<%BANNER%>

Adolescent-Mother Discrepancy in Perceptions of Family Relations as a Predictor of Depression among Chronically Ill Adol...

Permanent Link: http://ufdc.ufl.edu/UFE0021578/00001

Material Information

Title: Adolescent-Mother Discrepancy in Perceptions of Family Relations as a Predictor of Depression among Chronically Ill Adolescents
Physical Description: 1 online resource (118 p.)
Language: english
Creator: Aristizabal, Natalia
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: adolescent, chronic, depression, discrepancy, family, illness, mother, relations
Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: This study examined the association of perceived family relations (family cohesion, family conflict) and adolescent depressive symptoms among lower-income African American adolescents with a chronic illness and their mothers (n = 64) and among lower-income White American adolescents with a chronic illness and their mothers (n = 98). Secondly, this study examined whether adolescent-mother discrepancies in perceived level of family relations were stronger predictors of adolescents' reported depressive symptoms, as compared to their individual and their mothers' perceived level of family relations. Participants in the study completed inventories assessing their perceptions of family cohesion and family conflict; adolescents also rated their own depressive affect. Pearson correlation analyses, conducted separately by racial group, revealed that perceived levels of family cohesion were negatively associated with adolescent depressive symptoms and perceived levels of family conflict were positively associated with adolescent depressive symptoms among African American adolescents, White American adolescents, and White American mothers. The present study did not find evidence that discrepancies in family members? perceptions of family relations are related to adolescent depressive symptoms among chronically ill adolescents. However, multiple regression analyses, conducted separately by racial group, revealed that adolescent perception of family cohesion was the only significant predictor of adolescent depressive symptoms for both groups. Additionally, adolescent perception of family conflict was the only significant predictor of White American adolescent depressive symptoms. These findings suggest that adolescent perception of family cohesion may be an important factor in adolescent adjustment among African American and White American adolescents living with a chronic illness and that perceptions of family conflict may be an important factor in the occurrence of adolescent depressive symptoms among White American adolescents. These findings provide support for examining family relations and adolescent depressive symptoms separately by race as suggested by the Difference Model research approach.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Natalia Aristizabal.
Thesis: Thesis (M.S.)--University of Florida, 2007.
Local: Adviser: Tucker, Carolyn M.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2008-12-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021578:00001

Permanent Link: http://ufdc.ufl.edu/UFE0021578/00001

Material Information

Title: Adolescent-Mother Discrepancy in Perceptions of Family Relations as a Predictor of Depression among Chronically Ill Adolescents
Physical Description: 1 online resource (118 p.)
Language: english
Creator: Aristizabal, Natalia
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: adolescent, chronic, depression, discrepancy, family, illness, mother, relations
Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: This study examined the association of perceived family relations (family cohesion, family conflict) and adolescent depressive symptoms among lower-income African American adolescents with a chronic illness and their mothers (n = 64) and among lower-income White American adolescents with a chronic illness and their mothers (n = 98). Secondly, this study examined whether adolescent-mother discrepancies in perceived level of family relations were stronger predictors of adolescents' reported depressive symptoms, as compared to their individual and their mothers' perceived level of family relations. Participants in the study completed inventories assessing their perceptions of family cohesion and family conflict; adolescents also rated their own depressive affect. Pearson correlation analyses, conducted separately by racial group, revealed that perceived levels of family cohesion were negatively associated with adolescent depressive symptoms and perceived levels of family conflict were positively associated with adolescent depressive symptoms among African American adolescents, White American adolescents, and White American mothers. The present study did not find evidence that discrepancies in family members? perceptions of family relations are related to adolescent depressive symptoms among chronically ill adolescents. However, multiple regression analyses, conducted separately by racial group, revealed that adolescent perception of family cohesion was the only significant predictor of adolescent depressive symptoms for both groups. Additionally, adolescent perception of family conflict was the only significant predictor of White American adolescent depressive symptoms. These findings suggest that adolescent perception of family cohesion may be an important factor in adolescent adjustment among African American and White American adolescents living with a chronic illness and that perceptions of family conflict may be an important factor in the occurrence of adolescent depressive symptoms among White American adolescents. These findings provide support for examining family relations and adolescent depressive symptoms separately by race as suggested by the Difference Model research approach.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Natalia Aristizabal.
Thesis: Thesis (M.S.)--University of Florida, 2007.
Local: Adviser: Tucker, Carolyn M.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2008-12-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021578:00001


This item has the following downloads:


Full Text

PAGE 1

1 ADOLESCENT-MOTHER DISCREPANCY IN PE RCEPTIONS OF FAMILY RELATIONS AS A PREDICTOR OF DEPRESSION AM ONG CHRONICALLY ILL ADOLESCENTS By NATALIA M. ARISTIZABAL A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORI DA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2007

PAGE 2

2 2007 Natalia M. Aristizabal

PAGE 3

3 Para mi querida Mami. Eres mi inspiracin.

PAGE 4

4 ACKNOWLEDGMENTS I would like to thank my advisor and committ ee chair, Dr. Carolyn M. Tucker, for her assistance in this process. I would also like to thank my committee members, Dr. Kenneth Rice and Dr. Julie Graber, for their support.

PAGE 5

5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 ABSTRACT....................................................................................................................... ..............8 CHAPTER 1 INTRODUCTION..................................................................................................................10 2 REVIEW OF THE LITERATURE........................................................................................14 Adolescents with a Chronic Illness.........................................................................................14 Psychosocial Impact of Chr onic Illness on Adolescents........................................................15 Psychosocial Impact of Adolescen t Chronic Illness on the Family.......................................18 Factors that Influence Adjustment of Chronically Ill Adolescents........................................20 Family Cohesion and Family Conflict and Their Influence on the Adjustment of Chronically Ill Adolescents.................................................................................................21 Depressive Symptoms and Chr onic Illness in Adolescence...................................................25 Adolescent Depressive Symptoms..................................................................................25 Chronic Illness and Depressive Symptoms.....................................................................27 The Association of Chronically Ill A dolescents Depressive Symptoms with Perceived Level of Family Cohesion and Family Conflict..........................................30 The Association of Adoles cents Depressive Symptoms with Discrepancies in Perceived Level of Family Cohesion and Family Conflict..........................................33 Purpose of the Proposed Study...............................................................................................35 3 METHODOLOGY.................................................................................................................36 Participants................................................................................................................... ..........36 Instruments.................................................................................................................... .........37 Procedure...................................................................................................................... ..........40 Recruitment of Participants.............................................................................................40 Procedure...................................................................................................................... ...42 4 RESULTS........................................................................................................................ .......45 Descriptive and Normative Data for all Major Variables.......................................................46 Correlations Between Variables of Interest and the Marlowe-Crowne Social Desirability Scale-Short Form............................................................................................................... .46 Results of Analyses to Test Hypothesis 1...............................................................................47 Results of Analyses to Test Hypothesis 2...............................................................................47 Results of Analyses to Test Hypothesis 3...............................................................................48 Results of Analyses to Test Hypothesis 4...............................................................................49

PAGE 6

6 Results of Research Question Analyses.................................................................................50 5 DISCUSSION..................................................................................................................... ....58 Results Regarding Hypotheses 1 and Hypothesis 2...............................................................58 Results Regarding Hypothes is 3 and Hypothesis 4................................................................62 Results of Analyses to Examine a Research Question...........................................................65 Limitations of the Research....................................................................................................67 Implications for Future Research............................................................................................68 Implications for the Field of Counseling Psychology............................................................69 APPENDIX A YOUTH INFORMATI ON QUESTIONNAIRE....................................................................72 B ADULT INFORMATI ON QUESTIONNAIRE.....................................................................75 C FRI............................................................................................................................ ..............77 D CES-D.......................................................................................................................... ...........79 E M-C SDS-SF..................................................................................................................... ......81 F INFORMED CONSENT ADULTS.......................................................................................83 G ADOLESCENT ASSENT FORM..........................................................................................94 H INVITATION LETTER.........................................................................................................99 I COVER LETTER (ADOLESCENT)...................................................................................101 J COVER LETTER (PRIMARY PARENT/CAREGIVER)..................................................102 LIST OF REFERENCES.............................................................................................................103 BIOGRAPHICAL SKETCH.......................................................................................................118

PAGE 7

7 LIST OF TABLES Table page 3-1 Demographic Description of African American and Wh ite American Participant...........44 4-1 Descriptive and Normative Data for the FRI, CES-D, and M-C SD-SF Inventories........52 4-2 Relationship Between Social Desirability Scores and Variables of Interest.....................53 4-3 Pearson Correlations Among Study Vari ables for Adolescents and Mothers by Ethnic Group................................................................................................................... ...54 4-4 Multiple Regression Predicting Adolescent Depressive Symptoms Scores from Adolescent Family Cohesion, Mother Fa mily Cohesion, and Cohesion Difference Scores......................................................................................................................... ........55 4-5 Stepwise Regression Predicting Adoles cent Depressive Symptoms Scores from Adolescent Family Conflict, Mother Family Conflict, and Conflict Difference Scores Using African American Participants Data......................................................................56 4-6 Multiple Regression Predicting Adolescent Depressive Symptoms Scores from Adolescent Family Conflict, Mother Family Conflict, and Conflict Difference Scores Using White American Participants Data.........................................................................56 4-7 Summary of MANOVA Models to Test Research Question.............................................57

PAGE 8

8 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science ADOLESCENT-MOTHER DISCREPANCY IN PE RCEPTIONS OF FAMILY RELATIONS AS A PREDICTOR OF DEPRESSION AM ONG CHRONICALLY ILL ADOLESCENTS By Natalia M. Aristizabal December 2007 Chair: Carolyn M. Tucker Major: Psychology This study examined the association of percei ved family relations (family cohesion, family conflict) and adolescent de pressive symptoms among lower-income African American adolescents with a chronic i llness and their mothers (n = 64) and among lower-income White American adolescents with a ch ronic illness and their mothers (n = 98). Secondly, this study examined whether adolescent-mother discrepancies in perceived level of family relations were stronger predictors of adoles cents reported depressive symp toms, as compared to their individual and their mothers perceived level of family rela tions. Participants in the study completed inventories assessing their perceptions of family cohesion and family conflict; adolescents also rated thei r own depressive affect. Pearson correlation analyses, conducted separate ly by racial group, revealed that perceived levels of family cohesion were negatively associ ated with adolescent de pressive symptoms and perceived levels of family conflict were posi tively associated with adolescent depressive symptoms among African American adolescents, White American adolescents, and White American mothers. The present study did not find evidence that discrepancies in family members perceptions of family relations are related to adolescent depressive symptoms among

PAGE 9

9 chronically ill adolescents. However, multiple regression analyses, conducted separately by racial group, revealed that adolescent percepti on of family cohesion was the only significant predictor of adolescent depressive sympto ms for both groups. Additionally, adolescent perception of family conflict wa s the only significant predictor of White American adolescent depressive symptoms. These findings suggest that adolescent percep tion of family cohesion may be an important factor in adolescent adjustment among African American and White American adolescents living with a chronic illness and that pe rceptions of family conflict may be an important factor in the occurrence of adolescent depres sive symptoms among White Am erican adolescents. These findings provide support for examining family re lations and adolescent depressive symptoms separately by race as suggested by the Difference Model research approach.

PAGE 10

10 CHAPTER 1 INTRODUCTION A chronic illness is a long-term condition that is either incurable or that requires special assistance or adaptation in function (Eiser, 1993; Hayes, 1997; Jessop & Stein, 1985). Such conditions have various degrees of severity some may be perm anent and require intensive care while others are transitory and treated without difficulty. Moreover, a di agnosis does not always suggest the severity of a chronic condition; for instance, asthma, which is considered a chronic illness, may either impair ones functioning on a daily basis or only occasionally cause disability. Epidemiological studies have reve aled that 20-30% of teenagers have a chronic illness and that 10-13% of those adolescents requir e extensive care and have subs tantial limits in their daily functioning (Yeo, & Sawyer, 2003). Although there is a diverse rang e of illnesses, adolescents with a chronic illness have great si milarities in their life experiences. Chronic illness in adolescents, such as asthma or diabetes, affects all of the members of the family system (Kazak, 1989). For example, chal lenges brought by the ch ronic illness usually increase adolescents reliance upon the immediate family, particularly the mother or mother figure. Traditionally, the mothers role in the family system is to assist their offspring to meet developmental, emotional, and social needs. In a ddition to these roles, studi es have indicated that mothers of an adolescent with a chronic illness are more likely to also coordinate and provide medical care to that adolescent. Mothers are al so typically more responsible for the daily maintenance of illness-related care than are fathers. Moreover, mothers, as compared to fathers, report significantly greater emotional strain in managing their illness-related care-giving role (Quittner, DiGirolamo, Michel, & Eigan, 1992). Add itionally, mothers of chronically ill children are more likely to feel responsib le for their childs happiness, a nd become depressed themselves (Mastroyannopoulou, & Stallard, 2001).

PAGE 11

11 An important feature of all adolescents family environment is the relationships that they have with their mothers. Adolescent-mother relationships, specifically those perceived as positive, may serve as a valuable source of suppor t for a youth with a chr onic illness whereas the absence of such support has been linked to the onset of depressive symptoms (Moos, Cronkite, & Moos, 1998). Yet, there is evidence that conf lict is more frequent among adolescent-mother relationships than among adolescent-father dyads (Hill, 1988; Montemayor, 1983; Smetana, 1988). As the result of the onset of a chronic illness, some families come together and enhance their relationships by being supportive and cohe sive. These families can be as supportive and cohesive as families with healthy adolescents. However, some families respond to the chronic condition negatively, suffering notic eable signs of despair and dys function (Hostler, 1991; Moos, 2002). Reacting negatively to a chronic hea lth condition could place stress on family relationships which, in turn affect adolescent adjustment to the chronic illness. Maternal support has a signifi cant influence on the psycholog ical adjustment of an adolescent with a chronic illnes s. Adolescents look toward their mother for comfort and support, especially when challenges arise. Without support, particularly from thei r mothers, adolescents with a chronic illness will likely have difficu lties coping with the stre ssors of managing their chronic illness (Bobrow, AvRuskin, & Sill er,1985; Perrin, Ayoub, & Willet, 1993). Moos and Moos (1994) reported that the quality of adolesce nt relationships with their mother moderated or reduced the potential nega tive affect of acute and chronic stressors. Specifically, Moos found that when adolescents w ith juvenile rheumatic disease experienced low or moderate level of acute or chronic stressors, those who reported a better relationship with their mother had more social competence and fewer behavioral problems.

PAGE 12

12 The literature concerning the effect of family relations on the adaptation of a child or an adolescent diagnosed with a chronic illness suggest s that family cohesion is positively associated with better adaptation of the child and adol escent (Davis, Tucker, & Fennel, 1996; Meijer & Oppenheimer, 1995; Moos & Moos, 1994; Reiche nberg & Broberg, 2005), whereas a high level of family conflict is associated with increas ed signs of psychological dysfunction (Anderson et. al., 2002; Hamlet, Pellegrini, & Katz, 1992; Mahoney, OSullivan, & Robinson, 1992) and increases behavioral problems (Miller-J ohnson et. al., 1994; Varn i et al., 1996) among adolescents with a chronic illness. It is likely that families characterized by high family cohesion and low family conflict function as an integrat ed unit that promotes th e mental and physical well-being of adolescents (Pender, 1996). Recent studies have indicated that the early ons et of physical illnesses such as diabetes or asthma increases the risk of psychosocial adjustme nt problems such as de pression in adolescents (Anderson, 2004; Canning, Canning, & Boyce, 1992; Klinnert, McQuiad, McCormick, Adinoff, & Bryant, 2000). However, previous research studi es have not investigated perceived level of family relations among adolescents with a chronic illness and their mother s and how the level of discrepancies in these perceptions might be rela ted to depressive sympto ms in the adolescents. Researchers have found that adolescents and pare nts often differ in their views of family relations (e.g., Henggeler, Bo rduin, & Mann, 1987; Pelton & Fo rehand, 2001; Tein, Roosa, & Michaels, 1994). Discrepancies in perceived family relations may be attributed to home environments where there are changes in family members roles, lack of communication, and trust issues. The discrepant ways in which a mother and her adol escent view their relationship may contribute to adolescent adjustment difficulties, which may, in turn, cont ribute to adolescent depressive symptoms. For example, Tein, R oosa, and Michaels (1994) proposed that such

PAGE 13

13 discrepancies may partially contribute to an adolescents externalizing and internalizing symptomatology (e.g., conduct disorder, depression). Examining the differences in perceived level of family relations between adolescents with a chronic illness and their mothers is important given that found discrepancies may obstruct the provision of support that such adol escents need to adjust psychol ogically and socially to their illness. Thus, the present study examined adolescent s and their mothers perceptions of family cohesion and family conflict and discrepancies in these perceptions as pred ictors of adolescents reported level of depressive symptoms.

PAGE 14

14 CHAPTER 2 REVIEW OF THE LITERATURE Adolescents with a Chronic Illness Living with a chronic illness involves unique an d complex challenges for adolescents. One such challenge is having to d eal with treatment regimens that can be time consuming and monotonous. For example, on average it takes an hour a day for adolescents with diabetes to manage their illness, which includes giving them selves or receiving insulin injections and monitoring or having their blood glucose level monitored (Sawye r, Reynolds, Couper, et al. 2005). For adolescents with cystic fibrosis, tr eatment regimen tasks such as physiotherapy, overnight feeding, and use of inhalers take 1.5 hours a day (Sawyer, Reynolds, Couper, et al. 2005). Many adolescents living with a chronic illness face the challenges of managing their illness with resilience and ad just well to their conditi on (Olsson, Boyce, Toumbourou, & Sawyer, 2005). However, some epidemiological st udies have reported that adolescents with a chronic illness have twice the ra te of mental health disorders as their healthy peers (Mrazek, 1994). The diagnosis of a chronic illnes s is typically a stressful life event that is undesirable and usually beyond the control of the afflicted indi vidual. Because of the cognitive development of adolescents, they may have a greater understandi ng of the impact of di sease than children, and therefore suffer from higher stre ss level than children in asso ciation with having a chronic illness. Stress among adolescents may result in th e experiencing of depressive symptoms (Cole, Nolen-Hoeksema, Girgus, Paul, 2006). Moreover, a dolescents with more severe chronic illness and those who have additional life stressors (e.g., poverty) are at risk of developing behavioral and psychosocial adjustment problems (Moos, 2000).

PAGE 15

15 The family has been recognized as an importa nt factor in the process and outcome of medical care (Hayman, Mahon, Turner, 2002). Treatme nt requirements, medical interventions such as surgery, and symptom management are some of the challenges which adolescents and their family face together. Those adolescents w ho perceive their families to be supportive and caring during an illness are be tter equipped to cope emotionally and adapt to their condition (Perrin, Ayoub, Willet, 1993) Mother-adolescent relationships have a significant influence on the emotional and physical well-being of adolescents with a ch ronic illness. For example, relationships with mothers that are perceived as supportive can serve as a buffer for adolescent illnessrelated stress. Relationships perceived as high in family cohesion and low in family conflict maximize the use of family resources and strengthen the mental and phys ical health of adol escents (Pender, 1996). In a study of 187 children (age s 7 ) and their mothers, Perrin, Ayoub, & Willet (1993) found that the social and environmental character istics of the family were important to the psychological adjustment of these children, includ ing those that were healthy and those with various chronic illnesse s, independent of age and socioec onomic status. According to report accounts by the children in the study, family e nvironment and their health status directly influenced their psychosocial adjustment. When childrens ad justment was reported by their mother, the reported adjustment level was also po sitively related to the childrens health status and family environment. Additionally, mothers pe rception of their childrens adjustment varied with disease severity. Overall, mothers of child ren with a chronic illness rated their children as less adjusted than did pa rents of healthy children. Psychosocial Impact of Chronic Illness on Adolescents Adolescence is a stressful developmental process that is further complicated by a diagnosed chronic illness. Illness related disrupti ons in daily and age-appropriate activities may

PAGE 16

16 indeed threaten normal psychosocial adjust ment including social adjustment, school performance, and autonomy from parents (Bau man, Drotar, Leventhal, Perrin & Pleass, 1997). The psychological and social complications that may accompany a chronic illness can potentially affect normal developmental processe s experienced during adolescence. Establishing of peer relationships and e xperiencing social adjustment are major developmental tasks of adolescen ce (Hartup, 1989). However, adoles cents with a chronic illness may have difficulty with these developmental ta sks due to their physical condition. For example, altered physical appearance related to their illness may make it diffi cult for adolescents to make friends and be accepted by their peers. Diminish ed physical ability and stamina may interfere with playing team sports and participating in ex tracurricular activities (S nethen, Broome, Kelber, & Warady, 2004). Being absent from social activiti es because of illness-re lated factors may limit opportunities for social interactions, making it difficult to develop friendships (La Greca, 1990). Attending school is important to an adoles cents academic development. Yet, due to illness-related factors, adolescents with a chronic illness may many days from school. This absenteeism can lead to academic difficulty, havi ng to repeat a grade, and withdrawal from school. Epidemiological studies have found differences in school problems among children with chronic illnesses in comparison to their healthy peers. For example, the U.S, National Health Interview Survey on Child Health (1988) reported that ch ildren with asthma ha d higher rates of grade failure than did healthy child ren and were twice as likely to have a learning disability as reported by their parents. Children with cancer ha ve rates of absenteeism that are four times higher than their healthy peers (Stehbens, Ki sker, & Wilson, 1983). Moreover, children with cystic fibrosis and sickle-cell disease miss 23 to 25 days from school per year (Fowler, Johnson,

PAGE 17

17 Atkinson, 1985). An adolescents inability to engage in the academic process could have deleterious effects on their pursuit of higher education and future careers. When adolescents have a chronic illness, they are inclined to be dependant on their parents and are not as inclined to seek independence from their parents. Additionally, parents are more resistant to their adolescent childrens efforts towards autonomy. Therefore, the normative task of gaining independence from their parents towa rd individuation may become more taxing for teenagers with a chronic illness and may threat en their normal developmental processes. Individuation has been defined as an individual having achie ved a level of differentiation that allows him or her to function within relati onships as autonomous a nd self-directed without being controlled, impaired, or f eeling overly responsible for signi ficant others, particularly the nuclear family (Harvey & Bray, 1991). According to transgenerational family theory, family systems that allow differentiation among family members, encourage cohesion and adaptability, and are openly receptive to the expression of i ndividual thoughts and ideas, keep harmony in the system. When a family system resists individual growth and change, the process of self-identity as well as decision-making can be compromi sed (Meeus, Iedema, Maassen, & Engels, 2005). Shulman, Seiffge-Krenke, and Samet (1987) believe that family types supportive of change foster in adolescents more adaptive, self -confident attitudes for de aling with the demands of the outside world, whereas overprotective a nd highly controlled family climates are more likely to interfere with the adolescents development of co mpetent methods for dealing with stressful situations. Shulman et al. (1987) su rveyed 186 healthy twelfth grade students to examine the relationship between coping ability and family environment, which was assessed using the Family Environment Scale (Moos & Moos, 1986). They found that family cohesion and respect for individual development were positiv ely related to functiona l coping, and that lack

PAGE 18

18 of family support and an over-controlling family climate were associated with dysfunctional coping. Psychosocial Impact of Adolescen t Chronic Illness on the Family For the parents of an adolescent, receiving the news that their adolescent has a chronic illness is a traumatic experience that ofte n involves a period of mourning, grieving, and adjustment (Blacher, 1984). Research on trauma to the care-giving system suggest that unresolved trauma can impact the care-giving system and lead to relationship problems between the parent and offspri ng (Main & Hesse, 1990). In a study of mothers resolution or nonr esolution of their ch ilds chronic illness diagnosis, Sheeran, Marvin, and Pianta (1997) found that mothers ability to accept their childs illness and adjust to the diagnosis was strongly co rrelated with secure child-mother relationships, less parenting stress, and mar ital satisfaction. Those mothers who experienced ongoing distress and/or denial regarding their childs illness reported more parenting difficulties, higher level of stress, and insecure child-mother relationships. Even though this study was of families who have young children diagnosed with a chronic disorder, th e results of this research study can likely be extended to adolescent-mother relationships. When an adolescent has a chronic illness, the management of this illness nearly always involves the parents or other prim ary caregivers. However, the moth er or mother figure is usually responsible for the daily care of an adolescent and management of his or her illness (Gallo & Knafl, 1998; Glazer, 1990; Jessop, Reissman, & Stein, 1988; Kazak, 1989). Some mothers give up employment or choose to not work in orde r to meet the medical care demands of their teenager (Mastroyannopoulou, Stallard, Lewis, Lenton, 1997; Rearson, Urban, Baker, McBride, Tuttle, & Jaward, 2000). For these mothers, trea tment and management of their adolescents chronic illness becomes a main fo cus of their role as caregiver.

