response to questions about how sadness works in their life These types of responses mimic Gottman and his colleagues findings ( 1996) where parents who were dismissing tended to minimize the emotion or not recognize it in themselves These parents would also respond to the question about how they would respond to their own children's sadness when they came home with a bad grade with statements such as: 30

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"[I would] try to cheer him up Talk about the next time the future "Try to use positive reinforcement" and "[Tell them] it will be ok and next time work harder. These statements represent a general lack of awareness, or a minimization of emotion. Although these parents have their children's best interests in mind the goal is to move on and "fix the situation instead of recognizing the emotion and helping the child resolve their feelings. Some parents who are dis missing will also put the burden on their children to resolve their emotions and offer little guidance: "She should a s k her teacher about the bad grade ." When asked about how they respond to their o w n and their children s anger the dismissing parents again showed low awareness and low coaching levels in their answers For example one parent associated her anger only with her menstrual cycle and implied that she is ne v er angry otherwise : I associate it with PMS because I m usually low key. Other parents admitted that they Try to keep it under wraps or [Felt a] loss of control [ w hich is] not a good feeling ." When asked how they would respond to their child s anger at not getting onto a sports team they tried out for dismissing parents again did not acknowledge ofthe emotion behind the situation but rather attempted to fix the problem or even got angry themselves instead of focusing their attention on their child s emotions and needs. One parent responded "[I would] tell them they need to channel and deal with disappointment better ", and another responded [I would] t ell her that there is always next year. Althou g h these parents are trying to help their direction for their child has little to do with Emotion-31

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Coaching and does not provide much guidance on how the child should deal with disappointment better. The Disapproving Parent It was found that 1 out of the 26 parents (3%) responded to the pre-diagnosis questions consistent with a Disapproving parenting style more than other parenting styles. This parent displayed low awareness of their own and their child's emotions and low coaching when asked how they felt about negative emotions such as sadness and anger and how they responded to these emotions in their children prior to their child's diagnosis of cancer. Disapproving parents display many of the Dismissing parents' traits, but in a more negative way. Disapproving parents tend to believe that negative emotions are unproductive and a waste of time When asked how sadness works in their life this parent responded "It doesn't" and [Sadness is] irritating [it] gets in the way of other things" implying that sadness is not a productive way for these parents to work through pain and they may not see it as a helpful tool. Gottman (1997) also described Disapproving parents as parents who are over concerned with the child's obedience to authority as well as the need to set limits on their children. This parent believed that they should "Teach [their child] what is expected to achieve goals" when asked how they would respond to their child's sadness about a bad grade. Although this is a lesson that may be necessary the key component of empathy and validation of their child's emotion is missing. Disapproving parents also believe 32

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in putting time limits on their child's negative emotion because they are uncomfortable and unsure of how to deal with their child s sadness. One parent stated, "It s okay to be sad for a time but we must move on." When asked about how they respond to their own and their children s anger the Di s approving parent again showed low awareness and coaching levels in their answers but in a more negative way than Dismissing parents This parent associated their anger with others manipulating her and stated I hate having my buttons pushed to the point of anger. Instead of recognizing that anger can be a product of many events in life and that it is a natural emotion and process that humans go through This same parent felt frustrated with her anger as many Dis approving parents do with sadness, because she believes that anger is unproductive "[I feel] frustrated because I am ineffective when angry [and I] try to avoid it." The need for limiting the amount of time their child shows the emotion was evident in Di s approving parents responses to the hypothetical situation where their child was angry because they did not get onto the sports team One parent (not labeled as Disapproving" ultimately) wondered why their child needed to be so angry about not getting onto the sports team. "Why be so angry? There will be other teams, other things to do It can be political. Life isn't fair. As with the Dismis s ing parent this parent lacks empathy and validation for their child's emotion but in addition they are expressly questioning the need for their child s anger in a more negative way. Finally, parents who are disapproving often see expressions of emotion as a representation of bad character. When asked what, if 33

