Received: 16 July 2019 Revised: 9 October 2019
DOI: 10.1002/pon.5258
PAPER
Impact of the parent-child relationship on psychological
and social resilience in pediatric cancer patients
Rachel Tillery1 | Victoria W. Willard1 | Katianne M. Howard Sharp1 |
Kimberly L. Klages1,2 | Alanna M. Long1 | Sean Phipps1
1
Department of Psychology, St. Jude
Children's Research Hospital, Memphis,
Tennessee
2
Department of Psychology, The University of
Memphis, Memphis, Tennessee
Correspondence
Rachel Tillery, Department of Psychology,
St. Jude Children's Research Hospital,
262 Danny Thomas Place, #740, Memphis, TN
38105.
Email: rachel.tillery@stjude.org
Funding information
American Lebanese-Syrian Associated
Charities, Grant/Award Number: ALSAC;
National Institutes of Health, Grant/Award
Number: NIH R01 CA136782
Psycho-Oncology. 2020;29:339–346.
Accepted: 10 October 2019
Abstract
Objectives: The primary objective of this research was to examine patterns of
parent-child relationship functioning among pediatric cancer survivors and their care-
givers across a variety of relationship indicators (ie, Involvement, Attachment, Com-
munication, Parenting Confidence, and Relational Frustration), and evaluate how
these factors relate to psychosocial outcomes in survivors.
Methods: Young survivors aged 10 to 18 and their caregivers (N = 165) completed
measures related to posttraumatic stress and general distress. Caregivers also com-
pleted assessments of parent-child relationship functioning, and survivors completed
assessments of social functioning. Latent profile analysis was performed to identify
patterns of relationship functioning. Medical, demographic, and parent functioning
variables were examined as predictors, and youth's psychological and social function-
ing were examined as outcomes.
Results: A three-class solution was the best fit to the data. The struggling parent-
child relationship profile (15%) evidenced below average levels of parent-child rela-
tionship functioning across several domains. The normative parent-child relationship
(60%), was characterized by average levels of parent-child relationship functioning
across all domains. Finally, the high-involved parent-child relationship profile (25%)
demonstrated above average levels of parent-child relationship functioning in
involved activities, communication, and attachment and normative levels of function-
ing across all other domains. Medical and parent functioning factors predicted profile
membership. In turn, profile membership was associated with survivor psychological
and social outcomes.
Conclusion: Findings document the importance of extending existing research to
examine patterns of parent-child relationship functioning, which may serve as a clini-
cally relevant target to improve psychological and social outcomes in young survivors
of childhood cancer.
KEYWORDS
cancer, caregiver-child relationship functioning, oncology, pediatric cancer, survivor emotional
adjustment, survivor social adjustment
wileyonlinelibrary.com/journal/pon © 2019 John Wiley & Sons, Ltd. 339
340
Advances in cancer therapies have resulted in improved survival rates
among patients diagnosed with a pediatric malignancy over the last
several decades,1 yet psychosocial concerns remain an ongoing unmet
need for this expanding population.2 Specifically, it is well docu-
mented as a significant subset of young survivors experience ongoing
difficulties with anxiety and depression,3 as well as social functioning.4
These concerns may be particularly prevalent during early adoles-
cence, which is a period critical for social-emotional development.
