Overprotective and Overcontrolling Parenting

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OVERPROTECTIVE AND OVERCONTROLLING PARENTING

OF EMERGING ADULT SURVIVORS OF CHILDHOOD CANCER:

LINKS TO COPING STYLES, ANXIETY, AND DEPRESSION

Amanda Katherine Sherman

A thesis submitted in conformity with the requirements

for the degree of Doctor of Philosophy

Graduate Department of Psychology

University of Toronto

Overprotective and Overcontrolling Parenting of Emerging Adult Survivors of Childhood

Cancer: Links to Coping Styles, Anxiety, and Depression

Amanda Katherine Sherman

Doctor of Philosophy

Graduate Department of Psychology

University of Toronto

2015

Abstract

The goals of this study were, in a sample of emerging adult survivors of childhood cancer, 1) to compare levels of psychological distress with general population norms, 2) to examine the association between overprotective parenting and psychological distress, 2) to differentiate between maternal overprotection and maternal overcontrol, and 3) to uncover mechanisms linking overprotective parenting to psychological distress, including the assessment of emerging adults’ coping styles and perceptions of their mothers’ overprotective parenting.

Participants were 109 emerging adult survivors of childhood cancer, ranging in age from

18 to 30 years (M = 23 years; 60% female). Ninety of the emerging adults’ mothers also participated in this research. Survivors were recruited from the waiting room of The Pediatric

Cancer AfterCare Clinic at Princess Margaret Cancer Centre in Toronto, Canada. Emerging adults and their mothers provided ratings of mothers’ overprotective and overcontrolling parenting practices on the Overparenting of Emerging Adults Scale (OPEAS), a measure

designed for this study. Emerging adults’ coping styles and symptoms of anxiety and depression were also assessed.

Factor analysis of the OPEAS revealed seven overparenting subscales; four subscales conceptually similar to the construct of overprotection: infantilization, medical management, parenting anxiety, and harm reduction, and three subscales conceptually similar to the construct of overcontrol: problem solving intervention, intrusive decision making, and discounting of opinions/ideas. Nearly half of the sample reported clinically significant levels of anxiety symptoms, although levels of clinically significant depression symptoms did not differ from general population norms. Further analyses revealed that mother-reported overprotective practices of infantilization and parenting anxiety were indirectly related to emerging adults’ anxiety and depression symptoms through serial multiple mediation, and that the mother- reported overcontrolling practice of intrusive decision making was indirectly related to depression symptoms through serial multiple mediation. Specifically, the mediators were emerging adults’ perceptions of the overparenting and emerging adults’ nonproductive coping style. The theoretical and practical implications of these findings are discussed in terms of the relations of overprotective and overcontrolling parenting to emerging adults’ mental health, and importance of the socialization of coping.

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Acknowledgements

I would first like to thank the research participants. Many of you told me that, as patients of the Princess Margaret, you are used to volunteering your time, information, and sometimes even tissue to help scientists better understand cancer survivorship. Your contributions to my research are deeply appreciated, and I hope that the findings benefit you in some way.

Thank you to the undergraduate research assistants who spent many hours working on various aspects of this study. Vicky Zasowski, Becky Crawford, Rebecca Zhu, and Mary Anne

Perta, you went above and beyond. I really do not know what we would have done without you.

The Pediatric Oncology Group of Ontario (POGO) was incredibly generous in providing financial support for this research. Thank you also to their staff and my fellow research fellows.

Joan Grusec, my mentor and faculty supervisor, when I began graduate school I couldn’t believe my luck in being accepted by one of the most renowned experts in our field. That feeling has not faded. I treasure the wealth of skills and knowledge that you have taught me, and I am so grateful for your unwavering commitment to my training, development, and well being. I will truly miss being a member of your lab, but I look forward to our continued collaboration.

Thank you to my committee members, David Haley and Tina Malti. Your time and attention to my work, including your enthusiasm, insights, expertise, and kindness, have been invaluable. Thank you also to my final oral exam committee members, Judith Andersen, Mary

Gick, and Charles Helwig. Norma D’Agostino, you have been intimately involved in this research since day one; you have opened doors and provided your unique and valuable perspective. Thank you for taking me on as an inexperienced practicum student years ago, giving me the opportunity to become inspired by survivors of childhood cancer.

To my friends in psychology, Lisa Lipschitz, Sarah Spence, Caitlin Burton, Justin

McNeil, Megan Johnston, Julia Vinik, Suzanne Robinson, and more recently, Tanya Danyliuk,

Hali Kil, and David O’Neill. What a collection of brilliant and compassionate minds. I marvel at all that you have accomplished, and all that you will go on to achieve in our exciting field. Maria

Paula Chaparro–my partner in crime–every aspect of our work on this study, across many years, has always been better because we have done it together. You’ve taught me more than I care to admit about teamwork, problem solving, and stress management. My lifelong colleague and friend, you are a truly special person.

To my friends outside of psychology, Kate Hunter and Erick Duan, Heather Bragg and

Andrew Beck, Kelly Hunt, Erin Styles, and Cassel Busse. At various points along this journey you’ve been my closest friends and housemates. I can always depend on you to turn a bad day around, and to make even the worst setbacks seem manageable. I deeply value your friendship, and hope that we will continue to support each other through life’s challenges.

McKinley Raham, my partner and best friend, thank you for your amazing ability to help keep me mindful. Through being with you I have learned about all of the meaningful rewards that can come from pursuits outside of work. Your calming presence and thoughtful advice have been a tremendous help in this final phase of my degree. Wherever I go, there you are.