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anything, the parent would try and teach their child about anger, one parent responded, "That anger can lead to other issues" implying that bad behavior often comes from anger. The Laissez-Faire Parent It was found that no parents responded to the pre-diagnosis questions consistent with a Laissez-Faire parenting style more than other parenting styles. However, as with the other parenting styles, parents who were categorized with another parenting style based on the majority of the answers they made also sometimes responded using Laissez-Faire type statements. Parents who respond consistent with the Laissez-Faire parenting style have a high amount of awareness of emotion but lack the coaching element. This makes it difficult to distinguish between Laissez-Faire and Emotion-Coaching parents on questions that do not ask for examples of the parents' actions, since Emotion-Coaching is primarily an action. For example, when asked how they feel about being sad, one parent responded "At times everyone is sad." This statement shows a higher level of awareness than a parent who says, "I'm not sad." However since the question does not probe for action, we cannot undeniably say that this parent is primarily Laissez-Faire. It is the combination of a response like this with a response to a later question about what they would do in a situation where their child was sad where their parenting style can be better determined. Using this technique it was determined that no parents could be primarily 34

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identified as Laissez-Faire prior to their child's diagnosis. The "action oriented" questions of the pre-diagnosis section, though, did have some examples of a Laissez Faire style. When asked how they would react to their child's sadness when they because of a bad grade some parents answered: "Help him understand it's ok to feel the way he does," "Empathize," "Sympathize with the child-offer [them] comfort This demonstrates the extreme acceptance oftheir children's emotions, however there is a lack of guidance or help with problem-solving through the situation. Laissez-Faire responses to a child's anger were similar to the responses to a child's sadness. When asked how they would react to their child's anger about not getting onto a sports team, and what they would try to teach their child, two parents responded, "[I would] try to be compassionate and understanding," and "[I would try to teach them] it's okay to be mad." Again, this shows that the parents freely accept their children's emotions, but the parents' responses do not indicate that they would help their child work through the emotion or problem-solve through the situation. The Emotion-Coaching Parent It was found that 11 out of the 26 parents ( 42%) responded to the pre diagnosis questions consistent with an Emotion-Coaching parenting style more than other parenting styles. However, as with the other styles, parents who were categorized with another parenting style based on the majority of the answers they made also sometimes responded using emotion-coaching statements. These parents 35

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displayed high awareness of their own and their children's emotions and a high level of coaching when asked how they felt about negative emotions such as sadness and anger and how they responded to these emotions in their children prior to their child's diagnosis of cancer. For these parents emotions are an important and enriching part of their lives. They use these emotions as an opportunity for intimacy with their children and they know what needs to be done when their child expresses emotion They seem to have great respect for the child s emotions and they don't feel they ha v e to fix everything but rather listen and help the child label the emotion and learn to regulate their emotions. In addition, these parents seem to set limits on their child's behavior that results from the emotion and give them acceptable outlets for their emotions. These features are evident in the responses of the parents who reported primarily with emotion-coaching responses For example Emotion-Coa c hing parents responded to their feelings and reactions to their own sadness stating, "Being sad is ok. But it isn t an emotion to dwell on I see it [as] more of an emotion to motivate or help with self-awareness ," "It happens to all of us at times and we need to figure out why and try to fix it, feel better I go with it: sit with it, try to understand what it' s about, and "I use it to make choices that will have positive results. When asked how they would react to their child s sadness when they came home with a bad grade parents whose reports were consistent with an Emotion-Coaching style recognized the need to validate and empathize with their children as well as help them problem-solve and label the emotion "First I would ask about the feelings and rephrase with 36

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understanding I would ask what they might do next time and show understanding and validation of their feelings "Talk about it then problem-solve," "Ask (conversation with the child) 'How did that make you feel?' 'Why?' 'What are you going to avoid this type of situation in the future?'" Finally, a key component to Emotion-Coaching is what they parents feel they can teach their child about dealing with that emotion in the moment. When these parents were asked what, if anything, they would try and teach their child they responded: "It is okay to feel sad it just means that they care about their school work, life etc," "[I would] use examples from my own life ," implying that they would take the opportunity to teach the child about the emotion and emotion regulation. Parents who responded consistently with an Emotion-Coaching parenting style to questions about their child's sadness pre-diagnosis responded similarly to their own and their child's anger. These parents when asked how they felt about being angry and what their reactions were to their own anger saw anger as a beneficial emotion as long as it has behavioral limits. They stated: "It is natural and okay as long as no one gets hurt by physical actions," "Anger needs to be expressed as long as it's not destructive ," and I feel it is ok to be angry if you can verbalize your anger in an appropriate way. I work towards finding ways to solve the situation that created my anger." Also these parents saw anger as productive in their lives like one parent who stated "[My anger] makes me motivated to solve problems. In reaction to their children s hypothetical anger about not getting onto a sports team these parents again 37

