Firas G. Youssif
Master Thesis Clinical Psychology Supervisor: D. S. Sieh, PhD
Faculty Social and Behavioral Sciences – Leiden University Department: Clinical Psychology
Student number: s1348256 1 July 2019
The relationship between parental depression symptoms and problem
behavior in adolescents of parents with a chronic medical condition
2 Abstract
Being the teenager of a parent with a chronic medical condition (CMC) is associated with a range of adverse psychological consequences. Notably, these adolescents are more likely to suffer from both internalizing and externalizing behavioral symptoms. Similarly, adolescents whose parents suffer from depression also show more of these symptoms than peers with non-depressed parents. Few studies have considered the combined effect of parental CMC and depression symptoms. This study assessed internalizing and externalizing behaviors in adolescents with parents with a CMC and parents with a CMC and depressive symptoms.
A total of 133 adolescents (Meanage = 14.6 years) and their parents (n = 100) participated
in this study. We examined whether adolescents of parents with only a CMC (112 adolescents) and adolescents of parents with both a CMC and depressive symptoms (21 adolescents) differed in terms of internalizing (anxious/depressed, withdrawn and somatic) and externalizing (aggression and rule-breaking) behavior using the Youth Self Report questionnaire.
We found that comorbid chronic illness and depression in parents influences an aspect of adolescent internalizing but not externalizing behavior. More specifically, adolescents with comorbid parental CMC show more somatic symptoms (a subscale of the Youth Self Report) than adolescents of parents with CMC. Further, adolescents whose parents have both a CMC and depressive symptoms do not differ in terms of internalizing and externalizing behaviors. These results indicate that there is an additive impact of parental chronic illness and
depressive symptoms on adolescent functioning. Adolescents of chronically ill parents may be sensitive to the negative impact of parental depression; however larger studies are required to support this suggestion.
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Table of Contents
1. Introduction ... 4 2. Aims ... 7 3. Hypotheses ... 8 4. Methods ... 94.1 Procedure and participants ... 9
4.2 Instruments ... 10
4.2.1 Demographic Variables ... 10
4.2.2 Problem behavior ... 10
4.2.3 Parental depressive symptoms ... 10
5. Statistical analysis ... 11 6. Results ... 12 7. Discussion ... 14 8. Limitations ... 15 9. Conclusion ... 16 References ... 18
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1.
Introduction
Adolescents of parents with chronic illness frequently carry extra caretaking responsibilities alongside their own self-care, normal household chores, schoolwork, and maintaining a healthy social life (Pakenham & Bursnall, 2006; Visser-Meily et al., 2005). The additional responsibility may evoke problem behavior and psychological distress in these adolescents (Sieh, Visser-Meily, Oort, & Meijer, 2012), especially given that adolescence is a period of change and difficulty for many (Wigfield & Eccles, 1994). Adolescence is a biological and cognitive transition period, during which an adolescent develops abilities such as self-awareness, which helps them to learn how to deal with social challenges and emotional changes within themselves (Wigfield & Eccles, 1994; Crone & Dahl, 2012). Therefore, living with a chronically ill parent during adolescence may have a lasting negative impact on adolescent behavior (Krattenmacher et al., 2012). Indeed, it has been shown that children with chronically ill parents feel that they are limited in their daily activities, disconnect themselves from others, and develop problems such as anxiety, depression, delinquency, and rule breaking behavior (Earley & Cushway, 2002). Considering these findings, it is crucial to examine the effect of parental chronic illness on adolescent behavior (Sieh, Meijer, Oort, Visser-Meily, & Van der Leij, 2010).
Brown (2006) defines chronic illness, or a chronic medical condition (CMC), as a syndrome affecting one or more organs and impeding health and psychological functioning for the duration of at least 3 months. As noted, parents’ CMCs pose a threat to normal adolescent development with studies showing that parental CMCs are related to the development of a variety of problem behaviors in adolescence (Sieh, Meijer, Oort, Visser-Meily, & Van der Leij, 2010; Pedersen & Revenson, 2005). Problem behaviors can manifest as internalizing or externalizing (Brown, 2006). Internalizing problem behaviors refer to cases where the pathology manifests in relation to the self, whereas externalizing problem behaviors refer to conflict with or unpleasant feelings toward other people (Sieh et al., 2012). Internalizing problem behaviors are associated with less social contact, difficulty with emotion regulation, and the development of anxiety or depression (Connell & Goodman, 2002). Externalizing problem behaviors are associated with delinquency, drug use, aggression, and rule-breaking behavior (Connell & Goodman, 2002; Arthur, Hawkins, Pollard, Catalano, & Baglioni Jr, 2002).
