A Mother Diagnosed With Cancer Psychology Essay

Published Date: 23 Mar 2015

At that time, cancer for me and probably for anyone else was an unknown monster who spared no life when it hits you. There were endless nights full of hope for her recovery. At night before I would doze off to sleep I would look at her closely. She still had that same pretty face, beautiful eyes, lovely shaped lips and brilliant mind. But deep inside, it was too painful to see my ever energetic mother lying in bed with all the tubes in her body. Too hurtful to think that all we had shared, our plans might come to an end…

This is an adolescent daughter's account of her journey with having a mother diagnosed with cancer. Dealing with maternal cancer can cause distress and anxiety because this illness is usually associated with poor prognosis, agonizing pain, negative effects of the treatment, and low survival rates. Cancer is considered by many as a "silent killer," which unsuspectingly ravages the body from within. It can be a stressful experience, not only for the patients themselves, but also for the entire family. Every member of the family, especially the children, has to adjust to the emotional burden, physical demands, and lifestyle changes which cancer brings about.

The occurrence of cancer has alarmingly increased throughout the years, affecting and claiming many lives around the world. It has been estimated that around 12.2 million people are diagnosed with cancer worldwide (American Cancer Society, 2007). It is also projected that the number of cancer cases and deaths will continue to escalate in the future. New cancer cases are estimated to increase from 11.3 million in 2007 to 15.5 million in 2030 (WHO, 2008). Based on the worldwide proliferation of cancer cases, this disease is now considered to be a major health problem.

In the local scene, it is estimated that one in every 1,800 Filipinos will suffer from cancer every year ("Philippines' Breast Cancer," 2008). Based on the 2005 Cancer Facts and Estimates (cited in "A Look at Cancer," 2007), approximately 39,929 men and 32,917 women were diagnosed with cancer that year. Consistent with the worldwide trend, the number of cancer patients in the Philippines is also expected to increase in the coming years. The most common cancer sites for both men and women are as follows: lung, breast, liver, cervix, and colon ("A Look at Cancer," 2007).

Young and middle-aged women are at great risk of developing cancer. According to Hamouy (2007), statistics show that females have one in three chances of getting cancer in their lifetime. This risk is also due to the drastic increase in the number of breast and cervical cancer cases, which are commonly and specifically associated with women. The breast is the most common cancer site among Filipinas. As of 2008, the Philippines had the highest reported cases of breast cancer in Asia, even surpassing other European countries ("Philippines' Breast Cancer," 2008). Cervical cancer ranks as the second most frequent type of cancer among Filipino women (World Health Organization, 2007). According to the Department of Health (cited in "DOH Launches," 2008), approximately 10 Filipinas die from cervical cancer each day.

Women diagnosed with cancer belong to various age groups. However, findings consistently show that cancer risk is positively correlated with age (Baum & Andersen, 2001; "A Look at Cancer," 2007). This puts older women at greater risk for developing this dreaded disease. In the past years, majority of cancer cases were diagnosed at 50 years old or at a postmenopausal age (Bobadilla, 2006). Unfortunately, there has been an increase in the occurrence of cancer among women in their midlife (Bobadilla, 2006) as well. Recently, the battle against cancer has started to affect younger women. A significant number of women who belong to this population are mothers. It is estimated that 30% of women diagnosed with breast cancer has one or more dependent offspring still under her care (Faulkner & Davey, 2002). The growing incidence of cancer among younger mothers means that more families are being challenged to cope with this disease.

Mothers diagnosed with cancer are faced with various issues in the different facets of their lives. On a personal level, their concerns include experiencing the physical rigors of the disease and treatment, emotional issues, and preoccupation with existential matters. Aside from these, they also have additional sources of stress such as meeting the demands of being wives, mothers, and professionals in their respective fields. Being diagnosed with cancer at this stage in one's life can be stressful and in some cases, traumatic. This can be attributed to the pressure of having to fulfill different roles despite the physical and emotional demands of the disease. Mothers with cancer are forced to shift their role from taking care of their family to the one being cared for. In effect, although a maternal cancer diagnosis is experienced as a personal crisis, it also makes a great impact on the whole family system.

These families are put in a predicament wherein they have to adapt with the changes and stresses brought about by maternal cancer. As the patient's roles as a mother and spouse are disrupted, dealing with the illness becomes a shared crisis within the family. The husband and children are forced to adapt with the situation by handling the responsibilities which the mother could not perform, while dealing with their own emotional distress. The stressful nature of the situation puts other family members at risk for psychological distress, especially the children.

In families dealing with maternal cancer, the adolescent daughters are expected to assume the responsibilities of the mother. In the Filipino culture, daughters are reared to help out in domestic chores and assist the mother with her duties (Liwag, Dela Cruz, & Macapagal, 1998). Thus, when the mother is not well enough to carry out her responsibilities, adolescent daughters take over in caring for the family. This additional burden makes adolescent daughters the most vulnerable to experience psychological distress. Such circumstances subject the daughters to witness drastic physical and emotional changes in their mothers, disruption in their daily routines and changes in family roles. Aside from sharing the burden with their family, the daughters are also faced with the challenge of dealing with the developmental demands of being an adolescent. They may experience a variety of emotional responses, the most common of which are depression and anxiety, as a way to cope with their stress. Parents may fail to recognize the distress their daughters are experiencing due to preoccupation with the treatment and their own distress. In effect, the emotional issues harbored by the daughters may not be addressed appropriately.

In the field of psychological research, a large body of studies had already been devoted to investigating the effects of cancer on the different aspects of a patient's life. It has only been recently that researchers also recognized the need to shift their attention to the children of cancer patients. It is in this vein that the focus of this research will be centered on adolescent daughters whose mothers have cancer. This research will look into the psychological impact of maternal cancer on adolescent daughters, specifically in terms of emotional, behavioral, and social functioning. The mothers' perceptions regarding how their daughters are dealing with situation will also be explored. It is also of interest to know how maternal cancer affects the relationship between the mother and adolescent daughter.

Review of Literature

Impact of Parental Cancer on the Family

Cancer was found to be associated with psychological distress. Much of past research on cancer has focused mainly on the psychological impact of cancer on the patients themselves (Veach, 1998). Researchers have acknowledged that it is also necessary to look into the effect of cancer within the context of the family.