Patti Sherman and Paul Sherman–Mom and Dad–after studying parenting for seven years, I have come to the conclusion that I won the lottery. There is more to thank you for than I can express, so I will just say that I have tremendous gratitude for all that you have done for me, and all that you continue to do. There is so much to admire about you both. Thank you for helping me get to where I am today. This thesis is dedicated to you.

Table of Contents

Abstract ...... ii

Acknowledgements ...... iv

Table of Contents ...... vi

List of Tables ...... x

List of Figures ...... xi

List of Appendices ...... xii

Introduction ...... 1 Psychosocial Development in Emerging Adulthood ...... 2 Parental Overprotection ...... 4 Overprotection of children with illnesses...... 5 Overprotection and psychological distress in children with illnesses...... 6 Overprotection of emerging adults...... 8 Limitations of Current Parental Overprotection Research ...... 9 Domains of socialization...... 11 A new measure of overprotection and overcontrol (overparenting) for emerging adult survivors of childhood cancer...... 13 How Does Overparenting Relate to Psychological Distress? ...... 14 Coping with distress...... 14 The importance of coping abilities...... 16 The development of coping abilities...... 16 Emerging Adults’ Perceptions of Parental Overparenting Versus Mothers’ Reports ...... 19 Summary of the Present Study, Research Questions, and Hypotheses ...... 21 Research questions and hypotheses...... 22

Method ...... 23 Participants ...... 23 Procedure ...... 29 Measures ...... 31

Demographics...... 31 Overparenting...... 31 Psychological distress...... 33 Depression...... 33 Anxiety...... 34 Coping style...... 35

Results ...... 37 Preliminary Analyses ...... 38 Descriptive statistics...... 38 Data screening...... 38 Comparison of participants with participating and nonparticipating mothers...... 39 Development and Psychometric Properties of the Overparenting of Emerging Adults Scale (OPEAS) ...... 40 Factor analysis...... 40 Emerging adult-reported items...... 40 Mother reported-items...... 44 Computing factor scores...... 48 Psychological Distress in Emerging Adult Survivors of Childhood Cancer ...... 49 Research question 1: How do levels of psychological distress in emerging adult survivors of childhood cancer compare with general population norms? ...... 49 Depression...... 49 Anxiety...... 49 Summary...... 50 Research question 2: How do mother-reported levels of overparenting compare in emerging adults who score above and below clinical cutoffs for psychological distress? ...... 51 Depression...... 51 Anxiety...... 51 Summary...... 52 Research question 3: How do perceived levels of overparenting compare in emerging adults who score above and below clinical cutoffs for psychological distress? ...... 52 Depression...... 52

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Anxiety...... 53 Summary...... 54 The Effect of Overparenting on Coping Style ...... 55 Research question 4: Does mother-reported overparenting predict the use of productive coping styles and a nonproductive coping style? ...... 55 Dealing with the problem...... 56 Sharing...... 56 Optimism...... 56 Nonproductive...... 56 Summary...... 56 Perceptions of Overparenting and Nonproductive Coping as Mediators of The Influence of Overparenting on Psychological Distress ...... 62 Research question 5: Is the effect of overparenting on anxiety symptoms mediated by emerging adults’ perceptions of overparenting and nonproductive coping? ...... 64 Overprotection - Infantilization...... 66 Overprotection - Medical management...... 66 Overprotection - Parenting anxiety...... 66 Overprotection - Harm reduction...... 67 Overcontrol - Intrusive decision making...... 68 Overcontrol - Discounting of opinions/ideas...... 68 Overprotection summary...... 68 Overcontrol summary...... 69 Research question 6: Is the effect of overparenting on depression symptoms mediated by emerging adults’ perceptions of overparenting and nonproductive coping? ...... 69 Overprotection - Infantilization...... 72 Overprotection - Medical management...... 72 Overprotection - Parenting anxiety...... 72 Overprotection - Harm reduction...... 73 Overcontrol - Problem solving intervention...... 73 Overcontrol - Intrusive decision making...... 74 Overcontrol - Discounting of opinions/ideas...... 74

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Overprotection summary...... 75 Overcontrol summary...... 75

Discussion ...... 76 Psychological Distress in Emerging Adult Survivors of Childhood Cancer ...... 76 Anxiety and depression symptoms...... 76 Overparenting and survivors’ psychological distress...... 79 Mother-reported overparenting...... 79 Emerging adult-reported overparenting...... 79 The Effect of Overparenting on Coping Style ...... 81 Perceptions of Overparenting and Nonproductive Coping as Mediators of The Influence of Overparenting on Psychological Distress ...... 84 Strengths and Contributions ...... 94 Limitations and Future Directions ...... 97 Conclusion ...... 100

References ...... 101

Appendices ...... 116

List of Tables

Table 1. Demographics of Emerging Adults ...... 26

Table 2. Demographics of Mothers ...... 27

Table 3. Cancer Demographics of Emerging Adults ...... 28

Table 4. Descriptive Statistics for Study Variables from Previously Validated Measures ...... 38

Table 5. Maternal Overprotection Measure, Emerging Adult Version (N = 109) ...... 42

Table 6. Maternal Overcontrol Measure, Emerging Adult Version (N = 109) ...... 43

Table 7. Maternal Overprotection Measure, Mother Version (N = 90) ...... 46

Table 8. Maternal Overcontrol Measure, Mother Version (N = 90) ...... 47

Table 9. Descriptive Statistics for the OPEAS Factor Scores ...... 48

Table 10. Intercorrelations among Mother-Reported Overparenting and Emerging-Adult Coping

Styles ...... 55

Table 11. Summary of Linear Regression Analyses for the Prediction of Dealing with the

