Parent Anxiety and Child Psychopathology: A Longitudinal Study of Children with Physical Illness

Abstract

Estimates suggest that one in four children live with a chronic physical illness (CPI), such as arthritis, asthma, and diabetes. Children with CPI are vulnerable to developing psychopathology, known as multimorbidity. Approximately 40% of children with CPI experience multimorbidity, which is associated with lower self-esteem, poorer health-related quality of life, and a greater risk of substance use and suicidality. These negative outcomes may be a consequence of the substantial illness-related stress and uncertainty experienced by children with CPI and their families. To mitigate the compounding effects of child multimorbidity, it is essential to prioritize the health of these children by providing comprehensive, evidence-based healthcare services. However, doing so requires a deeper understanding of child multimorbidity, particularly in the family context. Beyond the affected child, parents of these children are likely to experience greater anxiety, resulting from managing CPI-related practical and emotional strains. This added stress and anxiety experienced by caregiving parents is posited to strengthen the association between parent and child mental health. Indeed, parent psychopathology has been identified as a key determinant of child multimorbidity; thus, efforts to improve the mental health of parents, in addition to the child, are paramount.

Although there is consensus in the literature regarding the risk of children with CPI to developing multimorbidity, several knowledge gaps remain. Studies on child multimorbidity are predominantly illness specific, cross-sectional, and have short follow-up periods. Moreover, few studies have examined anxiety trajectories among parents of children with CPI, and the intersection between parent anxiety and child psychopathology. Although a handful of studies in non-clinical samples have explored associations between parent anxiety and child psychopathology, this knowledge is unlikely to generalize to the unique circumstances of childhood CPI. Accordingly, the aim of this dissertation was to obtain a more robust understanding of child multimorbidity, parent anxiety, and the complex association between parent anxiety and child psychopathology in this population. Opportunities to improve child and parent mental health via tailored, integrated, and family-centered approaches are emphasised.

This dissertation is comprised of three distinct longitudinal studies which examined the onset of child multimorbidity, trajectories of parent anxiety, and the association between parent anxiety and psychopathology among children with CPI. Specific objectives were to: 1) evaluate child multimorbidity onset; 2) identify multimorbidity risk factors; 3) delineate trajectories of parent anxiety; 4) identify predictors of parent anxiety trajectories; 5) quantify the association between parent anxiety and child psychopathology; and 6) assess parenting stress and family functioning as moderators of this association. Data for this dissertation come from the Multimorbidity in Children and Youth across the Life-course (MY LIFE) study, a prospective cohort study of 263 children with CPI and their parents, who were followed for 48 months.

The first study utilized survival analysis to determine that over the 48-month follow-up, 64% of children experienced multimorbidity (i.e., internalizing or externalizing psychopathology). Internalizing psychopathology was associated with greater child disability, older child age, and younger parent age, while the emergence of externalizing psychopathology was associated with male child sex and greater parent psychopathology symptoms. These findings suggest that a large proportion of children with CPI will develop multimorbidity and illustrates that multimorbidity onset is nuanced. Specifically, internalizing and externalizing psychopathologies were associated with distinct profiles of children. Findings highlight the importance of integrated physical and mental healthcare services to support the mental health of children with CPI.

The second study examined the 48-month trajectories and predictors of parent anxiety symptoms using latent class growth modelling. Four trajectories of parent anxiety were identified: minimal, mild, moderate, and high. Approximately 40% of parents had persistent, moderate or high anxiety. Risk factors for less favourable anxiety trajectories were greater depression symptoms, higher educational attainment, having a female child, and having a child with multimorbidity. Results suggested that parents of children with CPI are at-risk of persistent anxiety, and parent- and child-related variables were associated with poorer anxiety trajectories. Because parents are responsible for the care of their children, promoting parental mental health is essential to ensure their well-being and that of their children. These findings garner support for greater refinement of pediatric healthcare services to be more family-centered and include strategies to promote the mental health of parents caring for children with CPI.

The third study used linear mixed-effects modelling to examine associations between parent anxiety and child psychopathology. Results indicated that greater parenting anxiety was associated with greater child internalizing and externalizing symptoms over 48-months. Product-term interactions suggested that parenting stress and family functioning moderated the association between parent anxiety and child internalizing symptoms, while only family functioning moderated the association with externalizing symptoms. Results demonstrate the link between parent anxiety and child multimorbidity, and underscore the importance of evaluating parent anxiety, stress, and family functioning to support child mental health. These findings illustrate that to effectively manage the health of children with CPI, implementing evidence-based healthcare services which are family-centered must be prioritized.

Knowledge from this dissertation addresses critical gaps in the understanding of child CPI, including multimorbidity onset, parent anxiety, and the association between parent anxiety and child psychopathology over time. Findings from this research reinforce that children with CPI and their parents face ongoing risk of psychopathology. Moreover, parent anxiety is associated with child multimorbidity, and family environmental factors likely influence this association. This research highlights five salient opportunities to refine pediatric healthcare: 1) early and routine mental health surveillance among children with CPI; 2) integrated physical and mental health services; 3) prioritizing family-centered care strategies; 4) targeted screening and interventions for at-risk subpopulations of children and parents; and 5) evidence-based interventions tailored to the unique experiences of children with CPI. Additional longitudinal studies are needed to explicate causal mechanisms which underpin the association between parent anxiety and child psychopathology, particularly among these vulnerable families. Providing comprehensive and integrated healthcare will help to reduce the incidence of multimorbidity and ensure the best possible outcomes for children with CPI and their parents.