Family Systems Theory

The family is defined by Buckley (as cited in Papadopolous, 1995) as a system made up of sets of different parts which are interdependent and interconnected. A change in one part causes a change in the entire system. It is comprised of several subsystems which characterize the existing relationships within the family such as parental, marital, and sibling relationships (Faulkner & Davey, 2002). According to the family systems theory, the condition of one family member influences the condition of other family members. It proposes that all the subsystems within the family interact and affect each other (Faulkner & Davey, 2002; Papadopolous, 1995). The members of the family operate in a way that it maintains a balanced level of functioning, also known as equilibrium. The well-being of the family members and the family's functioning depend greatly on the interaction of the subsystems (Faulkner & Davey, 2002).

Due to the dynamic and interdependent nature of the family system, the roles and psychological functioning of individual members can affect the whole system. A role change initiated by one member will alter how the rest of the members play their roles. In this case, the whole system has to make corresponding changes in their behavior in order to compensate for the disruption in the roles among the members. This adjustment has to be made in order to regain the family's equilibrium (Jolley & Mitchell, 1996). In the same way, a member's psychological functioning is strongly influenced by one's interaction with the other members (Oster & Caro, 1990). In families which are under a great deal of stress, the child is vulnerable to everything that is going on between the parents. The tension or conflict within a family can also induce distress within the child, whether the child is directly exposed to the stressor or not (Sokolova, n.d.).

The Filipino Family

The Philippine society is familial in nature (Jocano, 1995). Filipinos recognize that the family is the most basic institution in the society and is at the center of the affairs of the community. The high regard given to the family can be seen in the strong and pervasive influence this institution exerts towards individuals.

According to Jocano (1995), the Filipino family is superordinate over the members. The life of each member is strongly influenced by the dynamics within the family. An individual must involve the family in decision-making and resolution of important issues. This is because the entire family is affected if something happens to its member, regardless of whether this occurrence is positive or negative. Thus, the Filipino family tends to be protective of its members, as a way to preserve not only the individual but the entire system as well.

In order to uphold the traditional Filipino family system, cultural ideals which guide one's behavior are instilled in the individual. These ideals are learned through rearing practices and adherence to the society's norms. The following standards are honored and imbibed by traditional Filipino families: "kapwa," "damdamin," and"dangal" (Jocano, 1995, p.7). "Kapwa" refers to establishing interpersonal relationships which are based on equality and empathy. "Damdamin" on the other hand, deals with valuing others people's emotions and striving in order not to hurts the feelings of others. Lastly, "dangal," pertains to honoring and respecting others. Despite the changes in the society, in light of modernization, Jocano (1995) found that many Filipino parents continue to inculcate the following cultural ideals to their children: "paggalang," which is giving respect to people and venerated customs; "pagbabalikatan," which is empathizing and sharing the burden of others; "pagbabayanihan," which is cooperating with one another; and" pagmamalasakit," which is being considerate and concerned with other people's welfare (Jocano, 1995, pp.7-8).

The Filipino family is also described to be bilateral (Jocano, 1995). This refers to the establishment of close relationships with relatives from both the sides of the mother and father. An individual's level of affinity towards the maternal and paternal relatives are said to be equal. This bilateral characteristic of the family makes the relationships within the family system wider and more intertwined. In effect, the typical Filipino's concept of family is not only limited to the nuclear family structure, which is comprised of the parents and their children, but also includes the extended family which includes the relatives from both sides. By going beyond the immediate family, the individual can draw support and security from both the immediate and extended family. Jocano (1995) considers this close kinship among Filipinos as a significant source of strength. This provides an individual with an assurance that there will always be someone to count on when problems arise.

The close ties among relatives and the ideals which families uphold influence the structure of Filipino households (Torres, 1995). It is typical for a nuclear family to share a roof with a few relatives and a nonrelative, which is usually the househelp. This is true, most especially for middle class urban families. In some cases, nuclear families who belong to the same clan reside in separate dwellings which are close in proximity. By maintaining geographical nearness, the extended family and its members are able to strengthen the support that they derive from each other.

Carandang (1987) applied the family systems approach within the context of Filipino families. In line with Western theories on family systems, she suggested that any stress experienced by one member can be vicariously felt by the other members. Each of the family members responds to this stress by acting out in their own unique way.

It has to be taken into consideration that the Filipino family is usually comprised of immediate family members, as well as extended relatives. There is also greater emphasis on maintaining close emotional bond among the family members. This nature of Filipino families makes it a more dynamic and complicated system. In effect, the children are challenged to gain recognition so as not to be lost within the larger system. This makes the children the most vulnerable members of the family because they can be easily affected by the stresses experienced by the family (Carandang, 1987).

When the family is in the middle of a crisis, there is a tendency for the children not to directly articulate their feelings, especially if these are negative and are felt towards the adults in the family. In some cases, these stresses are manifested through the children's behavior. Carandang (1987) found out that regardless of the socioeconomic status of the family, the children play the role of the family's protector. Being the protectors, the children absorb the family's stress and respond through their behaviors.

In the Philippine setting, the family's "tagasalo" (Carandang, 1987, p. 47) or the one who takes care of the family is considered to be at risk for developing distress. Older siblings, most especially the daughters, are commonly expected to fulfill the role of being the family's "tagasalo." Daughters are groomed at an early age to assist in tasks which are domestic and nurturant in nature, such as household chores and caretaking duties. By the time Filipino daughters reach adolescence, they are expected to become "mother substitutes" (Liwag, Dela Cruz, & Macapagal, 1998, p.155). With this new role, adolescent daughters assume a considerable number of their mothers' household responsibilities.

The study of Go Tian (2003) supports Carandang's premise that daughters are more likely than sons to assume the role of the tagasalo. Based on her research among Filipino college students, females exhibited higher tagasalo traits than males. In contrast, Udarbe's (2001) research proposed that the family's tagasalo is not necessarily related to the child's gender or birth order. Her findings suggest that the tagasalo generally possesses the following characteristics: strong sense of responsibility, good listener, nurturant, peacemaker and a strong need for control.