Major depressive disorder (MDD) is one of the most common chronic illnesses (Compas et al., 2009), affecting approximately 12% of people living in Europe (World Health
5 Organization, 2017), and is frequently comorbid with other CMCs and mental health problems (Goodwin, 2006). MDD is more common in people with stroke, heart disease, nonspecific somatic complaints, chronic pain, chronic fatigue, and rheumatic disease than in otherwise healthy individuals (Goodwin, 2006). In addition to that, approximately 10% of adolescents grow up in families where a parent has been diagnosed with a CMC (Chen, 2017). Strikingly, children of parents with depression are almost four times more likely than children of nondepressed parents to develop an affective disorder themselves (Weissman, Warner, Wickramaratne, Moreau, & Olfson, 1997). As with parental CMCs, parental depression can have a negative impact on children’s development, including the development of internalizing and externalizing problem behaviors (Sieh, Visser-Meily, & Meijer, 2013; Hughes & Gullone, 2010).
Parental depression can increase stress within the family, particularly stressful parent-adolescent interactions relating to parental intrusiveness, withdrawal, irritability, or hostility (Jaser et al., 2005). Langrock, Compas, Keller, Merchant, and Copeland (2002) found a positive relationship between parental depression and adolescent symptoms of anxiety/depression and aggression. The influence of parental depression on adolescent externalizing and internalizing behavior indicates that parental depression can lead to more extreme negative outcomes (Breslend, et al., 2016), such as conduct disorder (Marmorstein, & Iacono, 2004), which includes disruptive, aggressive, defiant and oppositional behavior (Callender, Olson, Choe, & Sameroff, 2012). These negative consequences are seen to an even greater extent than for children of parents with other CMCs like cancer or physical disabilities (Sieh et al., 2013; Harris & Zakowski, 2003; Korneluk & Lee, 1998).
The diagnosis of a CMC in a parent causes changes in family functioning as parental behavioral, emotional and physical functioning affect the adolescent’s behavioral, emotional, and physical functioning and their school achievement (Visser, Huizinga, van der Graaf, Hoekstra, & Hoekstra-Weebers, 2004). Notably, adolescents of parents with chronic pain score higher on a measure of delinquency (Armistead, Klein, & Forehand, 1995) and tend to be absent from school more days than adolescent with parents are not ill (Chen, & Fish, 2013). CMCs are often comorbid with psychiatric conditions (primarily depression and anxiety) and, conversely, psychiatric conditions are linked to higher rates of physical symptoms (Kaasbøll, Lydersen, & Indredavik, 2012). Depression is associated with almost all other psychiatric and physical diagnoses (Goodwin, 2006). For example, studies have indicated a higher rate of depression in patients with diabetes mellitus (DM; Andreoulakis, Hyphantis, Kandylis, & Iacovides, 2012), various cancers (Krebber et al., 2014), and inflammatory bowel disease (IBD; Byrne et al.,
6 2017). Adolescents with a parent with a CMC may fear that their parent could die, and this may manifest as somatic symptoms (Grabiak, Bender, & Puskar, 2007). Following from this, several studies have noted that physical illness negatively affects adolescents’ functioning, including poorer academic functioning and mental health issues, and that these students also display behavior problems (Grabiak, Bender, & Puskar, 2007).
Other studies have shown that worsening parental health is seen as a stressor that taxes adolescents’ coping strategies and increases the likelihood that the adolescent will develop problem behaviors (Forehand, Biggar, & Kotchick, 1998; Pakenham & Bursnall 2006; Pedersen & Revenson 2005). Contrary to these findings, many studies have found that adolescents’ problem behaviors may relate more to daily stress and life pressures than to the severity of their parents’ illness (Dufour, Meijer, Van de Port, & Visser-Meily, 2006; Korneluk & Lee, 1998; Verhaeghe, Defloor, & Grypdonck, 2005). Furthermore, several studies assessing the relationships between parental CMCs and adolescent behavior have found no differences between adolescents with an ill parent and adolescents with no ill parents (Houck, Rodrigue, & Lobato, 2006; Judicibus, & McCabe, 2004; Hoke, 2001).
Taken together, the literature outlined here indicates that parental CMCs are likely to have a negative impact on adolescent functioning and that additional parental depression may increase this impact. Following from this, this study aims to answer the question: Is the behavior of adolescents impacted more negatively when parents experience only one CMC or when parents experience depression alongside another type of CMC?