Problem Coping Style from Mother-Reported Overparenting ...... 58

Table 12. Summary of Linear Regression Analyses for the Prediction of Sharing Coping Style

from Mother-Reported Overparenting ...... 59

Table 13. Summary of Linear Regression Analyses for the Prediction of Optimism Coping Style

from Mother-Reported Overparenting ...... 60

Table 14. Summary of Linear Regression Analyses for the Prediction of Nonproductive Coping

Style from Mother-Reported Overparenting ...... 61

Table 15. Intercorrelations among Variables of Interest ...... 62

List of Figures

Figure 1. Statistical diagram of serial multiple mediation model 1, anxiety symptoms as outcome

...... 65

Figure 2. Statistical diagram of serial multiple mediation model 2, depression symptoms as

outcome ...... 71

List of Appendices

Appendix A. Emerging Adult Participants’ Recruitment Script …………………………... 117

Appendix B. Emerging Adult Participants’ Consent Form ………………………………... 118

Appendix C. Template for First Email to Emerging Adult Participants …………………... 122

Appendix D. Template for First Letter to Emerging Adult Participants …………………... 123

Appendix E. Template for Second Email to Emerging Adult Participants ………………... 124

Appendix F. Template for Second Letter to Emerging Adult Participants ………………... 125

Appendix G. Mother Participants’ Consent Form and Instructions …………...... 126

Appendix H. The Overparenting of Emerging Adults Scale (OPEAS) …………………… 129

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Overprotective and Overcontrolling Parenting of Emerging Adult Survivors of Childhood

Cancer: Links to Coping Styles, Anxiety, and Depression

The recent, dramatic decline in mortality rates of individuals diagnosed with childhood cancers can be considered one of modern medicine’s greatest successes. For those diagnosed prior to age 15, the average 5-year survival rate has shifted from less than 50% in 1975 to 82% in

2008, and is now as high as 99% for some forms of cancer (Canadian Cancer Society’s Steering

Committee on Cancer Statistics, 2011). Today, most children diagnosed with cancer overcome their illness, and in developed nations approximately 1 in 1,000 individuals is a survivor of childhood cancer (Ries et al., 2008).

This large cohort of survivors now living as adults has allowed for in-depth research on the long-term health effects of undergoing cancer treatment as a child. Indeed, the medical community has been alarmed by the discovery that approximately one-third of survivors will develop one or more serious or life threatening sequelae of their cancer treatment (Canadian

Cancer Society/National Cancer Institute of Canada, 2008). Accordingly, much of recent childhood cancer research has focused on identifying, preventing, and repairing survivors’ physical and neurocognitive long-term effects (for a review, see Ness & Gurney, 2007). A growing consensus in survivor care, however, indicates that the psychosocial consequences of childhood cancer are as much a central issue as medical sequelae (see Nathan, Hayes-Lattin,

Sisler, & Hudson, 2011). The smaller field of psychosocial development answers important questions about survivors’ psychological well-being and social and emotional development across the lifespan.

Experiencing cancer in childhood or adolescence can markedly affect psychosocial development. Diagnosis and treatment directly overlap with formative periods of physical

1 2 maturity, emotional development, and crucial life experiences (Stam, Grootenhuis, & Last,

2005). Cancer involves hospitalization and surgery, physical pain, fatigue, disruptions to life and daily activities, appearance changes, functional limitations, altered relations with friends and family, and confrontation of mortality (Rowland, 1993). In comparison to healthy children, those with cancer are more dependent on adults, and have fewer normative opportunities to interact with same-aged peers (Spirito et al., 1990; Strax, 1991). Family functioning is also greatly influenced by childhood cancer (Kazak et al., 2006). Childhood cancer, therefore, can threaten the course of psychosocial development, and in particular, the accomplishment of healthy, normative developmental tasks.

The primary aim of this study is to investigate one particular indicator of family functioning in emerging adult survivors of childhood cancer, the experience of overprotective parenting, and its impact on survivors’ psychological health. The main questions addressed by this research include: a) are overprotective parenting practices related to psychological distress symptoms in a sample of emerging adult survivors of childhood cancer? and b) what mechanisms link overprotective parenting practices to psychological distress in this population?

Psychosocial Development in Emerging Adulthood

Emerging adulthood is a developmental period that spans the late teens to the mid-to-late twenties, capturing the increasingly prolonged transition from adolescence to adulthood, and extended parental involvement, that occurs in postindustrial societies (Arnett, 2000; Nelson et al., 2007). Emerging adulthood is a self-focused time of identity exploration. It is a stage of life that is full of possibilities, but also involves much instability and uncertainty. Autonomy is a central developmental task during this period, as individuals gradually learn independence in decision-making and finances, take on adult roles and responsibilities, and commit to stable

3 romantic partners, employment, and places of residence (Arnett, 2007). From a medical standpoint, the onset of emerging adulthood also corresponds with the transition from child to adult care.

Compared with adolescents, emerging adult survivors of childhood cancer have a greater cognitive capacity and readiness to understand the impact of their illness–retrospectively, currently, and prospectively. During this stage, life domains of educational attainment, employment, intimacy, marriage, and fertility become increasingly relevant. However, emerging adult survivors of childhood cancer achieve fewer milestones with respect to psychosocial development, both in comparison with healthy peers and with other disease groups (Stam,

Grootenhuis, & Last, 2005; Stam, Hartman, Deurloo, Groothoff, & Grootenhuis, 2006). In particular, childhood cancer survivors are at an increased risk of academic failure, and are less likely than the general population to be employed and married (Gurney et al., 2009). It is clear that psychosocial development in emerging adulthood is impacted by the experience of childhood cancer.