PAGE 19

19 Having an adolescent with a chronic illness is emotionally demanding on the mother or mother figure who is the adolescents primar y caregiver. The feeli ngs of powerlessness, isolation, and fear that often come with having an adolescent with a chronic illness can be overwhelming to the primary caregiver of the adol escent. Often, mothers of an adolescent with a chronic illness compare themselves to their peers who are not burdened by an illness, and ask why me? However, the majority of mothers deve lop coping strategies to deal with illness related stressors and are resilie nt to the associated negative life events (Eiser, 1990). In a longitudinal study of adolescents with juvenile rheumatic disease, it was found that when mothers felt better able to manage the stress associ ated with their adolescents chronic illness, the adolescents reported experiencing less distress participated in more activities with friends, and were more socially integrated at school (Moos, 2002). This suggest s that there is a link between the psychological adjustment of the mother and that of th eir chronically ill adolescent. Research has suggested that mothers psyc hosocial functioning may impact the medical outcome of their adolescents chronic illne ss. For example, in a study by Chen, Bloomberg, Fisher, and Strunk (2003), the relationship between children with asthma (ages 4-18) and their mothers characteristics (psychos ocial adjustment) were examine d. They found that high level of family conflict and mother characteristics (e.g, being emotionally bothered by asthma, lower sense of mastery) were associated with higher le vel of adolescent hospitalization due to asthma complications. Furthermore, those mothers who fe lt less confidence in thei r ability to provide adequate asthma-related treatment to their adoles cent experienced greate r personal strain. These findings are consistent with prev ious studies that demonstrated the relationship of mother characteristics and asthma prevalence (Wade et al., 1997) as well as other childhood chronic illnesses (Zahr, Khoury, & Saoud, 1994).

PAGE 20

20 Factors that Influence Adjustment of Chronically Ill Adolescents Adolescents with a chronic illness have to cope with the dema nds of illness-related stressors, everyday stressors, and developmental tasks. Stress increases when the adolescent with a chronic illness is not able to cope with, or does not believ e that they can cope with, their life altering medical condition. To cope with stressful life events, adolescents with a chronic illness need to rely on their own resources a nd social support (e.g., suppor t from their family, friends, and health care providers) to manage the demands or their illness and their illness related stress (Folkman & Lazarus, 1988). Adjustment of an adolescent with a chronic illn ess is influenced by characteristics of the adolescent, the illness, and the family. Parents or parental figures are an important source of support for coping and adjusting to a chronic physi cal illness. In a study of adolescents with juvenile rheumatic disease, Timko, Stovel, M oos, & Miller (1992) found that the quality of relationship with their mother moderated or redu ced the potential negative affect of acute and chronic stressors. Their results indicated that those adolescents who reported experiencing close and supportive relationships with their mothers were more socially competent and had fewer behavioral problems while experiencing low or a moderate level of acute or chronic stressors. A stress adaptation model, proposed by Pollack (1993), posits a fram ework of adolescent adjustment to chronic illness. In this framew ork, adaptation is an active process in which the chronically ill adolescent adjust s to her/his environment. The stress adaptation model proposes that an individuals level of adju stment to physical illness is as sociated with the psychological response to the condition (e.g., depressive sympto ms), individual differences that may influence the response and adaptation (e.g., fa mily relations, coping responses), and characteristics such as age and gender. Difficulty in adjusting to a ch ronic illness could stem from psychological and individual characteristics as well as from compli cations of medical factors such as chronic pain.

PAGE 21

21 The degree to which chronic illness affects an adolescents psychological adjustment is debated within the literature. Inconsistent fi ndings may be due to methodological differences among research studies. Wallander and Thompson ( 1995) propose that there is no direct relation between psychosocial adjustment and chronic i llness among adolescents. Rather, adolescents have a wide range of psychosocial responses to the stress associated with a chronic illness. Some studies indicate that major illness related ps ychological disturbance is not common among these youth (Capelli et al., 1989; Kellerman, Zeltzer Ellenberg, Dash, & Zigler, 1980; Key, Brown, Marsh, Spratt, Recknor, 2001). However, clinical a nd epidemiological studies generally indicate that adolescents with a chronic illness are at increased risk for psychosocial problems (e.g., depression, anxiety) (Bennett, 1994; MacLean, Perrin, Gortmaker, & Pierre, 1992; Seigel, Golden, Gough, Lashley, & Sacker, 1990). Family Cohesion and Family Conflict a nd Their Influence on the Adjustment of Chronically Ill Adolescents Family relationship dimensions, such as fam ily conflict and family cohesion, are part of the nuclear family climate that sets the stage fo r adolescent development and affects adolescents reactions to life transitions and cr ises (Moos, 2002). Family conflict refers to level of verbal and aggressive behaviors and attit udes between and among adolescents and their parents. Family cohesion is characterized by the level of closen ess, support, and caring relations between and among adolescents and their parents. Family relati ons has the potential to reduce the effects of stressors of chronic illness or to contribute to the stressors and di sruption caused by such illness. It is widely accepted that during adolescen ce, adolescent-mother conflict increases (Richardson, Galmbos, Schulenberg, & Peterson, 1984). Additionally, family conflicts arise due to issues such as disagreement on family ma nagement, differences in values between the adolescent and her/his parents, and the adolescents pursuit of autonomy. Negative emotions

PAGE 22

22 accompanying adolescent-mother conflict can direc tly influence an adolescents management of a chronic illness. For instance, as the leve l of adolescent-mother conflict increases, the adolescents energy may be diverged from self -care due to increases in arousal and negative emotions. Such negative emotions can also w eaken the adolescent-mother relationship and the mothers motivation to engage in stressful and time consumi ng medical treatment regimens (Orem, 2001). Furthermore, family conflict in general can have a ne gative effect on the management of a chronic illness (e.g., diabetes, asthma, sickle cell disease); if treatment is compromised, negative medical consequen ces may occur for the adolescent. There have been few studies that examined th e impact of family cohesion, family conflict, the adolescent-mother relationship, and the adjustment of adolescents with a chronic illness. The few studies investigating family relations have focused on the adjustment of children with a chronic illness and on medical tr eatment compliance. However, a review of current empirical studies reveal that family rela tions play a significant role in the psychological adjustment and physical wellbeing of children and adolescents with a chronic illness, regardless of age and disease type. In a cross-sectional st udy of children and adolescents w ith diabetes and their parents, Anderson et al. (2002) found that diabetes-related conflict sign ificantly predicted glycemic control. Families characterized as high in family cohesion and low in family conflict tend to have adolescents who exhibited good glycemic control and psychological adjustment. It was also found that tension caused by family conflict ca n make it more difficult for adolescents to perform diabetes self-care and obt ain adequate treatment for thei r diabetes (Miller-Johson et al., 1994). Miller-Johnson et al. suggest that positiv e family interaction and involvement around diabetes-related tasks is impor tant for diabetes management among children and adolescents.

PAGE 23

23 Research studies have emphasized that family relationships are more important than family rules and structure when it comes to the metabolic status of adolescents with diabetes (Moos, 2002). For example, high level of family support a nd family cohesion are a ssociated with better adjustment among children with diabetes. Diabetic adolescents who perceive their families as supportive and cohesive are more likely to follow their prescribed diet and adhere to their treatment regimen. Those who perceive their fami ly as having a high level of conflict are more likely to have poor metabolic control and to not follow glucose testing procedures (Moos, 2002). Several studies have reported that family c ohesion and family conflict are associated with adjustment among children with cancer. For example, in a study which investigated the influence of family relations on the psychological adjustme nt of pediatric cancer patients, Varni, Katz, Colegrove, and Dolgin (1996) found that family cohesion was a predictor of lower psychological distress among the children. Moreover, family conflict was a predicto r of child behavior problems among their sample of pediatric cancer patients. Likewise, Rait, Ostroff, and Smith (1992) found that a high level of perceived family cohesion was associated with the psychological adjustment of adolescent cancer survivors after cancer treatment. Studies have indicated that sp ecific aspects of family relations are associated with the experience of pain among pediatric patients. Among adolescents who underwent orthopedic surgery, those who reported a high level of fam ily conflict reported more physical pain after surgery (Gil, Ginsberg, Muir, Sullivan, & Williams, 1992). Similarly, among children with arthritis, those who reported a high level of family cohesion reported less pain (Thompson, Varni, & Hanson, 1987). These findings are compar able to findings on adult pain management and family relations (Moos, 2002).

PAGE 24

24 Asthma is one of the most widely inves tigated chronic illness among children, however, there are few published studies that have investigated the impact of family relations on the adjustment of adolescents with as thma. In general, research studi es suggest that positive family interactions are favorable to the adjustment of children with asthma. Moreover, high level of family conflict and reduced family cohesion have been related to poorer psychological adjustment among children with asthma (Hamlett, Pellegrini, & Katz, 1992). In a cross-sectional study of children with asthma and their parents, Reichenberg and Broberg (2005) found that family cohesion has a direct linear relationship to positive family outcomes. In other words, high level of repor ted cohesion are relate d to optimal family functioning. Moreover, childrens psychological ad justment (e.g., few emotional and behavioral problems) was positively associated with family cohesion and negatively associated with family conflict. In a study of families with children who have uncontrolled or controlled asthma, Meijer and Oppenheimer (1995) found that families characterized as high in cohesion tended to have children with controlled asthma and psychological adjustment. The authors suggest that the way mothers or mother figures and children deal wi th disease-related medical treatment as well as factors that influence compliance to medical tr eatment by children are associated with family cohesion and can predict child adjustment to asthma. Gender is an important factor th at influences family relations and adolescent adjustment of chronic illness. In a study of child and family adjustment to chronic childhood illness, differences based on child gender were evident (Holden, Chmielewski, Nelson, Kager, & Foltz, 1997). Mothers of girls who have a chronic illness repor ted experiencing higher level of family cohesion than mothers of boys who have a chroni c illness. In a qualita tive study of mother-

PAGE 25

25 daughter interactions and adolescent diabetes care, Bobrow, Avuskin, and Siller (1985) reported that when conflict between the dyad was more emotionally charge d, coupled with less capacity between members to negotiate matters, the daughter reported less self-care management skills and less adherence to medical treatment regimen. Likewise, Jacobson et al (1994) reported that adolescent boys were more sensit ive to conflict in the family in comparison to adolescent girls. These researchers also reported that longitudina lly, measures of family cohesion and family conflict were related to glycemic control with b oys being especially sensitive to conflict level. Those boys who reported experienci ng high level of conflict were f ound to have deterioration in glycemic control four years later. In conclusion, empirical studies have revealed that perceived quality of family relations, including family cohesion and family conflict, ar e associated with adolescent adjustment to a chronic illness, regardless of di sease type. Most of these studies have focused on adjustment with regard to disease management and compliance to medical treatment (e.g., glycemic control, asthma hospitalization) rather than on psycholog ical adjustment. Furthe rmore, existing studies are limited to certain illnesses that are more common among adolescents (e.g, asthma, diabetes) and are exclusive to illnesses that are not as prevalent. Depressive Symptoms and Chronic Illness in Adolescence Adolescent Depressive Symptoms A combination of biological, genetic, and ps ychosocial factors are involved in the development of depressive symptoms among ad olescents (U.S. Department of Health and Human Services, 1999). Currently, several epidemio logical and clinical st udies have evidenced an early onset of depressive symptoms in adolescence (e.g., Harrington, 1992; Cicchetti & Toth, 1998; Chrisman, Egger, Compton, Curry, & Go ldston, 2006). Such studies have found that depressive symptom patterns in adolescence are si milar to those of adults including anhedonia,

PAGE 26

26 low self-esteem, sadness, social withdrawal, we ight changes, vegetative signs, and suicidal behavior (Wight, Sepulveda, & Aneshensel, 2003 ). Additionally, adolescents have unique symptoms which include the following symptoms : irritability, somatic complaints, familial aggression, and school withdrawal (Crowe, Ward, Dunnachie, & Roberts, 2006; Chrisman et al., 2006). However, disturbed mood is the core-d efining characteristic of depression among adolescents (Chrisman et. al., 2006 ). The symptoms of depression that begin in childhood often increase in early adolescence (Rutter, 1986) and may persist or reoccur in adulthood, often with increased symptom severity (Weissman et al. 1999). It is common to find discor dant reports of depressive symptoms from parents and adolescents (Chrisman et al., 2006). Research has found that parents are even less likely to identify depressive symptoms in their adolescen ts than are the adolescen ts themselves (Fleming, & Offord, 1990). Parents often mistake depressi ve symptoms as rebellion or acting out behavior. Further complicating this problem is th at the psychological condition of the parent can affect the perception of adolescent depressive symptoms. For example, depressed mothers have been found to over report the depressive sympto ms of their adolescent (Renouf & Kovacs, 1994). Such varying reports on adolescent adjustment ar e influenced by interpre tations of adolescent behavior and are dependent on the parent as an observer as well as the relationship between the parent and the adolescent. In comparison to normal or nondepressed teenager s, clinically depre ssed adolescents report family relations as less cohesive and express less secure attachment st yle with their parents (Armsden, McCauley, Greenberg, Burke, & Mitche ll, 1990). Insecure a ttachment organization have been found to contribute to adolescent depressive symptoms (e.g., low self-esteem, helplessness, hopelessness, negative attributional biases) and to interpersonal difficulties during

PAGE 27

27 adulthood (Kobak, Sudler, & Gamble, 1991). More over, studies have found that quality of family relations contributes to adolescents intern al representation of self and affect regulation (Cicchetti & Toth, 1998). Thus, it is notable that depressive sy mptomatology has been found to be related to family relations. Chronic Illness and Depressive Symptoms Considerable disagreement exists as to whethe r chronic medical proble ms increase the risk of depressive symptoms among adolescents. Pub lished studies have reported conflictive and inconclusive evidence of higher depression ra tes among this clinical population with some studies citing more emotional problems among chronically ill adolescents (Anderson, 2004; Canning, Canning, & Boyce, 1992; Klinnert, McQuiad, McCormick, Adinoff, & Bryant, 2000) and others reporting no difference in these rates between healthy adolescents and those with a chronic illness (Capelli et al ., 1989; Kellerman, Zeltzer, Ellenbe rg, Dash, & Rigler, 1980; Key, Brown, March, Spratt & Recknor, 2001). For example, Canning, Canning, and Boyce (1992) found more depressive symptoms among adolescents with a chronic illness, while Capelli et al. (1989) and Kellerman, Zeltzer, Ellenberg, Dash, a nd Rigler (1980) reporte d finding no difference in the amount of reported depressive symptoms between healthy adolescents and those with a chronic illness. Researchers have found links between asthma and internalizing behavior among children and adolescents (Klinnert, McQuiad, McCormick, Adinoff, & Bryant, 2 000; Wambolt, Fritz, Mansell, McQuaid, & Klein, 1998). Moreover, Seigel, Golden, Gough, Lahley, and Sacker (1990) reported finding that adolescents with asth ma have more depressive symptoms than their healthy peers. Similar research studies have found evidence that children and adolescents who have asthma experience psychosocial problems that place them at risk fo r depressive symptoms (McNelis, et al., 2000; Shasha, Lavigne, Lyons, Pongracic, & Martini, 1999). Other studies,

PAGE 28

28 however, reported that depressive symptoms of adolescents with asthma were within the normal range (Bender, Lerner, & Poland, 1991; Koinis Murdock, & Berz, 2004; Roder, Kroonenberg, & Boekarerts, 2003; Sandler, Reynolds, Kliewer, & Ramirez, 1992). Several studies have found high levels of depressive symptoms among adolescents with cancer as reported by their pa rents (Armstron, Wirt, Nesbit, & Martinson, 1982; Sanger, Copeland, & Davidson, 1991). However, some st udies have found no differences between adolescents with or without cance r in their level of depressive symptoms (Greenberg, Kazak, & Meadows, 1989; Kaplan, Busner, Weinhold, & Lenon, 1987; Radcliffe, Bennett, Kazak, Foley, Phillips, 1996). Several studies of the prevalence rates of major depressive disorder among adolescents with cystic fibrosis using diagnostic inte rviews have found prev alence rates among these adolescents for this disorder to be within the normal range (2 4%) (Burke et al, 1989; Thompson, Hodges, & Hamlett, 1990), while others have reported a higher prevalence ra te (9%) of a major depressive disorder among adolescent s with cystic fibrosis than among children without a chronic illness (Thompson, Gustafson, Hamlett, & Spock, 1992). In addition, Simmons et al. (1985) reported more depre ssive symptoms among girls with cy stic fibrosis compared to a normalized sample. Although most studies of adolescents with diabetes mellitus have reported rates of depressive symptoms similar to those of healt hy adolescents, several exceptions exist. For example, Hood (2006) found that adolescents with diabetes reported more depressive symptoms than their healthy peers with depressive sympto ms. Moreover, their sample of adolescents with type 1 diabetes nearly doubled the highest estim ated depression rate in community adolescents.

PAGE 29

29 Seigal et al (1990) found that th e rates of depressive symptoms among adolescents with diabetes were similar to those with asthma and sickle cel l disease and higher than a healthy control group. In a study of adolescents with Crohns diseas e and ulcerativ e colitis, the investigators found that those with a chronic condition were mo re depressed than their healthy peers (Raymer, Weininger, & Hamilton, 1984). Burke et al. (1989) found that adolescents with Crohns disease have a higher prevalence rate of depressive symptoms than a normal control group. Additionally, Engstrom (1992) found that adolescents with in flammatory bowel dise ase had higher reported level of depressive symptoms than healthy cont rols, with 25% of the adolescents meeting the criteria for a major depressive disorder. Several studies have reported that adolescents with recurrent abdominal pain are at higher risk for depressive symptoms than their healt hy peers. For example, Garber, Zeman, and Walker (1990) reported a prevalence rate of major depr ession to be 38% among children and adolescents with recurrent abdominal pain. Similarly, Walker et al. (1993) also repo rted more depressive symptoms among adolescents with recurrent abdo minal symptoms than their healthy peers. There are similar findings for studies on adolescent s with sickle cell anemia. For example, in a study of 327 children and adolescents with sick le cell disease, Barbarin, Whitten, and Bonds (1994) found that 25 percent of th eir sample had significantly high level of depressive symptoms and higher level of depressive symptoms than healthy controls. Key, Brown, Marsh, Spratt, and Recknor ( 2001) compared adolescents with various chronic illnesses to healthy co mparison controls on reports of depressive symptoms. They hypothesized that the prevalence of depressive symptoms among the ch ronically ill group would be higher than those in the h ealthy adolescent group. They found few differences between these groups. However, their findings indi cate that adolescents with asth ma and sickle cell disease had

PAGE 30

30 higher level of depressive symptoms relative to other groups with a chroni c illness. Adolescents who perceived their illness as se vere reported more depressive symptoms than those who rated their illness as mild. The authors suggest that distorted or inaccurate perceptions of disease severity are likely to result in the learned he lplessness phenomenon and hi gh level of depressive symptoms. Likewise, Frank, Blount, and Brown (1997) found that depr essive attitudes, such as helplessness and distortions, predicted de pression in children with cancer. The inconclusive and conflictive evidence regarding the association of chronic illness with depression among adolescents may be due to varia tions in research met hodology and a lack of an empirically based taxonomic classification sy stem in which research findings could be integrated. However, general conclusions regardi ng the emotional adjustment of adolescents with a chronic illness indicate that these adolescent s are at risk of having depressive symptoms (Thompson & Gustafson, 1996). The Association of Chronically Ill Adolescents Depressive Symptoms with Perceived Level of Family Cohesion and Family Conflict It is notable that the relati onship between depressive symptomatology and family relations has been extensively examined among physically healthy adolescents; however, there has been very limited attention to examining this relati onship among adolescents w ith a chronic illness. Much of the prior research on th e psychosocial adjustment of adol escents with a chronic illness has focused solely on the individu al, without considering the family 's role in patient adjustment. Furthermore, most studies of adolescent adjustme nt that include a focus on family relations have investigated adherence to trea tment regimen, disease management, and family functioning at the time of diagnosis. Only a small number of studi es have focused on family relations and the psychosocial adjustment of chronically ill adolescents.