Traditionally, women are considered to be central to the functioning of the family. This is due to gender role socialization, which dictates that women are expected and trained to take care of household matters (Liwag, Dela Cruz, & Macapagal, 1998). As the major female figure in the family, the mother's main role is to handle domestic responsibilities at home. Thus, when a mother is diagnosed with cancer, the family adapts to the situation by assuming the responsibilities which the mother could not handle. This burden is often passed on to the adolescent daughter, who had been trained since childhood to carry out domestic chores.

The impact of cancer within the Filipino family was evident in a local study done by Gorospe (2002). A cancer diagnosis affects the different aspects of a patient's life, as well as the rest of the family members. The debilitating effect of cancer on the patient can cause a disruption in routine, changes in lifestyle, and limitations in performing one's responsibilities. Thus, the patient and his family are confronted with overwhelming changes which they have to adjust to. As a reaction to these changes, the entire family undergoes a process of emotional distress characterized by disbelief, denial, and initial resistance to the diagnosis. The roles within the family also have to be re-assigned in order to compensate for the changes related to the patient's inability to fulfill one's role.

Family Changes Brought About by Parental Cancer

A mother's diagnosis of cancer is not an individual struggle. The entire family is subjected to the repercussions of dealing with maternal cancer. According to Robinson, Caroll, and Watson (2005), cancer within the family can be considered as an emotional crucible. This is the shared experience in which the family goes through a series of emotional adjustments. Such experience has been described as both draining and empowering, not only for the cancer patient but for all the family members. The profound stress brought about by the illness affects the relationships and interactions within the family. As a response, the family members' reactions are manifested through their behavior and emotions (Sargent, 2003).

Parents diagnosed with cancer reported that due to the illness, they were unable to spend time with and address the needs of their children (Walsh, Manuel, & Avis, 2005). This was supported by the study of Faulkner and Davey (2002) which revealed that parental cancer can lead to impaired parenting. The demands of the illness made both the healthy and ill parents less available to their children, emotionally and physically. There were also cases of less communication, decrease in supervision, and lack of consistency in discipline and nurturance.

Such disruption in the family system undeniably exposes the children to many psychological stressors such as: threat of permanent loss of parent to death, temporary loss of parent due to the treatment demands, and changes in family roles and routines (Davey, Askew, & Godette, 2003). This may result in adjustment difficulties and psychological consequences, thus, making the children vulnerable to the impact of having a parent with cancer.

Cancer blurs the roles in the family. The study of Walsh, Manuel, and Avis (2005), which investigated the impact of maternal breast cancer on the family, revealed that because the mothers were not well enough to perform their usual responsibilities at home, they had to transfer some of their family duties to their spouses and children.

Generally, adolescents in the family had to take on more responsibilities at home, such as household chores and caregiving tasks for their younger siblings and the ill parent (Davey, Askew, & Godette, 2003; Davey, Gulish, Askew, Godette, & Childs, 2005; Grabiak, Bender, & Puskar, 2007; Visser, Huizinga, Van der Graaf, Hoekstra, & Hoekstra-Weebers, 2003). Aside from dealing with worry over the ill parent's condition, the adolescent children in the family felt that their lives were complicated due to the additional responsibilities they had to carry out in order to augment the deficiencies caused by maternal cancer (Davey, Gulish, Askew, Godette, & Childs, 2005).

Psychological Adjustment Among Adolescents of Cancer Patients

The psychological effects of maternal cancer on children are widely investigated. The qualitative study of Forrest, Plumb, Ziebland, and Stein (2006) reported that children already suspected that something was wrong even before they were told about their mother's diagnosis. They based this suspicion on the mood and behavior changes in their mother. Upon knowing about the maternal cancer diagnosis, the adolescents experienced emotional distress. The initial emotional responses were shock and disbelief, followed by devastation and intense feelings of sadness (Davey, Askew, & Godette, 2003; Davey, Gulish, Askew, Godette, & Childs, 2005).

Compas, Worsham, Ey, and Howell (1996) assessed the emotional distress experienced by children of cancer patients by looking into their depression and anxiety. Their distress arose from their considerable worry about their mother's health and fear of losing their mother from cancer (Davey, Askew, et al., 2003; Davey, Gulish, et al., 2005; Grabiak, Bender, & Puskar, 2007; Kristjanson, Chalmers, & Woodgate, 2004; Walsh et al., 2005). In some studies, adolescents were also concerned with the possibility of potentially inheriting the cancer (Davey, Askew, et al., 2003; Walsh et al., 2005).

The adolescents' emotional difficulties partly stemmed from feeling powerless over their parent's illness. The adolescents felt that they did not have control over the outcome of the diagnosis and treatment, which in turn also affected the moods and accessibility of both parents (Davey, Askew, et al., 2003). Another cause of the adolescents' distress was witnessing their parent's pain. Some of the adolescents reported that they were bothered by the side effects of chemotherapy (Forrest et al., 2006). They had to adapt to seeing their usually healthy parent slowly become weak and ill (Davey, Askew, et al., 2003). The positive effect this had on the children was that they became more empathic towards their ill parent. They were also more tolerant and understanding of both their parents, who exhibited increased irritability and moodiness (Davey, Askew, et al., 2003). This was consistent with the findings of Kristjanson et al. (2004) which revealed that the adolescents were sensitive to the suffering of their ill mother. The teenagers expressed that they felt guilty because their own lives were normal, whereas their mother was enduring the painful physical and psychological consequences of cancer. They were able to empathize with their mother's suffering but they expressed guilt about their own situation.

A local research done by Tantoco (1992) examined the issues confronted by terminally ill mothers and their eldest offspring. Results revealed that the eldest children exhibited considerable anxiety during the process of dealing with their mother's illness. Many of the participants described their journey as an "emotional roller coaster ride" (Tantoco, 1992, p.73). This experience compelled them to prioritize their mother's condition. This forced them to put other aspects of their lives, such as studies, work, and heterosexual relationships aside. Given that the eldest children focused much of their attention on their ill mother, they became sensitive to their mother's physical, emotional, and mental anguish. The children shared that they had difficulties in dealing with their ill mother's emotional outbursts. Despite this, the eldest in the family also felt the need to give emotional support, security, and assurance to their ill mother. Another source of the eldest children's stress was their informal role of being next to their parents in terms of responsibility and authority. Being the eldest, they had to take on additional household responsibilities, including caring of their ill mother and younger siblings. These extra tasks required them to make personal sacrifices such as not being able to engage in their usual adolescent activities.