Family systems theories suggest the dynamic and multilevel trans-
actions between the family unit, the individuals that make up the fam-
ily unit (eg, caregivers, children), and dyadic interactions (eg, marital
relationship, caregiver-youth relationship) can have significant implica-
tions on youth's social and emotional well-being.5 There is extensive
research within pediatric oncology documenting the impact of family
6 7
functioning and caregiver functioning on youth's social and emo-
tional adjustment following pediatric cancer; however, the role of the
caregiver-youth relationship has been overlooked.8
The broader developmental literature has documented the role that
the caregiver-youth relationship plays in supporting social and emotional
functioning during early adolescence.9 Relationship factors such as
attachment,10 communication,11 involvement in activities,12 conflict,13
and parenting confidence14 play a critical role in youth's social function-
ing and emotion regulation. However, findings within the developmental
literature may not directly translate to children with a chronic illness and
their families. Research within chronic illness populations has docu-
mented differences in parent-child functioning across illness types and
15
between families with and without a chronic illness, though relation-
ship patterns were similarly related to social and emotional health out-
comes across groups.16 Although the literature is sparse within pediatric
cancer, early studies found parent-child relationship quality was associ-
ated with better psychological quality of life, with father-child relation-
ships specifically linked to children's social quality of life.17 Outside of
global relationship quality, indicators of caregiver-youth relationship
functioning have largely been unexamined.18
Considering the proximity between caregivers and youth during
cancer treatment, it stands to reason that this relationship would
remain influential into survivorship. However, how the parent-child
relationship influences youth's social and emotional adjustment in the
context of cancer survivorship has not been well described. As such,
the primary aim of this study was to identify patterns of parent-child
relationship characteristics between young survivors of childhood
cancer and their caregivers. Given limited research across these
domains among pediatric cancer populations, this aim was largely
exploratory. As a secondary aim, we sought to examine predictors of
relationship characteristic patterns, hypothesizing that caregiver dis-
tress would be predictive of poorer parent-child relationship quality
6
characteristics. Our final aim was to examine links between patterns
of relationship characteristics and social and emotional outcomes in
survivors, including posttraumatic stress symptoms (PTSS), internaliz-
ing symptoms (ie, depression and anxiety), and social functioning. We
hypothesized relationships characterized by a high degree of Involve-
ment, Attachment, and Confidence and low Relational Frustration
would predict better social and emotional outcomes.
TILLERY ET AL.
1 | METHODS
1.1 | Procedures
Youth with cancer and their caregivers were approached during routine
care visits to St. Jude Children's Research Hospital as part of a larger,
longitudinal study examining stress and adjustment, and were recruited
in one of four strata derived from time elapsed since their cancer diag-
nosis: 1 to 6 months; 6 to 24 months; 2 to 5 years; >5 years. Partici-
pants were eligible if they were (a) aged 8 to 17 years at the initial study
visit, (b) English-speaking, (c) did not have any significant cognitive or
sensory deficit that would preclude completion of study measures,
(d) and a parent/legal guardian was willing to participate and provide
consent for their child. Data collection procedures were conducted
with approval from the Institutional Review Board (Pro00000872).
Data from this study were collected as a part of the third time point
only (Time 3; 3 years post study enrollment). Of the 225 caregiver-youth
dyads enrolled at Time 1, 170 (67%) were included in the present
research. There was 6% loss to mortality, 17% aged out of the standard-
ized study measures (ie, could not compute standardized scores due to
participants age), and 9% declined to participate in Time 3 study proce-
dures or did not return study measures. Approximately 3% of partici-
pants remained on-treatment at Time 3 and were subsequently removed
from the analyses, resulting in a sample of survivors. Time 3 participants
and non-participants did not significantly differ by diagnostic category
(χ2 [4, n = 255] = 2.13, P = .71) sex (χ2 [1, n = 255] = 0.00, P = 1.00), race
(χ2 [2, n = 255] = .18, P = .91), or socioeconomic status (SES;
F [1, 254] = 1.47, P = .23). Age was not examined as a predictor, as par-
ticipants >18 years of age did not have standardized measures com-
puted. At Time 3, participants and their caregivers had the option to
complete forms during routine follow-up visits or were mailed forms that
were subsequently returned upon completion.
1.2 | Measures
1.2.1 | Demographic and clinical variables
Parents reported on their own and their child's socio-demographic
information respectively, including age, race, sex, education, and occu-
pation. Participants’ medical diagnosis, date of diagnosis, and treat-
ment information were systematically collected through medical
record review.