Some research indicates that clinical levels of psychological distress, including depression and anxiety, are approximately twice as prevalent in emerging adult survivors of childhood cancer than in their siblings (Zeltzer et al., 2009). Other research has shown that, whereas cancer survivors generally display worse psychological health than their siblings, survivors’ symptoms of psychological distress are still lower than the general population averages (Zeltzer et al.,

2008). More studies of psychological outcomes in emerging adult survivors of childhood cancer are warranted, and in particular, the effect of poor psychosocial development on levels of psychological distress in this population is not well understood. In addition, although parents are clearly present and important in the lives of emerging adults, the role of parents in the

4 psychosocial development of emerging adult survivors of childhood cancer has not been the focus of empirical research.

Parental Overprotection

Protection of one’s offspring is a crucial feature of successful parenting. Children seek out their caregivers in times of real or potential threat, and caregivers, in turn, typically provide support. Parents who respond appropriately to their child’s needs for protection foster a sense of security, allowing the child to feel comfortable enough to independently explore his or her world

(Ainsworth, Blehar, Waters, & Wall, 1978). In its most extreme form, however, parental protection can reach a level that is excessive and inappropriate for a child’s developmental stage and abilities. This has been labeled parental overprotection (Thomasgard, Metz, Edelbrock, &

Shonkoff, 1995). Overprotective parenting practices are typically characterized by extended infantilization, excessive physical or social contact, separation problems, encouragement of dependence, anxiety in the parenting role, and issues with control involving either an overindulgent permissiveness or an authoritarian excess (Levy 1931; Levy, 1970; Thomasgard &

Metz, 1993).

Research overwhelmingly indicates that overprotective parenting is a risk factor for children’s development and can contribute to psychological distress. In their meta-analysis of 47 studies testing the association between parenting and children’s anxiety disorders, McLeod,

Wood, and Weisz (2007) reported a strong influence of overinvolvement, defined as parental interference with children’s autonomy and emotional independence, boundary problems, restrictiveness, and encouragement of dependence on parents. In addition, adults who retrospectively reported that their mothers were overprotective were more likely to be diagnosed with anxiety and mood disorders (Enns, Cox, & Clara, 2002), and in a sample of clinically

5 depressed patients, parental overprotection was associated with trait depression, longer duration of depressive episodes, trait anxiety, neuroticism, and (negatively with) self-esteem (Parker,

1979). Individuals diagnosed with panic disorder, agoraphobia, social anxiety disorder, and specific phobia were all more likely to report maternal overprotective behavior than controls

(Silove, Parker, Hadzi-Pavlovic, Manicavasagar, & Blaszczynski, 1991; Heider et al., 2008).

There is also strong support for a link between what has been termed oversolicitous parenting and children’s development of shyness in early childhood. Oversolicitous mothers are warm and intrusively involved in their toddler’s activities, while being (paradoxically) insensitive and unresponsive to the cues and needs of their child. Oversolicitous mothers’ inappropriate use of positive parenting practices, therefore, teaches children that unfamiliar situations are threatening. Indeed, research has found that children of oversolicitous mothers were more withdrawn and inhibited with unfamiliar peers and adults than toddlers of mothers who were not oversolicitous (Rubin, Hastings, Stewart, Henderson, & Chen, 1997). Shyness in children of oversolicitous mothers persisted over time, across early childhood (Rubin, Burgess,

& Hastings, 2002; Degnan, Henderson, Fox, & Rubin, 2008) and from middle childhood to early adolescence (Kennedy, Root, & Rubin, 2009). Extant empirical research clearly indicates that overprotective parenting, and related constructs, has negative psychological and psychosocial consequences for children, with the potential for these outcomes to persist into adulthood.

Overprotection of children with illnesses. Parents of chronically or critically ill children are especially vulnerable to overprotective behaviors (Cappelli, McGrath, MacDonald,

Katsanis, & Lascelles, 1989; Davies, Noll, DeStefano, Bukowski, & Kulkarni, 1991; Holmbeck et al., 2002; Thomasgard, Shonkoff, Metz, & Edelbrock, 1995). Childhood illnesses, like all illnesses, require extensive medical management and care, though it is not always appropriate or

6 reasonable to expect children to manage these responsibilities independently. It is therefore adaptive for parents to increase their levels of protection to some degree in order to facilitate effective treatment and aftercare of their child’s illness. This protective behavior can also become problematic, however. When parents of ill children develop unnecessary or excessive levels of protective behavior, this is a form of overprotection that Anderson and Coyne (1991) label miscarried helping. Well-intentioned protective behavior, therefore, becomes overprotective behavior when the parent’s concern for the child’s health becomes more important than, and interferes with, the parent’s responsibility to socialize the child’s autonomy development.

A small literature exists on overprotective behavior in parents of children being treated for and having survived cancer. Survivors ages 14 to 23 were more likely than healthy controls to retrospectively report that their mothers and fathers were overprotective during treatment

(Pelcovitz et al., 1998). In qualitative research on changes in the caregiving role as a result of childhood cancer, main themes expressed by parents were the risk of spoiling while supporting and the risk of overprotecting while being careful with the child. Parents also exhibited uncertainty about limit setting and making demands on the child (Norberg & Steneby, 2009;

Freeman, O’Dell, & Meola, 2000). Indeed, mothers and fathers of children being actively treated for cancer were significantly more likely to report that they spoiled their children than parents of healthy children were (Hillman, 1997). Pediatric oncology professionals have also reported that parents of children with cancer spoiled their children more than parents of children who did not have cancer (Long et al., 2014). This limited but specific evidence for pediatric cancer is consistent with theories and research on the overprotective parenting behavior of parents of children with other serious illnesses.