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recognized the need to validate and empathize with their children as well as help them problem-sol v e and label the emotion. One parent stated "[I would] let them vent show them love and help them to solve the problem. Finally as with sadness these parents saw their child s anger as an opportunity to become closer to their children and teach them how to regulate their anger For example statements like There is always next time and it' s ok to be disappointed ," were common along with others who stated "[I would teach them] when something doesn t go as planned try to learn and cope and press on," "[I would teach them that they] can t be good at everything and it is ok to just find the right fit." Post-Diagnosis Parenting Styles and Themes The Dismissing Parent We found that 3 out of the 26 parents (11.5 % ) responded to the post-diagnosis questions consistent with a Dismi ss in g parenting style more than other parenting styles 1 of these 3 parents' responses to the pre-diagnosis questions were more similar to an Emotion-Coa c hin g style while their post-diagnosis responses were more consistent with a Di s mi ss ing parenting style (Figure 3 2) Consistent with the previous descriptions of a dismissing parent, these parents tended to minimize sadness in themselves and their children and displayed low awareness oftheir own and their children's emotions and maintained low levels of coaching throughout. When 38

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thinking about their present sadness these parents tended to respond w ith statements like : "I'm not [sad] ," I try to ignore it and not let it consume me and "I've felt too busy to be sad When asked about what they have done in situations where their child shows sadness parents stated [I] changer her mood which is pretty easy," and "I want to protect him from too much sadness Again, this demonstrates that dismi ss ing parents want to fix the situation and protect their children from the sadness instead of empathize and validate their child s emotion and use this as a teaching opportunity. These parent s had similar responses to anger in themselves and their children but there were more comments in the post-diagnosis section that minimized or denied anger. 7 out ofthe 26 responses to the question "How do you feel about being angry now ?" were parents denying, not recognizing or minimizing their anger. For example parents said things like [Anger] is not an issue for me," [It] won t help the situation," ''[Anger] doesn't get you anywhere or take away the cancer and I know not to suppress it but I still do it. I don't want to talk about my anger." All three parents who responded to the majority of the post-diagnosis questions with a Dis missing parenting style stated that they "do not have time for anger." When these parents were asked how they dealt with their child s anger and what they would try and teach their child these parents showed that they would rather fix the problem and move on rather than helping their child through their anger. For example one parent stated that Anger and negative feelings are real and 39

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understandablebut [I] encourage her not to focus on them ." Another parent re s ponded similarly : "[I would teach her to] move on to a better solution and acceptance. It seems like their child's emotions in response to their cancer exacerbates certain parent s feelings of fear and a loss of control when it comes to negative emotions. The parents also may have a difficult time identifying that emotion in themselves and their child (i e "He's not angry ," "I'm not angry ) The Disappro v ing Parent We found that no parents responded to the majority of the post-diagnosis questions in a manner consistent with a Dis appro v ing parenting style. There were also no comments that resembled this style (Figure 3.2) The Laissez-Faire Parent Interestingly we discovered that many parents response style changed when they answered the post-diagnosis questions from a Dis mi ss ing (2 parents 7 % ) or Em o tion-Coa c hing parenting style (5 parents 19% ) to a Lai ssez -Fai re parenting style. Including one parent who had an equal response style during the pre-diagnosis questions who then had a consistent Lai ssez -Fair e response style during the post diagnosis questions there were 8 parents total (30 % ) in this group (Figure 3.2). Consistent with the previous descriptions of a Lai ssez -Fai re parent these parents tended to acknowledge sadness in themselves and their children and display high 40

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levels of awareness of their own and their children s emotions but maintained low levels of coaching throughout. When asked how they react to their child s sadness as it relates to their cancer these parents responded with answers like "He doesn't express his sadness very often but when he does we talk about it and I give him a hug and lots of love ," "I let her be sad hold her and tell her to cry and "Hugs, kisses and thoughts uplifting and positive when s he feels sad ." Although these parents are clearly concerned about their child's emotional state they seem not to know how to help them through it or problem-solve with them. Similarly when these parents were asked how they react to their child s anger as it relates to their cancer Laisse z -Faire parents seemed to respond with extreme acceptance but gave their children minimal guidance on how to work through their anger. I allow him to express it," I listen [and] wish my child didn t have to go through cancer and Let them vent and listen were common answers. The Emotion-Coaching Parent It was found that overalllO out of the 26 parents (38 % ) responded to the post diagnosis questions consistent with an Emotion-Coa c hing parenting style more than other parenting styles. Interestingly we discovered that 3 parents' response styles (11.5 % ) remained the same from pre to post-diagnosis questions and 5 parents' response styles (19 % ) changed from a Di s mi ss ing parenting style to the Emotion Coaching parenting style during the post-diagnosis questions Two parents (7.6%) 41