1.2.2 | Caregiver-reported measures
Posttraumatic stress symptoms
PTSS were evaluated throughout caregiver completion of the Impact of
Events Scale-Revised (IES-R).19 The IES-R is a 22-item self-report measure
of parents own PTSS about an event spontaneously identified as their
most traumatic. Just over a third of caregivers (n = 62) reported their chi-
ld's cancer as their most stressful event. This total score was used in this
TILLERY ET AL.
study as an indicator of PTSS associated with the identified event. The
IES-R has demonstrated strong test-retest reliability and internal valid-
ity ; α = .99 for the current study).
19
Global distress
The Brief Symptom Inventory 18 (BSI)20 is an 18-item self-report mea-
sure that was used to measure psychological symptoms among par-
ents. The BSI-18 was shown to be a psychometrically sound short
form alternative for the BSI-53 and the originally developed Symptom
Checklist-90-Revised20 The BSI has three symptom scales and a widely
used summary scale of overall distress, the Global Severity Index
(GSI). The GSI was used in the current study as a measure of care-
givers’ overall distress. The GSI has demonstrated excellent reliability
and validity (α = .92 for the current study).
Parent-child relationship quality
Caregivers also completed the Parenting Relationship Questionnaire
(PRQ),21 which is a 71-item measure that assesses the parent-child
relationship. The PRQ consists of seven subscales, and the current
study focused on the following subscales: Attachment (feelings of
closeness, empathy, and understanding), Communication (quality of
information exchanged), Involvement (participation together in vari-
ous activities), Parenting Confidence (comfort and confidence in
parental role), and Relational Frustration (overall parental stress and
difficulties in relation to the identified child). Raw scores were
converted to age- and sex-normed T-scores (M = 50, SD = 10). Stan-
dardization data collection for the PRQ occurred between April 2013
and December 2014.Scores between 40 and 60 indicate normal func-
tioning, scores above 60 indicate above average functioning, and
scores below 40 are reflective of significant relationship risk. These
criteria are reverse for Relational Frustration. The PRQ has demon-
strated high internal consistency and moderate to high convergent
21
validity (α = .87 for the current study).
1.2.3 | Survivor-reported measures
Posttraumatic stress symptoms
22
Youth completed the 22-item UCLA PTSD Reaction Index for DSM-IV
as an assessment of PTSS. Specifically, youth reported on the fre-
quency of PTSS symptoms within the past month about a spontane-
ously identified traumatic event. Approximately half of youth reported
a cancer-related event (n = 83) as their most stressful. This measure
has demonstrated excellent psychometric properties including high
internal and test-retest reliability.23 The present study used an overall
total score as an indicator of PTSS (α = .88 for the current study).
Internalizing difficulties
The Behavior Assessment System for Children, Second Edition (BASC-
2)24 is a self-report questionnaire assessing behavioral, emotional and
adaptive functioning of children and individuals between 8 and
21 years of age. The current study used the anxiety and depression
subscales as an assessment of youth's internalizing functioning. Raw
341
scores are converted to T-scores based on age and sex norms
(M = 50, SD = 10), with scores below 60 indicating normal func-
tioning, scores between 60 and 69 indicating “at risk“ behavior
implying mild to moderate impairment, and scores above 70 indicat-
ing “significant risk“ requiring follow-up. The BASC-2 has been
shown to be internally consistent (α = .80-.90) and has demon-
strated good test-retest reliability.24 The BASC-3 was not available
during the time of data collection.
Social functioning
Youth also completed the Social and Emotional Assets and Resilience
Scale (SEARS).25 The SEARS is a 35-item measure of social-emotional
strengths in youth across four subscales: self-regulation, empathy,
responsibility, and social competence. In the current study, a total score
was derived (by summing all 35 items) and used as an overall proxy of
social functioning. Raw scores were converted to T-scores based on age
norms (M = 50, SD = 10). Reliability and validity with other well-known
measures of social functioning (eg, Social Skills Rating System)26 has
been demonstrated (α = .95 for the current study).