Aside from emotional problems, behavioral changes were also observed among children of cancer patients. Increased crying, clinging, difficulty in sleeping, and changes in the intensity of talking were some of the behaviors which children engaged in after their parent was diagnosed with cancer (Visser et al., 2003). There are inconsistent findings in terms of the children's school performance. Some adolescents showed a decline in their academics and attendance (Visser et al., 2003; Grabiak, Bender, & Puskar, 2007. This was due to their inability to concentrate during school hours because of their preoccupation with their parent's illness and the disruptions in their routine (Visser et al., 2003; Forrest et al., 2006). However, some adolescents actually performed better in school even though they were dealing with parental cancer (Visser et al., 2003).

Positive behavioral changes also surfaced as the adolescents were dealing with their mother's cancer. The adolescents expressed that they appreciated their mother more even when the diagnosis and treatment were over. They showed this newfound appreciation by constantly checking on how the ill mother is doing, wanting to be physically close, paying more than usual attention to mother's needs, and wanting to offer support (Visser et al., 2003; Davey, Gulish et al., 2005). Some adolescents also reported that they took over their mother's role even if it meant an increase in their responsibilities. This contributed to their perception that they were older than their years, after having gone through that experience (Davey, Gulish et al., 2005). Daughters whose mothers have cancer also became more involved with the medical aspects of the treatment. Even though they were less convinced that things will work out, they took more initiative in handling the medical concerns of their mother (Gilbar & Borovik, 1998).

According to Grabiak, Bender, and Puskar (2007), the behavioral adjustment of adolescents rely heavily on the emotional condition of both parents and on the family functioning. When both parents display symptoms of depression, adolescents tended to show increased behavioral problems. Between the two parents, maternal depression exerts a stronger influence on the child's behavioral functioning. It was also found that adolescents who experienced difficulty with behavioral adjustment perceived their families as having poor quality of communication, responsiveness, and involvement.

In the aspect of social functioning, the study of Osborn (2007) found no evidence to suggest that social competence is negatively affected among children of cancer patients. In a few studies, adolescents of cancer patients even reported handling their social lives more effectively than those from the norm groups (Osborn, 2007). This favorable social functioning may be attributed to the strong social support which the adolescents actively seek and maintain.

Common sources of social support were family, friends, school counselors, teachers, and support groups (Davey, Askew, & Godette, 2003; Grabiak, Bender, & Puskar, 2007; Huizinga, Van der Graaf et al., 2005). Adolescents felt that their peers were positive sources of support with whom they could talk openly about their feelings and fears. However, some teenagers expressed that their friends had difficulty empathizing with their situation. They felt that their friends could not really understand what it is like to have a mother diagnosed with cancer. This feeling further highlights the sense of isolation which the adolescents sometimes feel. They felt more consoled when they talked to peers who were also experiencing the same adversity (Huizinga, Van der Graaf et al., 2005).

Similarly, Filipina adolescents place importance on having strong social ties. Being more emotionally involved in relationships and having higher levels of interpersonal needs, warmth, and sensitivity are important factors which contribute to the finding that female adolescents are less lonely than their male counterparts. Their need for interaction actually reduces the feelings of loneliness because Filipina adolescents have a richer source of social and emotional support (Jimenez, 2009).

Adolescents of Cancer Patients in Comparison With Control Groups

Several studies compared the psychological functioning of adolescents whose parents have cancer vis-a-vis a control group. Inconsistent findings were found.

A number of studies reveal that adolescents of cancer patients and the control group did not significantly differ in terms of emotional, behavioral, and social functioning (Brown et al., 2006; Harris & Zakowski, 2003; Hoke, 2001; Huzinga, Van der Graaf, Visser, Djikstra, & Hoekstra-Weebers, 2005; Osborn, 2007; Visser, et al., 2007). The similarity in the levels of psychological distress between adolescents of cancer patients and the control group can be attributed to the children's efforts to mask their true feelings. They were aware that their parents were already under a great deal of stress. The adolescents showed that they were not affected by the situation so that their parents would not worry about them. This was their way of protecting their parents from additional stress (Visser et al., 2007).

Although no significant differences were found in terms of psychological distress, a percentage of the adolescents of cancer patients exhibited scores within the clinical range. In the study of Houck, Rodrigue, and Lobato (2006), one-third of the adolescents whose parents have cancer reported clinical levels of posttraumatic stress in response to their parents' illness. In addition, approximately 25% to 30% of the adolescents in both the studies of Visser et al. (2007) and Huizinga, Van der Graaf et al. (2005) reported clinically elevated scores in internalizing and externalizing problems. Internalizing problems refer to turning one's emotions inward. This is manifested through withdrawal, somatic symptoms, anxiety, and depression. On the other hand, externalizing problems are more noticeable ways of dealing with stress because they are reflected through one's behavior. This can be in the form of socially unacceptable, delinquent, and aggressive behavior (Visser et al., 2005). Consistent with the abovementioned, Osborn (2007) proposed that adolescents of cancer patients generally did not experience higher levels of psychological distress compared to reference groups. However, they were slightly at increased risk for internalizing problems.

Some studies found that adolescents of cancer patients are more emotionally distressed than those from the control sample. The research of Grabiak et al. (2007) revealed that adolescents whose parents have cancer displayed a significantly higher level of anxiety compared to the age-normed sample. Visser et al. (2003) supported this claim as their study found that when compared to a control group, adolescents dealing with parental cancer exhibited significantly higher stress-response symptoms, which included avoidance and intrusive thoughts. In another study, adolescents of cancer patients also displayed significantly higher levels of perceived risk for developing cancer than adolescents who have healthy parents (Harris & Zakowski, 2003). Despite this, it is interesting to note that these two groups did not differ in depression and anxiety. Hoke (2001) found that adolescents coping with maternal cancer did better in their social and academic endeavors when their mother was more distressed. This is in comparison with adolescents in the control group who did less well when their mother was more distressed.