PAGE 31

31 In a study of adolescents with juvenile rheu matic disease, important associations between life stressors, family relations, and adaptation were identified. Timko, Stovel, Moos, and Miller (1992) found that those adolesce nts who experienced more nega tive life events reported more depression. After negative life events were controlled, chronic stre ssors among parents (e.g., conflict) were associated with depressive symp toms among the adolescents. Overall, chronic and acute stressors and lack of support from parent s were associated with depressive symptoms among adolescents with juvenile rheumatic diseas e. In a similar study th at included adolescents with juvenile rheumatic disease and healthy adolescents, support from family members was associated with more self-confidence and le ss depressive symptoms (Moos & Moos, 1994). Likewise, among studies of children with asthma researchers have found a positive relationship between family cohesion and child psychologica l adjustment (Reiche nberg & Broberg, 2005; Donnelly, 1994). In a study on families with children who ha ve epilepsy, the children with epilepsy who reported high level of depressive symptoms sc ored lower on family support and cohesion than did children with epilepsy who had low or no depressive sympto ms. (Rodenburg, Meijer, Dekovic, & Aldenkamp, 2005). Similarly, Dunn, Au stin, and Huster (1999) reported that children with epilepsy who experienced high le vel of family conflict had high level of depression. Depressive symptomatology has al so been found to be related to adolescents and mothers reports of confictual family relations in phys ically healthy adolescen ts (Fendrich, Warner, & Weissman, 1990; Stark, Hum phrey, Crook, & Lewis, 1990, Cole & McPherson, 1993; Forehand et al., 1988; Hops, 1990). Conflict ma y be a source of stress in the relationship and could result in a stressful family environment. Studies have indicated that perceptions of high level of

PAGE 32

32 adolescent-mother conflict among adolescents are correlated with high level of adolescent depressive symptoms (Marmorstein, & Iacono, 2004). Moreover, adolescents who report high level of depressive symptoms also report less wa rmth, closeness, support, and intimacy in their relations with their mothers (Gre enberger, Chen, Tally, & Dong, 2000). In a study using a community sample of healt hy adolescents and their mothers, Sheeber, Hops, Alpert, Davis, Davis, and Andrews (1997) reported that the qua lity of family relationships is associated to depressive symptomatology among adolescents. Specifically, low level of family cohesion and high level of fam ily conflict were associated with greater depressive symptomatology at baseline and pr ospectively over a 1-year peri od. These results are similar to clinical studies which have show n that parent-adolescent inter actions predict the course of adolescent depressive disord ers (Asarnow, Tompson, & Woo, 2001; Sanford et al., 1995). Similarly, Sheeber, Hops, Alpert, Davis, and Andrews (1997) demonstrated that adolescent perceptions of negative family re lations (high level of conflict and low level of cohesion) were a stable characteristic of those adolescents w ith depressive symptomatology. Consequently, a conflictive, stressful family environment could be associated with depressive symptoms among chronically ill adolescents (Ge, Lo renz, Conger, Elder, & Simons, 1994). It has also become evident that the associa tions between family relations and depressive symptomatology may vary according to the gender of the adolescent (Kavanagh & Hops, 1994). Several studies have indicated th at a lack of cohesive and s upportive family relations has a stronger association with depressive symp tomatology among girls than boys (Avison & McAlpine, 1992; Rubin et al., 1992; Slavin & Rainer 1990; Windle, 1992). Similarly, Windle (1992) found that low level of family cohesion was a predictor of depressive symptomatology among adolescent girls. A reason for this may be because girls gain individuation more slowly

PAGE 33

33 than boys (Huston & Alvarez, 1990). Girls often ha ve more conflictive re lationships with their mothers and are monitored more closely on thei r activities than boys (H uston & Alvarez, 1990). Furthermore, girls are more oriented toward in terpersonal relationships and place greater value on interpersonal concerns than boys, making girls more susceptible to experiencing depressive symptoms when they are in conflictive and unful filling family relations (Jones & Costin, 1995; Wong & Csikszentmihalyi, 1991, Hops, 1995; Leadbeater, Blatt, & Quinlan, 1995). Cultural and ethnic differences among fam ily relations and adolescent depressive symptoms have not been thoroughly investigat ed. In a study by Cuffe, McKeown, Addy, and Garrison (2005), undesirable life events and low family cohesion were associated with adolescent depression among Afri can American and White Ameri can participants. The authors reported that African-American adolescent females we re at significantly lowe r risk of depressive symptoms than African-American adolescent males, whereas white adolescent females showed a higher risk than white males, bu t not at a significant level. The Association of Adolescents Depressive Symptoms with Discrepancies in Perceived Level of Family Cohesion and Family Conflict Disagreement between mother and adolescent pe rceptions of the quality of their family relations is not uncommon (Henggeler, Bor duin, & Mann, 1987; Pelt on and Forehand, 2001; Noller & Callan, 1986). Reported differences on view s of the family environment often reflect unique perspectives, different experiences, and biases among different family members (Achenback, McConaughy, & Howell, 1987; Offord, Boyle, & Racine, 1989). Therefore, each family member may perceive fam ily interactions differently. To date, research has shown that there is considerable disagreement between mothers and adolescents perceptions of family relati ons (Henggeler, Bourduin, & Mann, 1987; Pelton & Forehand, 2001; Noller & Callan, 1986). However, few published studies have examined the

PAGE 34

34 association of depressive symptoms with disc repant views of family relations among healthy adolescents, and there are no such published st udies examine these associations that involve chronically ill adolescents. Paikoff, Calton-Ford, and Brooks-Gunns ( 1993) studied divergent perceptions (or discrepant perceptions) within the mother-daughter relationship and the association of such divergence with the daughters emotional and behavioral ad justment. Specifically, they investigated how much of a di screpancy exists between groups of mother versus groups of daughters on their perceived family relations and whether the leve l of discrepancy was associated with depressive symptomatology a nd dieting behavior among the daughters. These researchers found that high level of discrepanc ies between mothers and daughters on perceived family conflict and family cohesion was related to depressive symptoms and dieting behavior of the daughters. Moreover, the au thors reported a significant asso ciation between the level of discrepancy between mothers and daughters reports of family conf lict and adolescent depressive symptoms, with higher level of depressive symp toms related to higher level of discrepancy between mother-daughter perceptions of family conflict. Given the research findings indicating that di screpancies in percepti on between adolescents and their mothers may be negatively related to adolescent adjustment, it is important to study how such discrepancies may be linked to depressive symptoms among chronically ill adolescents. Yet, studies to investigate such links have not been published. This study will address this gap in the a dolescent health research.

PAGE 35

35 Purpose of the Proposed Study The present exploratory study examined chroni cally ill adolescents and their mothers perceptions of family cohesion and family conf lict and discrepancies in these perceptions as predictors of the adolescents reported level of depressive symptoms. The four hypotheses and one research question that were investigat ed are presented in the following section. Hypothesis #1: Family cohesion, as perceived by the chronically ill adolescents and their mothers, would have a significant nega tive association with the level of depressive symptoms reported by the a dolescents such that higher perceived family cohesion level would be associ ated with lower reported level of depressive symptoms by the adolescents. Hypothesis #2: Family conflict, as perceived by chronically ill adolescents and their mothers, would have a significant positive association with the level of depressive symptoms reported by the adolescents such that higher percei ved family conflict level would be associated with higher reported level of depressive symptoms. Hypothesis #3: Discrepancies in perceived level of family c ohesion between chronically ill adolescents and their mothers would be a stronger predictor of the level of depressive symptoms reported by the adolescents, as compared to their individual and their mothers perc eived level of family cohesion. Hypothesis #4: Discrepancies in perceived level of family c onflict between ch ronically ill adolescents and their mothers would be a stronger predictor of the level of depressive symptoms reported by the adolescents, as compared to their individual and their mothers perc eived level of family conflict. Research question: Will there be significant differe nces in adolescents perceived level of family cohesion and family conflict, or re ported level of depres sive symptoms in association with their gender and age?

PAGE 36

36 CHAPTER 3 METHODOLOGY Participants This study is a secondary study from a larger study of hea lth promoting behaviors and health risk behaviors among African American a nd White American adolescents diagnosed with a chronic illness (i.e., asthma, diabetes, hyperten sion) who receive health care through Childrens Medical Services (CMS) in Gainesville, Florida. CMS is a healthcare agency that primarily provides and coordinates health care services for children an d adolescents in low-income families. The present study approaches th e investigation of adjustme nt among adolescents with a chronic illness by including differe nt types of chronic i llnesses rather than researching a specific illness. Lavigne and Faier-Routman (1990) presen ted a framework for organizing approaches towards researching adjustment of children and adolescents living with a chronic illness. This framework emphasized the importance of inves tigating generic factors that extend across different types of chronic illness that may influen ce adjustment difficulties as well as factors that are specific to individual illnesses. The au thors recommend that both types of research approaches are important and should serve as guides for subsequent research. A total of 145 eligible CMS patients agreed to participate in this study. From those 145 adolescent-mother pair participan ts, 87 pairs (64% return rate) returned their assessments to the principal investigator. Of thos e who did not return their assessments, 10 indicated that they changed their mind about participating in this study and the remaining 38 either could not be contacted or did not return our follow-up calls. It is not known whether those who participated are a representative sample of all eligible CMS patients because the CMS data management

PAGE 37

37 system was not capable of identifying demogr aphic distributions (e.g., ethnicity, race, gender) regarding their pa tient population. The participants for the present study are the sa me as those who participated in the larger study. These participants consisted of 32 African American adolescents (23 females and 9 males) and their mothers (32 females) and 49 White Am erican adolescents (28 females and 21 males) and their mothers (49 females). The adolescent participants ranged in age from 12 to 17 years old, with a mean age of 13.3 for th e African American adolescents ( SD = 1.5) and 13.8 for the White American adolescents ( SD = 1.3). The adult participants ranged in age from 30 to 67 years old, with a mean age of 44.1 for the African Am erican mothers and 41.1 for the White American mothers. The demographic characteristics of the pa rticipants in this study are presented in more detail in Table 1-3. The criteria for inclusion in this study were as follows: (a) is between the ages of 12 and 17 years old; (b) has attended CMS at least once in the year prior to the start of planned research; (c) identifies as African American not of Hispan ic origin or White American not of Hispanic origin (d) has had a diagnosis of a chronic medical illness (i.e., asthma, diabetes, hypertension) for at least one year prior to the planned rese arch, (e) reports as being able to communicate effectively verbally or in writing in her or his native language, (f) gives written assent or consent to be a research participant. The criteria for exclusion from this study were as follows: (a) children younger than 12 and adolescents older than 18, (b) identifies her or his race or ethnicity as being other than African American and White American, (c) is part of an adolescent-male primary caregiver pair. Instruments All participants (adolescents and their moth ers) were asked to complete an assessment battery that consisted of severa l research instruments. The adol escents were asked to complete

PAGE 38

38 the Family Relations Index, the Center for Epidemiologic Studies-Depression Scale, the Marlowe-Crowne Social Desi rability Scale-Short Form, and the Youth Information Questionnaire. Their mothers were asked to comp lete the Family Relatio ns Index, the MarloweCrowne Social Desirability Scale-Short Form, and the Adult Information Questionnaire. These instruments are described in the following section. The Family Relations Index (FRI; Moos & Moos, 1994). The conceptualization of family relations used in the present study is based on Moos and Mooss (1986 ) empirical approach which measures family characteristics, specifica lly those that are important in the psychological adaptation of family members. Moos and Mooss model describes the family environment in terms of three dimensions: a) relationship di mension, which measures the overall quality of family support, b) personal growth dimension, wh ich describes the familys goal orientation and activity, and c) system maintenance dimensi on, which describes the familys control and structure. The Family Relations Index (Moos & Moos, 1986) assesses the quality of a familys social relationships by measuring family cohesion, family expressiveness, and family conflict. The FRI consists of three subscales, Cohesion, Expre ssiveness, and Conflict, with each subscale comprised of nine true or false items. The c ohesion subscale measures the general degree to which family members display receptivity and em otional support of one anot her. It is the degree of commitment, help, and support family members provide for one another. An item example is Family members really back each other up. The conflict subscale measures the level of openly expressed anger, aggression, a nd conflict among family member s. Therefore, the conflict subscale is the negative direction variable on which healthier families score lower. An item example is We fight a lot in our family. The Expressiveness subscale measures the level to

PAGE 39

39 which family members are encouraged to expres s their feelings and act openly towards each other. An item example is We tell each other about our personal proble ms. For the purpose of this study, only Family Cohesion data and Family Conflict data were considered for statistical purposes. For the Cohesion subscale, high scores i ndicate very connected, supportive family relationships. For the Conflict subs cale, low scores indicate low le vel of conflict and high scores indicating high level of conflict among family members. The FRI subscales have moderate to high internal consistencies, with Cronbachs alphas ranging from .61 to .78. Two-month test retest reliabilities for two of the subscales are .86 for cohesion, and .85 for c onflict. The authors of the instrument report the FRI as has having high internal consistency (Cronbachs alpha = 0.89). Additionally, the FRI was found to significantly co rrelate with other social support inventories and outcome measures. The Center for Epidemiologic Studies-Depression Scale ( CES-D; Radloff, 1977). The CES-D scale is a short report scale designed to m easure 20 depressive symptoms in the general population. Each item is rated on a Likert-type scale with the follo wing four response categories: Rarely or None of the time, S ome or a little of the time, O ccasionally or a moderate amount of the time, and Most or all of the time. An item example is I felt depressed. Scores range from 0 to 60, with higher scores indi cating higher level of depressive symptoms. The CES-D has high internal consistency with Cronbachs al phas ranging from .85 to .90. Correlations of the CES-D with other report depressi on scales give reasonable evid ence of discriminant validity (i.e., Bradburn Balance Scale .62; Bradburn Negati ve Affect Scale .63; L ubin Affect Scale .70). The Marlowe-Crowne Social Desirability Scale-Short Form (M-C SDS-SF: Crowne & Marlowe, 1960). The M-C SD-SF scale is used to measure the degr ee to which those who

PAGE 40

40 completed it tend to present themselves in a soci ally desirable manner. It is based on a 33-item instrument originally developed by Crowne a nd Marlowe (1960). The M-C SD-SF scale consist of 20 questions to be responded to using a true or false format. An item example is I like to gossip at time. Scores on the M-C SD-SF range from 0 to 20, with high scores indicating high need for approval. Research studies have repor ted high Pearson correlations of .98 between the original version and the short version of the M-C SD-SF indicating adequate construct validity for the short version (Fraboni & Copper, 1989; Strahan & Gerbasi, 1972) The authors of the measure report M-C SD-SF test-r etest reliabilities range from .80 to .84. The Youth Informat ion Questionnaire (YIQ; developed by the re searchers who conducted the larger study). The Youth Information Questionnair es was designed to elicit personal information about the adolescent partic ipants that may be relevant to th e analysis and results of the study. The YIQ has questions that ask for: (a) dem ographic data (e.g., age, ethnicity, level of education), (b) reported chronic health conditions (e.g., diabetes, obesity, and/or hypertension), and (c) leisure activities. Adult Information Questionnaires (AIQ; developed by the re searchers who conducted the larger study). The Adult Information Questionnair es was designed to elicit personal information about the adult research participan ts that may be relevant to the analysis and results of the study. The AIQ has questions that ask for: (a) demogra phic data (e.g., age, ethnicity, work information, level of education), (b) information about family size, and (c) information about their adolescent. Procedure Recruitment of Participants Permission to conduct research using adolesce nts and their primary parent/caregiver who utilize the health care services of Childrens Medical Services (CMS) was obtained from CMS.

PAGE 41

41 Approval of the research protoc ol was obtained from the Instit utional Review Board-01 of the University of Florida and from Floridas Depa rtment of Health. Once the sought permission and approvals were obtained, participants were recru ited using two methods let ters of invitation and recruitment posters. The letters of invitation method involved having CMS staff member s identify potential CMS adolescents and their primar y parents/caregivers for partic ipation in the larger study of which the present study is a part using the spec ified inclusion and exclusion criteria. Each potential adolescent and primary parent/caregiver pair identified using this method was mailed an invitation packet which included: (a) an inv itation letter, (b) two copi es of the Adult Consent Form, (c) two copies of the Adolescent Assent Form, (d) the Youth Information Questionnaire, (e) the Adult Information Questionnaire, and (f) postage-paid, pre-addre ssed envelopes one for the mothers completed packet and the other fo r the adolescents completed packet. The invitation letter included a brie f summary of the study and specifi ed the participation criteria. Additionally, it stated that (a ) each adolescent-mother pair would be paid $20 for their participation, (b) the duration of participati on would be approximately 45 minutes, (c) not all volunteer patient-parent pairs w ould be selected for particip ation in the study, (d) neither participation nor nonparticipati on would affect the adolescents healthcare in any way, (f) selected adolescent-mother pairs would be assigned (by researcher) to one of three parts of the larger research project, (g) invited interested parents should read a nd sign the Adult Consent Forms, (h) invited interested adolescents should r ead and sign the Adolescent Assent Forms, (i) interested parents shou ld return the signed Adult Consen t Form and the Adult Information Questionnaire in an enclosed postage-paid, pre-a ddressed envelope, (j) in terested adolescents should return the signed Adoles cent Assent Form and the Youth Information Questionnaire in an

PAGE 42

42 enclosed postage-paid, pre-addr essed envelope, (k) a copy of the Adult Consent Form and the Youth Assent Forms should be kept as r ecords of their participation agreement. The recruitment poster method involved displa ying recruitment posters with an attached drop-box and contact information requests at Child rens Medical Services offices. The posters: (a) briefly described the study and specified the part icipation criteria, (b) ha d attached cards with blanks for the parent(s) name(s), address, ethnicity/race, and phone number, (c) gave instructions to place completed cards in the attached drop-box, and (d) indicated that if a card was filled out and put in the drop-box, someone w ould call the primary parent/caregiver within five days to explain the study mo re fully. During this telephone call, primary parents/caregivers were told (a) what would be expected of her/ him as a research participant, (b) that each adolescent-parent pair would be paid $20 for their participation, (c) that the duration of participation would be approximately 45 minutes (d) that not all volunt eer adolescent-parent pairs would be selected for pa rticipation in the study, (e) th at neither participation nor nonparticipation would affect the adolescents healthcare in a ny way, and (f) that selected adolescent-parent pairs would be assigned (by researcher) to one of three parts of the larger research project. Once a adolescent-parent pair verb ally agreed to particip ate in the research, the pair was sent an invitation pack et which included (a) an invita tion letter (b) two copies of the Adult Consent Form, (c) two copies of the Adol escent Assent Form, (d) the Youth Information Questionnaire, (e) the Adult Information Questi onnaire, and (f) posta ge-paid, pre-addressed envelopes one for the mothers completed packet and the other for the adolescents completed packet. Procedure Regardless of the technique used to recruit participants, after all interested participants returned the Adult Consent Form or the Adolescent Assent Form, they were then sent an

PAGE 43

43 individual assessment packet containing: (a) a c over letter, (b) The Family Relations Index, (c) The Center for Epidemiologic Studies-Depressi on Scale, (d) The Marlowe-Crowne Social Desirability Scale-Short Form, and (e) a postage-paid, pre-addressed envelope. The cover letter described the content of the packet, gave brief instructions on how to complete the assessments, and included that it w ould take approximately 45 minutes to complete. It also included the instruction to (a) read and carefully follow the instruc tions at the top of each instrument/questionnaire, (b) res pond to the questions as honestly as possible, and (c) choose the responses that best fit how they f eel, think, and behave. It was also stated in the cover letter that all information provided would be used exclus ively for research purposes and would remain completely confidential and anonymous. To ensure anonymity, researchers pre-assigned c odes (instead of names) to all instruments in the assessment packet. Participants were asked not to write any identifiers (e.g., names, addresses) on their inventorie s or on their postage-paid, pre-ad dressed envelopes. Adolescentmother pairs were asked to separately complete and return all assessment packets in the postagepaid, pre-addressed envelopes within two weeks of receiving them. Each of the adolescent-mother pairs were given a monetary compensation of $20.00 for participation within two weeks of receiving their completed p acket. To ensure confidentiality, all Adult Consent Forms and Adolescent Assent Forms were kept in a locked file cabinet separate from participants research data.