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who had an equal response style during the pre-diagnosis questions had a consistent emotion-coaching response style during the post-diagnosis questions (Figure 3 2). Consistent with the previous descriptions of an Emotion-Coaching parent, these parents tended to acknowledge sadness in themselves and their children and display high levels of awareness of their own and their children's emotions and were also very good at helping their children learn to regulate their emotions and problem solve. When asked how sadness works in their lives now these parents responded with statements such as: "[I] vent my sadness talk cry and try to move forward to happier thoughts ," "[I] let the tears flow-let others lend their support, care, [and] empathy, and "It gives me strength." These parents are expressing their awareness oftheir emotions as well as a good understanding of how they deal with their own sadness. This level of awareness in themselves in turn makes them more aware of the sadness in their children as well as how to help their children when they are sad. These parents react with "compassion, and listening and "try to support and be there for [their children]," when they are sad. One mother stated that her daughter s sadness "Makes me feel protective [ofher] and love her even more, while another parent stated that they "give an example of how strong she is-how good she is and let her know this won t last forever," which demonstrates these parents' overall view of the world of emotion-that it is something to use for developing intimacy and teaching emotion regulation. Consistently these parents responded with words like compassion", "empathy" "validation and "understanding" when asked how they 42

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respond to their child s sadness about their cancer and what their child's sadness brings out in them When these parents children display anger they are able to recognize it, empathize and help the child learn to deal with their anger. These parents also recognize what makes them angry and how to deal with it in themselves. "I vent at timesI just try to ask as many questions about cancer so I don t get frustrated." These parents recognize that in this situation anger and sadness are inevitable and they have learned how to deal with this like these parents' response to a question about their anger It s totally ok. Although I feel helpless that I can t take away that feeling "It's okay to be angry [I] just try to keep it focused instead of getting mad at other things ." These parents respond to their child's anger about having cancer by Find[ing] out the cause and try[ing] to be positive and help fmd solutions ," and Just try[ing] to help her through her anger and frustration. Finally, these parents took the opportunity to teach their child how to deal with their anger and set limits on their behavior. For example one parent stated that they tell their child, "You can be angry but there is a limit on how you handle yourself while being angry." 43

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Number o f P a rents Parenting Styles Pre and Post-Diagnosis Dism iss ing D is approving LaissezF ai r e Emo t io n Coach i ng Parenting Style Equal R espo n ses P re-Diag n osis Post-Diag n osis Figure 3.2 Breakdown of parents in pre and post-diagnosis parenting styles based on the meta-emotion questionnaire Positive Cognitive Restructuring As hypothesized parents whose responses were consistent with an EmotionCoa c hin g parenting style in the meta-emotion questionnaire tended to use more positive cognitive restructuring to respond to their child s sadness and anger postdiagnosis Other parents whose responses were consistent with the other three parenting styles also tended to use positi v e cognitive restructuring to comfort their children in the post-diagnosis section of the meta-emotion questionnaire. However they u s ed these statements less than responses consistent with their other parenting 44

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style. Statements such as, "[I tell them to] try and stay positive," Always try to be positive and try not to dwell on sadness ," [I] try to cheer her up and talk about the positives ," and Keep going shake off the bad and look for the good ," were coded as positive cognitive restructuring and are consistent with this type of thinking In total there were 32 positive cognitive restructuring responses in the post-diagnosis section as compared with no positive cognitive restructuring in the pre-diagnosis section Cogniti v e restructuring a process of recognizing challenging and changing cognitive distortion s and negative thought patterns can impro v e a person's mood and mental state (Beck 1995). Eisenberg (1996) stated that this could be a useful coping strategy for children and that it would be interesting to see if parents' using this technique results in positive outcomes for the child. 45

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CHAPTER4 DISCUSSION This study examined the relationship between parenting style and pediatric oncology patients' level of distres. It also explored the relationship between parents' parenting style before and after their child's cancer diagnosis It was hypothesized that children whose parents utilized an Emotion-Coa c hing parenting style as measured by the parenting style true / false survey would have significantly lower scores on the DASS21 than children of parents who practiced Dismissing, Disapproving or Laissez-Faire parenting styles. No significant relationship was found between parenting style and the mean scores on the DASS21 although the children whose parents practiced a Laisse z -Faire parenting style had consistently lower scores on the DASS21 than the children whose parents practiced an Emotion-Coaching parenting style The children s scores on the DASS21 were also not at a clinically significant level although they were slightly higher than the mean scores of the normative sample. Although there was no significant difference between the children s scores on the DASS21 based on their parent's parenting style it is interesting to note that these findings support the research that indicates that pediatric oncology patients tend to have distress scores that are at or below the normative data (Lavigne & Faier46