Overprotection and psychological distress in children with illnesses. It is well established that parents of children with illnesses, including cancer, asthma, diabetes mellitus type 1, cystic fibrosis, and juvenile rheumatoid arthritis, display overprotective behaviors (see

Hullmann, Wolfe-Christensen, Ryan, et al., 2010; Power, Dahlquist, Thompson, & Warren,

2003). Given the adaptive significance of this overprotection, however, are these behaviors as harmful for children’s psychological and psychosocial development as they are in healthy populations? There is some evidence that parental overprotection of children with illnesses other than cancer has deleterious effects on development. In children with spina bifida, maternal overprotection has been associated with externalizing symptoms, depression, and lower perceived self-competence for appropriate behavioral conduct (Holmbeck et al., 2002). Maternal overprotection has also been linked with poor psychosocial functioning in children with cystic fibrosis, when compared with healthy controls (Cappelli, McGrath, MacDonald, Katsanis, &

Lascelles, 1989). However, a study of children with diabetes mellitus type 1 with mild to moderate disease severity did not find a link between mothers’ overprotective parenting and children’s depressive symptoms (Mullins et al., 2004).

Like other disease groups, research on the effects of parental overprotection on children’s psychosocial development in the childhood cancer population is extremely scarce.

Overprotection has been linked with children’s poorer health-related quality of life, an effect that was mediated by the child’s perceived vulnerability (Hullmann, Wolfe-Christensen, Meyer,

McNall-Knapp, & Mullins, 2010). Colletti and colleagues (2008) did not find an association between parental overprotection and children’s adjustment, although perceived child vulnerability and parenting stress during cancer treatment contributed to poorer emotional, social, and behavioral outcomes. However, in a longitudinal extension of this research, maternal

8 overprotection of children being treated for cancer significantly predicted children’s internalizing symptoms one to two years later (Fedele, Mullins, Wolfe-Christensen, & Carpentier, 2011).

Overprotection of emerging adults. To date, parents’ overprotective parenting practices concerning their emerging adult children has not been the subject of empirical study. The term helicopter parenting, however, originated in popular culture (Gibbs, 2009; Bips et al., 2010;

Nelson, 2010) and is beginning to be used in research1 to describe parents of emerging adults who are overly concerned about well-being and success, leading to inappropriate parenting behaviors (Padilla-Walker & Nelson, 2012). Helicopter parenting differs from the construct of parental overprotection because it includes more of an element of overcontrol, while not always involving the excessive care of overprotection; helicopter parents are achievement-oriented and interfere in their emerging adults’ decisions, difficulties, and opportunities.

The findings of preliminary research examining the effects of helicopter parenting on development have been mixed. While there is some evidence that university students who experienced helicopter parenting were less engaged in academics, those students also reported relationships with their parents characterized by guidance, disclosure, and emotional support

(Padilla-Walker & Nelson, 2012). Others have found that helicopter parenting was associated with less open and more problematic parent-child communication, as reported by parents and emerging adults, as well as emerging adults’ greater sense of entitlement. This research did not find any links between helicopter parenting and emerging adults’ self-efficacy, emotional intelligence, or positive relations with others (Segrin, Woszidlo, Givertz, Bauer, & Murphy,

2012). Thus, while helicopter parenting may not be especially destructive, there is growing consensus that it limits emerging adults’ opportunities to practice autonomy and independence,

1 Segrin and colleagues (2012; 2013) prefer the term overparenting to the more colloquial helicopter parenting. Their definition includes parental overinvolvement, risk aversion, preoccupation with the emerging adult’s happiness, and a drive to solve the emerging adult’s problems.

9 and is therefore not conducive to developmental growth (Padilla-Walker & Nelson, 2012; Segrin et al., 2012).

Limitations of Current Parental Overprotection Research

The most popular measure of parental overprotection is the Parental Bonding Instrument

(PBI; Parker, Tulping, & Brown, 1979), which includes a 13-item subscale of children’s perception of overprotective parenting in their first 16 years of life. Issues with this measure include its retrospective nature and broad span of measurement, giving no weight to variations in parental attitudes and behaviors that undoubtedly occur over different phases in childhood and adolescence. The authors assume that overprotective parents maintain a general pattern of overprotectiveness across development, although they acknowledge that this has not been empirically tested (Parker, 1998). Construct validity is also a concern. While all of the

“protection” items load on a single factor, it can be argued that this factor measures other parenting behaviors in addition to protective behavior. The authors use the titles control and protection interchangeably for this subscale, and the items, “Tried to control everything I did”, and “Let me dress in any way I pleased”, for example, are clearly measuring controlling rather than protective behaviors.

The second leading measure of parental overprotection is the Parent Protection Scale

(PPS; Thomasgard, Metz, et al., 1995), developed specifically to measure parental overprotection in the context of child vulnerability to illness or injury. The PPS is a 28-item parent-report scale with four subscales: supervision, separation problems, dependence, and control. While the PPS is a measure of current behavior and is more specific than the PBI about the timeframe of measurement, it still shares the PBI’s critical flaw; the construct validity of this measure is compromised by the inclusion of a “control” dimension in the measurement of overprotective

10 parenting behavior. It is therefore apparent that neither of the existing measures of

“overprotection” adequately measure the construct of overprotective parenting.