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2. Aims
Research suggests that growing up with a chronically ill parent may have a negative impact on adolescents’ behavior. Further, having a parent with a CMC is associated with internalizing and externalizing behavior in adolescents (see Figure 1). Moreover, depression decreases quality of life in patients with a range of chronic illnesses, including IBD (Byrne et al., 2017), and is prevalent in patients with DM (Andreoulakis et al., 2012). This study aimed to assess the relationship between parental depressive symptoms and adolescent problem behavior in adolescents whose parents have a CMC (outlined in Figure 1) and to test whether these relationships hold true within a Dutch population.
Figure 1. Model for the relationships between parental chronic illness and adolescent problem behavior. Independent variables (IVs): CMC versus depressive symptoms and CMC and demographic variables. Dependent variables (DVs): problem behavior (including internalizing and externalizing behavior).
Demographic variables Age, gender, SES
Internalizing Anxious / depression, withdrawn Parental CMC Externalizing Aggressive, rule breaking behavior Comorbid parental depressive symptoms Adolescent problem behavior Adolescent
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3. Hypotheses
The hypotheses of this study are based on earlier studies, which showed that adolescents of depressed chronically ill parents are more vulnerable to internalizing problem behaviors than to externalizing problem behaviors (Sieh et al., 2013). This thesis hypothesizes that parental CMCs are associated with problem behavior in adolescents. It also hypothesizes that adolescents with a parent with both a CMC and depressive symptoms will display more problem behaviors and psychological stress than adolescents with a parent with only a chronic illness. In this study, different types of problem behaviors of adolescents are compared between adolescents with parents who have a CMC and those with parents with additional depressive symptoms. To account for possible confounders, we also take demographic variables into account. This leads to the following hypotheses:
Hypothesis 1:
Adolescents of parents with a CMC and depressive symptoms score higher on internalizing (anxious/depression, withdrawn and somatic) and externalizing (aggression and rule-breaking) problem behaviors than adolescents with family members who have only a CMC.
Hypothesis 2:
Adolescents of parents with a CMC and depressive symptoms score higher on internalizing (anxious/depression, withdrawn and somatic) than on externalizing (aggression and rule-breaking) problem behaviors.
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4. Methods
4.1 Procedure and participants
The data used in this study comes from a larger cross-sectional study. Parents with a CMC and their children were recruited from across the Netherlands. Participants were recruited from rehabilitation centers, hospitals, community centers, schools, and major organizations for chronically ill patients. A total of 100 families participated in the study, after 16 families dropped out. In total, 133 adolescents aged 10 to 20 years (M = 14.59; SD = 2.39) who were living at home with their parent(s) were included. This sample consisted of 63 fathers and 70 mothers, for descriptive statistics see Table 1. One or both of the adolescents’ parents had to have been diagnosed with a chronic illness lasting more than 3 months. Various types of chronic illnesses were included, such as brain injury, rheumatic disease, neuromuscular disease, IBD, and Parkinson’s disease. A team of trained research assistants administered the questionnaire to the participants in their homes after the parents provided informed consent.
Tabel 1. Demographic Information Describing the Adolescent Participants
Condition CMC only CMC and Depression Age Age Sex n M SD n M SD Total 112 14.66 2.47 21 14.19 1.94 Male 52 14.44 2.43 11 14.18 1.66 Female 60 14.85 2.50 10 14.20 2.30
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4.2 Instruments
4.2.1 Demographic Variables
This study included demographic questionnaires for adolescents and their parents, which included questions about age, gender, employment status, family income (for the parents), and educational level. The questionnaires for parents with a CMC specifically included questions about illness type and duration.
4.2.2 Problem behavior
Problem behavior was assessed using the Youth Self-Report (YSR) questionnaire for internalizing and externalizing problem behaviors in adolescents developed by Achenbach (1991; Reitz, Dekovic, & Meijer, 2005). Adolescents were asked to respond to questions about their behavior on a 3-point scale including answer options not true (0), sometimes true (1), or
very true (2). Items were averaged (sum-scores would be not be comparable because of
comparison between different scales) to obtain a total score for internalizing symptoms (including items regarding anxious/depressed behavior, withdrawn/depressed behavior, and somatic complaints) and externalizing symptoms (including items regarding aggression and rule-breaking behavior).