PAGE 44

44 Table 3-1: Demographic Descri ption of African American a nd White American Participant Variable African American White American Adolescent MotherAdolescent Mother N = 32N = 32N = 49 N = 49 Age Range 12 -1730 6712 17 30 67 Mean 13.344.113.8 41.1 Gender N N N N Female 233228 49 Male 921 Diagnosis N N Asthma 615 Diabetes 53 Other 2131 Income Level N N Below $10,000 7 6 $10,000-$19,000 11 19 $20,000-$29,000 6 20 $30,000-$39,000 2 3 $40,000 or above 3 1 Missing 3 0 N = 162

PAGE 45

45 CHAPTER 4 RESULTS This chapter presents the descriptive data and the results of the data analyses conducted to test the hypotheses and examine the research ques tion set forth in this study. All data analyses were conducted separately on the African Amer ican adolescent-mother group and the White American adolescent-mother group consistent w ith the culturally sensitive Difference Model research approach (Oyemade & Rosser, 1980). This approach stress es the importance of recognizing within-group differences by identifyi ng culture-specific factors when investigating academic, cognitive, or social behavior of diverse cultural groups. This is important because differences found between these groups could be th e result of cultural di fferences rather than deficits or deficiencies in one culture as opposed to the other. The results are presented in five major parts. First, descrip tive and normative data on all of the measures are presented. Second, Pearson co rrelation analyses to assess the degree of relationship between the Marlowe-Cr owne Social Desirability Scal e-Short Form and each of the independent and dependent variab les are reviewed. Third, the results of a series of Pearson correlation analyses to test Hypotheses 1 and 2 are discussed. Fourth, the results of multiple regression analyses used to de termine the amount of variance th at each predictor variable accounted for in each of the cr iterion variables are discusse d. Lastly, the results of two MANOVAs used to test the research question are discussed. All statis tical analyses were performed using the Statistical Packag e for Social Science 15.0 for Windows. With respect to the third and fourth hypothesis, the present study appr oached disagreement in perception of family functioning as the discre pancy in reported level of family conflict and family cohesion between adolescent and mother pairs. To examine the level of discrepancy, standardized difference scores we re computed for statistical anal yses (Carlton-Ford, Paikoff, &

PAGE 46

46 Brooks-Gunn, 1991; Reyes, & Kazdin, 2004). These scor es were derived in two steps: (1) raw discrepancy scores were created by subtracting adolescen t and mother pair reports of level of family cohesion and level family conflict; and (2 ) absolute difference scores were created by taking the absolute value of the raw discrepancy scores. The absolute difference score tests the possibility that discrepancy in ei ther direction (adolescen t over mother, or vice versa) would play a role in adolescent adjustment (Pai koff, Carlton-Ford, & Brooks-Gunn, 1993). Descriptive and Normative Data for all Major Variables Table 1-4 presents the means, standard de viations, and range for each variable under investigation in this study. Additionally, normativ e data for all available measures are presented in Table 1-4. It should be noted that the Marl owe-Crowne Social Desirability Scale-Short Form does not have norms available for adults and adolescents. Correlations Between Variables of Interest a nd the Marlowe-Crowne Social Desirability Scale-Short Form A preliminary Pearson Correlation analysis wa s performed to examine the relationships between social desirability as measured by the Ma rlowe-Crowne Social De sirability Scale-Short Form (M-C SDS-SF) and scores on the Family Relations Index (family conflict and family cohesion scores) and the Center for Epid emiologic Studies-Depression Scale (CES-D) (adolescent depressive symptoms scores). This procedure was conducted to determine if any of the ratings of the variables of interest were infl uenced by the tendency to give socially desirable responses by the adolescent and mo ther participants. The results in dicated that only one of the family relation variables correlate d significantly with social desi rability: the African American mothers scores on the M-C SDS-SF had a low but significant negative relationship (r = -.357, p < .05) with mothers level of perc eived family conflict. Thus, soci al desirability was controlled in data analyses involving Afri can American mothers perception of family conflict. Scores on

PAGE 47

47 the M-C SDS-SF were not significantly associated with any of the other variables of interest among the African American or th e White American groups. Table 2-4 contains the results of this analysis. Results of Analyses to Test Hypothesis 1 A series of Pearson correlation analyses were performed in order to test Hypothesis 1, which stated that family cohesion (as perceived by adolescents and their mothers) would have a significant negative association with the leve l of depressive symptoms reported by the adolescents. The result of the correlation an alysis involving African American adolescents revealed that the adolescents perceived leve l of family cohesion had a significant negative association with their reported level of depressive symptoms (r = -.534, p < .01), thus supporting Hypothesis 1. The result of the correlation an alysis involving African American mothers indicated that the mothers perc eived level of cohesion was not significantly associated with adolescents reported level of depressive symptoms (r = -.279, p > .05) and does not support Hypothesis 1. The result of the correlation analys is involving the White American adolescents revealed that the adolescents perceived level of family cohesion had a moderate, significant negative association with their reported level of depressive symptoms (r = -.415, p < .01), which provides support for Hypothesis 1. The result of the correlation analys is involving the White American mothers revealed that the mothers perceived level of cohesion had a moderate but significant negative association with adolescents reported level of depressive symptoms (r = .382, p < .01), thus providing support for Hypothesis 1. Table 3-4 presents the results of these analyses. Results of Analyses to Test Hypothesis 2 A series of Pearson correlation analyses were performed in order to test Hypothesis 2, which stated that family conflict, as perceived by adolescents and their mothers, would have a

PAGE 48

48 significant positive association with the level of depressive symptoms reported by the adolescents. The result of the correlation an alysis involving the Afri can American adolescent revealed that the adolescents perceived leve l of family conflict had a significant positive association (r = .575, p < .001) with their reported level of depressive symptoms, thus providing support for Hypothesis 2. The result of the corre lation analysis involving African American mothers perceived level of fa mily conflict was not significantly associated with adolescents reported level of depressive symptoms and does not support Hypothesis 2, (r = .215, p > .05). The result of the correlation analysis involving th e White American adolesce nts revealed that the adolescents perceived level of family conflic t had a significant positiv e association (r = .577, p < .001) with their reported leve l of depressive symptoms, whic h provides support for Hypothesis 2. The result of the correlation involving the White American mothers revealed that mothers perceived level of family conflict had a modera te but significant positive association (r = .353, p < .01) with adolescents reported level of de pressive symptoms, thus providing support for Hypothesis 2. Table 3-4 presents th e results of these analyses. Results of Analyses to Test Hypothesis 3 Hypothesis 3 stated that disc repancies in perceived level of family cohesion between chronically ill adolescents and their mothers (cohesion difference scor e) would be a stronger predictor of the level of depres sive symptoms reported by the adol escents, as compared to their individual and their mothers perceived level of family cohesion. Two forced entry multiple regression analyses were conducted to test H ypothesis 3one with the data of the African American participants and one w ith the data of the White American participants, in accordance with the Difference Model research approach (O yemade & Rosser, 1980). The criterion variable for these analyses was adolescents reported leve l of depressive sympto ms and the predictor variables were the adolescents level of perceived family c ohesion, the mothers level of

PAGE 49

49 perceived family cohesion, and level of adolescent -mother pair perceived differences in family cohesion (as represented by cohesi on difference scores). The pred ictor variables were entered simultaneously in the multiple regression analyses. These findings are summarized in Table 4-4. The model for the group of Af rican American adolescent-moth er pairs was tested first. Variance inflation factors (VIF) and tolerance statistics were examined. There was no evidence of multicollinearity; VIF values were between 1.30 and 1.03 and all tolerance values were between .96 and .76. This model was significant F (3,23) = 5.09, p < .01 and accounted for 32.1% of the variance in adolescent depressive symptoms. However, adolescent perception of family cohesion was the only significant pred ictor of adolescent depressive symptoms ( t = -3.41, p < .01). The results of this analysis do not provide support for Hypothesis 3. Lastly, the model for the group of White Amer ican adolescent-mother pairs was tested. There was no evidence of multicollinearity; VIF values were between 2.02 and 1.16 and all tolerance values were between .86 and .49. This model was significant F (3,43) = 4.68, p < .01, and accounted for 24.6% of the variance in a dolescent depressive symptoms. However, adolescent perception of family cohesion was the only significant pr edictor of adolescent depressive symptoms ( t = -2.53, p < .05). The results of this analysis do not provide support for Hypothesis 3. These findings ar e summarized in Table 4-4. Results of Analyses to Test Hypothesis 4 Two separate multiple regression analyses were conducted to test Hypothesis 4, which stated that discrepancies in perc eived level of family conflict be tween chronically ill adolescents and their mothers would be a stronger predictor of the level of depressive symptoms reported by the adolescents, as compared to their individual and their mothers perceived level of family conflict. The criterion variable for these analyses was adolescents level of depressive symptoms, and the predictor variables were th e adolescents level of perceive d family conflict, the mothers

PAGE 50

50 perceived level of family conflict, and levels of adolescent-mother pair perceived differences in family conflict (as represented by conflict differe nce scores). These findings are summarized in Tables 5-4. and 6-4. A stepwise multiple regression analysis was pe rformed to test Hypothesis 4 using the data from the African American participants. The Ma rlowe-Crowne Social Desirability Scale-Short Form scores for the African American mothers was entered in the first step in order to control for social desirability, given that these scores were significantly correlated with their scores on the perceived family conflict measure. There was no evidence of collinearity; VIF values were between 1.01 and 1.12 and tolerance values we re between .89 and .99. This model was not significant F (3,21) = 2.53, p > .05. The results of this analysis do not provide support for Hypothesis 4. These findings are summarized in Table 5-4. A forced entry multiple regression analysis wa s performed to test Hypothesis 4 using the data from the White American participants. There was no evidence of multicollinearity; VIF values were between 1.09 and 1.45 and tolerance values were between .68 and .91. This model was significant F (3,44) = 7.50, p < .001, and accounted for 33.8% of the variance in adolescent depressive symptoms. However, adolescent percepti on of family conflict was the only significant predictor of adolescent depressive symptoms ( t = 3.57, p < .001). The results of this analysis do not provide support for Hypot hesis 4. These findings are summarized in Table 6-4. Results of Research Question Analyses To examine the research question, which asked whether there are significant differences in adolescents perceived level of family cohesion a nd family conflict or in their reported level of depressive symptoms in associa tion with their gender and age, two Multivariate Analyses of Variance (MANOVA) were performe d-one using the data of the African American adolescents and one using the data of the White American a dolescent participants. The independent variables

PAGE 51

51 in the MANOVAs were age and gender, and the dependent variables were the adolescents perceived level of family cohesion, family conf lict, and their own depressive symptoms. The data of adolescent age was entered as a categorical variable and was distri buted into one of two groups: early adolescence or late adolescence. Results of the MANOVA for the group of Afri can American adolescents, using Wilkss criterion, did not reveal significant effects for age F (18, 563) = .76, p > .05, = .64, or gender F (18, 563) = 2.25, p > .05, = .74. No significant inte raction effects emerged. The results of the second MANOVA for the group of White American adolescents, using Wilkss criterion, indicated a significant effect for gender, F (36, 1014) = 2.83, p < .05, = .80, but not for age, F (36, 1014) = .62, p > .05, = .77. However, the results of the tests of between-subjects effect for gender did not reveal significant effects for cohesion F (1, 45) = 2.76, p > .05, conflict, F (1, 45) = 2.09, p > .05, or adolescent depressive symptoms, F (1, 45) = .633, p > .05. Additionally, the interaction between age and gender was not significant, F (36, 1014) = 1.15, p > .05, = .68. These findings are summarized in Table 7-4.

PAGE 52

52 Table 4-1: Descriptive and Normative Data fo r the FRI, CES-D, and M-C SD-SF Inventories Present Study Norms Variables Mean SDRangeMean SD Adolescent 6.09 2.11 6.23 1.872 9 FRI Cohesion African American White American 5.97 2.041 9 4.30 2.27 3.10 1.990 7 FRI Conflict African American White American 3.62 2.330 9 N/A N/A 12.09 4.124 20 Social Desirability African American White American 13.71 3.775 20 13.8 9.09 16.18 15.310 51 CES-D African American White American 11.92 12.470 46 Adult 6.80 2.02 6.30 2.071 9 FRI Cohesion African American White American 6.26 2.490 9 3.76 2.32 2.89 2.370 9 FRI Conflict African American White American 3.24 2.000 8 N/A N/A 14.58 3.933 20 11.98 3.594 18 1.56 1.880 8N/A N/A 1.82 1.620 6 1.80 1.320 5N/A N/A Social Desirability African American White American Cohesion Difference Score African American White American Conflict Difference Score African American White American 1.70 1.420 5 N = 162 N/A = Norm data is not available

PAGE 53

53 Table 4-2: Relationship Between Social Desi rability Scores and Variables of Interest Adolescent M-C SD-SF Mother M-C SD-SF Adolescent Depressive Symptoms African American -.054 White American .111 Adolescent Family Cohesion African American .288 White American -.134 Adolescent Family Conflict African American .045 White American -.015 Mother Family Cohesion African American -.032 White American .149 Mother Family Conflict African American -.357* White American -.224 Correlation is significant at the 0.05 level (1-tailed)

PAGE 54

54 Table 4-3: Pearson Correlations Among Study Va riables for Adolescents and Mothers by Ethnic Group 1 2 3 4 5 6 7 1. Adolescent Cohesion African American -.00 -.12 -.42* -.02 .02 -.53** White American -.37** -.68** -.53** -.31* -.33* -.42** 2. Mother Cohesion African American --.24 -.43** -.55** .46** -.28 White American --.10 -.44** -.73** -.20 -.38** 3. Cohesion Difference Score African Ameri can -.38* .30 -.17 .23 White American -.22 .01 .35** .13 4. Adolescent Conflict African American -.48** -.01 .57** White American -.50** .22 .58** 5. Mother Conflict African American -.07 .22 White American -.06 .35** 6. Conflict Difference Score African Am erican --.04 White American -.13 7. Adolescent Depression African American -White American -Note: p < .05, ** p < .01

PAGE 55

55 Table 4-4: Multiple Regression Predicting Adolescent Depressive Symptoms Scores from Adolescent Family Cohesion, Mother Fa mily Cohesion, and Cohesion Difference Scores Variable Standardized Beta t African American (n = 32 pairs) Adolescent Cohesion -.562 -3.41** Mother Cohesion -.071 -.389 Cohesion Difference Score .179 .971 White American (n = 49 pairs) Adolescent Cohesion -.477 -2.53* Mother Cohesion -.234 -1 .64 Cohesion Difference Score -.217 -1.21 Note: p < .05, ** p < .01

PAGE 56

56 Table 4-5: Stepwise Regressi on Predicting Adolescent Depressive Symptoms Scores from Adolescent Family Conflict, Mother Fa mily Conflict, and Conflict Difference Scores Using African American Participants Data Variable Standardized Beta t African American (n = 32 pairs) Step 1 Mother M-C SDS-SF .439 Step 2 Adolescent Conflict .536 2.72* Mother Conflict -.112 -.567 Conflict Difference Score -.032 -1.68 Note: p < .05, ** p < .01 Table 4-6: Multiple Regression Predicting Adolescent Depressive Symptoms Scores from Adolescent Family Conflict, Mother Fam ily Conflict, and Conflict Difference Scores Using White American Participants Data Variable Standardized Beta t White American (n = 49 pairs) Adolescent Conflict .528 3.56** Mother Conflict .090 .619 Conflict Difference Score .018 .140 Note: p < .05, ** p < .01

PAGE 57

57 Table 4-7: Summary of MANOVA Models to Te st Research Question Variable F African American Model Age .762 .644 Gender 2.25 .738 Age x Gender .546 .921 White American Model Age .620 .765 Gender 2.83 .795* Age x Gender 1.15 .679 Note: p < .05, ** p < .01

PAGE 58

58 CHAPTER 5 DISCUSSION The purpose of this chapter is to summarize and interpret the results of the performed data analyses. This chapter is organize d in four parts. First, result s regarding Hypotheses 1 and 2 are reviewed and discussed. Second, the results re garding Hypothesis 3 and 4 are reviewed and discussed. Next, the results of a research quest ion concerning gender and age differences in the variables of study are discussed. Lastly, limitati ons of the present study and implications for future research and for the field of counseling psychology are presented. Results Regarding Hypotheses 1 and Hypothesis 2 Hypothesis 1 proposed that family cohesion, as perceived by adolescents with a chronic illness and their mothers, would have a significant negative association with the level of depressive symptoms reported by the adolescents such that highe r perceived level of family cohesion by the adolescents and th eir mothers would be associated with lower reported level of depressive symptoms by the adolescents. To ad dress Hypothesis 1 two Pearson correlations were conducted for each ethnic group one that included the cohesion and depressive symptoms data of the adolescents and one that included the c ohesion data of the mothers and the depressive symptoms data of the adolescents. Findings included that among the African American adolescents perceived level of fa mily cohesion was significantly associated with their reported depressive symptoms. Those adol escents with high scores on family cohesion had low scores on depressive symptoms, providing support for H ypothesis 1. Additionally, it was found that among the African American mothers, perceived le vel of family cohesion was not significantly correlated with level of adoles cent depressive symptoms. For the group of White Amer ican adolescents, it was found th at perceived level of family cohesion was significantly associated with thei r reported level of depressive symptoms. Those

PAGE 59

59 adolescents with high scores on family cohe sion had low scores on depressive symptoms, providing support for Hypothesis 1. Additionally, it was found that White American mothers perceived level of family cohesi on was significantly associated with their adolescents reported level of depressive symptoms, providing support for Hypothesis 1. Hypothesis 2 proposed that perceived level of family conflict, as experienced by adolescents with a chronic illness and thei r mothers, would have a significant positive association with the level of depressive sympto ms reported by the adolescents such that higher level of family conflict by the adolescents and their mothers would be associated with higher reported level of depressive symptoms by the a dolescents. To address Hypothesis 2 two Pearson correlations were conducted for each ethnic group one that included the conflict and depressive symptoms data of the adolescents and one that include d the conflict data of the mothers and the depressive symptoms data of the adolescents Findings included th at among the African American adolescents perceived level of family conflict was significantly associated with their reported level of depressive symptoms such that those adolescents with high scores on family conflict had high scores on depressive symptoms, providing support for Hypothesis 2. Additionally, it was found that among the African American mothers, perceived level of family conflict was not significantly correlated with level of adol escent depressive symptoms. For the White American adolescents, it was f ound that perceived level of family conflict was positively associated with their reported leve l of depressive symptoms. Additionally, it was found that White American mothers perceived leve l of family conflict was positively associated with their adolescents reported level of depressive symp toms, providing support for Hypothesis 2.

PAGE 60

60 The findings for Hypothesis 1 and 2 in the pres ent study are consistent with earlier studies on family relations among adolescents with a chr onic illness. Previous studies have indicated that there are protective factor s associated with high level of family cohesion (Donnelly, 1994; Moos & Moos, 1994; Reichenberg & Broberg, 20 05; Timko, Stovel, Moos, & Miller, 1992) and maladaptive factors associated with high leve l of family conflict (Cuffe, McKeown, Addy, & Garrison, 2005; Dunn, Austin, & Huster, 1999) among adolescents with a ch ronic illness. This suggests that family relations, such as those pe rceived as cohesive by adolescents, serve as a buffer that reduces stressful life events and dise ase-related stressors. On the other hand, family relations perceived as high in conflict by adoles cents are associated w ith added stressors and increased depressive symptoms among adolescents with a chronic illness. It should be noted that percei ved level of family relations (family conflict and family cohesion) by African American mothers was not asso ciated with adolescent reports of depressive symptoms. This finding is similar to a longi tudinal study by Sagrestano, Paikoff, Hombeck and Fendrich (2003) which found that African American parents reports of family conflict were not associated with child and adolescent depressive symptoms whereas child and adolescent reports of family conflict were positively associated with their depressive symptoms. A reason for this could be that reports of family relations as perceived by family members are subjective. Moreover, subjective reports are subject to report bias. As su ch, adolescent perceptions are stronger predictors of adolescen t outcomes and mother perceptions are stronger predictors of mother outcomes. A second factor which may have influenced th e findings in relation to African American mother participants in this study may be due to variation in parenting behaviors among different ethnic groups (Dearing, 2004). It is likely that effective parenting behavior may depend on

PAGE 61

61 cultural and environmental differences as well as individual family charact eristics. For example, African American mothers value obedience, co nformity, and respect fo r authority as childrearing goals. They tend to use restrictive monito ring and parental control as effective parenting behaviors more than White American parents wh o have similar socio-economic status (Elder, Eccles, Ardelt, & Lord, 1995; Furstenberg, C ook, Eccles, Elder, & Sameroff, 1999). Recent studies have found benefits of restrictive parentin g styles for African American children and not for White American children living in similar se ttings (Dearing, 2004). The measures used in this study may not have been sensitiv e to cultural differences in pa renting styles and values among African American mothers. Another possible reason for the insignificant findings in relation to African American mothers report of family cohesion and family conflict, and adolescent report of depressive symptoms is the questionable validity of data in th e current study. It is po ssible that the wording of items could have been misinterpreted. It may be that participants were confused or did not understand some items but completed them without clarification. Thus, scores on the Family Relations Index could have failed to reliably reflect level of family cohesion and family conflict as perceived by African American mothers. Mo reover, since the Family Relations Index was normed on a mostly white, middle S.E.S. sample fr om mid-western states, it is possible that the communication, actions, customs, beliefs, and valu es of low income African American families were not taken into consideration in the development of the instrument. Another reason could be that response bias ma y have threatened the validity of the data acquired by African American mothers complete d questionnaires. Some respondents may have completed the questionnaires with the intention of portraying socially desirable family

PAGE 62

62 interactions. Although efforts were made to control for socially desirable re sponses, it is possible that social desirability systematically biased the family relations variables investigated. Results Regarding Hypothesis 3 and Hypothesis 4 Hypothesis 3 proposed that discrepancies in perception of family cohesion between chronically ill adolescents and their mothers w ould be a stronger predictor of the level of depressive symptoms reported by the adolescents, as compared to their individual and their mothers perceived level of family cohesion. Re sults of two forced entry multiple regression analyses yielded significant models for the group of African American adolescent-mother pairs and for the group of White American adolescent -mother pairs. However, discrepancies in perceived level of family cohesion between a dolescents and their mothers did not predict adolescent depressive symptoms In contrast, for both ethnic groups, adolescent perception of family cohesion predicted adolesce nt depression. The results of these analyses did not provide support for Hypothesis 3. Hypothesis 4 proposed that discrepancies in perception of family conflict between chronically ill adolescents and their mothers w ould be a stronger predictor of the level of depressive symptoms reported by the adolescents, as compared to their individual and their mothers perceived level of family conflict. Results of a step-wis e regression analysis yielded an insignificant model for the group of African Amer ican adolescent-mother pairs. Therefore, discrepancies in perceived level of family c onflict between African American adolescents and their mothers perceived level of family conflict, as well as their individual and their mothers perception of family conflict, did not predict adolescent depressive symptoms. For the group of White American adolescent-mother pairs, a forced-entry multiple regression analysis yielded a significant mode l. However, adolescent perception of family conflict was the only predictor of adolescent depression. Discrepa ncies in perceived level of