The lack of a definitive definition of and method with which to measure the parental overprotection construct is a major concern for the ability to conduct valid and reliable research on the subject. Indeed, Thomasgard and Metz (1993) express unease about the lack of clarity in the dimensions of parental overprotection, with terms such as overindulgent, oversolicitous, overprotective, and overanxious being used interchangeably in the literature. Holmbeck and colleagues (2002) contend that the construct of overprotection overlaps with that of psychological control, sharing some attributes (e.g., intrusiveness), but not all. In research examining associations between parenting style and children’s development of anxiety, the construct of “control” has been defined with features such as a pattern of excessive regulation of children’s activities and routines, autocratic decision making, overprotection, and/or instruction to children on how to think and feel (Barber, 1996; Steinberg, Elmer, & Mounts, 1989). Here, overprotection is subsumed under the construct of control. Furthermore, helicopter parenting, a practice involving emerging adult children, is often conceptualized as an elder cousin to overprotection, yet is dissimilar on many levels. The major concern with this lack of clarity in definition is that both overprotective and overcontrolling parental behaviors have been considered overprotective, yet the antecedents and consequences of such behaviors may be quite different. In the present study, then, we propose to develop a clearer measure of overprotection and overcontrol. When the two constructs are discussed collectively, the term overparenting will be used. In this way, we aim to recognize the commonalities between overprotective and overcontrolling parenting practices, while making a clear distinction between the two constructs.

Domains of socialization. The importance of distinguishing between protective and controlling parenting behaviors in the measurement of overprotection becomes clear when one considers the type and purpose of interactions that occur in the different domains of socialization

(for a review of the domain-specific approach to socialization, see Grusec & Davidov, 2010;

Grusec, 2011). When parent-child dyads operate in the protection domain, appropriate parenting involves responding to a distressed child in a manner that the child perceives to be comforting or helpful. The mechanism of socialization here is the child’s confidence that the caregiver will be available in times of need. Indeed, attachment theory (Bowlby, 1958; Ainsworth, 1985) is based on the principle that, depending on how sensitively, appropriately, and promptly mothers respond to their infants’ signals for attention and comfort, individuals develop an internal working model that influences how they think about themselves and others in their close relationships. In contrast, appropriate parenting in the control domain centers on exercising the right amount and type of authority necessary to manage the child’s behavior. The mechanism of socialization in the control domain is the internalized self-control over behavior that the child eventually acquires. Indeed, self-determination theory (SDT; Deci & Ryan, 1985; Deci & Ryan,

2000) purports that individuals who have developed internalized motivations are not controlled by external forces (e.g., obeying parental rules to avoid punishment, avoidance of guilt about a parent’s feelings), but instead are self-governing, basing their actions on personal interests, values, and goals.

This distinction between protection and control is especially relevant for examining child outcomes associated with overprotective parenting. If overprotective parenting is measured strictly in the protection domain, child outcomes such as the inability to respond appropriately to and regulate stress should be observed. When one adds control to a measure of overprotective

12 parenting, self-control over moral and principled behavior becomes an anticipated outcome.

Therefore, while individuals who are subject to parental overcontrol may very well experience psychological distress, the domain-specific framework suggests that overcontrolling parenting behaviors (e.g., autocratic decision-making) do not operate by the same mechanism as overprotective parenting behaviors to produce psychological distress in the child. Therefore, what has been missing from prior examinations of overprotective parenting is a division of interactions between parent and child by domain of socialization (i.e., protection domain or control domain), rather than by specific features that may or may not belong to the same domain, for example, indulgent versus overprotective parenting, and overprotection versus psychological control (Thomasgard, Metz, et al., 1995; Holmbeck et al., 2002).

The present study examines overprotection and overcontrol individually. However, while there is a strong tradition of research on overprotection, constructs that are most accurately defined as overcontrol have often been overlooked, or have been incorporated into studies as a feature of overprotection. This lack of a comprehensive and cohesive literature on overcontrol may be a reflection of the predominant emphasis on parents’ excessive authoritarian discipline in response to children’s misbehavior, thereby minimizing attention given to other forms of overcontrol that may occur in the absence of misbehavior, such as restricting autonomy, excessive monitoring, or autocratic decision making. Whatever the reason for the lack of a broader perspective on parental overcontrol in the literature, the construct of overprotection has been researched more systematically, and therefore is a main focus of this research, with hypotheses that are based on prior research on theory. Though the ideas pertaining to overcontrol that are presented in this research have been guided by the domain-specific approach to socialization (Grusec & Davidov, 2010), at this time they are considered exploratory and thus no

13 specific predictions are made.

A new measure of overprotection and overcontrol (overparenting) for emerging adult survivors of childhood cancer. Not only is there confusion in the literature about the construct of overprotection–what is it? How can it best be assessed?– but there is also a lack of research on parental overprotection during the developmental stage of emerging adulthood. The closest construct studied in emerging adult populations is that of helicopter parenting, which focuses less on overprotection but captures specific aspects of overcontrol, in addition to an emphasis on achievement-orientation. This second gap in the literature is expected, as parental overprotection that extends past adolescence is a phenomenon that would be rare in healthy populations. In survivors of childhood cancer, however, it may be much more common due to the (perceived) vulnerable nature of this population, and the entrenched styles of interaction between mothers and their formerly ill children.

This study aims to answer the question of whether parental overprotection of emerging adult survivors of childhood cancer is related to psychological distress in those emerging adults.

It will also distinguish between parental overprotection and overcontrol in the relations with these outcomes. Due to the inability of existing measures of overprotection to meet the goals of this study–to distinguish between protection and control, to assess these practices in the emerging adulthood period, and to allow for multiple informants–a new measure was developed specifically for this research. This measure has been named the Overparenting of Emerging

Adults Scale (OPEAS), with the term overparenting intended to comprise both maternal overprotection and overcontrol.

The OPEAS includes items designed to assess the established overprotection dimensions of infantilization and parenting anxiety, with the addition of two overprotection dimensions aimed

14 specifically at this study’s sample of survivors of childhood cancer: medical management and harm reduction. In terms of overcontrol, our measure includes items designed to assess dimensions similar to those found in the relevant literature (e.g., helicopter parenting), but only those that are appropriate for the developmental phase of emerging adulthood. The dimensions of overcontrol include problem solving intervention, intrusive decision making, and discounting of opinions/ideas.

How Does Overparenting Relate to Psychological Distress?