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Routman, 1992; Boman & Bodegard, 1995; Elkin et al., 1997; Gray et al., 1992; Kazak, 1994; Kazak et al., 1997; Kupst et al., 1995; Mackie et al., 2000; Madan Swain et al., 1994; Radcliffe Bennett, Kazak, Foley, & Phillips, 1996; Simms, Kazak Golomb, Goldwein, & Bunin 2002). This was true for their anxiety depression and stress levels. One explanation for this could be that oncology patients may tend to minimize their displays of emotional distress in order to present themselves in a positive way. They may feel this is necessary to help those around them not experience distress because of their condition as well as to help themselves feel better. Elkin et al. (1997) proposed this repressive adaptive style and stated that children with this tendency may decrease their reporting of their symptoms. Parents responses to hypothetical meta-emotion questions about their children's sadness and anger were compared to their responses to the meta-emotion questions about their children's sadness and anger as it related to their cancer. When looking at parents responses to the pre and post diagnosis questions about their parenting styles in the meta-emotion questionnaire parents tended to respond consistent with a Dismis s ing or Emotion-Coa c hing parenting style during the pre diagnosis section. However the trend shifted during the post-diagnosis section ofthe questionnaire so that most parents' responses were consistent with a Lai ssez -Faire or Emotion-Coaching parenting style which is consistent with the two parenting styles 47

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that were found in the parenting style true / false survey which targets present parenting style One explanation for this finding could be that parents, regardless of their previous parenting style, feel they need to be completely accepting of their child s emotions and condition in order to help the child get through the psychological and physical symptoms of the illness. Because parents were only identified as Lai s sez Fair e and Emotion-Coa c hing through the true / false survey and most were identified as Lai ss ez-Fair e and Emotion-Coaching through the meta-emotion questionnaire this may reflect an interesting caretaking trend in parents responding to the emotional needs of their children. Although the Lai s s ez -Fair e parenting style does not have the coaching element, it may be that many parents do not feel that they should coach their children s emotions during a time that seems so uncertain for them as well and where any emotional expression or behavior seems appropriate and acceptable. Possibly the child knowing that their emotions are completely accepted and just seeing their parents freely expressing their emotions may help them learn to regulate their own emotions over time instead ofbeing directly "coached by a parent. Another reason why parents responses in the post-diagnosis section of the meta-emotion questionnaire may have been more consistent with a Lai ssez -Fair e parenting style may be that since their children are adolescents and in some cases young adults they believe that their time for coaching their child's emotions is over. Gottman et al. ( 1996) interviewed parents whose children were between the ages of 4 48

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and 5 an age where children need lots of guidance to be able to navigate through new and strong emotions. It may be that some parents who appear more Laisse z -Faire were Emotion-Coaches earlier in their child's life but now believe that their child can manage their emotions on their own. The shift in parenting style from more dismissing responses to Laiss ez -Fair e or Emotion-Coaching responses in the post-diagnosis section became increasingly evident as parents discussed their compassion, empathy and understanding for their child s emotions. E v en parents who had expressed disapproval at their child s anger or sadness prior to their child's diagnosis were more likely to share their acceptance of these negative emotions in their children post-diagnosis. There were no questions about why their child needed to be angry or sad although some parents had more difficulty recognizing these emotions in themselves and their children in the post diagnosis questions Although Gottman and his colleagues ( 1996; 1997) may describe these parents as dismissing (i.e. a parent who responds "I'm not angry or She's not angry ) ifElkin's (1997) repressive adaptive style theory is correct it may be that these children are minimizing their displays of distress and therefore the negative emotions as well so that the parents are actually not seeing these emotions in their children. The repressive adaptive style could also apply to parents of the child with cancer, so that they in tum minimize their own distress and negative emotions so as not to make their child upset. It also could be, however that these parents and patients are actually not experiencing these emotions. 49