1.3 | Planned analyses
Latent profile analyses were conducted using Mplus Version 8.3 to
empirically derive parent-child relationship functioning patterns across
Involvement in shared activities, Attachment, Communication, Parenting
Confidence, and Relational Frustration (aim 1). The model was specified
with uncorrelated indicators and freely estimated variances across clas-
ses. The Bayesian information criterion (BIC),27 was used to determine
model fit for each number of classes estimated, with lower BIC values
indicating better model fit. The Lo-Mendell-Rubin (LMR)28 and the Boot-
strap Likelihood Ratio Test (BLRT)29 were also used to compare model
improvement between neighboring classes (eg, 2 class solution vs 3 class
solution, 3 class solution vs 4 class solution). A significant P-value
derived from these tests indicates statistically significant improvement
in fit by the addition of a class. To confirm that differences among clas-
ses were driven by multiple constructs, mean differences across profiles
for each indicator were examined by creating additional copies of the
indicators and treating them as auxiliary variables.30
To evaluate predictors of the latent profiles (aim 2; demographic,
medical, and caregiver psychological functioning), the three-step
approach was used to compare identified classes based on these vari-
ables.31 The three-step approach allows covariates to be tested as
predictors of latent classes in a multinomial logistic regression while
maintaining the probabilistic nature of the latent profile variable. In
the first step, the model is estimated using only the latent class indica-
tors. In the second step, the most likely class variable is created for
each subject. Finally, the most likely class is regressed on the predictor
variable taking into account the probability of misclassification of the
class assignment generated in step 2. Finally, to examine differences
in social and emotional functioning across latent profiles, the three-
step approach31 was again used; however variables were specified as
outcomes rather than covariates.
342 TILLERY ET AL.

2 | RESULTS 2.2 | Patterns of parent-child relationship

characteristics
2.1 | Participants
Overall model fit indices indicated a three-class solution provided the
Participants included 165 youth with a history of cancer and their pri- best fit to the data (see Table 1). Classifications were derived based
mary caregivers. Youth were on average 14.55 years of age on population norms for the PRQ (ie, T = 40-59 is “average“; T ≥ 60 is
(SD = 2.24; range = 10-18) at Time 3, approximately half were male “above average;” T ≤ 39 is “below average“ for all domains except
(52%), predominately White (72% White, 24% Black, and 4% other), Relational Frustration in which higher scores indicate worse func-
and represented various cancer diagnoses (33% Leukemia, 12% tioning). Most participants (60%) fell in the “normative“ group,
Lymphoma, 37% Solid Tumor, 18% Brain Tumor). Average treat- which was characterized by caregiver reports of average levels of
ment intensity, measured by the Intensity of Treatment Rating Scale Involvement, Attachment, Communication, Relational Frustration,
2.0 (ITR-2),32 provided an overall rating of participants’ treatment and Parenting Confidence. One quarter (25%) of participants fell
intensity using participants’ diagnosis, stage/risk level, and treat- into the “High-Involved“ profile, which included caregiver reports
ment modality information. Approximately 5% were categorized as of above average levels of Involvement, Attachment, and Commu-
“least intensive,” 39% as “moderately intensive,” 29% as “very nication. Parenting Confidence and Relational Frustration. A sizable
intensive,” and 27% as “most intensive.” Survivors were on average minority (15%) were classified as “struggling.” This group was char-
6.5 years from diagnosis (SD = 3.73; range 2.9-16.5 years). Care- acterized by caregiver reports of significantly below average
givers were 43.45 years of age (SD = 6.90; range 18-72) and the reports of Attachment, Communication, and Parenting Confidence;
majority were mothers (mother = 83%, father = 13%, other = 4%). however, Involvement and Relational Frustration fell within the
SES scores, measured using the Barratt Simplified Measure of Social normal range (Figure 1).
Status,33 ranged from 12 to 66, with higher scores indicating higher
SES (M = 43.36, SD = 12.15).