PAGE 63

63 family conflict between adolesce nts and their mothers did not pr edict adolescent depressive symptoms. Hypothesis 4 was not supported. The findings from the present study did not supp ort the view held by some family theorist and clinicians (e.g., Moos & Moos 1986; Tein, Roosa, & Michaels, 1994) that discrepancies in family members perception of family relations ar e related to adolescent internalizing behaviors (Ohannessian, Lerner, Lerner, & von Eye, 1995) a nd problems in family relationships (Moos & Moos, 1986). A study by Carlson, Cooper, and Spradli ng (1991) yielded some interesting results which are relevant to the presen t study. They examined adolescent-mother perceptions of family cohesion and family conflict and reported that di screpancies in adolescents and their mothers perception of family conflict was related to lower level of adolescents self-esteem and selfcompetence. However, the reverse was found when they examined discrepancies between the level of family cohesion between boys and th eir mothers with high level of discrepancy positively associated with adolescent self-compete nce and self-esteem. According to the authors, their findings suggest that there may be an ad aptive component to discrepancies in adolescentmother perception of family relations. Moreover, according to some developmen talists (e.g., Montemayor & Flannery, 1991; Steinberg, 1990, 1991) discrepancies in adolescent-mother perceptions of family relations may be adaptive in some respects. Minor disagreement s in perceptions of family cohesion and family conflict may be necessary for mastery of specific developmental tasks such as the development of identity and autonomy. For ex ample, Holmbeck and ODonne ll (1991) found that conflicts related to adolescen t issues (e.g., chores, appearance) may re sult in discrepancies in perceptions of family conflict and cohesion. In that study, the author s note that changes in family relations convey changes in the adol escent and their role in the family and provide support for successful

PAGE 64

64 individuation. This is consiste nt with models of individuatio n (e.g, Grotevant & Cooper, 1986) which state that in order for adolescents to su ccessfully develop their identity they need to individuate from their family. Even though discre pancies in perceptions of family cohesion and family conflict are associated wi th increased level of conflict and stress among family members, discrepancies in perceptions of family re lations may be adaptive for adolescents. A factor which may have influenced the nons ignificant findings on the relation between discrepancies of family relations and adolescent depressive sy mptoms was the low levels of discrepancy of family relations reported by part icipants in the present study. For the African American adolescent-mother pair group, the mean for the conflict difference score was 1.8 and the mean for the cohesion difference score was 1.6. For the White American adolescent-mother pair group, the mean for the conflict difference score was 1.7 and the mean for the cohesion difference score was 1.8. This indicates that ove rall there was a small degree of variation in perception of family conflict and family cohesion between adolescents and mother participants in this study. It should be noted that including a larger sample of adolescent-mother pair participants who have higher level of discrepancie s in their view of family relations may yield significant findings. Interestingly, low level of family cohesion predicted depressive symptoms for African American adolescents and White American adol escents whereas high level of family conflict predicted adolescent depressive symptoms unique ly for White American adolescents. This finding is consistent with previous studies which indicate that family cohesion is the most critical family relations variable that predicts adolescent depressi ve symptoms among low-income African American families (Carlton-Ford, Paikoff, Oakley, Brooks-Gunn, 1996; Herman, Ostrander, & Tucker, in press). The importan ce of family cohesion among African American

PAGE 65

65 families could be due to traditional values of family connectedness which includes a broader network of relationships and extended family me mbers. Hill (1998) described several strengths of contemporary African American families wh ich includes formation of strong kinship bonds and flexible family roles. One strategy to he lp prevent or treat Afri can American adolescent depressive symptoms is to build on these cultur al values and strengthen family connectedness and cohesion. White American families are generally less in clusive, with limited number of family members, and an emphasis on the nuclear family st ructure. The traditiona l family is generally defined in terms of autonomy, individual res ponsibility, and individua l happiness (Stone, 1994). The importance of individual happiness and auto nomy allows children and adolescents to disagree and argue with their pa rents. Generally, people from othe r cultures would consider such disagreements as signs of disrespect and la ck of family connectedness however; it is considered part of developing indi viduality. Seen in this context, some degree of conflict is common amongst family members. However, increasing communication and support among family members and decreasing family conflict w ould be effective interventions to prevent or treat adolescent depressive symptoms. Results of Analyses to E xamine a Research Question The research question asked whether there we re significant differen ces in adolescents perceived level of family cohesion and family conflict and their reporte d level of depressive symptoms in association with their gender and ag e. The results of a Multivariate Analysis of Variance (MANOVA) analyses for the African Am erican adolescent group revealed that there were no differences among the dependent variab les in association with gender and age. The results of a second MANOVA analyses for the White American adolescent group revealed that there was a signifi cant effect for gender but not for age. However, test of between-

PAGE 66

66 subjects effects did not find a si gnificant effect for gender in re lation to family cohesion, family conflict, or adolescent depressive symptoms. Considering that the mean age of participants in present study was 13, the insignificant findings of the age and gender variables in both MANOVAs are consistent with th e literature in the area, wh ich suggests that depressive symptoms are more prominent during late adoles cence. Prior research ha s indicated that gender differences associated with depr ession begin at age 13 but are mo st detectable at age 16 (Angold & Rutter, 1992). After puberty, the ratio of depression is approximately two females to one male, reaching the prevalence rate found in adu lts (Allgood-Merten, Lewinsohn, & Hops, 1990; Hankin et al., 1998; Petersen et al., 1993. Similarly, in a longitudinal study of family relations, parenting style, and depression among low-income African American adolescents (ages 9 15), Sagrestano, Paikoff, Holmbeck, and Fendrich (2003) did not find ge nder or age differences in association with adolescent symptomatology across 2 waves of data collection. Further, in a study of depressive symptoms among adolescents with a chronic illness, Key, Brown, March, Spratt & R ecknor (2001) did not find differences among gender, race, and socioeconomic status in predicting depressive symptoms among adolescents. A factor that could have affected this study s nonsignificant results is the small number of adolescent subjects (n = 32 African American; n = 49 White American) participating in the present study. The small amount of adolescent participants may have resulted in inadequate power in the statistical analyses to detect any significant differences between family conflict, family cohesion, and adolescent depressive symptoms in relation to gender and age. Moreover, a sample with greater variation in adolescen t age could have yielded different findings.

PAGE 67

67 Limitations of the Research Although the current study contributes to the body of literature in a number of ways, it is worthy to note limitations. It should be noted that the present study had a sample of adolescent mother pair participants who repor ted low levels of discrepancy in perception of family relations which may have in turn reduced th at possibility of important vari ation. The next step in the study of discrepancy of family relations among adoles cents with a chronic il lness and their mothers should involve the use of adolescent-mother pa irs who have higher level of discrepancy in perception of family relations. Another limitation of this study was that the sample size was re latively small and restricted to a particular geographic area (North Central Florida). More over, the sample only included African American and White American adolescent -mother pairs. Therefore, the present study has limited generalizability, and interp retations should be viewed w ith caution. Longitudinal studies with a larger group of ethnically and culturally diverse participan ts are needed to confirm the proposed relationships and causal sequence. Furthermore, a larger sample size may reveal stronger findings than those found in the present study. This study relied on self-report measures of fa mily relations and adolescent depressive symptoms, which might represent another limita tion. Even though the present study included use of a social desirability scale to control for source bias, there is a common method variance that arises from purely self-report measures. Moreov er, including self-report depressive symptoms scores gathered during one time point might not have given an exact assessment of adolescent depressive symptoms which might have change d over time. Lastly, as with any study an unexplained third variable may influence the asso ciation of perception of family relations and adolescent depressive symptoms. Therefore, the findings of the pr esent research study cannot be

PAGE 68

68 assumed to be causal. Even given these limitatio ns, the present research study has implications for future research. Implications for Future Research While there has been previous research studi es conducted on the association of family relations and the adjustme nt of adolescents with a chronic illn ess, the study of the discrepancies in the perceptions of family cohesion and fa mily conflict among adoles cents with a chronic illness and their mother as predictors of adoles cents depressive symptoms is novel. Published studies have yielded inconclu sive and conflictive evidence regarding the association of discrepancies of family relations and the adjustme nt of physically healthy adolescents, with some studies reporting adolescent adjustment prob lems and others reporting positive adolescent outcomes. The present study did not find evidence that discrepancies in family members perceptions of family relations are related to adolescent depre ssive symptoms among chronically ill adolescents. Further examination of adolescent-mother discrepancies in perceptions of family relations as adaptive or maladaptive among adoles cents with a chronic i llness are warranted and should address the limitations of the present study. Future studies of discrepancies in family me mbers perceptions of family relations and adolescent adjustment should include families who report high levels of discrepancies in perception of family relations as well as in clude more representati ve samples (e.g., age, race/culture, and socio-economic diversity). Incl usion of both parents or primary caregivers, siblings, and extended family members may provi de further insight on th e relationship between family relations and adjustment of adolescents with a chronic illness. Additionally, longitudinal research designs that incorporate culturally sens itive inventories, measures of observation and behavioral analysis, and diagnosti c measures of adolescent depres sion should be a next step in

PAGE 69

69 research studies aimed at understanding the imp lications of family member discrepancies in perceptions of family relations among a dolescents living with a chronic illness. Implications for the Field of Counseling Psychology One implication of the findings of this study is that that family cohesion and family conflict may be useful indicators of psychosoc ial functioning among adoles cents with a chronic illness. Assessment of African American adolesce nt perceptions of family cohesion and White American adolescent perceptions of family cohe sion and family conflict are important because they are linked to adolescent depressive symp toms. Moreover, assessment of family cohesion and family conflict facilitates the identification of family strengths and weaknesses on which to build on through counse ling interventions. Considering that the findings of the present study sugg est that adolescent perceptions of family relations are better predic tors of adolescent de pressive symptoms, individual therapy may better facilitate treatment a nd prevention of adolescent depr essive symptoms. Clinical intervention and prevention programs should eval uate perception of family relations and depressive symptoms among adoles cents with a chronic illness a nd incorporate improving family communication, mutual respect, and family s upport as targets for individual and family interventions. Ideally, interventions would be adaptable to the part icular aspects of the individual and the familys cultural background as well as br oadly applicable to various cultures. As a result, studying the factors that contribute to adolescent adjustment can help improve positive health outcomes and adolescent adjustment. Conclusions The present study was conducted for two major purposes. First, this study was conducted to examine the association of family relations (family cohesion, family conflict) and adolescent depressive symptoms among Afri can American adolescents with a chronic illness and their

PAGE 70

70 mothers and among White American adolescents with a chronic illnes s and their mothers. Second, this study was conducted to examin e among chronically ill African American adolescents and their mothers and among chronica lly ill White American adolescents and their mothers whether discrepancies in perceived levels of family relations (family cohesion, family conflict) were stronger predicto rs of adolescents reported de pressive symptoms than their individual or their mothers per ception of family relations. Statistic al analyses were performed to test four hypotheses related to the above stated major purposes of this study and one research question. These analyses were performed separa tely by race according to the Difference Model research approach (Oyemade, & Rosser, 1980). Findings from this study did not support the view that discrepancies in family relations among adolescents with a chronic illness and their mother predicts adolescent depression. However, it should be noted that African American adolescents perception of family cohesion and White American adolescent perception of fa mily cohesion and family conflict did predict adolescent depressive symptoms Thus, the present study could be interpreted as suggestive of patterns of family relations and adjustment of African American adolescents and White American adolescents with a chroni c illness. According to the resu lts, it is possible that family cohesion may serve as a buffer against depressi ve symptoms for African American and White American adolescents with a chro nic illness regardless of discre pancies of perception of family cohesion among family members. These findings suggest that improving family cohesion (or positive family relations) may help prevent or alleviate depressive symptoms among African American and White American adolescents with a chronic illness. More over, reducing family conflict, for White American families, may help prevent or alleviate adolescent depressive symptoms.

PAGE 71

71 Rather than using universal ex planations for the results of the present stud y, separately examining predictors of adolescent outcomes w ithin specific racial and ethnic groups yielded unique relationships between family cohesion, family conflict and adolescent depressive symptoms. Findings such as these support the Di fference Model research approach (Oyemand & Rosser, 1908) and the understandin g that the socio-contextual factors associated with adolescent adjustment may vary among different ethnic groups.

PAGE 72

72 APPENDIX A YOUTH INFORMATION QUESTIONNAIRE Directions: Please give all of your answers by comple tely filling in the circle beside your answer. It should look like this : Remember, your answers to all que stions in this packet will be kept completely private. Are you female or male? O Female O Male How old are you? O 12 O 15 O 13 O 16 O 14 O 17 How do you describe yourself? O African-American/Black-American (not of Hispanic origin) O Caucasian/White/European-Ame rican (not of Hispanic origin) O Hispanic/Latino O Multi-Racial (please describe:____________________________) What grade are you in? O 5th O 10th O 6th O 11th O 7th O 12th O 8th O I do not go to school O 9th How many hours per week do you usually take part in sports and at hletics at school or in your community (such as soccer, football, cheer leading, swimming, r unning, walking, or weightlifting)? O None O 1-5 hours each week O 6-10 hours each week O 11 or more hours each week When we mail you things would you like them to be written in: O English O Spanish Have you felt any of these things? (Fill in all that you have felt.) O blurry vision O shortness of breath O dizzy O thirsty a lot of the time

PAGE 73

73 O headaches O tired a lot of the time O none Which of the following, if any, has your doctor or someone else at your do ctors office asked you to do to treat your health c ondition or illness? (Fill in all that you have been told to do.) O take medication O change the kinds of things you eat O exercise O lose weight O OTHER: ________ ____________________ _________________ ______________ Do you think your doctor or someone else at you r doctors office has taught you how to take care of your health condition or illn ess? (Fill in one answer only. ) O Agree a lot O Agree a little O Not Sure O Disagree a little O Disagree a lot Do you have (Fill in all that you have): O high blood pressure O ADHD O diabetes (sugar) O cardiac (heart) disease O asthma O allergies O other: ___________________________________ Do you think you are overweight? O No O Yes In school, which of these gr ades do you mostly make? O A O B O C O D O F This year, what is your overall Grade Point Averag e (GPA)? _________ This year, what grade have you mostly made in English/Language Arts/Reading? O A O B O C O D

PAGE 74

74 O F This year, what grade have you mostly made in Math? O A O B O C O D O F This year, what grade have you mostly made in Social Studies/History? O A O B O C O D O F This year, what grade have yo u mostly made in Science? O A O B O C O D O F

PAGE 75

75 APPENDIX B ADULT INFORMATION QUESTIONNAIRE Directions: Please give all of your answers by completely filling in the circle beside your answer. It should look like this: Remember, your answers to a ll questions in this packet will be kept completely private. What is your sex? O Female O Male How do you describe yourself? O African-American/Black-American (not of Hispanic origin) O Caucasian/White/Eu ropean-American (not of Hispanic origin) O Hispanic/Latino O Multi-Racial (Please describe:_____________________________) What is your current relationship status? O Divorced or separated O Married, living with partner O Married, not liv ing with partner O Single, living with partner O Single, living without partner O Widow/Widower What is your employment status? O Work Full Time (30-40 hrs) O Work Part Time (10-30 hrs) O Do not work What is the highest level of edu cation that you have completed? O Elementary School O Middle/Junior High School O High School O Some College/Technical School O College O Professional/Graduate School What is your annual hou sehold income level? O Below $10,000 O $10,000 to $19,999 O $20,000 to $29,999 O $30,000 to $39,999 O $40,000 or above

PAGE 76

76 How many children currently live with you in your home? O none O five O one O six O two O seven O three O eight O four O other:_______ How many adults currently live with you in your home? O none O five O one O six O two O seven O three O eight O four O other:_______ Do you believe your child is overweight? O Yes O No When we mail you things would you like them to be written in: O English O Spanish Which county do you live in? O Alachua O Hernando O Bradford O Levy O Columbia O Marion O Dixie O Putnam O Gilchrist O Other (Please specify: ________________________) Please write your answers to the followi ng questions in the blanks provided: In the last year, how many times have you visi ted the medical clinic you usually attend: _______ How many years have you lived in this community: __________ Your age: __________ PLEASE RETURN BOTH PAGE S OF THIS QUESTIONNAIRE Thank you for helping us with this research!

PAGE 77

77 APPENDIX C FRI Directions: There are 27 statements on these page s. They are statements about families. You are to decide which of these statements are true of your family and which are false. True Fill in the circle under the True column when you think the statement is True or mostly True of your family. False Fill in the circle under the False column when you thi nk the statement is False or mostly False of your family. You may feel that some of the statements are true for some members and false for others. Fill in the circle under the True column if the statement is true for most members. Fill in the circle under the False column if the statement is false for most members. If the members are evenly divided, decide what is the stronger ove rall impression and answer accordingly. Remember, we would like to know what your fam ily seems like to you. So do not try to figure out how other members see your family, but do give us your general impression of your family for each statement. 1. Family members really help and support one another. 2. Family members often keep their feelings to themselves. 3. We fight a lot in our family. 4. We often seem to be killing time at home. 5. We say anything we want to around home. 6. Family members rarely become openly angry. 7. We put a lot of energy into what we do at home. 8. Its hard to blow off steam at home without upsetting somebody. 9. Family members sometimes get so angry they throw things. 10. There is a feeling of unity and cohesion in our family. 11. We tell each other abou t our personal problems. 12. Family members hardly ever lose their tempers. 13. We rarely volunteer when something has to be done at home. 14. If we feel like doing something on the spur of the moment we often just pick up and go. 15. Family members often criticize each other. True False O O O O O O O O O O O O O O O O O O O O O O True False O O O O O O O O O O

PAGE 78

78 16. Family members really back each other up. 17. Someone usually gets upset if you complain in our family. 18. Family members sometimes hit each other. 19. There is very little group spirit in our family. 20. Financial matters are openly discussed in our family. 21. If theres a disagreement in our family, we try hard to smooth things over and keep the peace. 22. We really get along well with each other. 23. We are usually careful about what we say to each other. 24. Family members often try to one-up or out-do each other. 25. There is plenty of time and attention for everyone in our family. 26. There are a lot of spontaneous discussions in our family. 27. In our family, we believe you dont ever get anywhere by raising your voice.

PAGE 79

79 APPENDIX D CES-D Directions: For the 20 items listed below, please fill in the answer that best describes how you have felt over the last week. It should look like this : Rarely or none (<1 day) Some or a little (1-2 days) Occasionally (3-4 days) Most or all of the time (5-7 days) 1. I was bothered by things that usually dont bother me. 2. I did not feel like eating; my appetite was very poor. 3. I felt that I could not shake off the blues even with the help from my family and friends. 4. I felt that I was not as good as other people. 5. I had trouble keeping my mind on what I was doing. 6. I felt depressed. 7. I felt that everything I did was an effort. 8. I felt hopeless about the future. 9. I thought my life had been a failure. 10. I felt fearful. 11. My sleep was restless. 12. I was unhappy. 13. I talked less than usual. 14. I felt lonely. 15. People were unfriendly. 16. I did not enjoy life.

PAGE 80

80 17. I had crying spells. 18. I felt sad. 19. I felt that people disliked me. 20. I could not get going.

PAGE 81

81 APPENDIX E M-C SDS-SF Directions : For each of the following statements, pl ease completely fill in the answer you consider to be True (T) or Fa lse (F). It s hould like this: True False 1. I never hesitate to go out of my way to help someone in trouble. O O 2. I have never intensely disliked anyone. O O 3. I sometimes feel resentful when I dont get my way. O O 4. I like to gossip at times. O O 5. There have been times when I fe lt like rebelling ag ainst people in authority even though I knew they were right. O O 6. I can remember playing sick to get out of something. O O 7. There have been occasions when I took advantage of someone. O O 8. Im always willing to admit it when I make a mistake. O O 9. I always try to practice what I preach. O O 10. I sometimes try to get even, rather than forgive and forget. O O 11. When I dont know something I dont at all mind admitting it. O O 12. I am always courteous, even to people who are disagreeable. O O 13. At times I have really insisted on havi ng things my way. O O 14. There have been occasions when I felt like smashing things. O O 15. I would never think of letting someone else be punished for my wrong-doings. O O 16. I never resent being asked to return a favor. O O 17. I have never been irked when people expressed ideas very different from my own. O O 18. There have been times when I was quite jealous of the good

PAGE 82

82 fortune of others. O O 19. I am sometimes irritated by people who ask favors of me. O O 20. I have never deliberately said something to hurt someones feelings. O O

PAGE 83

83 APPENDIX F INFORMED CONSENT ADULTS UF-IRB01 194-2003, RCHS 1266 Informed Consent to Ta ke Part in Research and Authorization for Collection, Use, and Disclosure of Protect ed Health Information (Parents/Caregivers CMS) You are being asked to take part in a research study. This form provides you with information about the study and seeks your authorization fo r the collection, use and disclosure of your protected health information necessary for the st udy. The Principal Inves tigator (the person in charge of this research) or a representative of the Principal Investigator will also describe this study to you and answer all of your questions. Be fore you decide whether or not to take part, read the information below and ask questi ons about anything you do not understand. Your participation is entirely voluntary. 1. Name of Parent/Caregiver Participant (please print): _____________________________________________________________ Last name First name Middle name 2. Title of Research Study The Childrens Health Self-Empowerment Project 3a. Principal Investigator and Telephone Number(s): Carolyn M. Tucker, Ph.D. University of Florida Distinguished Alumni Professor Professor of Psychology and Director of Training Professor of Pediatrics Professor of Community Health and Family Medicine 352-392-0601 Ext. 256 3b. Co-Investigator Sharon Surrency, RN, MPH Childrens Medical Services

PAGE 84

84 Executive Nursing Director, Gainesville/Ocala/Daytona/Jacksonville 4. Source of Funding or Other Material Support The State of Florida Department of Health, Division of Childrens Medical Services, is funding this research. 5. What is the purpose of this research study? The goal of this project is to teach young people ways to live mo re healthy lives. The project will involve both teen agers and their parents or gua rdians. The people who take part in the project will be African America n, Hispanic/Latino(a) American and Caucasian American. Teenagers who take part in the study will be patients at Childrens Medical Services (CMS). There will be about 270 teenag ers who will take part in this project. One parent or guardian will take part with each teenager, so there will be about 270 adults taking part in this project. Another goal of this project is to teach wa ys to live more healthy lives to a group of African American teenagers who took part in a neighborhood after school program. The teenagers parent or guardian will also take part. If these teenager s want to take part, they must tell us that they are overweight and/or have high blood pr essure. They might also say that their parent or guardian is ove rweight and/or has high blood pressure. There will be 25 teenagers and 25 adults in this group. The project will use 3 workshops to teach: 1. ways to eat healthier, ex ercise, and worry less. 2. ways to not fight, not use dr ugs and alcohol, and not have protected or unprotected sex. 3. ways to lose weight if they are overweight. 4. ways to lower their blood pressure if they have high blood pressure. 5. ways to lower their blood sugar levels if they have diabetes. The project will also ask teenagers who have CMS health care providers and their parents or guardians: 1. What behaviors and attitudes of their CMS Nurse Care Coordinators, doctors, nurses, a nd clinic staff can make them feel: a) more comfortable b) more respected c) more trusting 2. how the waiting room and doctors exam room of the clinic can make them feel: a) more comfortable b) more respected c) more trusting 6. What will be done if you take part in this research study? You are being invited to take part in this project because your child: 1. Is 12 to 17 years old. 2. Is a patient of Children s Medical Services (CMS).

