Although parental distress did not predict variance in family functioning, results partially supported the primary hypothesis in that parent-reported adolescent behavioral problems contributed more variance to family functioning than did parental distress. This finding might indicate that child behavioral functioning acts as a more salient barometer of family functioning compared to parent functioning in this population. Alternatively, it may underscore the need to assess parenting stress in a manner more proximal to adjustment to IBD. We also anticipated that adolescent internalizing behaviors would account for the majority of variance in family functioning. In contrast to this hypothesis, results revealed that parent-reported externalizing
behaviors accounted for more variance in family functioning than did internalizing behaviors, indicating that families with children who demonstrate more overt behavioral problems may have greater family dysfunction. These findings are supported by prior research on family functioning in pediatric populations in which internalizing/externalizing behaviors in children have been associated with family conflict/dysfunction (Sourander et al., 2006
; Wertlieb, Hauser, & Jacobsen, 1986
). However, the significant relationship between externalizing behavior problems and family functioning has not been found in pediatric IBD. This may be because externalizing behavior problems have not been a primary focus of research in this population to date. Instead, internalizing symptoms have largely been targeted in IBD studies, perhaps because of the higher prevalence of these symptoms. Consequently, the decreased focus on externalizing behaviors in prior research may have resulted in underestimation of the impact of these symptoms on adolescent psychosocial outcomes, including family functioning. Indeed, results from this study demonstrated that a greater proportion of the sample exhibited clinically significant internalizing behavior problems than externalizing behavior problems despite the latter accounting for more variance in family functioning. However, caution is warranted in interpreting this higher prevalence as the somatic complaints subscale is included in the computation of the internalizing behavior problems scale, which is likely to be inflated in a sample of IBD patients due to disease symptoms including abdominal pain. Nevertheless, the observed relationship between externalizing behavior and family functioning might suggest that while externalizing problems are less prevalent, they are more likely to inform change in family-level behavioral functioning. Moreover, family functioning might be more sensitive to subtle, yet salient child behaviors that are perceived as disruptive to the family unit.
The present findings certainly do not indicate that externalizing behaviors are more important than internalizing behaviors. Rather, externalizing behaviors may be more disruptive to family adaptation than internalizing behaviors. This may be due in part to families’ anticipation and normalization of internalizing symptoms given the increased prevalence in IBD and in adolescents in general. Thus, externalizing behaviors are perceived by families as abnormal and unsettling. Alternatively, externalizing behaviors may have a greater impact on family functioning because internalizing behaviors are often more self-regulated compared to externalizing behaviors, which require corrective feedback and are primarily managed by parents, which consequently causes stress on the family system.
The results of this study offer important clinical implications. Assessment of child behavioral functioning, as part of patients’ clinical care, should also involve the extent to which it is impacting other family members’ adaptation to the child’s illness and its management. Family functioning in the context of a child’s chronic illness may be an important factor in patient psychosocial and health outcomes. Indeed, a recent study suggests that higher family conflict may lead to difficulties in adolescent disease management (Pereira, Berg-Cross, Almeida, & Machado, 2008
). Thus, early identification of child behavioral problems and dysfunctional family adjustment is critical so that these problems can be addressed appropriately. The current findings might suggest that parent perceptions of family functioning are sensitive to low levels of externalizing behavior problems; thus parent perception may be an avenue for intervention with these families. Given that pediatric gastroenterologists and other health care professionals often see these patients more than other providers, they are the most likely sources for early identification of problem behaviors and subsequent referrals for treatment. Thus, development and maintenance of referral resources that would be feasibly accessed by the patient/family for further assessment and treatment is a critical component to ensuring comprehensive care.
This study was limited by a few methodological issues that warrant discussion. First, the sample size was fairly modest, which precludes broad generalization of the findings to the overall IBD population. However, the number of participants in the sample was larger than several extant studies in pediatric IBD. In addition, the samples used were drawn from two separate sites in different regions of the U.S., which helped control the influence of site-specific subject characteristics (Drotar, 1994
). Second, the study was correlational in nature; thus, causal inferences about the relationship between patient and family behavioral functioning would be inappropriate. A further limitation of the study concerns the assessment of family functioning. Although the FAD is a well-validated measure, only parent report data were obtained. These data were collected as part of a larger longitudinal study with additional child-report behavioral measures, and the exclusion of child-report data on the FAD was done in order to provide a less taxing assessment battery overall. Nevertheless, child-report of family functioning data will be an important future direction in this area of research, particularly as this will rule out relationships among the CBCL and FAD that may be influenced by the use of only one informant. Additionally, the sample was comprised of patients seen in outpatient follow-up clinic visits, which resulted in disease severity ratings in the inactive to mild range. Thus, generalization of these findings to hospitalized patients who are experiencing more severe IBD symptoms may not be warranted. Finally, the majority of this sample was Caucasian and from higher socioeconomic backgrounds. Though this sample is representative of other published studies on IBD (Mackner & Crandall, 2005
), generalization of these findings to patients and families from minority or lower socioeconomic backgrounds is not recommended.
In conclusion, results of this study indicate that there is a significant positive relationship between parent-reported patient externalizing behaviors and family dysfunction, after accounting for internalizing behaviors, in pediatric IBD. Given the novelty of these findings and the limitations of this study, future research should aim to replicate these findings, taking into account patient as well as caregiver perceptions of family functioning. Additionally, future studies should expand the examination of the relationship between externalizing behaviors and additional psychosocial and/or disease outcomes in this population. Further research is also needed to evaluate specific externalizing behavior problems that are most salient to family functioning in this population, which will also help to identify at-risk families. Research should also focus on identifying the causal relationship between child behavioral functioning and family functioning as it is also possible that family dysfunction informs change in child behavior in this population. Particular emphasis should be placed on the potential effect these constructs may have on treatment implications and clinical decisions by both providers and patients/families. Moreover, the influence of child and family functioning on patient and family outcomes including disease management behaviors should continue to be a focus of research in this population.