2.3 | Predictors of parent-child relationship
characteristic profiles
TABLE 1 Model fit indices for the latent profile analysis
Demographic variables (ie, age, caregiver age, socioeconomic sta-
LMR BLRT
tus) did not explain the variance in profile membership status
BIC Entropy P-value P-value
(Table 2). Increased time since diagnosis increased the odds of
2 class solution 5976.13 0.85 <.01 <.001
falling into the struggling profile (OR = 1.22, P = .04) and the
3 class solution 5891.88 0.86 .01 <.001 normative profile (OR = 1.20, P = .03) compared to the high-
4 class solution 5898.59 0.85 .13 .01 involved profile. Caregivers of youth who experienced relapsed
5 class solution 5923.94 0.87 .51 .67 disease were more likely to be assigned to the high-involved
BIC, Bayesian information criterion; BLRT, Bootstrap Likelihood Ratio group compared to the normative (OR = 7.48, P = .01) and strug-
Test; LMR, Lo-Mendell-Rubin. gling profiles (OR = 4.61, P = .05). Treatment intensity did not

F I G U R E 1 Patterns of parent-child
relationship functioning. For the
Involvement, Attachment, Communication
and Confidence subscales, higher scores are
indicative of better functioning. For the
Relational Frustration subscale, higher scores
are indicative of worse functioning. Note:
*P < .001. Different alpha superscripts
within columns indicate significant
differences between the profiles at least
at P < .05
TILLERY ET AL. 343

TABLE 2 Predictors of parent-child relationship functioning profiles

Odds ratio Estimate Standard error (SE) Estimate/SE P-value

Struggling profile as reference group
High-involvement profile ON
Socioeconomic status 1.053 0.052 0.037 1.413 .158
Patient age 1.014 0.014 0.191 0.071 .943
Caregiver age 0.851 ‑0.162 0.132 ‑1.227 .220
Relapse status 4.613 1.529 0.807 1.894 .058
Treatment intensity 0.569 ‑0.564 0.423 ‑1.333 .182
Time since diagnosis 0.818 ‑0.201 0.098 ‑2.053 .040
Caregiver posttraumatic stress 0.992 ‑0.008 0.030 ‑0.256 .798
Caregiver global distress 0.946 ‑0.055 0.037 ‑1.488 .137
Normative profile ON
Socioeconomic status 1.068 0.066 0.042 1.553 .12
Patient age 0.938 ‑0.064 0.206 ‑0.312 .755
Caregiver age 0.864 ‑0.147 0.146 ‑1.001 .317
Relapse status 0.617 ‑0.483 0.744 ‑0.649 .516
Treatment intensity 1.000 0.000 0.411 0.001 .999
Time since diagnosis 0.983 ‑0.017 0.085 ‑0.201 .840
Caregiver posttraumatic stress 0.986 ‑0.014 0.03 ‑0.465 .642
Caregiver global distress 0.939 ‑0.062 0.03 ‑2.082 .037
High‑involved profile as reference group
Normative profile ON
Socioeconomic status 1.014 0.014 0.023 0.589 .556
Patient age 0.925 ‑0.078 0.112 ‑0.699 .485
Caregiver age 1.015 0.015 0.039 0.380 .704
Relapse status 0.134 ‑2.012 0.798 ‑2.522 .012
Treatment intensity 1.758 0.564 0.328 1.718 .086
Time since diagnosis 1.202 0.184 0.086 2.141 .032
Caregiver posttraumatic stress 0.994 ‑0.006 0.018 ‑0.343 .732
Caregiver global distress 0.993 ‑0.007 0.028 ‑0.248 .804

differentiate profile membership assignment. Regarding caregiver 2.4.2 | Internalizing symptoms

functioning, PTSS were not linked to profile membership; how-
ever, increased caregiver distress increased the odds of falling
into the struggling profile compared to the normative profile
(OR = 1.06, P = .04).
2.4 | Adolescent social-emotional functioning
2.4.1 | Posttraumatic stress symptoms
Youth in the struggling parent-child relationship profile reported ele-
vated levels of internalizing symptoms compared to youth in the high-
involved parent-child relationship profile (χ2 [1, n = 165] = 10.62,
P = .001) and youth in the normative profile (χ2 [1, n = 165] = 4.85,
P = .03). Differences did not emerge in youth's report of internalizing
symptoms between the normative and high-involved profiles (χ2 [1,
n = 165] = 2.91, P = .09; Figure 2).