PAGE 85

85 This project has two parts: Part I and Part II. If you want to take part in this project, you will be chosen for only one of the two parts. Here is what will happen in each of the two parts: Part I. If you are chosen to be in this part of the projec t, you will be asked to: 1. answer questions about your childs Nurs e Care Coordinator, doctors, nurses, and clinic staff. The questions will ask what these persons can do to make you feel: a) more comfortable b) more respected c) more trusting of them 2. rate how important some behavior s and attitudes are to make you feel : a) more comfortable b) more respected c) more trusting of them 3. answer some true or fals e questions about yourself It should take about one hour to answer all of these questions. Your name and your childs name will not be put on a ny of your answers to the questions that you are asked to fill out. Instead of us ing your name we will give you a code. We will write this code on all of the research forms to protect your privacy. None of your childs CMS Nurse Care Coordinators, docto rs, nurses, or clinic staff will see your answers These persons will also not be told if your family is taking part in the project. If you are chosen to take part in Part I, you will get a packet in about 3 weeks. You will be asked to fill out the forms a nd send them back to us in about 2 weeks. We will send the packet after we get your completed and signed Informed Consent Form. Once you finish the packet and send it to the CHSE research team you should get paid in about 3 weeks (go to item numb er 10 on page 8 to lear n about getting paid for taking part in this research ). The total time you could be asked to take part in this research is about 3 months. A person from the CHSE research team may call you if the packet is not completed and sent back to us in about 2 week s. This call will be made to make sure that you got the packet. You may also be called after you send your packet to us. A person from the CHSE research team may call you if some of the information is missing. When we call, if you do not want to answer the questions you do not have to. All information about you will be kept pr ivate. All information about you will be given a code to make this information privat e. Your name will be kept in a locked file cabinet in the Psycho logy building at the University of Florida. None of your childs CMS Nurse Care Coordinators, doctors, nurses, or clinic staff will be told if you are in this project. Part II: If you are chosen for this part of the project, you will be asked to: 1. take part in 3 health workshops. Each workshop will be about 4 hours long. The health workshops will teach you things like: how to have less family worry and sadness

PAGE 86

86 how to make and eat healthier food how to exercise more and worry less the risks of having unprotected a nd protected sex, and so on. You will be asked to take part in all of the works hop activities. You can choose not to take part in any activity that makes you feel uncomfortable. You can also choose not to finish any activity that you may have started. 2. answer some questions about things like: your health behaviors and beliefs how your family deals with worry and sadness if you have unprotected sex smoking drug use alcohol use violent behaviors if you have tried to kill yourself if you exercise what kinds of foods you eat how motivated you are whether some questions about you are true or false If you have problems or need help with th ese things, please talk to your doctor. We will not be able to help you. Your an swers to these questions will be kept private. It should take you about two hours to answ er all of the questions. You should take breaks when filling out the form s so that you do not get tired. Please try to work on the forms for only 45 mi nutes at a time. Then take at least a 2hour break before working some more on finishing the forms. Your name will not be put on any of the questions or forms you fill out Instead of using your name we will give you a code We will write this code on all of the forms that you fill out to protect you and your childs pr ivacy. None of your childs CMS Nurse Care Coordinators, doctors, nurses, or clinic staff, will see your answers. They will not be told if your family is taking part in the project. There will be 2 different groups in Part II. If you are chosen to take part in Part II, you will be put in only one of the groups. Part II Intervention Group o About 3 weeks after we get your co mpleted Informed Consent Form you will get your first packet of questionnaires and forms. o Once you finish the packet and send it to the CHSE research team you should get paid in about 3 weeks ( go to item number 10 on page 8 to learn about getting paid for ta king part in this research). o About 2 months later you will be asked to take part in the 3 workshops.

PAGE 87

87 o The 3 workshops will be about 3 weeks apart. Each workshop will be about 4 hours long. You should get pa id about 3 weeks after you go to the 3rd workshop (go to item number 10 on page 8 to learn about getting paid for taking part in this re search). You will need to go to all 3 workshops to get paid. o About 6 months after the 3rd workshop you will get your 2nd packet of questionnaires and forms. o Once you finish the packet and send it to the CHSE research team you should get paid in about 3 weeks ( go to item number 10 on page 8 to learn about getting paid for ta king part in this research). This means that if you are chosen to be in the Part II Intervention Group you would take part for about 9 months. Part II Control Group o About 3 weeks after we get your co mpleted Informed Consent Form you will get your first pack et of question forms. o Once you finish the packet and send it to the CHSE research team you should get paid in about 3 weeks ( go to item number 10 on page 8 to learn about getting paid for ta king part in this research). o About 9 months later you will get your 2nd packet of questionnaires and forms. o About 3 weeks later you will be asked to take part in the 3 workshops. o The 3 workshops will be about 3 weeks apart. Each workshop will be about 4 hours long. You should get pa id about 3 weeks after you go to the 3rd workshop (go to item number 10 on page 8 to learn about getting paid for taking part in this research). You will need to go to all 3 workshops to get paid. o About 6 months after the 3rd workshop you will get your 3rd packet of questionnaires and forms. o Once you finish the packet and send it to the CHSE research team you should get paid in about 3 weeks ( go to item number 10 on page 8 to learn about getting paid for ta king part in this research). This means that if you are chosen to be in the Part II Control Group you would take part for about 18 months. A person from the CHSE research team ma y call you if a packet is not sent back in about 2 weeks. This call will be made to make sure that you got the packet. You may also be called after you send a packet to us. A person from the CHSE research team may call you if some of the information is missing. When we call, if you do not want to answer the questions you do not have to. Lastly, a person from the CHSE research team may call to remind you about upcoming project activities. All information about you will be kept pr ivate. All information about you will be given a code. Your name will be kept in a locked file cabinet in the Psychology building at the University of Florida. None of your childs CMS Nurse Care Coordinators, doctors, nurses, or clinic sta ff will be told if you ar e in this project. 7. What are the possible discomforts and risks?

PAGE 88

88 If you want to take part in this research, there should be no physical or psychological risks to you. Some of the questions that will be asked may make you feel uncomfortable If you do feel uncomfortable, please feel free to sk ip the questions that caused this feeling. During the study we will tell you of any cha nges in the risk of you taking part in the research. We will also tell you about any info rmation that may change your wanting to take part in the study. If you want to talk about the information above or any worries you may have, please call the Principal Investigator of th e research, Dr. Carolyn M. Tucker. Dr. Tuckers phone number is (352) 392-0601 Ext. 256. 8a. What are the possible benefits to you? If you are chosen for Part I, there is no instant or direct benefit to you. If you are chosen for Part II, you may gain he lpful ways to make healthy life choices. Your family may gain from learning how to d eal with worries and di sputes better in the health workshops. 8b. What are the possible benefits to others? Your answers to the questions during the st udy will be joined with the answers of the other people in the study. When put together your answers may help other people. They may help teach teenagers and their parents or guardians ways to live healthier lives. Your answers may also help teach CMS Nurse Care Coordinators, doctors, nurses, and clinic staff helpful ways to give better health care to all of their patients. These results may also raise patients liking of the health care that they get. 9. If you choose to take part in this research study, will it cost you anything? No, this research will not cost your family any money. 10. Will you receive compensation for taking part in this research study? Yes. How much you will get paid depends on th e part of the study you take part in. You cannot choose the part of the study that you will take part in. The amount of money that will be paid to you (and your child) for taki ng part in the research study is explained below: 1) Each family (you and your child togethe r) in Part I who fill out and send back the question form packet will get a total of $20. 2) Each family (you and your child together) in Part II who is aske d to take part in the intervention group and who fill out and send back the question form packet will get $20. Each family is asked to do this 2 times for a total of $40. You will get another $40 for going to all 3 workshops So, each family in the intervention group will get a total of $80. 3) Each family (you and your child together) in Part II who is aske d to take part in the control group and who fill out and send back the question form packet will get $20. Each family is asked to do this 2 times for a total of $40. You will get another $40 for going to all 3 workshops. After the 3 workshops you will be asked to fill out and send back the question form packet a 3rd time. You will get an

PAGE 89

89 extra $10 for doing this. So, each family in the control group will get a total of $90. Please Note: You will not get paid for sending us back this Informed Consent Form and the Adult Information Questionnaire. The quest ion forms you will get paid for filling out will be sent to you after you agree to take part in the project. In order to pay you, we will have to give your name and social security number to the people at the University of Florida who wr ite the checks. They will also write down that you have been paid. You will get paid about 3 weeks after we get each of your packets. You will also get paid about 3 weeks after you go to all 3 workshops. If you stop taking part during the research study, you will only be paid for the parts that you took part in. 11. What if you are injured because of the study? If you get hurt as a direct result of this study, you can be seen by a professional consultant at the University of Florida Health Science Center free of charge. But, hospital bills will have to be paid by you or your insurance provider. No other payment for being injured is offered. 12. What other options or treatme nts are available if you do not want to be in this study? We do not know of any other options or treatme nts that are available to you if you do not want to be in this study. 13a. Can you withdraw from this research study? Yes, you may stop taking part in or decide not to take part in this study at any time. If you do choose to stop taking part in the middle of the study, you will not be punished your child will not be punished you will still be paid for the parts that you took part in If you decide to stop taking part in th e middle of the study for any reason, you should contact Dr. Tucker, the Principal Investigator, at (352) 392-0601 ext. 256. If you have any questions regarding your rights as a research subject, you may phone the Institutional Review Board (IRB) office at (352) 846-1494 or the Florida Department of Health Review Council for Human Subjects at (850) 245-4585, or toll free in Florida at (866) 433-2775. 13b. If you withdraw, can information about you still be used and/or collected? Yes. Any information collected about you can be used for further research purposes. Any information given directly to us by you can be used for further research purposes. Only information collected before your decision to no longer take part in this research study will be used. No further information will be collected after you decide to stop taking part in this research study.

PAGE 90

90 13c. Can the Principal Investigator wi thdraw you from this research study? Yes, we may not allow you to stay in the study if: 1) You do not return this Informed Co nsent Form (or contact the principal investigator) within two weeks of getting it. 2) You do not send us the question sheets we send you to fill ou t within two weeks of getting them. 3) You are sent to jail or prison for more than one month while you are in the study. 4) The Principal Investigator (Dr. Tucker) gives you a job while you are in the study. 5) You do not meet the rules for taking pa rt in the study. If you are not sure about these rules, please call the Principal Inve stigator (Dr. Tucker) at (352) 392-0601 Ext. 256. 6) The Principal Investigator (Dr. Tucker) or Co-Investig ator (Ms. Surrency) think that you might be hurt if you stay in the study. 7) The study is stopped by the State of Flor ida Department of Health and/or is stopped for other administrative reasons. 14. How will your privacy and the confidentiality of your protected health information be protected? To keep your privacy: your Informed Consent Forms which iden tify you will be separated from your Adult Information Questionnaire both will be locked in separate filing cab inets in the Psychology Building at the University of Florida. a 3-digit number code followed by a P for parent will be placed on your questionnaires in place of your name. the master-list that identifies you will be kept in a separate key-locked filing cabinet in Dr. Tuckers office in the Ps ychology Department at the University of Florida. If you take part in this research, your privat e health information will be collected, used, and shared under the terms speci fied in sections 15 below. 15. If you agree to participate in this research study, what protec ted health information about you may be collected, used and disclosed to others? To find out if you can be in the study, the following information may be collected, used, and shared with other Your name, address, and phone number (whi ch will not be shared with others) Your age and ethnicity Your answers to the questions that you will be asked to complete 16. For what study-related purpos es will your protected health information be collected, used and disclosed to others? No personal protected health information wi ll be given out. All of your information will be joined with other pe oples information. Your protec ted health information will be collected to make a general report. Your protected health information will be used to find out if you are eligible for our study. Your information added to information

PAGE 91

91 from others to report how useful the work shops are for helping people (teenagers and parents or guardians) with: o lowering blood pressure o lowering body weight o lowering blood sugar level o lowering drug use, violence, and unprotected sex in teenagers o helping people to exercise, eat healthy foods, and worry less. 17. Who will be authorized to collect, use and disclose to others your protected health information? Your private health information may be co llected, used, and shared with others by: Dr. Carolyn M. Tucker, Ms. Sharon Surre ncy, and Dr. Tuckers research staff (Dr. Frederic Desmond, Dr. Keith Herman, Christopher Mack, Kellie Hyde, Phyllis Ivery, Rachelle Stude r, and Cynthia Karlson) Other professionals at the University of Florida or Shands Ho spital that provide study-related treatment or procedures The University of Florida Institutional Review Board The Florida Department of Health Review Council for Human Subjects 18. Once collected or used, whom may your protected health information be disclosed to? Your protected health information may be given to: a. The Florida Department of Health Review Council for Human Subjects b. US and foreign governmental agencies w ho are responsible for overseeing research, such as the Food and Drug Administrati on, the Department of Health and Human Services, and the Office of Human Research Protections c. Government agencies who are responsible for overseeing publ ic health concerns such as the Centers for Disease Control and Fede ral, State and local health departments 19. If you agree to participat e in this research, how lo ng will your protected health information be collected, used and disclosed? Your private health information may be coll ected, used, and shared until the end of our study. The subject identifiers wi ll be removed at the end of the study and the information will be maintained in a secure database forever. 20. Why are you being asked to authorize the collect ion, use and disclosure to others of your protected health information? Under a new Federal Law, researchers cannot collect, use or shar e any of your private health information. Researchers must get you to allow them to do so by having you sign this consent form. 21. Are you required to sign this consent and authorization and allow the researchers to collect, use and disclose (giv e) to others of your protec ted health information? No. If you do not want them to get your private health information, do not sign this consent form. It will not change anything of yours outside of this research study. If you do not sign this consent, you ca nnot take part in the resear ch study. If you do not send this consent form back to us, you will not be contacted again.

PAGE 92

92 22. Can you review or copy your protected health information collected, used or disclosed under this authorization? Yes. You have the right to look at and c opy your private health information. But, you will not be allowed to do so until after the study is done. 23. Is there a risk that your protected health information could be given to others beyond your authorization? Yes. There is a small risk that informati on given to the researchers could be given to others. It would be outside of your control and not covered by the law. 24. Can you revoke (cancel) your authorization for collection, use and disclosure of your protected health information? Yes. You can stop allowing the collection, use, and sharing of your private health information at any time. It could be before, dur ing or after you take pa rt in the research. No new information will be collected about you after you tell us to stop. If information was already collected it may still be used a nd shared with others. You can tell the researchers to stop collecting information by writing to us and signing your name. 25. How will the researcher(s) benefi t from your being in this study? In general, doing research helps the career of a scientist. So, Dr Carolyn M. Tucker and her research team may benefit. They will benefit if the re sults of the study are shown at scientific meetings or in scientific journals. 26. Signatures As the Principal Investigator of this study, I have shared with you: the goals the things that you will have to do if you want to take part the possible benefits the risks of this research study the other options to being in the study how your private health information w ill be collected, used, and shared. ______________________________________________ _______ Carolyn M. Tucker, Ph.D. (Principal Investig ator) Date As the person who wants to take part in this study, you agree that you have been told about: the goals the things that you will have to do if you want to take part the possible benefits the risks of this research study the other options to being in the study how your private health information will be collected, used, and shared. You have been given the chance to ask ques tions before you sign. You have also been told that you can ask other questions at any time.

PAGE 93

93 You voluntarily agree to take part in this study. By signing this Form, you are allowing the collection, use, and sharing of your privat e health information. This is described in sections 15-24 above. By signing this Form you are not giving up any of your legal rights. __________________________________________ _________ Parent/Guardian Signature Date

PAGE 94

94 APPENDIX G ADOLESCENT ASSENT FORM You are being asked to take part in a research study. The goal of the project is to teach young people ways to live more healthy lives. The project will involve bot h teenagers and their parents (or guardians). There will be about 270 te enagers who will take part in this project. One parent or guardian must take part with each teenag er. Most of the teenagers who take part in this project will be patients at Childrens Medical Servi ces. To take part in this project you will need to be African American, Caucasian Ameri can, or Hispanic/Latino(a) American. Your parent must give permission for you to be in this study, but you can make up your own mind whether or not you wa nt to take part in it. 1. What is the name of the research project? The name of the project is the Childrens Health Self-Empowerment Project (CHSE). 2. Who is in charge of the project? Dr. Carolyn M. Tucker is in charge of the proj ect. Dr. Tucker works at the University of Florida. A group of university students help Dr. Tucker with the project. 3. Why are you being invited to ta ke part in this project? You are being invited to take pa rt in this project because you: 1. are 12 to 17 years old 2. are a patient of Childrens Medical Services 4. What will you be asked to do if you want to take part in this project? There are two parts of the project, Part I and Part II. You will be asked to take part in only one of the two parts of the project. You cannot choose which part you want to be in. Part I. If you are chosen to be in this part I of the project, you will be asked to: 1. answer questions about your Nurse Care Coordinator, doctors, nurses, and clinic staff. The questions will as k what they can do to make you feel: d) more comfortable e) more respected f) more trusting of them 2. rate how important some behaviors a nd attitudes are to make you feel: d) more comfortable e) more respected f) more trusting of them 3. answer some true or fa lse questions about yourself If you are chosen to take part in Part I, you will get a packet of question forms in about 3 weeks. We will send the question forms after we get your completed and signed Assent Form. You will be asked to fill out the forms and send them back to us in about 2 weeks. If you are chosen to be in Part I, you will be in the project for about 3 months. Part II: If you are chosen for this part of the project:

PAGE 95

95 1. You will be asked to take part in 3 health workshops. Each workshop will be about 4 hours long. The health workshops will teach you things like: to have less family worry and sadness how to make and eat healthier food how to exercise more and worry less the risks of having unprotected sex and protected sex, and so on. You will be asked to take part in all of the works hop activities. You can choose not to take part in any activity that makes you feel uncomfortable. You can also choose not to finish any activity that you may have started. 2. You will be asked to answer so me questions about things like: your health behaviors and beliefs how your family deals with worry and sadness if you have unprotected sex smoking drug use alcohol use violent behaviors if you have tried to kill yourself if you exercise what kinds of foods you eat how motivated you are whether or not some questions about you are true or false If you have problems or need help with th ese things, please talk to your doctor. We will not be able to help you. Your an swers to these questions will be kept private. There will be 2 different groups in Part II. If you are chosen to take part in Part II, you will be put in only one of the groups. Part II Intervention Group o About 3 weeks after we get your comple ted Assent Form you will get your first packet of question forms. o About 2 months later you will be asked to take part in the 3 workshops. At the workshops, trained nursing st udents will collect your height, weight, and blood pressure. o Each workshop will be about 4 hours long. o About 6 months after the 3rd workshop you will get your 2nd packet of question forms. o At this time you may be asked to go to your local Health Department or to a central location to have your height, weight, and blood pressure taken. This means that if you are chosen to be in the Part II Intervention Group you would take part in the pr oject for about 9 months. Part II Control Group o About 3 weeks after we get your comple ted Assent Form you will get your first packet of question forms.

PAGE 96

96 o At this time you may be asked to go to your local Health Department or to a central location to have your heig ht, weight, and blood pressure taken. o About 9 months later you will get your 2nd packet of question forms. o About three weeks later you will be asked to take part in the 3 workshops. At the workshops, trained nursing st udents will collect your height, weight, and blood pressure. o Each workshop will be about 4 hours long. o About 6 months after the 3rd workshop you will get your 3rd packet of question forms. o At this time you may again be as ked to go to your local Health Department or to a central location to have your height, weight, and blood pressure taken. This means that if you are chosen to be in the Part II Control Group you would take part in the project for about 18 months. 5. Will you get paid for taki ng part in this project? Yes. How much you will get paid depends on th e part of the study you take part in. You cannot choose the part of the study that you will take part in. The amount of money that will be paid to you and your parent or guardian for taking part in the research study is stated below: 1) Each family (your child and you together) in Part I that fills out and sends back the question forms we send you will get a total of $20. 2) Each family (you and your child togethe r) in the Part II in tervention group that fills out and sends back the question fo rms we send you will get $20. Each family is asked to fill out questions forms two tim es for a total of $40. Each family will get another $40 for going to all 3 works hops. So, each family in the Part II intervention group will get a total of $80. 3) Each family (you and your child together) in the Part II control group that fills out and sends back the question forms we send you will get $20. Each family is asked to fill out question forms two times for a total of $40. Each family will get another $40 for going to all 3 workshops. After the 3 workshops each family will be asked to fill out question forms a third time. Each family will get an extra $10 for doing this. So, each family in the Part II control group will get a total of $90. 4) Each child that goes to her or his local Health Department or a central location to have her or his height, weight, and blood pressure taken will be given a gift certificate to a local business Please Note: You will not get paid for sending us back this Informed Consent Form and the Adult Information Questionnaire. The question forms you will get paid for filling out will be sent to you after you ag ree to take part in the project. You will get paid about 3 weeks after we get each of your packets of question forms. You will also get paid about 3 weeks after you go to all 3 workshops. If you stop taking part during the research study, you will only be paid for the parts that you finished. 6. What information will we ask about you?