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Finally, as hypothesized, parents whose responses were consistent with an Emotion-Coaching parenting style tended to use more positive cognitive restructuring to respond to their child's sadness and anger post-diagnosis. Than other parents whose responses were consistent with the other three parenting styles. Positive cognitive restructuring, which was not found in the pre diagnosis section of the meta-emotion questionnaire was used 32 times by parents with a Di s missing, Lais s e z -Fair e or Emotion-Coa c hing parenting style in the post-diagnosis section. As previously mentioned positive cognitive restructuring is a process of recognizing challenging and changing cognitive distortions and negative thought patterns can improve a person s mood and mental state (Beck, 1995) Parents may view this as a necessary technique to help their children through their emotions about having cancer because there is little opportunity for the parents to assist their children by problem solving Unlike other circumstance in their child s life where problem solving may help overcome the situation, beyond working through the treatment solutions with their doctor and finding ways to make their children happy there is little problem solving that can be done to help their child through the situation Therefore saying Keep going, shake off the bad and look for the good," may be the one thing parents feel they can say to help their children cope. This may explain why parents did not use positive cognitive restructuring in the pre-diagnosis section of the meta-emotion questionnaire. They may have felt that the hypothetical circumstances with which they were presented were "controllable situations where problem-solving 50

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would help their child and therefore positive cognitive restructuring was not used as a coping strategy. Limitations Due to the fact that this was a pilot study there were many limitations. This study was limited by its small sample size and the sample size was also primarily Caucasian so its generalizability may be limited. In addition the convergent validity of this study may be low due to the lack of both parents responses to the parenting style survey and questionnaire. The environment of the study was also a limitation. Due to the nature of some of the drugs that the patients need to take when receiving their chemotherapy infusion, which often had adverse effects (i.e sedation and nausea) surveys had to be completed over long periods of time and multiple visits and were sometimes never fmished It was also difficult to recruit participants due to the nature of the Children's Hospital as a research hospital where there are many studies going on at once, especially for the oncology patients Families were sometimes hesitant to participate because they were already participating in another study. It was also difficult to maintain communication between the various doctors and the researchers in order to identify eligible patients and make sure that the doctors had the materials they needed if the patients could participate. Doctors that did participate in recruitment for this study may have also selected participants based on what they new about the patients 51

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and their families. For example, they may have enough experience with a family to know whether or not they would be willing to participate and this may account for all families that were approached agreeing to participate. Finally, because the meta-emotion questionnaire was abridged into a written questionnaire from the original Meta-Emotion Interview the researcher was not able to directly interview the parent and probe for clarification (Gottman, Katz & Hooven, 1996). An interview would have allowed statements such as "I'm not sad, to be clarified as well as many others that could have been interpreted differently than the parents intended. Also, because the meta-emotion questionnaire was retrospective as well as hypothetical in some instances, we cannot determine whether the parents' statements are what they actually did or would do in that situation, or what they would like to have done or did. Future Directions Future research should focus on replicating this study with a larger sample as well as obtaining data from both parents. Adding a broader range of ages, including the original population age of 4 and 5-years-old would aid in understanding the process of parenting while a child has a serious illness, and how parenting style may change over the years as children get older and more independent. Gottman (1996) proposed that meta-emotion is related to child regulatory physiology in that coaching a child's emotions has ... a soothing effect on the child 52

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that may change some key aspects of the child's peripheral nervous system (PNS)" (Gottman, Katz, & Hooven, 1996). The major nerve ofthe PNS is the vagus nerve and research by Porges ( 1992) has shown that high vagal tone is associated with emotion regulation abilities and the ability to suppress vagal tone predicted a child's ability to regulate their behavior and arousal without help from others. In addition, the vagal nerve innervates the thymus gland, which is involved in the production ofTcells so basal vagal tone is related to better physical health. Therefore, it was found that children whose parents were Emotion-Coaching parents had fewer infectious illnesses. This is important information for work with pediatric cancer patients since the cancer itself can lower the immune system as does the cancer treatment. A stronger immune system may help the child fight cancer longer, so it could be that children of parents who use an Emotion-Coaching parenting style have stronger immune systems and increased ability to fight cancer. Although it was beyond the scope of the present study to address the relationship between parenting style and remission rates, this connection is important because if correlated, may provide hospitals and physicians with a valuable parent teaching resource that may increase their child's chance of survival. Additionally, measuring child regulatory physiology in the future, including vagal tone and the resulting T -cell production as Gottman et al. (1996) did may help us determine if during times of crisis both the Laissez-Faire and Emotion-Coaching parenting styles have an impact on physiological response. Further research should be 53