A second focus of the present research is to examine how overprotection and overcontrol relate to psychological distress in emerging adult survivors of childhood cancer. The research reviewed above provides clear evidence that parental overprotection and related constructs, in both healthy and chronically ill populations, has harmful effects on children’s psychosocial development (e.g., Fedele, Mullins, Wolfe-Christensen, & Carpentier, 2011; Holmbeck et al.,

2002; McLeod, Wood, & Weisz, 2007). Less is known about why or how the association between overparenting and psychological distress exists. In other words, what is the mechanism or mediator linking overprotection with psychological distress?

Coping with distress. A possible mediator between overprotection and psychological distress is the emerging adult’s coping ability. Coping can be defined as the use of thoughts and behaviors, referred to as coping strategies, to manage stressors and the negative emotions that are associated with them (Folkman & Lazarus, 1980). A wide variety of coping strategies exist, and these can vary across and within individuals depending on the situation and type of stressor, ranging broadly from seeking emotional support to denial (Folkman & Lazarus, 1980). Some theorists have found it useful to categorize coping strategies into dimensions; popular schemes include the transactional model of problem-focused and emotion-focused coping (Lazarus &

Folkman, 1984), primary and secondary coping (Band & Weisz, 1988), and approach and avoidance coping (Roth & Cohen, 1986). According to the transactional model, problem-focused coping strategies include those aimed at confronting the stressor itself, such as information seeking or taking action, whereas emotion-focused coping strategies are aimed at regulating the negative emotions associated with the stressor, such as expressing emotions or avoidance

(Lazarus & Folkman, 1984). Similarly, primary coping strategies involve directly influencing the stressor or one’s emotions, such as problem solving or expressing emotions, whereas secondary coping strategies are efforts to adapt to the stressor, such as acceptance (Rudolph, Dennig, &

Weisz, 1995). In contrast, approach coping includes strategies that are oriented toward the stressor, such as problem solving or seeking support, whereas avoidance strategies reflect disengagement from the stressor, such as withdrawal or denial (Suls & Fletcher, 1985).

While these dimensions can be useful from a theoretical standpoint, on an empirical basis they have been criticized for being overly broad and assigning many distinct coping strategies to just two categories, likely concealing many of the unique aspects of the individual strategies

(Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001). It is instead recommended that researchers work with specific coping actions that make up subtypes of coping strategies

(e.g., social support, distraction, and avoidance), although the choice of subtypes tends to vary greatly among studies (Compas et al., 2001). The present study assesses Frydenberg and Lewis’s

(1997) four coping styles, termed dealing with the problem, nonproductive, optimism, and sharing. Each of the four coping styles is comprised of groups of empirically and conceptually related strategies that reflect specific domains of adult coping. The dealing with the problem coping style incorporates coping strategies of focusing on solving the problem, working hard, improving relationships, seeking relaxing diversions, physical recreation, protecting the self, and

16 humor. The nonproductive coping style involves worrying, wishful thinking, tension reduction, avoidance, self-blame, withdrawal, and distancing. The optimism coping style involves wishful thinking, seeking spiritual support, focusing on the positive, and seeking relaxing diversions.

Finally, the sharing coping style includes seeking social support, social action, seeking professional help, and engaging with others.

The importance of coping abilities. Why is it important to learn to regulate and respond to stress? There is strong support for the link between poor ability to cope with distress and internalizing problems. For example, theories of the development of anxiety disorders postulate that anxiety is the result of sensitivity to threat and the perceived inability to influence, control, or cope with threat (Chorpita & Barlow, 1998; Hudson & Rapee, 2004). The development of depression is somewhat more complex, and is believed to originate from biased core beliefs, forming schemas, assumptions, and cognitions involving a strong and negative view of the self, others, and the future (Beck, 1963). Depressed individuals perceive a lack of agency over their actions, which eventually fosters a sense of helplessness (Seligman, & Peterson, 1986). This helplessness and hopelessness hinders the development of supportive social relationships and renders individuals unable to combat the rumination of negative thoughts, all contributing to the development and maintenance of depression (Bandura, 1997). Individuals who have developed effective coping strategies are able to utilize their skills through actions such as actively solving problems, combatting biased cognitions, and seeking social support. Individuals who have not developed effective coping skills are more vulnerable to experiencing distress from situations that they perceive to be challenging.

The development of coping abilities. Parenting behaviors and practices are instrumental in helping children, adolescents, and emerging adults develop effective coping abilities. In the

17 socialization of coping, parents begin by protecting their very young children from stressors, either by ensuring that the infant or young toddler avoids those stressors altogether, or by providing comfort if confrontation is unavoidable. Over time, children acquire their own coping strategies, and parents tend to decrease their level of protection accordingly in order to give children the opportunity to cope independently. In tandem with decreasing their protective behaviors, parents can also help children learn effective coping strategies that are eventually internalized and performed autonomously, either by directly teaching those strategies, or by modeling them for the child (see Power, 2004, for a review of the socialization of coping).

Different parenting practices, however, relate to children’s development of particular forms of coping. Correlates of children’s use of constructive coping strategies include warm, supportive, and accepting parenting, reactions to children’s distress that involve encouragement of emotional expression and focusing on the problem, authoritative control, and family cohesiveness (Herman & McHale, 1993; Kliewer, Fearnow, & Miller, 1996; McKernon,

Holmbeck, Colder, Hommeyer, Shapera, & Westhoven, 2001; Skinner & Edge, 2002;

Valentiner, Holahan, & Moos, 1994). However, authoritarian control, punitive and minimizing reactions to children’s distress, and family conflict are established correlates of children’s use of avoidant and ineffective coping strategies (Hanson, Cigrang, Harris, Carle, Relyea, & Burghen,

1989; Lohman & Jarvis, 2000; Wolfradt, Hempel, & Miles, 2003; Eisenberg, Fabes, & Murphy,

1996).