4.2.3 Parental depressive symptoms
Parental depressive symptoms were measured with the Beck Depression Inventory (BDI). The BDI uses a 3-point scale with a highest possible score of 42. A higher score indicates more severe depression (Beck, Ward, Mendelson, Mock & Erbaugh, 1961). A cut-off score of 20 for male and 23 female respondents was used to determine whether a parent is experiencing significant depressive symptoms (Rose, March, Ebener, & du Prel, 2015). While this does not allow us to assign a depression diagnosis to the parents, this cut-off score can be used as a proxy for a diagnosis of depression and reflects significant dysfunction in line with MDD.
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5. Statistical analysis
Before running main analyses, a dichotomized grouping variable was created (adolescents with one or both parents with a significant number of depressive symptoms and a CMC, and adolescents with a parent or parents with only a chronic illness). For all (sub-)scales used, reliability analyses (Cronbach’s a) were performed. Additionally, assumptions were checked (equal variances and normality of residuals on all dependent variables). First, the sample characteristics were reported (i.e., descriptive statistics for demographic variables). To investigate Hypothesis 1, first a one-way MANOVA was performed to check for (multivariate) differences between the two groups (adolescents with one or both parents with a significant number of depressive symptoms and a CMC, and adolescents with a parent or parents with only a chronic illness, the independent variable) in the (linear combination of) internalizing and externalizing problem behavior, which served as the two dependent variables, both the total scales are used here. This one-way MANOVA was followed by two one-way ANOVAs (or two t-tests) to check for univariate differences between the two groups. Secondly, for the first hypothesis, a one-way MANOVA including (five) follow up univariate analyses, was run with the same factor but now with the five subscales as dependent variables (for internalizing problem behavior; regarding anxious/depressed behavior, withdrawn/depressed behavior, and somatic complaints) and for externalizing symptoms; aggression and rule-breaking behavior). Finally, the mean difference in the total scores (internalizing plus externalizing) between the two groups was evaluated with a one-way ANOVA (or an independent t-test).
To investigate the second hypothesis, a paired t-test was run for the group of adolescents with one or both parents with a significant number of depressive symptoms and a CMC. Here we compared the average score for internalizing problem behavior and the average score for externalizing behavior using p-values and Cohen’s d. Additionally, the assumption of normality of difference scores (between internalizing and externalizing scores) was checked.
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6. Results
First reliability per (sub-)scale was checked; the values for Cronbach’s a varied between .65 (for Withdrawn) and .92 (for Total Score). To investigate Hypothesis 1, a one-way MANOVA was run. Multivariately, the difference between adolescents with parents with a CMC and depressive symptoms and adolescents with parents who have only a CMC on internalizing and externalizing problem behavior was not significant (F(2,130) = 2.12, p = .12, Pillai's Trace = .03). However, univariately, a marginal significant effect was found for the dependent variable internalizing problem behavior (F(1,131) = 3.80, p = .053, h2 = .03). Adolescents with parents
with both a CMC and depression symptoms, on average, score higher on internalizing symptoms (Mdep = 0.41, SE = 0.06) than adolescents with parents with only a CMC (Mno dep =
0.29, SE = 0.03). The univariate effect on externalizing problem behavior is non-significant (F(1,131) = 2.68, p = .10, h2 = .02), which means that, on average, adolescents with parents
suffering from depression symptoms in addition to a CMC (Mdep = 0.32, SE = 0.04), do not
differ significantly from adolescents with parents who only suffer from a CMC (Mno dep = 0.24,
SE = 0.02). Although the assumption of equal covariances and variances for the two populations
was met (Box’s M = 8.04, F(3,16383.49) = 2.58, p = .052), the normality (of residuals) assumption cannot be maintained. It appears that the two distributions of residuals for internalizing and externalizing behaviors show a strong positive skewness (resp., zskewness int. =
6.81 and zskewness ext. = 5.45).
