Research has found considerable variability in the adjustment of children with cancer (Vannatta & Gerhardt, 2003
). This study is the first, to our knowledge, to simultaneously examine how illness-specific stress and coping processes (Connor-Smith et al., 2000
), as well as more stable characteristics of temperament, (Anthony et al., 2002
), account for variability in anxiety and depression for children with cancer. Overall, we found partial support for this integrated approach.
As expected, we found that cancer-related stress was significantly associated with symptoms of depression, but not anxiety, in children. Consistent with previous findings regarding children with cancer (e.g., Noll et al., 1999), the mean levels of anxiety and depression fell well within the normative range. Most research using the CBCL in children with cancer has used the broad internalizing scale (e.g., Sawyer, Antoniou, Toogood, & Rice, 1997
; Noll et al., 1999) rather than differentiating anxiety and depression as we did using the CBCL DSM-Oriented scales. It has been argued that symptoms of anxiety and depression may represent a single internalizing syndrome in early childhood (e.g., Lonigan, Carey, & Finch, 1994
), and both were significantly correlated (r
= .48, p
< .01) in our sample. However, measuring anxiety and depression as a single construct could mask unique associations with different risk factors, as underscored by our findings.
Both primary and secondary control coping were negatively correlated with anxiety and depression, which is consistent with research among children exposed to family conflict and economic strain (Wadsworth & Compas, 2002
). In contrast to the previous work (Connor-Smith & Compas, 2004
), disengagement coping was unrelated to anxiety and depression, possibly due to the relatively low levels of disengagement coping in our sample. Children with cancer who are further from diagnosis may use more avoidant coping strategies than recently diagnosed children confronted with the daily demands of active treatment (Phipps, Fairclough, & Mulhern, 1995
). In addition, we assessed coping across a broad age range. Although the variety or types of coping strategies within each construct (i.e., primary, secondary, and disengagement) may differ across development, research has found that this three-factor structure is applicable to our age range (Compas et al., 2001
). Finally, contrary to expectations, mother's report of children's coping did not moderate the association between cancer-related stress and symptoms of anxiety or depression. Because other studies used healthy participants, cancer may be unique and may differentially affect the ability of active coping to buffer this type of stressor.
Partial support was also found for a temperament model. As expected, NA was positively associated with symptoms of both anxiety and depression. Contrary to Watson and Clark's (1991
) tripartite model, depression was unrelated to PA, showing a small effect [r
(75) = .13]. In our sample, we were able to detect moderate to large effects, whereas most literature has noted small to moderate effects between PA and depression (
Brown, Chorpita, & Barlow 1998
). Furthermore, research has consistently yielded stronger correlations between depression and NA than PA (e.g., Brown et al., 1998
). Our cross-sectional study prevents conclusions that NA is a predisposed vulnerability as opposed to a symptom of depression. However, because mother ratings on the CBQ and EATQ show stability from .50 to .79 across a 2-year period, it seems likely that NA precedes cancer as a temperamental characteristic (Capaldi & Rothbart, 1992
; Putnam & Rothbart, 2006
). Integrating coping and temperament models, children's primary control coping buffered the association between NA and depression, as in other research (Compas, Connor-Smith, & Jaser, 2004
). Primary and secondary control coping also mediated the association between NA and depression, but our cross-sectional findings provide stronger support for moderation rather than mediation.
Although EC was negatively associated with both anxiety and depression, it was unrelated to other variables and did not contribute to any of the models considered. This was surprising given evidence that EC moderates the link between NA and internalizing symptoms (Eisenberg et al., 2001
). However, much of this research has included children with inhibitory problems, such as externalizing disorders, that did not characterize our sample. It is possible that EC may play a greater role in the association between PA, NA, and internalizing symptoms for children receiving treatments (e.g., cranial radiation) that would leave them vulnerable to deficits in attention, inhibition, or executive function (Reeves et al., 2006
). Such deficits are often not visible until a year or more after treatment ends (Moleski, 2000
), whereas most of our sample (88%) was still on treatment and on average within 6 months of diagnosis or relapse. Assessing children later and including those at higher risk for attentional deficits (e.g., brain tumors, high risk leukemias) may shed more light on consequences related to differences in EC.
Limited research on adjustment to childhood cancer has included children who have relapsed. When analyses were run with and without relapses, few differences emerged in associations between stress, coping, temperament, and adjustment. Although it is often presumed that new diagnoses represent a more homogenous group, there may be considerable variability in perceptions of stress based on factors such as initial prognosis or treatment severity. It could be argued that the stress associated with having a relapse is not that distinct from a new diagnosis with a poor prognosis or from a more severe, initial treatment protocol. Thus, future research should continue to examine these issues and include children at different stages in their illness.
Our study has several additional limitations. First, we used mothers as single informants. The inclusion of multiple perspectives, including children and fathers, would enhance the validity of our study and provide a family perspective of child functioning. Second, although our sample is relatively large in comparison to many published pediatric oncology samples, we did not include controls and had limited ability to detect small effects. The literature on coping, temperament, and adjustment has consistently found small to medium effects (r
= .13–.40) (Connor-Smith & Compas, 2004
; Brown et al., 1998
). Finally, our sample was heterogeneous, but we were unable to make broader conclusions about specific groups such as brain tumor survivors or relapses.
Our findings provide partial support for integrated diathesis-stress models (Wallander & Varni, 1992
). Results highlight cancer-specific stress, primary control coping, and NA as factors that may play a role in symptoms of depression and, to a lesser extent, anxiety among children with cancer. Thus, it may be beneficial for future research to measure context-specific coping in response to a specific stressor (i.e., cancer) in order to better inform interventions. Clinically, our findings contribute a new understanding of potential risk factors (i.e., NA) for internalizing symptoms during treatment. Interventions teaching primary control coping skills might be useful for children identified as vulnerable to anxiety or depression based on temperament. Such interventions may help children cope with their disease and may curtail long-term difficulties.