The results also varied depending on the type of research method that was used, specifically in terms of behavioral problems. In quantitative studies, no significant differences were found between the behaviors of adolescents dealing with parental cancer and the control group. On the other hand, the difference between the two groups became apparent in qualitative studies (Visser et al., 2003). Results show that adolescent children made an extra effort to be closer to their mother who has cancer. They demonstrated this by being more affectionate, paying more attention, giving support, and taking on the responsibilities of their ill mothers. However, there were some adolescents who dealt with maternal cancer in less constructive ways such as avoidance, withdrawal, and creating conflicts with their parents, siblings, and friends (Visser et al., 2003).

The discrepant findings between quantitative and qualitative studies may have been brought about by differences in the type of data that was gathered. In quantitative studies, questionnaires which measure the emotional and behavioral functioning of children dealing with parental cancer were administered. In the study of Visser et al. (2003), it was found that quantitative studies used instruments which were not specifically designed to measure the functioning of children whose parents have cancer. It raises a concern as to whether the questionnaires were sensitive enough to measure the specific problems that these children encountered. Huizinga et al. (2005) added that questionnaires only describe significant emotional and behavioral problems. In effect, problems reported by the respondents are limited only to items indicated in the questionnaire.

Qualitative studies, on the other hand, rely on the richness of the data. Patterns and associations are revealed when qualitative methods are used (Davey, Askew, & Godette, 2003). Qualitative data provide a different and more comprehensive view on the various domains of the children's functioning. The different problems children of cancer patients experienced in terms of their emotions, behaviors, cognition, and social functioning were uncovered. More importantly, their own perceptions, emotions, and thoughts with regard to their situation were also elaborated in detail (Visser et al., 2003). However, the depth of qualitative data is dependent on the participant's ability to articulate feelings and thoughts (Robinson, Carroll, & Watson, 2005).

Factors Which Affect Psychological Adjustment of

Adolescents of Cancer Patients

The psychological adjustment of children of cancer patients were found out to be influenced by several factors. These include: child characteristics, specifically age and gender; ill parent's characteristics, specifically gender of ill parent, and nature of parental cancer.

Child Characteristics

Age of child. Parental cancer is encountered by individuals ranging from childhood to adulthood. In order to gain a deeper understanding of how each age group is affected by this situation, it is important to consider the developmental attributes which are characteristic of each developmental stage.

Based on previous literature, adolescents are particularly vulnerable to the disruptions caused by parental cancer. This is the point in their lives wherein they are trying to assert their independence and establish relationships outside of the family. However, studies showed that adolescents whose parents have cancer felt that they were being pulled back into the family in order to help their parents deal with the demands of the illness. This resulted in a struggle between fulfilling their developmental task and taking care of the needs of their parents (Davey, Askew, et al.,2003; Harris & Zakowski, 2003).

In qualitative studies which interviewed adolescents whose mothers have cancer, the conflict between breaking away from and being pulled back into the family became apparent. Adolescents reported that they had contradictory feelings regarding their mother's cancer. Consistent with the demands of their developmental stage, they felt the urge to gain autonomy from their parents and spend more time with their peers. However, with the realization and awareness that they could lose their mother anytime, they also expressed that they wanted to spend more time with their mother (Huizinga, Van der Graaf et al., 2005). This inner conflict arose because at times, they were forced to forego pursuing their own activities. This was due to the additional roles and responsibilities at home which they were compelled to fulfill. The adolescents reported that they felt burdened by the additional responsibilities and increased restrictions that were placed upon them (Davey, Gulish, et al., 2005; Nicholas & Veach, 1998).

Several studies compared the levels of emotional distress experienced by different age groups. Results show that the anxiety and depression levels of adolescents were significantly higher compared to preadolescents and young adults (Compas, Worsham, Epping-Jordan, & Grant, 1994). In another study by Compas, Worhsam, Ey, and Howell (1996), both adolescents and young adults experienced more symptoms of depression and anxiety compared to school-aged children (Compas, Worhsam, Ey, & Howell, 1996). Houck and Rodrigue (2006) proposed that post traumatic stress can best capture the emotional distress experienced by adolescents. Their results reveal that age and post traumatic symptoms have a moderate and positive correlation. This places adolescents at higher risk for experiencing distress compared to the younger age groups.

The emotional distress experienced by adolescents can also be related to their cognitive development. Cognitively, adolescents are more aware of the meaning and implications of cancer. They have a better understanding of the gravity of cancer and the consequences that the patient and the entire family have to go through. In effect, parents are more open to sharing information regarding the nature of their cancer with their adolescent children (Compas, Worsham, Epping-Jordan, & Grant, 1994). Such awareness leads to greater distress and challenged the ability of the adolescent to handle the stress (Compas, Worsham, Epping-Jordan, & Grant, 1994; Houck, Rodrigue, & Lobato, 2006).

Gender of child. Aside from the developmental stage, the child's gender also appeared to contribute to the impact of parental cancer. Huizinga, Visser, Van der Graaf, Hoekstra, and Hoekstra-Weebers (2005) found that daughters experienced more emotional distress than sons. This was evident in their finding that 34% of the daughters, compared to only 19% of the sons reported clinically elevated levels of posttraumatic stress symptoms. In addition, the daughters also scored significantly higher in intrusion, avoidance, and total distress.

The interaction between age and gender of the child must also be taken into consideration. Studies have consistently reported that adolescent daughters of cancer patients were the most emotionally vulnerable across all age groups and gender. In addition, they also expressed their distress through behavioral problems. In the literature review done by Osborn (2007), adolescent daughters were found to be most negatively affected by parental cancer. They reported more stress response symptoms, higher anxiety and lower self-esteem than adolescent sons. The daughters appeared to cope with the stress brought about by their parents' cancer by internalizing and externalizing their problems. Adolescent daughters scored higher in both of these coping strategies than the adolescent sons. This means that the daughters manifested their distress both emotionally and behaviorally. This finding is supported by Visser et al. (2005) whose study revealed that adolescent daughters reported more emotional and behavioral problems than adolescent sons. The researchers measured the children's levels of internalizing and externalizing problems. The level of total problems, which is a combination of both ways of coping, was also assessed. The daughters' scores in both internalizing and total problems fell within clinical ranges and were significantly higher than those of the adolescent sons. Consistent with the previous findings, Visser et al. (2003) reported that adolescent daughters were also more emotionally affected than the adolescent sons. The daughters also garnered the highest scores on aggressive behavior. There was also an increase in their engagement with risky behaviors.