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done to determine the specific mechanisms of the Laisse z -Faire and Emotion Coa c hing parenting styles that may play a role in moderating distress. If there is a connection between these parenting styles and vagal tone parent training in meta emotion should alter both parenting and the child's regulatory physiology and may then have a direct effect on child outcomes both psychologically and physically. 54

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APPENDIX A Parenting Style Questionnaire For each item, please circle the choice that best fits how you feel. If you're not sure, go with the answer that seems the closest. 1. Children really have v ery little to be sad about T F 2. I think that anger is okay as long as it's under control. T F 3. Children acting sad are usually just trying to get adults to feel sorry for them. T F 4. A child's anger deserves a time-out. T F 5. When my child is acting sad he / she turns into a real brat. T F 6. When my child is sad I am expected to fix the world and make it perfect. T F 7. I really have no time for sadness in my own life. T F 8. Anger is a dangerous state. T F 9 Ifyou ignore a child's sadness it tends to go away and take care of itself. T F 10. Anger usually means aggression. T F 11. Children often act sad to get their way T F 12. I think sadness is okay as long as it's under control. 55

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T F 13. Sadness is something one has to get over, to ride out, not to dwell on. T F 14. I don't mind dealing with a child's sadness, so long as it doesn't last too long T F 15. I prefer a happy child to a child who is overly emotional. T F 16. When my child is sad, it's a time to problem-solve T F 17. I help my childr en get over sadness quickly so they can move on to better things T F 18. I don t see a child's being sad as any kind of opportunity to teach the child much. T F 19. I think when kids are sad they have overemphasized the negative in life T F 20. When my child is acting angry, she/he turns into a real brat. T F 21. I set limits on my child's anger. T F 22. When my child acts sad, it's to get attention. T F 23. Anger is an emotion worth exploring. T F 24. A lot of a child's anger comes from the child's lack of understanding and immaturity. T F 25. I try to change my child's angry moods into cheerful ones. T F 26. You should express the anger you feel. T F 56

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27. When my child is sad, it's a chance to get close. T F 28. Children really have very little to be angry about. T F 29. When my child is sad I try to help the child explore what is making him/her sad. T F 30. When my child is sad, I show my child that I understand. T F 31. I want my child to experience sadness. T F 32. The important thing is to find out why a child is feeling sad. T F 33. Childhood is a happy-go-lucky time, not a time for feeling sad or angry. T F 35. When my child is sad, I try to help him figure out why the feeling is there. T F 36. When my child is angry it's an opportunity for getting close. T F 37. When my child is angry, I take some time to try to experience this feeling with my child. T F 38. I want my child to experience anger. T F 39. I think it's good for kids to feel angry sometimes. T F 40. The important thing is to find out why the child is feeling angry. T F 41. When she / he gets sad, I warn her about not developing a bad character. T F 42. When my child is sad I'm worried she / he will develop a negative personality. T F 43 I'm not really trying to teach my child anything in particular about sadness. 57

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T F 44. If there 's a lesson I ha ve about sadness it's that it's okay to express it. T F 45. I'm not sure there's anything that can be done to change sadness. T F 46. There's not much you can do for a sad child beyond offering him/her comfort. T F 47 When my child is sad, I try to let him/her know that I love him/her no matter what. T F 48. When my child is sad, I'm not quite sure what she / he wants me to do T F 49. I'm not really trying to teach my child anything in particular about anger. T F 50. If there's a Jesson I have about anger it's that it's okay to express it. T F 51. When my child is angry, I try to be understanding of his mood. T F 52 When my child is angry I try to let him/her know that I love him/her no matter what. T F 53. When my child is angry, I'm not quite sure what she / he wants me to do. T F 54. My child has a bad temper and I worry about it. T F 55. I don't think it is right for a child to show anger. T F 56. Angry people are out of control. T F 57. A child's expressing anger amounts to a temper tantrum. T F 58

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58. J(jds get angry to get their own way. T F 59. When my child gets angry, I worry about his / her destructive tendencies. T F 60. If you let kids get angry, they will think they can get their way all the time. T F 61. Angry children are being disrespectful. T F 62. J(jds are pretty funny when they're angry T F 63. Anger tends to cloud my judgment and I do things I regret. T F 64. When my child is angry, it's time to solve a problem. T F 65. When my child gets angry, I think it's time for a spanking T F 66. When my child gets angry, my goal is to get him to stop. T F 67. I don't make a big deal of a child's anger. T F 68. When my child is angry, I usually don't take it all that seriously T F 69. When I'm angry, I feel like I'm going to explode. T F 70. Anger accomplishes nothing. T F 71. Anger is exciting for a child to express T F 72. A child's anger is important. T F 59