Youth in the struggling parent-child relationship profile reported
elevated levels of PTSS compared to youth in the high-involved
parent-child relationship profile (χ2 [1, n = 165] = 35.06, P < .001)
and youth in the normative profile (χ2 [1, n = 165] = 48.83,
P < .001). Differences did not emerge in youth's report of PTSS
between the normative and high-involved profiles (χ2 [1,
n = 165] = 0.53, P = .47; Figure 2).
2.4.3 | Social functioning
Youth-reported social functioning scores were lower in youth who fell in
the struggling group compared to those in the high-involved profile (χ2 [1,
n = 165] = 16.38, P < .001) and the normative profile (χ2 [1, n = 165] = 7.33,
P = .007). Again, differences did not emerge between the normative and
high-involved profile (χ2 [1, n = 165] = 2.59, P = .11; Figure 2).
344
F I G U R E 2 Differences in social and emotional symptoms across parent-child relationship functioning profiles. Note. ***P < .001,
**P < .01, *P < .05
3 | DISCUSSION
Pediatric cancer is a significant and challenging life stressor. Many
young survivors remain psychologically and socially resilient following
their diagnosis and treatment34; yet, a significant subset experience
psychosocial difficulties that persist into survivorship.3 Prior research
has documented the importance of targeting caregivers and the family
system more broadly to reduce patient-related psychosocial difficul-
ties early in the treatment process.35 The present findings bolster
prior research36 and call for the need to provide ongoing support for
caregivers into the survivorship period, with particular consideration
given to psychological interventions that strengthen the caregiver-
youth relationship.
Overall findings documented variability in patterns of caregiver
perceptions of their relationship with their child across Attachment,
Involvement, Communication, Relational Frustration, and Parenting
Confidence. These findings are particularly important, as it calls for
the need for both researchers and providers to more comprehen-
sively examine strengths and weaknesses of these relationships.
Although caregivers may report normative or typical levels of frus-
trating interactions with their young survivor, other domains of the
relationship (ie, Attachment, Confidence, and Communication) may
be suffering and negatively impacting youth's psychological and
social functioning. In the present study, a significant minority
reported relationship difficulties, and given the potential emotional
and social implications this has for young survivors, there is a signif-
icant need to better understand correlates of these relationship
patterns.
Demographic factors were not associated with profile member-
ship; however medical factors were significantly linked to caregiver-
youth relationship patterns. In general, caregiver-youth dyads that fell
into the high-involved profile were closer to diagnosis and were more
likely to have experienced a relapse. Following diagnosis and through-
out active treatment, caregivers and patients spend a significant
amount of time together. Considering the proximity in time to diagno-
sis and likely longer treatment trajectory secondary to relapse status,
these caregiver-youth dyads may have been exposed to more
TILLERY ET AL.
opportunities for shared involvement in activities. These findings
seem to indicate that caregiver-youth dyads behave differently in
response to the medical experience but ultimately return to typical
patterns as time from diagnosis increases. Either way, the positive
relationship pattern demonstrated by the high-involved group, is con-
gruent with other research, which found caregiver-youth conflict to
be low following diagnosis and treatment.37
Partially consistent with our hypothesis, caregivers in the norma-
tive caregiver-youth relationship profile were less likely to experience
global psychological distress compared to caregivers in the struggling
profile. Ongoing psychological distress may impact caregivers’ emo-
tional bandwidth to communicate effectively, provide warmth, offer
support toward their child, and feel confident in their parenting deci-
sions. Of course, given the cross-sectional design of the study, it is
also possible caregiver psychological distress is impacted by poor rela-
tionship patterns with their child. Likely, however, these patterns are
reciprocal38 and an important area to expand upon in future investiga-
tions. It is interesting that caregiver distress did not differentiate care-
givers in the high-involved profile and the struggling profile. This may
be secondary to less time since diagnosis and relapse status of the
high-involved profile, which are both indicative of caregiver distress.39
A significant and robust association between patterns of
caregiver-youth relationship functioning and youth's social-emotional
functioning emerged. Youth of caregivers who reported struggling
relationship patterns were more likely to report increased levels of
PTSS, elevated levels of internalizing symptoms, and poorer social
functioning compared to youth of caregivers who reported normative
or above average levels of relationship functioning. These findings
suggest normative parent-child relationship functioning levels may be
protective against poor social-emotional outcomes, but there was no
added benefit for above average patterns of relationship functioning.