Due to this normality violation, the two original variables (internalizing and externalizing) were transformed (square-root transformation) to reduce skewness. After running the one-way MANOVA again, but now with the transformed variables, no significant effects were found, for either multivariate (F(2,130) = 2.07, p = .13, Pillai's Trace = .03) or univariate effects (Internalizing: F(1,131) = 3.63, p = .059, h2 = .03, Externalizing: F(1,131) =
2.54, p = .11, h2 = .02). No multivariate effect was found on the five subscales when running
the second MANOVA (F(5,127) = 1.21, p = .31, Pillai's Trace = .05). When considering univariate effects only for the dependent variable “Somatic”, a significant effect was found (F(1,131) = 4.03, p = .047, h2 = .03). It appeared that the condition with CMC and depression
scored higher on average (Mdep = 0.45, SE = 0.07) than the CMC only group (Mno dep = 0.30, SE
= 0.03). When running a one-way MANOVA on the transformed subscales (square-root), multivariately the effect remained significant (F(5,127) = 0.89, p = .49, Pillai's Trace = .03). This means that adolescents whose parents experience both a CMC and depressive symptoms
13 reported more somatic complaints than adolescents whose parents experience only a CMC. Finally, a one-way ANOVA was run to see whether there is a significant effect on the Total Score. The two groups differed significantly in means (F(1,131) = 4.28, p = .041, h2 = .03). The
group of adolescents whose parents have both a CMC and depression scored, on average, higher (Mdep = 0.37, SE = 0.05) than the group whose parents have only a CMC (Mno dep = 0.27, SE =
0.02). See Table 2 for a comparison of all scales and sub-scales.
To investigate Hypothesis 2 a paired t-test was run (only for the group of adolescents with parents with a CMC and depression) to compare internalizing and externalizing problem behavior. The difference scores were checked for normality and were found to follow an approximately normal distribution. On average, this group scored higher on internalizing problem behavior (Mint = 0.41, SD = 0.35) than on externalizing problem behavior (Mext = 0.32,
SD = 0.27) but the difference (MD = 0.092, SD = 0.27) did not reach significance (t(20) = 1.56,
p = .13, Cohen’s d = 0.34).
Table 2: Internalizing and Externalizing Behavioral Problems by Condition
Condition CMC (n =112) CMC & Depression (n = 21) Cronbach's 𝛂 N M SD N M SD t p YSR Total .92 112 0.26 0.19 21 0.37 0.28 2.07 .041 YSR Internalizing .91 112 0.28 0.25 21 0.41 0.35 1.95 .053 Anxious .89 112 0.26 0.30 21 0.40 0.39 1.84 .069 Withdrawn .65 112 0.31 0.31 21 0.38 0.32 0.86 .39 Somatic .75 112 0.30 0.29 21 0.45 0.44 2.01 .047 YSR Externalizing .84 112 0.24 0.18 21 0.32 0.27 1.64 .10 Aggressive .77 112 0.24 0.19 21 0.30 0.23 1.30 .20 Rule-Breaking .78 112 0.25 0.25 21 0.36 0.45 1.64 .10
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7. Discussion
The present study aimed to elucidate the relationships between parental CMCs and comorbid depression and adolescent behavior. To our knowledge, this is the first study to assess the effect of comorbid parental depression on adolescent internalizing and externalizing behavior. We found that, overall, the presence of parental depressive symptoms in addition to a CMC had a significant impact on adolescent problem behaviors.
In line with our expectations, we found that adolescents with parents with a CMC and depressive symptoms scored higher on internalizing problem behaviors than adolescents with family members who have only a CMC, although this finding only reached trend-level significance. Contrary to our hypothesis, adolescents with parents with a CMC and depressive symptoms did not score higher on externalizing problem behaviors than adolescents with family members who have only a CMC. Earlier studies examining the impact of parental CMCs on adolescent behavior found that these adolescents experienced more anxiety, depression, behavior problems, low self-esteem, and problems with social skills (Forsyth, Damour, Nagler, & Adnopoz, 1996; Hirsch, Moos, & Reischl, 1985; Pedersen & Revenson, 2005). Similarly, studies examining parental depression on adolescent behavior found that children of depressed parents have increased rates of major depressive disorder, phobias, panic disorder, and substance abuse (Weissman, Warner, Wickramaratne, Moreau, & Olfson, 1997). Following from this, it is plausible that the additive effect of both a CMC and depressive symptoms could lead to worse internalizing outcomes for adolescents.
Considering the internalizing and externalizing subscales of the YSR, we found that only somatic complaints differed significantly between the two groups, with the anxious subscale reaching trend-level significance. Adolescents whose parents experience depression in addition to a CMC reported more somatic symptoms than did those whose parents experience additional depression. One study indicated that parental pain and catastrophizing are associated with somatic symptoms, pain, and pain-related disability in adolescents (Wilson, Moss, Palermo, & Fales, 2014). Following from this, it is possible that parental depression may involve negative talk or catastrophizing around their experiences of having a chronic illness and that this may make adolescents more sensitive to their own somatic symptoms. In addition, many CMCs (e.g., autoimmune conditions like ankylosing spondylitis) have a genetic component (Tsui et al., 2014). Adolescents whose parents suffer from a heritable CMC may fear that they will develop the same condition and place undue attention on their physical experience (Goodwin, 2006). This overemphasis on somatic complaints (due to anxiety) may
15 explain our findings here. These theories should be further investigated in future research. It should be noted that somatic complaints only comprise one subscale of the internalizing section of the YSR and care should be taken in generalizing to other internalizing problems.