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73. Children have a right to feel angry T F 74. When my child is mad, I just fmd out what is making her mad. T F 75. It's important to help the child find out what caused the child's anger. T F 76 When my child gets angry with me I think, "I don't want to bear this. T F 77 When my child is angry I think, "If only she / he could just learn to roll with the punches. T F 78. When my child is angry I think Why can't she / he accept things as they are?" T F 79 I want my child to get angry, to stand up for himself/herself T F 80. I don t make a big deal out of my child's sadness. T F 81. When my child is angry I want to know what she is thinking. T F 60

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APPENDIXB Questions based on the Meta-emotion interview We would now lik e to ask you some questions about how you feel about your feelings For example, how you might feel about different kinds of feelings like surprise. Now some people don t like being surprised. They hate surprise birthday parties. Some people however love to be surprised and love surprising others. But mostly they enjoy the feeling and want to have more of it in their lives and they go out of their way to have it. Also, we re going to ask you about how your feelings relate to how you're raising your child-how you react to his or her feelings, and how you view his or her feelings. These next questions relate to the time prior to your child's diagnosi s of cancer. 1. How did you feel about being sad? 2. What were your reactions to your own sadness? 3. How did sadness work in your life ? 4. Imagine that your child came home from school prior to their diagnosis of cancer and was very sad because they had received a bad grade on a very important project in a class. a. How would you react to your child's sadness? b. What might you do in this situation? c What, if anything would you try and teach your child? d. What would your child's sadness bring out in you? 5. How did you feel about being angry? 6 What were your reactions to your own anger? 7. How did anger work in your life? 5. Imagine that prior to your child's diagnosis of cancer they became angry because they did not get on to a sports team that they tried out for. a. How would you react to your child's anger? b. What might you do in this situation? c. What if anything, would you try and teach your child? d. What would your child's anger bring out in you? 61

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These next questions relate to the present, or while your child is coping with cancer. 1. How do you feel about being sad now? 2. What are your reactions to your own sadness now? 3. How does sadness work in your life now? 4. Think about your child s sadness relating to coping with cancer and learning about their cancer diagnosis a. How do you react to your child's sadness as it relates to their cancer? b. What have you done in situations where your child shows sadness? c. What if anything, would you try and teach your child? d. What would your child's sadness bring out in you now ? 5. How do you feel about being angry now ? 6. What are your reactions to your own anger about your child's cancer? 7 How does anger work in your life now ? 5. Think about times when your child has been angry about having cancer and what that has looked like e. How do you react to your child's anger as it relates to their cancer? f. What have you done in situations where your child shows anger ? g. What if anything, would you try and teach your child? h What would your child s anger bring out in you now? 62

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APPENDIXC DASS21 DASS21 Name: Date: Please read each statement and circle a number 0, I 2 or 3 that indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. The ratin g sca le is as follows: 0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me to a considerable degree or a good part of time 3 Applied to me very much or most of the time I found it hard to wind down 0 2 3 2 I was aware of dryness of my mouth 0 2 3 3 I couldn't seem to experience any positive feeling at all 0 2 3 4 I experienced breathing difficulty (eg, excessively rapid breathing, 0 2 3 breathlessness in the absence of physical exertion) 5 I found it difficult to work up the initiative to do things 0 2 3 6 I tended to over-react to situations 0 2 3 7 I experienced trembling ( eg, in the hands) 0 2 3 8 I felt that I was using a lot of nervous energy 0 2 3 9 I was worried about situations in which I might panic and make 0 2 3 a fool of myself 10 I felt that I had nothing to look forward to 0 2 3 I l I found myself getting agitated 0 2 3 12 I found it difficult to relax 0 1 2 3 63

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13 I felt down-hearted and blue 0 2 3 14 I was intolerant of anything that kept me from getting on with 0 2 3 what I was doing 15 I felt I was close to panic 0 1 2 3 16 I was unable to become enthusiastic about anything 0 2 3 17 I felt I wasn't worth much as a person 0 2 3 18 I felt that I was rather touchy 0 2 3 19 I was aware of the action of my heart in the absence of physical 0 2 3 exertion ( eg sense of heart rate increase heart missing a beat) 20 I felt scared without any good reason 0 2 3 21 I felt that life was meaningle s s 0 2 3 64

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