PAGE 97

97 If you are chosen to be in the project, we will need to get your grade poi nt average (GPA). We will get it from the school board where you go to school. By signing this form, you are telling us that it is okay to get your GPA. We will also ask Childrens Medical Services Nurse Care Coordinators to give us the following medi cal information from your Childrens Medical Services medical chart: medical diagnosis body weight height blood pressure blood sugar level only medications that you are ta king for your medical diagnosis your social security number (to check your grades) the name of your Nurse Care Coordinator. the name of your regular doctors clinic This is the only information about you that our research team w ill get from Childrens Medical Services. This information will be used for research reasons only. We will only get this information during the time the research st udy is going on. By signing this form, you are telling us that it is okay for us to get your medical information. 7. How long will it take to answer the questions in the packets we send to you? Part I: It should take you about one h our to answer all of these questions. Part II: It should take you about two hour s to answer all of the questions. You should take breaks when filling out the form s so that you do not get tired. Please try to work on the forms for only 45 minutes at a time. Then take at least a 2-hour break before working some more on finishing the forms. You should work on the question forms in a quiet place, away from other people. This is so that no one else will see your answers. That way you will be able to answer the questions honestly. 8. Will we call you during the project? A person from the research team may call you if you do not send a packet back to us within 2 weeks of getting it. This call will be made to make sure that you got the packet. You may also be called after you send a packet to us. A person from the CHSE research team may call you if some of the information is missing. When we call, if you do not want to answer the questions, you do not have to. Lastly, a pers on from the CHSE research team may call to remind you about upcoming project activities. 9. Will all of your information be kept private? Yes. All information about you and your pare nt or guardian will be kept private. All information about you will be given a code to make this information private. Your name will be kept in a locked file cabine t in the Psychology Building at the University of Florida. None of your CMS Nurse Care Coordinators, doctors, nur ses, or clinic staff will be told if you are in this project. 10. Tell us what you would like to do by puttin g an X in only one of the boxes below : I agree to take part in this study.

PAGE 98

98 I do not want to take part in this study. _________________________________________ __________ Print your name here Date ________________________________________ __________ Sign your name here Date

PAGE 99

99 APPENDIX H INVITATION LETTER Date: Dear Parent/Caregiver: Childrens Medical Services is supporting a new health impr ovement research project in which children and parents are being invited to pa rticipate. Dr. Carolyn M. Tucker, who works at the University of Florida, is leading the proj ect. Because our records show that one of your children has attended Childrens Medical Services within the past 3 months, we are inviting both you and your child to take part in the project. One of the major reas ons for this project is to teach children who have health problems (are overweight have diabetesalso called sugar, and/or have high blood pressure) how to live healthier lives. A nother reason for this project is to find out what you think your healthcare providers (docto rs, nurses, clinic staff, etc.) and Nurse Care Coordinators can do to make you feel more comfor table, feel more respected by them, and also feel more trusting of them. This information ma y help healthcare profes sionals give healthcare that is more satisfactory to you and your family. Please carefully read the Adult Informed C onsent Form and the Adolescent Informed Consent that was included in this mailing. Also have your child read the Adolescent Assent Form. These forms explain the project and what you and your child will be asked to do, if you choose to participate. Basically, if you and your child agree to participate, both of you will complete some questionnaires during the next 12 months. Some parents and children will also be asked to attend three health improvement workshops If you decide to partic ipate in the project, you will be paid for completing the questionnai res and/or for attending the workshops. The amount of pay is explained in the Informed Consent Forms. A parent or primary caregiver must particip ate with each child. Also, only one parent (or primary caregiver) and one child from each fa mily can take part in the project. If you do not wish to participat e, do not return the forms sent along with this letter. If you do not participate, the healthcare your child receives at Childrens Medical Services will not change in any way. In fact, the doctors, nurses, and office staff at Childrens Medical Services and at the clinics will not know if you and your child do or do not take part in this project. If you and your child would like to partic ipate, you should do the following: 1. Read the Adult Informed Consent Form a nd the Adolescent Informed Consent Form. 2. Print your full name on the first page of the Adult Informed Consent Form and the Adolescent Informed Consent Form (item number 1). 3. Sign BOTH of the Adult In formed Consent Forms and BOTH of the Adolescent Informed Consent Forms. 4. Complete the Payment Release Form (the last page of the Adult Informed Consent Form) and sign your name at the bottom of the page. 5. Keep one of the Adult Informed Consent Forms and one of the Adolescent Informed Consent Forms for your records and information. 6. Complete the Adult Information Questionnaire. 7. Put the Adult Information Questionnaire, one copy of the signed Adult Informed Consent Form (please do not tear off the Payment Release Form), and one copy of the signed Adolescent Informed Consent Form in one of the pre-stamped, pre-addressed envelopes. 8. Put this envelope in the mail. Now,

PAGE 100

100 1. Have your child read and sign his/her na me on BOTH of the Adolescent Assent Forms. 2. Have your child complete the Youth Information Questionnaire. 3. Your child should keep one of the Adolescen t Assent Forms for her or his records and information. 4. Have your child put the Youth Informa tion Questionnaire and ONE copy of the signed Adolescent Assent Form in the second pre-stamped, pre-addressed return envelope. 5. Put this envelope in the mail. NOTE: Please do not put your forms and your chil ds forms in the same envelope. Also, if you want to participate please make sure that you return these materials within 2 weeks. Within two months of sending us these mate rials, we will send your first packet of questionnaires (if you and your child are selected to take part in the project). If you move before you receive this first packet, or at any time duri ng the project, please call th e researchers at (352) 392-0601, Ext. 260 to give them your new address. During the whole project, we will make sure that your confidentiali ty is protected as much as possible. Also, no one at Childrens Me dical Services will see what you or your child writes on any of the questionnaires. If you have any questions about taking part in this research project, or would like the materials we have sent you in Sp anish, call the Principal Investigat or of the research, Dr. Carolyn M. Tucker, at (352) 392-0601, Ext. 260. Thank you for your time. We hope you will think about participating in this project. Sincerely, Arlan Rosenbloom, M.D. Gainesville/Ocala Medical Director, Childrens Medical Services

PAGE 101

101 APPENDIX I COVER LETTER (ADOLESCENT) Dear Adolescent Participant: This is your first packet of question forms for the Childrens Health Self-Empowerment Project. These question forms ask you and your primary parent/caregiver about things like health behaviors and beliefs, your famil y, stress (worry), sadness, and so on. It should take you about 45 minut es to finish these question forms. Please finish the question forms in a quiet place, away from others in your household. All information about you will be kept completely private. Your name will not be used on the question forms. In order to finish your part in this research project please: Finish the enclosed question forms Finish the Payment Release Form Return all of the forms by mail in the envelope provided Return all of the finished question forms within three weeks When you finish and return these question forms, your family (you and your primary parent/caregiver together) w ill get a payment of $20. If you have any questions about this resear ch project, please call a member of my research team at (352) 392-0601 ext. 256, or toll free at 1-866-290-5770 ext. 256. Thank you for taking part in the research project. Sincerely, Dr. Carolyn M. Tucker Distinguished Alumni Professor Professor of Psychology Professor of Pediatrics Professor of Community Health and Family Medicine

PAGE 102

102 APPENDIX J COVER LETTER (PRIMARY PARENT/CAREGIVER) Dear Primary Parent/Caregiver: This is your first packet of question forms for the Childrens Health Self-Empowerment Project. These question forms ask you and your child about things like health behaviors and beliefs, your family, stress (worry), sadness, and so on. It should take you and your child about 45 minutes to fill out these question forms. Please finish the question forms in a quiet place, away from others in your household. All information about you and your child will be kept completely private. Your name and your childs name will not be placed on the question forms. In order to finish your part in this research project please: Finish the enclosed question forms Finish the Payment Release Form Return all of the forms by mail in the envelope provided Return all of the finished question forms within three weeks When you finish and return these question forms, your family (you and your child together) will get a payment of $20. If you have any questions about this research project, pleas e call a member of my research team at (352) 392-0601 ext. 256, or toll free at 1-866-290-5770 ext. 256. Thank you for taking part in this research project. Sincerely, Dr. Carolyn M. Tucker Distinguished Alumni Professor Professor of Psychology Professor of Pediatrics Professor of Community Health and Family Medicine

PAGE 103

103 LIST OF REFERENCES Achenback, T., McConaughy, S., & Howell, C. (1987). Child/adolescent behavioral and emotional problems: Implications of cro ss-informant correlations for situational specificity. Psychological Bulletin, 101 213-232. Allgood-Merten, B., Lewinsohn, P. M., & Hops H. (1990). Sex difference and adolescent depression. Journal of Abnormal Psychology 99 55-63. Anderson, B. J., Vangsness, L., Connell, A., Butler D., Goebel-Fabbri, A., & Laffel, L. M. B. (2002). Family conflict, adhere nce, and glycaemic control in youth with short duration Type 1 diabetes. Diabetic Medicine, 19 (8), 635-642. Anderson, N. (Ed.). (2004). Encyclopedia of Health & Behavior (Vol.1 ). Thousand Oaks, California: Sage Publications. Angold, A., & Rutter, M. (1992). Effects of age and pubertal status on depression in a large clinical sample. Development and Psychopathology, 4, 5-28. Armdsen, G. C., McCauley, E., Greenberg, M. T., Burke, J. R. (2005). Parent and peer attachment in early adolescent depression. Journal of Abnormal Child & Adolescent Psychology, 18 (6), 1573-2835. Armstrong, G. D., Wirt, R. D., Nesbit, M. E ., & Martinson, I. M. (1982). Multidimensional assessment of psychological problems in children with cancer. Research in Nursing and Health, 5 205-211. Asarnow, R. J., Tompson, M., Woo, S. (2001). Is Expressed Emotion a Specific Risk Factor for Depression or a Nonspecific Correlate of Psychopathology? Journal of Abnormal Child Psychology, 29 (6), 573-583. Avison, W. R., & McAlpine, D. D. (1992). Gende r differences in symptoms of depression among adolescents. Journal of Health and Social Behavior, 33, 77-96. Barbarin, O. A., Whitten, C. F., & Bonds, S. M. (1994). Estimating rates of psychosocial problems in urban and poor chil dren with sickle cell anemia. Health & Social Work, 19 (2), 112-119. Bauman, L. J., Drotar, D., Leventhal, J. M., Perr in, E. C., & Pleass, I. B. (1997). A review of psychosocial interventions for childre n with chronic health conditions. Pediatrics, 100 (2), 244-251. Bender, B. G., Lerner, J. A., & Poland, J. E. (1991). Association between corticosteroids and psychologic change in hosp italized asthmatic children Annals of Allergy, 66, 414-419. Bennett, D. (1994). Depression amo ng children with chronic medica l problems: A meta-analysis. Journal of Pediatric Psychology, 19 (2), 149-169.

PAGE 104

104 Blacher, J. (1984). Sequential stages of parental adjustment to the birth of a child with handicaps: Fact or artifact? American Journal of Mental Deficiency, 89, 653-656. Bobrow, E. S., AvRuskin, T. W., & Siller, J. (1985). Mother-da ughter interaction and adherence to diabetes regimens. Diabetes Care, 8 (2), 146-151. Burke, P., Meyer, V., Kocoshis, S., Orenstein, D.M., Chandra, R., Nord, D.J., Sauer, J., & Cohen, E. (1989). Depression and anxiety in pediatric inflammatory bowel disease and cystic fibrosis. Journal of the American Academy of Child and Adoles cent Psychiatry, 28, 948-951. Canning, E. H, Canning, R. D., & Boyce, W. T. (1992). Depressive symptoms and adaptive style in children with cancer. Journal of the American Ac ademy of Child and Adolescent Psychiatry, 31, 1120-1124. Capelli, M., McGrath, P., Heick, C., McDonald, N. E., Felman, W., & Rowe, P. (1989). Chronic disease and its impact: The adolescents perspective. Journal of Adolescent Health Care, 10, 283-288. Carlson, C. I., Cooper, C., & Spradling, V. Y. (1991). Developmental implications of shared versus distinct perceptions of family in early adolescence. In R. L. Paikoff, (Vol. Ed.) & W. Damon (Editor-in-Chief). Shared views in the fam ily during adolescence, New directions for child development (Vol. 51, pp. 13-32). San Francisco, CA: Jossey-Bass. Carlton-Ford, S., Paikoff, R. L., Oakley, J., & Brooks-Gunn, J. (1996). A l ongitudinal analysis of depressed mood, self-esteem, and family processes during adolescence. Sociological Focus, 29, 135-154. Chen, E., Bloomberg, G. R., Fisher, E. B., & Strunk, R. C. (2003). Predictors of repeat hospitalization in children with asthma: The role of psychosocial and socioenvironmental factors. Health Psychology, 22 12-18. Chrisman, A., Egger, H., Compton, S. N., Cu rry, J., Goldston, D. B. (2006). Assessment of childhood depression. Child and Adolescent Mental Health, 11 (2), 111-116. Cicchetti, D., & Toth, S. L. (1998). The developm ent of depression in ch ildren and adolescents. The American Psychologist, 53 (2), 221-242. Cole, D. A., & McPherson, A. E. (1993). Relati on of family sub-systems to adolescent depression: Implementing a ne w family assessment strategy. Journal of Family Psychology, 7, 119-133. Cole, D. A., Nolen-Hoeksema, S. N., Girgus, J ., Paul, G. (2006). Stress exposure and Stress generation in child and adolescent depression: A latent trait-state-error approach to longitudinal analyses. Journal of Abnormal Psychology, 115 (1), 40-51.

PAGE 105

105 Crowe, M., Ward, N., Dunnachie, B., & Robert s, M. (2006). Character istics of adolescent depression. International Journal of Mental Health Nursing, 15, 10-18. Crowne, D. P., & Marlowe, D. (1960). A new s cale of social desirabi lity independent of psychopathology. Journal of Consulting and Clinical Psychology, 24 349-353. Cuffe, S. P., McKeown, R. E., Addy, C. L., & Garrison, C. Z. (2005). Family and psychosocial risk factors in a longitudinal epid emiological study of adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 44 (2), 121130. Davis, M. C., Tucker, C. M., & Fennel, R. S. (1996). Family behavior, adaptation, and treatment adherence of pediatri c nephrology patients. Pediatric Nephrology, 10 160-166. Dearing, E. (2004). The developmental implicat ions of restrictive and supportive parenting across neighborhoods and ethnicities. Applied Developmental Psychology, 25 555-575. Donnelly, E. (1994). Parents of children with as thma: An examination of family hardiness, family stressors, and family functioning. Journal of Pediatric Nursing, 9 (6) 398-408. Dunn, D. W., Austin, J. K., & Huster, G. A. (1999). Symptoms of depression in adolescents with epilepsy. Journal of the American Academy of Child & Adolescent Psychiatry. 38 (9), 1132-1138. Eiser, C. (1990). Psychological effects of chronic disease. Journal of Child Psychology and Psychiatry, 31 85-98. Eiser, C. (1993). Growing up with a chronic disease: Th e impact on children and their families. London: Jessica Kingsley. Elder, G. H., Eccles, J. S., Ardelt, M., & Lo rd, S. (1995). Inner-city parents under economic pressure: Perspectives on the strategies of parenting. Journal of Marriage and the Family, 57, 771-784. Engstrom, I. (1992). Mental hea lth and psychological functioni ng in children and adolescents with inflammatory bowel disease: A comp arison with children having other chronic illnesses with healthy children. Journal of Child Psychology and Psychiatry, 33, 563-582. Fendrich, M., Warner, V., & Weissman, M. M. (1990) Family risk factors, parental depression, and psychopathology in offspring. Developmental Psychology, 26, 40-50. Fleming, J. E., & Offard, D. R. (1990). Epid emiology of childhood depressive disorders: A critical review. Journal of the American Academy of Child and Adolescent Psychiatry, 34 29, 571-580.

PAGE 106

106 Folkman, S., & Lazarus, R. S. (1988). Coping as a mediator of emotion. Journal of Personality and Social Psychology, 54 (3), 466-475. Forehand, R., Brody, G., Slotkin, J., Fauber, R., McCombs, A., & Long, N. (1988). Young adolescent and maternal depression: Assessmen t, interrelations, and family predictors. Journal of Consulting and Clinical Psychology, 56, 422-426. Fowler, M. G., Johnson, M. P., & Atkinson, S. S. (1985). School achievement and absence in children with chronic health conditions. Journal of Pediatrics, 106 683-687. Fraboni, M., & Copper, D. (1989). Sic clusteri ng algorithms applied to the WAIS-R: The problem of dissimilar cluster results. Journal of Clinical Psychology 45 (6): 932-35. Frank, N. C., Blount, R. L., & Brown, R. T. ( 1997). Attributions, coping and adjustment in children with cancer. Journal of Pediatric Psychology, 22 563-576. Friedman, S., Wentzel, K. R., & Gehring, T. M. (1989). A comparison of the views of mothers, father, and pre-adolescents a bout family cohesion and power. Journal of Family Psychology, 3 39-60. Furstenberg, F. F., Cook, T. D., Eccles, J., Elder, G. H., & Sameroff, A. (1999). Managing to make it: Urban families and academic success. Chicago: University of Chicago Press. Gallo, A., & Knafl, K. (1998). Parents report s of tricks of the tr ade for managing childhood chronic illness. Journal of Pediatric Nursing, 3 93-102. Garber, J., Zeman, J., & Walker, L. S. (1990). Re current abdominal pain in children. Psychiatric diagnoses and parental psychopathology. Journal of the Americ an Academy of Child and Adolescent Psychiatry, 29, 648-656. Gaylord-Harden, N., Ragsdale, B., Mandara, J., Richards, M., & Petersen, A. (2007). Perceived support and internalizing symptoms in Afri can American Adolescents: Self-esteem and ethnic identity as mediators. Journal of Youth and Adolescence, 36 (1), 77-88. Ge, X., Lorenz, F. O., Conger, R. D., Elder, G. H., Jr., & Simons, R. L. (1994). Trajectories of stressful life events and depressi ve symptoms during adolescence. Developmental Psychology, 30, 467-483. Gil, K. M., Ginsberg, B., Muir, M., Sullivan, F. & Williams, D. A. (1992). Patient controlled analgesia: The relation of psychological factor s to pain and analgesic use in adolescents with postoperative pain. The Clinical Journal of Pain, 8 (3), 215-221. Glazer, N. Y. (1990). The home as workshop: Women as amateur nurses and medical care providers. Gender & Society, 4 479-499.

PAGE 107

107 Greenberger, E., Chen, C., Tally, S. R., & D ong, Q. (2000). Family, peer, and individual correlates of depressive symptomatol ogy among U.S. and Chinese adolescents. Journal of Consulting and Clinical Psychology, 68, 209-219. Greenberg, H. S., Kazak, A. E., & Meadows, A. T. (1989). Psychological functioning in 8to 16year-old cancer survivor s and their parents. Journal of Pediatrics, 114, 488-493. Grotevant, H. D., & Cooper, C. R. (1986). Individuation in family relationships: A perspective on individual differences in the developmen t of identity and role-taking skill in adolescence. Human Development, 29 82-100. Grych, J. H., & Fincham, F. D. (2001). Interparen tal conflict and child adjustment: An overview. In J. H. Grych, & F. D. Fincham (Eds.), Interparental conflict and child development: Theory, research, and applications (pp. 1-6). Cambridge, England: Cambridge University Press. Hamlet, K., Pellegrini, D., & Katz, K. (1992). Childhood chronic illness as a family stressor. Journal of Pediatric Psychology, 17, 33-47. Hankin, B. L., Abramson, L. Y., Moffitt, T. E., Silva, P. A., McGee, R., & Angell, K. E. (1998). Development of depression from preadoles cence to young adulthood: Emerging gender differences in a 10-year longitudinal study. Journal of Abnormal Psychology 107 128140. Harrington, R. (1992). Annotation: The natural hi story and treatment of child and adolescent affective disorders. Journal of Child Psychology and Psychiatry, 33 (8), 1287-1302. Hartup, W. W. (1989). Social relationships and their developm ental significance. American Psychologist, 11, 120-126. Harvey, D. M., & Bray, J. H. (1991). Evaluation of an intergen erational theory of personal development: Family process determinants of psychological and health distress. Journal of Family Psychology, 4, 293-325. Hayes, V. (1997). Families and childrens ch ronic conditions: Knowledge development and methodological considerations. Scholarly Inquiry in Nursing Practice, 11 259-290. Hayman, L. L., Mahon, M. M., Turner, J. R. (Eds.). (2002). Chronic Illness in Children: An Evidence-Based Approach. New York: Springer Publishing Company. Henggeler, S. W., Bourduin, C. M., & Mann, B. J. (1987). Intrafamily agreement: Association with clinical status, social desi rability, and obser vational ratings. Journal of Applied Developmental Psychology, 8, 97-111.

PAGE 108

108 Herman, K., Ostrander, R., & Tucker, C. M. (i n press). Do family environments and negative cognitions of adolescents with depre ssive symptoms vary by ethnic group? Journal of Family Psychology. Hill, J. P. (1988). Adapting to menarche: Familial control and conflict. In M. R. Gunnar, & W. A. Collins (Eds.), Development During the Transition to Adolescence (Vol. 21, pp. 4377). Hillsdale, N. J.: Lawrence Erlbaum Associates. Hill, R. B. (1998). Understanding black fa mily functioning: A holistic perspective. Journal of Comparative Family Studies, 29 1-11. Hill, S. A., & Zimmerman, M. K. (1995). Valiant girls and vulnerable boys: The impact of gender and race on mothers care giving for chronically ill children. Journal of Marriage and the Family, 57 43-53. Holden, E. W., Chmielewski, D., Nelson, C. C., Ka ger, V. A. & Foltz, L. (1997). Controlling for general and disease-specific effects in child and family adjustment to chronic childhood illness. Journal of Pediatric Psychology, 22 (1), 15-27. Holmbeck, G. N., & ODonnell, K. (1991). Disc repancies between perceptions of decision making and behavioral autonom y. In R. L. Paikoff (Ed.). New Directions for Child Development: Shared Views in the Family during Adolescence (no. 51, pp. 51-69). San Francisco: Jossey-Bass. Hood, K. K., Huestis, S., Maher, A., Butler, D ., Volkening, L., & Laffel, L. M. B. (2006). Depressive symptoms in children and adolescents with type 1 diabetes. Diabetes Care, 29 (6), 1389-1391. Hops, H. (1995). Ageand gender-specific eff ects of parental depr ession: A commentary. Developmental Psychology, 31 428-431. Hops, H., Lewinsohn, P. M., Andrews, J. A., & R oberts, R. (1997). Psychosocial correlates of depressive symptomatol ogy among high school students. Journal of Clinical Child Psychology, 19 211-220. Hostler, S. L. (1991). Family-centered care. Pediatric Clinics of North American, 38, 1545-1560. Huston, A. C., & Alvarez, M. M. (1990). The soci alization context of ge nder role development in early adolescence. In R. Montemajor G.R., Adams, & T.P. Gullota (Eds.), Advances in adolescent development: Vol. 2. From childhood to adolescence: A transitional period? (pp. 156-182). Newbury Park, CA: Sage. Jacobson, A. M., Hauser, S. T., Lavori, P., Willett, J. B., Charlotte, F. C., Wolfsdorf, J. I., Dumont, R. H., & Wertlief, D. (1994). Family environment and glycemic control: A four year prospective study of children and adol escents with insulin dependent diabetes mellitus. Psychosomatic Medicine, 56, 401-409.