Finally, we found that there was no difference in internalizing and externalizing problem behaviors as displayed by adolescents with a CMC and depressive symptoms. We expected that adolescents would score higher on internalizing behavior than externalizing behavior based on previous studies that showed that (Sieh et al., 2013). However, these earlier studies primarily considered girls, which may not align with our sample.
Taken together, our findings suggest that there is may be an additional negative influence of depression on the relationship between parental CMC and internalizing behaviors. Notably, the relationship between parental CMC with additive depression and adolescent somatic symptoms warrants further investigation in a substantially larger population.
8. Limitations
This study has a number of limitations. As noted, the sample size in this study may be too small to draw firm conclusions. In particular, the fact that the group of adolescents whose parents have a CMC and comorbid depression comprised only 21 adolescents versus the 112 adolescents with parents with only a CMC limits comparability. While this may be representative of the occurrence of depression in the general population of parents with a CMC, to aid statistical comparability, future studies should recruit equal numbers of parents with a CMC and parents with a CMC and comorbid depression.
In addition to this, the large number of CMCs considered in this cohort may obscure the true influence of specific CMCs and their influence on adolescent behavior. Future studies would benefit from consider a narrower range of parental CMCs and including a similar number of people with each CMC.
Furthermore, many other underlying factors have been identified that are related to adolescent problem behaviors. Situational factors such as chronic illness duration or type, and social economic status also correlate with the presence of problem behaviors (Nelson & While 2002; Lee, Lee, & August, 2011). This study did not consider these factors in the statistical analyses. Some of the adolescents who participated in this study are siblings and therefore parented by the same people. This means that it is possible that some of the effects observed in this study may have been due to the influence of family-related factors not accounted for by chronic illness. Future studies should take this into account by either excluding children from
16 the same family unit, or by performing in-depth subgroup analyses to tease out possible family influences.
We further did not take into account the sex of the parent experiencing the chronic illness. While this is not overtly problematic, in many instances mothers still carry the bulk of parenting responsibilities and, as a result, the impact of a mother with a CMC on adolescent development may be greater than the impact of a father with a CMC. Moreover, Kaasbøll, Lydersen, and Indredavik (2012) found that children whose parents both suffered from chronic pain were significantly more likely to experience anxiety and depression than children with only one parent with chronic pain. This points to the need to evaluate the health status of both caregivers. Future studies would do well to characterize family dynamics to include an evaluation of responsibility carried within the family.
Finally, we used a cut-off score on the BDI to determine whether or not parents were experience significant depressive symptoms. However, this may not be as accurate as a clinical diagnosis of a depressive disorder. Future studies investigating these complicated relationships would do well to consider parents with a CMC and diagnosed depressive disorder. Moreover, future studies should exclude other comorbid mental illness (e.g., bipolar disorder) to ensure that the effect is truly related to depression.
Despite these limitations, this study is an interesting and relevant investigation into the combined effect of CMCs and depression on adolescent behavior. The study sample comprised adolescents whose parents experience a range of chronic illnesses, offering a representative picture of the Dutch population. The trend-level significance of the influence of parental CMC plus depressive symptoms on adolescent internalizing behavior warrants further investigation with a larger sample in a study assessing parents with a CMC and diagnosed depression.
9. Conclusion
This study showed that comorbid CMC and depression in parents influences adolescent internalizing but not externalizing behavior. More specifically, these adolescents show more somatic symptoms than adolescents whose parents have only a CMC.
It is plausible that adolescents are sensitive to their parents’ emotional experiences of their chronic illness and focus more on their own somatic complaints as a result. However, this hypothesis should be explored in greater depth in a more homogeneous population of chronically ill parents, controlling for factors such as family structure. Practitioners working with families with parents experiencing chronic illness(es) should take these findings into
17 account. Targeted interventions considering the impact of parental somatic and emotional experiences on adolescent somatic complaints should be developed. Ultimately, in families where chronic illness is present, attention should be paid to the entire family unit and not only to the person experiencing the illness.
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