Gender role socialization plays a role in the difference between how males and females are affected by parental cancer. At an early age, females are already socialized to place importance to interpersonal relationships. This higher sensitivity of daughters to interpersonal concerns makes them more empathic and vulnerable to experience distress when a parent is going through cancer diagnosis and treatment (Visser et al., 2005). Daughters are also encouraged to express their emotions whereas sons are trained to control their sentiments (Visser et al., 2005). The consequence of this socialization was apparent in the qualitative study of Davey, Askew, & Godette (2003). During the interviews, the daughters readily expressed their fear and sadness regarding their parent's cancer. On the other hand, interviews among the sons showed a different story. It was noted that the male participants in their study were generally less expressive and more introspective. Thus, the distress among daughters was more evident because it was openly articulated.

The coping strategies males and females employ in stressful situations are also influenced by socialization. The study of Davey, Gulish, et al. (2005) revealed that daughters of cancer patients utilized emotion-focused coping strategies. The daughters openly talked about their problems and feelings of sadness and worry. They placed importance to seeking social support and being able to share their sentiments with others. On the contrary, sons dealt with their situation by avoidance, keeping their routines in place, and distracting themselves with different activities. Previous research points out that the use of emotion-focused coping was related to higher symptoms of anxiety and depression (Compas, Worsham, Ey, & Howell, 1996; Grabiak, Bender, & Puskar, 2007).

Ill Parent's Characteristics

Gender of ill parent. The gender of the parent who is ill also apparently plays an important role in the emotional difficulties experienced by the child. In a study which measured the distress of first degree female relatives of breast cancer patients, it was found that the daughters were significantly more distressed than the mothers, sisters or distant relatives of the patient. The daughter's distress was generally manifested through mood disturbance. Based on this research, frequent contact with the patient amplified the effect of the treatment on the patient. This in turn, increased the daughters' own sense of risk. A higher perceived risk of developing cancer was proposed to be positively related to greater emotional distress (Zapka, Fisher, Lemon, Clemow, & Fletcher, 2006).

Findings suggest that adolescent daughters of mothers diagnosed with cancer were the most vulnerable to experience emotional distress and encounter more emotional problems (Fletcher, Clemow, Peterson, Lemon, Estabrook, & Zapka, 2006; Grabiak et al., 2007; Visser et al., 2003). Veach and Nicholas (1998) supported these claims and confirmed that adolescent girls dealing with maternal cancer were the most highly distressed and were at greater risk for developing anxiety and depression than other family members. Brown et al. (2007) similarly reported that adolescent daughters in the same situation had a higher frequency of depressive symptoms. Distress and stress response syndrome were also found to be strikingly high among adolescent daughters whose mothers were ill (Compas, Worsham, Epping-Jordan, & Grant, 1994). Faulkner and Davey (2002) recounted that adolescent daughters felt torn regarding their mother's illness. On one hand, they wanted to support their mother during this ordeal. However, they also at the same time felt anger and resentment toward their mother, which were expressed through being argumentative and distancing oneself both emotionally and physically.

These negative emotions and behaviors emanated from several causes, one of which was the increase in responsibilities at home and in taking care of the family. The duties which cannot be fulfilled by the mother were expected to be carried out by the adolescent daughter in the family (Compas, Worsham, Epping-Jordan, & Grant, 1994; Grabiak et al., 2007; Visser et al., 2005). The adolescent daughter also assumed the role of caregiver for the ill parent, especially in the cases of maternal cancer. Although the care which the daughter provided was described as more intimate, this caregiving role also caused anxiety in the adolescent daughter (Visser et al., 2003). Aside from giving physical support, adolescent daughters also felt burdened by the emotional support that they had to provide for their mother. A few studies revealed that mothers with cancer confided their thoughts and emotions with their daughters. In effect, the daughters reported that they had a difficulty meeting their mother's emotional demands (Faulkner & Davey, 2002; Fletcher et al., 2006; Visser et al., 2005). Lastly, daughters whose mothers have cancer also reported having fears of being diagnosed with cancer at some point in their lives. The increase in their distress was associated with the corresponding increase in their sense of personal vulnerability of inheriting the cancer (Compas, Worsham, Epping-Jordan, & Grant, 1994; Faulkner & Davey, 2002; Fletcher et al., 2006; Kristjanson et al., 2004; Visser et al., 2005; Visser et al., 2003).

Nature of parental cancer. Several cancer-related variables such as cancer type, cancer stage, intensity of treatment, side effects, and time of diagnosis were found to have an effect on the functioning of children who have a parent with cancer.

Types of cancer which are gender specific and which pose hereditary risks to the offspring of the patient appeared to have an impact on the children's functioning. Adolescent daughters whose mothers were either suffering from breast or gynecological cancer were aware of their vulnerability of inheriting the illness. They expressed worry about their own chances of developing cancer. They also exhibited increased high risk behaviors, withdrawal, and somatic complaints (Visser et al., 2003).

Parental cancer diagnosed in the later stages, specifically stages III and IV, were consistently associated with negative effects on children's adjustment. Children whose parents are in treatment for late-stage cancer reported higher levels of depression and anxiety, as well as low self-esteem (Su & Ryan-Wenger, 2007). Compas, Worsham, Epping-Jordan, and Grant (1994) supported this claim as their study revealed that the severity of the parent's cancer is moderately related to the child's depression, anxiety, and stress-response symptoms. Another study by Compas, Worsham, Ey, and Howell (1996) showed that the more serious the parent's cancer is, the more the children resorted to avoidance. The increase in avoidant behavior, however, contributed to increased distress. A qualitative study by Davey, Gulish, et al. (2005) garnered similar findings. It was found that children responded to their mother's late-stage cancer diagnosis with intense sadness, worries, and fears. Whereas children whose mother's cancer ranged from stages 0 to II, expressed that they have no current concerns with regard to their mother's illness. In spite of the minimal difficulties reported by children whose parents have early stage parental cancer, Osborn (2007) stated that these children are still slightly at increased risk for developing emotional problems.