3.1 | Limitations and future directions
Despite the important implications of these findings, there are several
limitations worth noting. First, the observational and cross-sectional
TILLERY ET AL.
design limits the interpretation of the study's findings regarding the
implications of the caregiver-youth relationship on survivors’ psycho-
social outcomes. In the broader literature, the caregiver-youth rela-
tionship appears to drive youth's social and emotional outcomes,9 and
longitudinal studies will be important to further evaluate the impact of
this relation on youth's social and emotional adjustment into long-
term survivorship. Second, parent-child relationship patterns were
only evaluated by the caregiver. Research has documented discrep-
ancies in perceptions of functioning between caregivers and
youth,40 thus, it is imperative future studies investigate youth per-
spectives as this also likely impacts youth's social-emotional func-
tioning into survivorship. Finally, the small sample of fathers and
other alternative caregivers limited our ability to examine how rela-
tionship patterns between mothers and alternative caregivers may
differentially impact psychosocial outcomes. Previous research
with survivors has indicated the importance of the father-child rela-
tionship on social outcomes,17 calling for the need to include
fathers within this research.
3.2 | Clinical implications
The research based on the parent-child relationship within pediatric
oncology is small, thus ongoing investigations within this area are
essential for the development of clinical recommendations and
methods for evaluation. Consistent with the Standards of Psychoso-
cial Care,41 these findings add further support for targeted interven-
tions for survivors and families. In conjunction with prior research in
pediatric oncology36 our findings indicate family-based interventions
may be an appropriate avenue for supporting young survivors’ psy-
chological and social health, particularly as it pertains to bolstering the
caregiver-youth relationship. At the very least, practitioners should be
mindful that although some caregivers and youth may present typi-
cally across certain domains of functioning (ie, Relational Frustration),
they may be meaningfully struggling across other, less observable
domains (ie, Communication, Involvement, Attachment) that carry sig-
nificant implications for youth's social and emotional outcomes.
Including parent-child relationship assessments as a part of clinical
evaluations, such as the PRQ or other related instruments, may be
fruitful for identifying these difficulties and informing clinical care.
3.3 | Conclusion
Variability exists across domains of caregiver-youth relationship func-
tioning, and it is critical for researchers and providers to more compre-
hensively examine the implications of these patterns on the social and
emotional wellbeing of pediatric cancer survivors. Findings from this
research indicate a pattern indicative of a struggling relationship is
related to caregiver distress as well as associations with young survi-
vors increased posttraumatic stress, elevated levels of internalizing
symptoms, and decreased social functioning scores. Thus, caregiver-
youth relationship patterns warrant ongoing investigation and may be
345
key to promoting optimal social and emotional health in young survi-
vors of childhood cancer.
CONFLIC T OF INT ER E ST
The authors declare no conflicts of interest.
DATA AVAILABILITY STAT EMEN T
The data that support the findings of this study are available on
request from the corresponding author. The data are not publicly
available due to privacy or ethical restrictions.
OR CID
Rachel Tillery https://orcid.org/0000-0001-6216-1502
Victoria W. Willard https://orcid.org/0000-0003-3340-1460
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How to cite this article: Tillery R, Willard VW, Howard
Sharp KM, Klages KL, Long AM, Phipps S. Impact of the
parent-child relationship on psychological and social resilience
in pediatric cancer patients. Psycho-Oncology. 2020;29:
339–346. https://doi.org/10.1002/pon.5258
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