PAGE 109

109 Jessop, D. J., Reissman, C. K., & Stein, R. E. K. (1988). Chronic childhood illness and maternal mental health. Journal of Developmental and Behavioral Pediatrics, 9, 147-156. Jessop, D. J., & Stein, R. E. K. (1985). Uncer tainty and its relation to the psychological correlates of chronic illness in children. Social Science and Medicine, 20, 993-999. Jones, C. J., & Costin, S. E. (1995). Frie ndship quality during preadolescence. In R. Montemayor, G. R., Adams, & T. P. Gullotta (Eds.), Advances in adolescent development: Vol 2. From childhood to adolescence: A transitional period? (pp. 156182). Newbury Park, CA: Sage. Kaplan, S. L., Busner, J., Weinhold, C. & Lenon, P. (1987). Depressive symptoms in children and adolescents with can cer: A longitudinal study. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 782-787. Kavanagh, K., & Hops, H. (1994). Good girls? Ba d Boys? Gender and development as contexts for diagnosis and treatment. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 16, pp. 45-79). New York: Plenum Press. Kazak, A. (1989). Families of chronically ill child ren: A systems and social-ecological model of adaptation and challenge. Journal of Consulting and Clinical Psychology, 57 25-30. Kellerman, J., Zeltzer, L., Ellenberg, L., Dash, J ., & Rigler, D. (1980). Ps ychological effects of illness in adolescence: I. Anxiety, self-esteem, and perception of control. Journal of Pediatrics, 97 127-131. Key, J. D., Brown, R. T., Marsh, L. D., Spratt, E. G., & Recknor, J. C. (2001). Depressive symptoms in adolescents with a chronic illness. Childrens Health Care, 30 (4), 283-292. Klinnert, M. D., McQuaid, E. L., McCormick, D ., Adinoff, A. D., & Bryant, N. E. (2000). A multimethod assessment of behavioral and emotional adjustment in children with asthma. Journal of Pediatrric Psychology, 25, 35-46. Kobak, R. R., Sudler, N., Gamble, W. (1991). Attachment and depres sive symptoms during adolescence: A developmental pathways analysis. Development and Psychopathology, 3 (4), 461-474. Koinis, M. D., Murdock, K. K., & Berz, J. B. (2002). Self-competence and coping in children with asthma. Childrens Health Care, 31 273-293. La Greca, A. M. (1990). Issues in adherence with pediatric regimens. Journal of Pediatric Psychology, 15 423-436. Lavigne, J. V., & Faier-Routman, J. (1992). Psyc hological adjustment to pediatric physical disorders: A meta-analytic review. Journal of Pediatric Psychology, 17, 133-157.

PAGE 110

110 Leadbeater, B., Blatt, S. J., & Quinlan, D. M. (1995). Gender-linked vulnerab ilities to depressive symptoms, stress, and problem behaviors in adolescents. Journal of Research on Adolescence, 5, 1-29. MacLean, W. E., Perrin, J. M., Gortmaker, S., & Pierre, C. B. (1992). Psychological adjustment of children with asthma: Effects of illness severity and recent stressful life events. Journal of Pediatric Psychology, 17, 159-171. Mahoney, G., OSullivan, P., & Robinson,C. (1992). The family environment of children with disabilities: Diverse but not so different. Topics in Early Childhood Special Education, 12 386-402. Main, M., & Hesse, E. (1990). Is fear the link betw een infant disorganized attachment status and maternal unresolved loss? In M. Greenberg, D. Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool years (pp. 161-182). Chicago: Univer sity of Chicago Press. Marmorstein, N. R., & Iacono, W. G. (2004). Ma jor depression and conduct disorder in youth: Associations with parental psychopa thology and parent-child conflict. Journal of Child Psychology and Psychiatry 45 377. Marteau, T. M., Bloch, S., & Baum, J. D. (1987). Family life and diabetic control. Child Psychology and Psychiatry, 28, 823-833. Mastroyannopoulou, K., & Stallard, P. (2001). The impact of childhood non-malignant lifethreatening illness on parents: Gender differences and predicto rs of parental adjustment. Journal of Child Psychology and Psychiatry and Allied Disciplines, 38 (7), 823-829. Mastroyannopoulou, K., Stallard, P., Lewis, M ., & Lenton, S. (1997). The impact of childhood non-malignant life threatening illness on parent s: Gender differences and predictors of parental adjustment. Journal of Child Psychology and Psychiatry, 38, 823-829. McNelis, A. M., Huster, G. A., Michel, M., Ho llingsworth, J., Eigen, H., Austin, J.K. (2000). Factors associated with self-c oncept in children with asthma. Journal of Child and Adolescent Psychiatric Nursing, 13 55-68. Meeus, W., Iedema, J., Maassen, G., & Engels, R. (2005). Separation-indivi duation revisited: on the interplay of parent-adolescent relations, identity, and emotional adjustment in adolescence. Journal of Adolescence, 28 (1), 89-106. Meijer, A. M., & Oppenheimer, L. (1995) The excitation-adaptation model of pediatric chronic illness. Family Process, 34 (4), 441-454. Michael, M. (2002). Scope and impact of pediatric asthma. Nurse Practitioner, (June), 3-7.

PAGE 111

111 Miller-Johnson, S., Emery, R. E., Marvin, R. S., Clarke, W., Lovinger, R., & Martin, M. (1994). Parent-child relationships and the management of insulin-dependent diabetes mellitus. Journal of Consulting and Clinical Psychology, 62, 603-610. Montemayor, R. (1983). Parents and adolescents in conflict: All families some of the time and some families most of the time. Journal of Early Adolescence, 3, 83-103. Montemayor, R., & Flannery, D. J. (1991). Pare nt-adolescent relations in middle and late adolescence. In R. M. Lerner, A. C. Peresen, & J. Brooks-Gunn (Eds.) Encyclopedia of adolescence (Vol. 2, pp. 729-734). New York: Garland. Moos, R. H. (2002). Life stressors, social resources, and coping sk ills in youth: Applications to adolescents with chronic disorders. Journal of Adolescent Health, 30S 22-29. Moos, R. H., Cronkite, R. C., & Moos, B. (1998) The long-term interplay between family and extrafamily resources and depression. Journal of Family Psychology, 12 (3), 326-343. Moos, R. H., & Moos, R. B. (1986). Family Environment Scale manual (2nd ed.) Palo Alto, CA: Consulting Psychologists Press. Moos, R. H., & Moos, R. B. (1994). Family Environment Scale manual (3rd ed.) Palo Alto, CA: Mind Garden. Morgan, S. A., & Jackson, J. (1986). Psychological a nd social concomitants of sickle cell anemia in adolescents. Journal of Pediatric Psychology, 11 429-440. Mrazek, D. A. (1994). Chronic pedi atric illness and multiple hospita lizations. In M. Lewis (Ed.), Child and adolescent psychiatr y: A comprehensive textbook (pp. 1041-1050). Baltimore, MD: Williams & Wilkins Co. National Center Health Statistics (1988). U.S. National Health Interview Survey on Child Health (AFDA Data Set No. 33-34) Hyattsville, MD. Noller, P., & Callan, V. J. (1986). Adolescent an d parent perceptions of family cohesion and adaptability. Adolescence, 9 97-196. Noller, P., Seth-Smith, M., Bouma, R., & Sc hweitzer, R. (1992). Parent and adolescent perceptions of family functioning: A comparison of clinic and nonclinic families. Journal of Adolescence, 15, 101-114. Offord, D. R., Boyle, M. H., & Racine, Y. ( 1989). Ontario Child Health Study: Correlates of disorder Journal of the American Academy of Child and Adolescent Psychiatry, 28 856860.

PAGE 112

112 Ohannessian, C. M., Lerner, R. M., Lerner, J. V., & von Eye, A. (1995). Discrepancies in adolescents and parents perceptions of family functioning and adolescent emotional adjustment. Journal of Early Adolescence, 15, 490-516. Olsson, C. A., Poyce, M. F., Toumbourou, J. W., Sa wyer, S. M. (2005). The role of peer support in facilitating psychosocial adjustment to chronic illness in adolescence. Clinical Child Psychology & Psychiatry, 10 (1), 78-87. Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.). St. Louis: Mosby. Oyemade, U. J., & Rosser, P. L. (1980). Development in black children. Advances in Behavioral Pediatrics, 1 153-179. Paikoff, R. L., Calton-Ford, S., & Brooks-Gunn, J. (1993). Mother-daughter dyads view the family: associations between divergen t perceptions and daughter well-being. Journal of Youth and Adolescence, 22 (5), 473-492. Pelton, J., & Forehand, R. (2001). Discrepancy between mother and child perception of their relationship: I. Consequences for adolescents considered within the context of parental divorce. Journal of Family Violence, 16, 1-15. Pender, N. J. (1996). Health Promotion in Nursing Practice (3rd Ed.). Stamford, CT: Appleton & Lange. Perrin, E. C., Ayoub, C. C, & Willet, J. B. (1993) In the eyes of the beholder: Family and maternal influences on perceptions of adjust ment of children with a chronic illness. Journal of Developmental and Behavioral Pediatrics, 14, 94-105. Petersen, A. C., Compas, B. E., Brooks-Gunn, J., Stemmler, M., Ey, S., & Grant, K. E. (1993). Depression in adolescence. American Psychologist 48 155-168. Pollack, S. E. (1993). Adaptation to chronic illness: A program of research for testing nursing theory. Nursing Science Quarterly, 6, 86-92. Quittner, A. L., DiGirolamo, A. M., Michel, M., & Eigen, H. (1992). Parental response to cystic fibrosis: A contextual analys is of the diagnosis phase. Journal of Pediatric Psychology, 17 (6), 683-704. Radcliffe, J. R., Bennett, D., Kazak, A., Foley, B, & Phillips, P. C. (1996). Adjustment in childhood brain tumor survival: Child, mother, and teacher report. Journal of Pediatric Psychology, 21, 529-539. Radloff, L. S. (1977). The CES-D scale: A self-report depression sc ale for research in the general population. Applied Psychological Measurement, 1 385-401.

PAGE 113

113 Rait, D. S., Ostroff, J. S., & Smith, K. (1992). Lives in a balance: Perceived family functioning and the psychosocial adjustment of adolescent cancer survivors. Family Process, 31 (4) 383-397. Raymer, D., Weininger, O., & Hamilton, J. R. (1 984). Psychological problems in children with abdominal pain. The Lancet, 8374 439-440. Rearson, M. A., Urban, A., Baker, L., McBride, J., Tuttle, A., & Jaward, A. (2000). Assessing parental concerns of children with diabetes. Nurse Practitioner Forum, 11, 20-25. Reichenberg, K., & Broberg, A. G. (2005). Childre n with asthma. Few adjustment problems are related to high perceived parental capacity and family cohesion. Nordic Journal of Psychiatry, 59 13-18. Renouf, A., & Kovacs, M. (1994). Concordance between mothers report and ch ildrens selfreports of depressive sy mptoms: A longitudinal study. Journal of American Academy of Child and Adolescent Psychiatry, 33 208-216. Reyes, A., & Kazdin, A. (2006). Informant discrepa ncies in assessing child dysfunction relate to dysfunction within mother-child interactions. Journal of Child and Family Studies, 15 (5), 643-661. Richardson, R. A., Galmbos, N. L., Schulenbe rg, J. E., & Peterson, A. C. (1984). Young adolescents perceptions of the family environment. Journal of Early Adolescence, 4, 131-153. Rodenburg, R., Meijer, A. M., Dekovic, M., & Al denkamp, A. P. (2005). Family factors and psychopathology in children with ep ilepsy: A literature review. Epilepsy and Behavior, 6, 488-503. Roder, I., Kroonenberg, P. M., & Boekaerts, M. (2003). Psychosocial functioning and stressprocessing of children with asthma in the sc hool context: Differences and similarities with children without asthma. Journal of Asthma, 40 777-787. Rubin, C., Rubenstein, J. L., Stechler, G., H eeren, T., Halton, A., Housman, D., & Kasten, L. (1992). Depressive affect in normal adolescen ts: Relationship to life stress, family, and friends. American Journal of Orthopsychiatry, 62, 430-441. Rutter, M. (1986). The developmental psychopathol ogy of depression: Issues and -perspective. In M. Rutter, C. E. Izard, & P. B. Read (Eds.). Depression in young people: Developmental and clinical perspectives (pp. 3-32). New York: Guilford Press. Sagrestano, L. M., Holmbeck, G. N., Paikoff, R. L., & Fendrich, M. (2003). A longitudinal examination of familial risk factors for depression among inner-city African American adolescents. Journal of Family Psychology, 17 (1), 108-120.

PAGE 114

114 Sandler, I. N., Reynolds, K. D., Kliewer, W., & Ramirez, R. (1992). Specificity of the relation between life events and psychological symptomatology. Journal of Pediatric Psychology, 16 463-474. Sanford, M., Szatmari, P., Spinner, M., Munroe-B lum, H., Jamieson, E., Walsh, C., & Jones, D. (1995). Predicting the one-year course of adolescent major depression. Journal of the American Academy of Child and Adolescent Psychiatry, 34 1618-1628. Sanger, M. S., Copeland, D. R., & Davidson, E. R. (1991). Psychosocial adjustment among pediatric cancer patients: A multidimensional assessment. Journal of Pediatric Psychology, 16 463-474. Sawyer, M. G., Reynolds, K. E., Couper, J. J., French, D. J., Kennedy, D., Martin, J., Staugas, R., & Baghurst, P. A. (2005). A two-year pr ospective study of the health-related quality of life of children with chronic-il lness the parents perspective. Quality of Life Research, 14 395-405. Seigel, W. M., Golden, N. H., Gough, J. W., La hley, M. S., & Sacker, I. M. (1990). Depression, self-esteem, and life events in ad olescents with chronic diseases. Journal of Adolescent Health Care, 11 501-504. Shasha, M., Lavigne, J., Lyons, J., Pongracic, J., & Martini, D. (1999). Mental health and service use among children with asthma: Results from a tertiary care center. Childrens Service: Social Policy, Research, and Practice, 2 (4), 225-243. Sheeber, L., Hops, H., Alpert, A., Davis, B., & Andrews, J. (1997). Family support and conflict: Prospective relations to adolescent depression. Journal of Abnormal Child Psychology, 25 (4), 333-344. Sheeran, T., Marvin, R. S., & Pianta, R. C. (1997) Mothers resolution of their childs diagnosis and self-reported measures of parenting st ress, marital relations and social support. Journal of Pediatric Psychology, 22 197-212. Shulman, S., Seiffge-Krenke, I., & Samet, N. ( 1987). Adolescent coping style as a function of perceived family climate. Journal of Adolescent Research, 2, 367-381. Simmons, R. J., Corey, M., Cowen, L., Keenan, N., Robertson, J., & Levinson, H. (1985). Emotional adjustment of early adolescent with cystic fibrosis. Psychosomatic Medicine, 47, 111-122. Slavin, L. A., & Rainer, K. (1990). Gender diffe rences in emotional support and depressive symptoms among adolescents: A prospective analysis. American Journal of Community Psychology, 18 407-421. Smetana, J. G. (1988). Concepts of self and social convention: Adolescents and parents reasoning about hypothetical and actual family conflicts. In Gunnar M., and Collins,

PAGE 115

115 W.A. (Eds.), Development During Transition to Adolescence: Minnesota Symposia on Child Psychology, Vol.21, Lawrence Erlbaum Associates, Hillsdale, N.J. Snethen, J. A., Broome, M. E., Kelber, S., & Wa rady, B. A. (2004). Coping strategies utilized by adolescents with end-stage renal disease. Nephrology Nursing Journal, 31 (1), 41-49. SPSS, Inc, (2001). SPSS for Windows, Rel. 11.01. Chicago: Author. Stark, K. D., Humphrey, L. L., Crook, K., & Lewis, K. (1990). Perceived family environments of depressed and anxious children: Children s and maternal figures perspectives. Journal of Abnormal Child Psychology, 18, 527-547. Stehbens, J. A., Kisker, C. T., & Wilson, B. K. (1983). School behavior and attendance during the first year of treatment for childhood cancer. Psychology in the Schools, 20, 223-228. Steinberg, L. D. (1990). Autonom y, conflict, and harmony in the family relationship. In S. S. Feldman & G. R. Elliot (Eds.), At the threshold: Th e developing adolescent (pp. 225276). Cambridge, M.A.: Harvard University Press. Steinberg, L. D. (1991). Parent-adolescent relations In R. M. Lerner, A. C. Petersen, & J. Brooks-Gunn (Eds.), Encyclopedia of adolescence (pp. 724-728). New York: Garland. Stone, L. (1994, November). Family values in a historical perspective. Paper presented at the Tanner lectures on human values, delivere d at Harvard University, Boston, MA. Strahan, R., & Gerbasi, K. C. (1972). Short, homogeneous versions of the Marlowe-Crowne social desirability scale. Journal of Clinical Psychology, 28 (2), 191-93. Tein, J. Y., Roosa, M. W., & Michaels, M. (19 94). Agreement between parent and child reports on parental behaviors. Journal of Marriage and Family, 56 341-355. Thompson, R. J., & Gustafson, K. E. (1996). Adaptation to chronic childhood illness. Washington, DC: American Psychological Association. Thompson, R. J., Jr., Gustafson, K. E., Hamle tt, K. W., & Spock, A. (1992). Psychological adjustment of children with cystic fibrosis : The role of child cognitive processes and maternal adjustment. Journal of Pediatric Psychology, 17 741-755. Thompson, R. J., Jr., Hodges, K., & Hamlett, K. W. (1990). A matched comparison of adjustment in children with cystic fibrosis and psychiatrically re ferred and non-referred children. Journal of Pediatric Psychology, 15 745-759. Thompson, K. L., Varni, J., W., & Hanson, V. (1987). Comprehensive assessment of pain in juvenile rheumatoid arthritis: An empirical model. Journal of Pediatric Psychology, 12 (2), 241-255.

PAGE 116

116 Timko, C., Stovel, K. W, Moos, R. H., & Miller, J. J. (1992). Adaptation to juvenile rheumatic disease: A controlled evaluation of func tional disability with a one-year follow-up. Health Psychology 11 67-76. U.S. Department of Health and Human Services (1999). Mental health: A report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Service. Varni, J. W., Katz, E. R., Colegrove, R., & Do lgrin, M. (1996). Family functioning predictor of adjustment in children with newly di agnosed cancer: A prospective analysis. Journal of Child Psychology and Psychiatry, 37 321-328. Wade, S., Weil, C., Holden, G. Mitchell, H. Evans, R., & Kruszon-Moran, D. (1997). Psychosocial characteristics of inner-city children with asthma: A description of the NCICAS psychosocial protocol. Pediatric Pulmonology, 24 263-276. Walker, L. S., Greene, J. W., Garber, J., Hor ndasch, R. L., Barnard, J., & Ghishan, F. (1993). Psychosocial factors in pediatric abdomina l pain: Implications for assessment and treatment. The Clinical Psychologist, 46, 206-213. Wallander, J. L., & Thompson, R. J., Jr. (1995) Psychosocial adjustment of children with chronic psychical conditions. In M.C. Roberts (Ed.), Handbook of Pediatric Psychology (2nd ed., pp. 124-141). New York: Guilford Press. Wambolt, M., Fritz, G., Mansell, A., McQuaid, E., & Klein, R. (1998). Re lationship of asthma severity and psychological problems in children. Journal of the Academy of Child and Adolescent Psychiatry, 37 (9), 943-950. Weissman, M. M., Wolk, S., Goldstein, R. B., Mo reau, D., Philip, A., Greenwald, S., Klier, C. M., Ryan, C. M., Ryan, N. D., Dahl, R. E., & Wickramaratne, P. (1999). Depressed adolescents grown up. Journal of the Americ an Medical Association 281 1701-1713. Wight, R. G., Sepulveda, J. E., & Aneshensel C. S. (2003). Depres sive symptoms: How do adolescents compare with adults? Journal of Adolescent Health, 34( 4), 314-323. Williamson D. S. & Bray, J. H. (1988). Family development change across the generations: An intergenerational perspectiv e. In C. J. Falicov (Ed.) Family transitions: Continuity and change over the life cycle (pp. 43-71). New York: The Guilford Press. Windle, M. (1992). A longitudinal study of stress buffering for adolescent problem behaviors. Developmental Psychology, 28, 522-530. Wong, M., & Csikszentmihalyi, M. (1991). Affilia tion motivation and daily experience: Some issues on gender differences. Journal of Personality and Social Psychology, 60 154-164. Yeo, M., Sawyer, S.M. (2003). Strategies to promote better outcomes in young people with chronic illnesses. Annals Academy of Medicine, 32, 36-42.

PAGE 117

117 Zahr, L. K., Khoury, M., & Saoud, N. B. (1994). Chronic illness in Lebanese preschoolers: Impact of illness and child temperament on the family. American Journal of Orthopsychiatry, 64, 396-403.

PAGE 118

118 BIOGRAPHICAL SKETCH Natalia Maria Aristizabal was born in Medelli n, Colombia. At age six, her family moved to Miami, Florida, where her family still resides. After graduating from Gulliver Preparatory, Natalia attended and graduated from Fashion In stitute of Technology with a Bachelor of Fine Arts degree in antique restor ation. Upon graduation, she worked as an antique restorer and conservator for several years be fore enrolling in postbaccalau reate classes in psychology at Hunter College City University of New Yo rk. She was accepted to the counseling psychology program at the University of Florida in 2004.