The nature of cancer treatment, more common of which are surgery, chemotherapy, and radiation therapy, is related to the intensity of side effects and level of impairment experienced by the patient. Several studies found that these two cancer-related variables, specifically, side effects of the cancer treatment and impairment caused by the cancer, do not directly affect the functioning of children of cancer patients. However, the effects of these variables create a strain on the parent-child relationship, which strongly influences the children's adjustment. When the parent underwent a serious surgery, had difficulty with the treatment, and suffered from more side effects, the parent-child relationship deteriorated (Visser et al., 2003; Su & Ryan-Wenger, 2007). According to Huizinga, Visser et al. (2005), parents who received nonintensive treatments appeared to be visibly well and were able to spend more time with their children. The physical and emotional availability on the part of the ill parent facilitated communication with the children, which is a necessary factor in fostering a healthy parent-child relationship. In another research, the distress of first degree female relatives, which specifically pertain to the mothers, daughters, and sisters of newly diagnosed breast cancer patients was studied. The intensity of treatment and the severity of the side effects were associated with higher distress among the relatives of the patients. This is due to their perception that the impact of cancer on the patients is detrimental, especially because their judgments are based on the negative physical effects of the treatment (Zapka et al., 2006).

Adolescents in the study of Visser et al. (2003), reported that the period of their mother's diagnosis and treatment was the most difficult for them. This was due to the uncertainty of their mother's condition and the diminished availability of their mother. As the time since last treatment grows longer, Osborn (2007) found that adolescents experienced fewer emotional and behavioral problems. To clarify the findings abovementioned studies, Su and Ryan-Wenger (2007) suggested that children were more likely to demonstrate adjustment problems in the acute diagnostic phase of the parent's illness than after an extended period.

This is consistent with the four stages of the clinical course of cancer proposed by Holland (1989, as cited in Veach & Nicholas, 1998). The first phase involves the identification of possible symptoms of cancer. Family members may or may not be informed regarding the first signs of the disease. The second phase is concerned with a confirmed cancer diagnosis. The challenge being posed to the patient is the disclosure of the diagnosis to the family. According to Veach and Nicholas (1998), the patient and family members experience heightened emotional distress during this period. This is due to the disruption of the family system and the need to adapt to the shock and uncertainty of the diagnosis. In the next phase, the patient and the family have to deal with the demands and side effects of the treatment. Stress emanates from seeing the debilitating effects of the treatment and adjusting to the new roles within the family, in order to augment the patient's inability to perform his duties. The last phase deals with survival issues. Even though anxiety diminishes when the patient is in remission, the uncertainty of future recurrence may still be a source of concern. During the clinical course of cancer, the stages which involve diagnosis and treatment were considered to be most distressing (Veach & Nicholas, 1998).

Despite the confirmation of significant findings regarding the effect of cancer-related variables on children's adjustment, several studies did not find evidence which support these findings. Based on these studies, no relationship was found between children's functioning and the nature of the cancer such as type and stage of cancer, time since diagnosis, illness severity, treatment regimen, and duration of treatment (Hoke, 2001; Visser et al., 2003; Visser et al., 2005; Brown et al., 2006; Osborn, 2007). To explain these unconfirmed associations, Visser et al. (2005) suggested that the objective characteristics of the parental cancer were not directly related to the distress experienced by the children. Instead, it is the children's perception of the severity and stressfulness of the cancer which are associated with emotional problems.

Agreement Between Parents' Perceptions of Child's Distress and

Child's Psychological Adjustment

Past literature on children of cancer patients looked into the parents' perceptions of their child's emotional functioning. According to Lewandowski (as cited in Su & Wenger, 2007), parents who were overwhelmed by the consequences brought about by cancer failed to take notice of their children's emotional responses and coping strategies. This assertion was verified by a couple of studies, which reveal that there is a low to moderate agreement between the parents' perceptions of their child's distress and the child's actual distress (Visser et al., 2005; Visser et al., 2003). The research of Osborn (2007) also stated that there was generally a low correlation between the parents' ratings and the adolescent children's self-reports of their emotional and behavioral concerns. The study reveals that adolescents reported more problems than their parents. Specifically, adolescent daughters reported significantly higher levels of internalizing problems than their parents. Regardless of the adolescent's gender, both the ill parents and their spouses reported significantly lower emotional and behavioral problems compared to their adolescent child. The study of Huizinga, Van der Graaf, et al. (2005) also found that the parents' ratings of their children's emotional and behavioral functioning differed from their children's ratings. Children reported higher externalizing problems than their parents, whereas the parents perceived their children to have higher levels of internalizing problems. This can be explained by the finding that the children expressed their externalizing behaviors in school and with their peers, not within the family. In the qualitative part of the study, the parents reported that their children had more problems than the children themselves reported. The parents shared that some of the problems they observed from their children were as follows: withdrawal, general anxiety, sleeping problems, and regressive behaviors.

It was also of interest to see whether the healthy or the ill parent was more attuned to the child's distress. Houck, Rodrigue, and Lobato (2006) measured both the chronically ill and healthy parents' perceptions and compared it with the child's actual psychological functioning. Results reveal that the ill parents' ratings of their adolescent children's anxiety and depression were significantly positively correlated with that of the adolescents' reports. On the other hand, there was a discrepancy in the ratings between the healthy parents and their adolescents. This indicates that the ill parents in the study were more aware of the distress their adolescents were going through than the healthy parents.

The study of Visser et al. (2005) which also investigated the emotional impact of parental cancer on children looked into the perspectives of the child and both parents. Their sample was comprised of latency-aged children and adolescents who have a parent diagnosed with cancer, 81% of whom were mothers, and 19% were fathers. Based on the results, mothers perceived comparable levels of emotional and behavioral functioning with their children. It was also found that there was a high agreement between mothers and their daughters. Mothers had a relatively accurate perception of their child's functioning because despite their illness, they made it a point to spend more time with their children and to openly communicate with them. On the contrary, fathers perceived their children's emotional concerns and behavioral problems to be less prevalent. They reported fewer problems than the mothers. This underreporting among the fathers was brought about by their preoccupation with their wife's illness. As a consequence, they were not able to pay enough attention to their children's concerns. Consistent with these findings, another study by Visser et al. (2007) reported similar results. This longitudinal study measured internalizing and externalizing problems among children and adolescents who have a parent with cancer. In this research, 67% of the mothers and 33% of the fathers were diagnosed with cancer. Mothers perceived their adolescent daughters' emotional concerns more accurately than the fathers.

Results in previous studies show that there is an inconsistency between the parents' perceptions of their children's distress and the children's actual distress. Although the children reported that parental cancer had a negative impact on their psychological functioning, parents generally reported that their children experienced minimal emotional and behavioral problems during this stressful time. The most common cause of this discrepancy is that both the healthy and ill parents had fewer opportunities to observe their children due to their preoccupation with the demands of the treatment (Osborn, 2007). In addition, parents also had a difficult time assessing their children's emotional state when they were distressed themselves (Huizinga, Visser et al., 2005). In a qualitative study done by Davey, Askew et al. (2003), parents shared that they were unaware of the overwhelming sadness and stress that their adolescent children were experiencing. The adolescents felt that it was their responsibility to protect their parents from additional stress, which was why they chose not to disclose their emotional concerns to their parents (Huizinga, Visser et al., 2005; Osborn, 2007; Visser et al., 2003). According to Forrest et al. (2006), parents sometimes misunderstood their children's reactions or underestimated the emotional impact of cancer in the family on their children. There were instances wherein the children were very distressed but they dealt with the situation by becoming detached or withdrawn. This type of coping possibly led parents to believe that their children were unaffected by the situation.

Changes in the Quality of Parent-Child Relationship

as an Effect of Maternal Cancer

­In the Philippine setting, daughters generally have a close emotional bond with their mothers. This intimate affinity is developed through the female offspring's natural tendency to assume the responsibilities at home after parents. There is also a need to gain approval by meeting parental expectations (Go Tian, 2003). However, this relationship may be strained when both the daughter and mother are experiencing crises and transitions in their lives. The local study of Mangona (1992) investigated the relationship between adolescent daughters and their midlife mothers. Results show that young adolescent daughters and early midlife mothers experienced more difficulty in terms of problem solving, communication, and roles. They also described their relationship to be stressful. According to Mangona (1992), the transitional stages experienced by both daughters and mothers, specifically adolescence and midlife respectively, contribute to the tension in their relationship. Both parties are in the process of adjusting to the new roles, expectations, and developmental challenges in the transitional stages of their lives. Aside from dealing with their own developmental concerns, they have to accommodate and understand each other during this demanding point in their lives. The challenge which adolescents go through is negotiating whether to individuate from the family or to maintain attachment and the parents' approval. Adolescents feel the need to break away from the family and establish one's identity. However, the Filipino culture makes individuation more difficult due to the strong attachment within the family. On the practical side, adolescents are also still dependent on their family to some extent. This creates an ambiguity in the daughters' relationship with their mothers (Mangona, 1992).

Maternal cancer, as a profound stressor within the family, affects the dynamics of the interaction between the ill mother and her adolescent child. According to Visser et al. (2003), adolescents who have a poor relationship with both parents found it more difficult to adapt with the situation. In several studies, dealing with maternal cancer brought the mothers and their adolescent children emotionally closer. The adolescents shared that it was difficult for them to see the transition of their mother's health from being healthy slowly deteriorate to being ill and weak. Due to the symptoms of cancer and the side effects of the treatment, the mothers became moody and irritable. In spite of this, the adolescent children were more tolerant and empathic toward their mother (Davey et al., 2003; Kristjanson, Chalmers, & Woodgate, 2004, Veach & Nicholas, 1998). In another study by Huizinga, Van der Graaf et al. (2005), adolescent children had contradictory feelings regarding their relationship with their mother. A part of them wanted to break away from their mother, which is a normative psychosocial challenge among adolescents. However, the awareness that they could lose their mother anytime soon made them want to spend more time with their mother.

An important aspect of parent-child relationship is the parents' emotional accessibility to their children. This refers to the children's perceptions that their needs are being met by their parents during the stressful ordeal of having a mother with cancer (Kristjanson, Chalmers, & Woodgate, 2004). Due to the demanding treatment which the mother has to undergo, the children's needs and experiences are often overlooked. Adolescents shared that they needed emotional support during this difficult time. According to a study by Kristjanson, Chalmers, and Woodgate (2004), adolescents valued verbal and nonverbal gestures such as encouraging words or hugs. They also wanted to feel genuine empathy from the people around them and they were sensitive to what they perceive to be insincerity. Adolescents also expressed the helpfulness of knowing that someone was there to talk to whenever they needed to unload their emotions. Most importantly, they felt it necessary for their family to provide a sense of normality in their lives. They considered this to be a vital need which can help facilitate their emotional adjustment considering the stressful situation they are in. Engaging in their usual or "normal" activities allows them to continue with their lives and to regain their sense of hope. However based on a few studies, adolescents reported that their support needs were poorly met within the family (Grabiak et al., 2007; Kristjanson, Chalmers, & Woodgate, 2004). Forrest and Plumb (2006) suggested that parents, who are overwhelmed by the cancer diagnosis, tend to misunderstand their children's reaction and fail to recognize their children's needs. For this reason, the needs of adolescent children are not addressed adequately, thus, making them more vulnerable to suffer from emotional distress.

There were inconsistent findings in terms of the quality of communication between the ill parent and child, specifically in terms of the adolescents' openness about their feelings. Some children were able to speak openly with their parents. Despite their own and their parents' distress, they were able to share their emotions and concerns with their ill mother (Davey, Gulish, et al., 2005; Visser, Huizinga, Van der Graaf, Hoekstra, & Hoekstra-Weebers, 2003). However, other studies found that some adolescents prefer to conceal their thoughts and emotions from their parents. They generally kept their feelings inside in order to protect their parents and not burden them with additional worries. This was also done so as not to cause tension in their relationship with their parents (Davey, Askew, et al., 2003; Grabiak et al., 2007; Visser et a