While there is a well-established literature on the link between parental overprotection and psychological distress, empirical research examining the direct effect of overprotective parenting on coping strategies is extremely limited. Adult outpatients in remission from major depressive disorder who retrospectively reported the experience of overprotective parenting used

18 more maladaptive emotion-focused coping strategies such as blaming, rumination, and fantasizing than those who did not report having had overprotective parents (Uehara, Sakado,

Sato, & Someya, 1999). The experience of helicopter parenting has been associated with emerging adults’ use of two avoidant coping strategies, internalizing (e.g., “getting mad at myself”) and distancing (e.g., “refusing to think about it”), and there was an indirect effect of helicopter parenting on emerging adults’ anxiety symptoms through avoidant coping (Segrin,

Woszidlo, Givertz, & Montgomery, 2013). This finding has yet to be replicated, but it provides promising support for the hypothesis that maladaptive coping strategies mediate the link between overprotective parenting and internalizing symptoms in a sample of emerging adult survivors of childhood cancer.

Developmental theory provides additional evidence for coping as a mechanism that connects overprotection and internalizing symptoms of psychological distress. Some theorists have described overprotection as a parent’s inability to adjust his or her level of protectiveness to the developing coping abilities of the child (e.g., Power, 2004). Thus, the very act of overprotection implicitly sends a message to the child that the parent believes that he or she is incapable of coping autonomously (Hastings, Nuselovici, Rubin, & Cheah, 2010). Over time, a child who is protected from threat in unnecessary or excessive amounts does not experience normative opportunities to increase self-confidence in, and experience mastery of, coping skills, and to learn that threats can be overcome without parental assistance (Rubin, Coplan, & Bowker,

2009; Segrin et al., 2013). Problems arise during emerging adulthood, when individuals leave the family home and spend the majority of their time away from parents. Overprotected emerging adults have had limited experience with specific types of stressors, and their overreliance on

19 parents to decrease negative affect leaves them ill-equipped to adapt to difficult situations, and vulnerable to difficulties with internalization such as anxiety and depression.

As a secondary point, parents also model anxious behaviors when they exhibit overprotective parenting. Observation of an anxious model who is unable to effectively cope with distress implicitly teaches children maladaptive coping strategies (Whaley, Pinto, &

Sigman, 1999; Wood, McLeod, Sigman, Hwang, & Chu, 2003). It is therefore plausible that emerging adults who experience overprotective parenting receive a double dose of the transmission of anxiety; not only is it directly taught through parents’ parenting practices, but also frequently observed in the home environment.

Emerging Adults’ Perceptions of Parental Overparenting Versus Mothers’ Reports

A third purpose of the present research is to test a somewhat novel method of incorporating mothers’ reports of parenting behaviors with emerging adults’ perceptions of their mothers’ same parenting behaviors. This aim arises from concerns about the implications of informants’ disparate reporting styles for the accuracy of data, which is a problematic issue in developmental psychology research. One consideration has been social desirability in parents’ ratings of their own parenting practices and family dynamics, particularly in the field of adolescent research. Indeed, parents consistently rate their parenting practices more positively than adolescents do (Schwartz, Barton-Henry, & Pruzinsky, 1985), and mothers are more likely than adolescents to rate their relationships as higher in intimacy, lower in conflict, and more democratic (Noller, Seth-Smith, Bouma, & Schweitzer, 1992). It is unclear whether parents’ positive response biases (or, potentially, adolescents’ negative response biases) are intentional or unconscious, but regardless of motivation, there is commonly a clear disagreement between parent and adolescent informants on questionnaire measures.

Some research suggests that adolescents’ perceptions of their parents’ behaviors may have a greater influence on adolescent outcomes than parents’ actual behaviors. For example, in a study of 10 to 17 year-olds with internalizing disorders and their healthy siblings, Yahav

(2006) concluded that children’s perceptions of their parents’ overprotection was critical in determining the development of internalizing symptoms, regardless of the objective reality of parents’ overprotective behaviors. Early adolescents’ school achievement was more strongly correlated with the adolescents’ perceptions of authoritative parenting and parental involvement than it was with parents’ perceptions of their own parenting style and level of involvement

(Paulson, 1994), and early adolescent-parent closeness (i.e., affection and disclosure) has been predictive of adolescent self-esteem and emotional expressiveness only when reported by adolescents, not by their parents (Paulson, Hill, & Holmbeck, 1991).

These studies suggest that adolescents may be more accurate informants of parent behaviors than parents are. Spera (2006) contends that children’s perceptions are more proximal than parents’ are, and measuring perceptions places the focus on children’s thoughts, emotions, and interpretations of parents’ actions. While this may be one explanation for the strong linkages between children’s reports of parenting and child outcomes, the possibility of respondent bias cannot be overlooked. For example, a child’s view of the world through “rose-colored glasses”

(or the opposite) will similarly affect his or her reports of parenting behaviors and child outcomes. In addition, the common method variance that results from a single informant providing all data increases the likelihood of statistically significant results and inflates correlations among variables (Lindell & Whitney, 2001).

Youniss (1989) has argued that both parents’ and children’s perceptions of family processes provide valid data, despite disagreements, because they are meaningful to all of the

21 individuals who are involved in the dynamic. In accord with this idea, and the research highlighting the importance of adolescents’ perceptions of parenting behaviors, the present study measured mothers’ overprotection as reported by both mothers and emerging adults. In addition, emerging adults’ perceptions of maternal overprotection were tested as a mediator between mothers’ reports of overprotection and emerging adult outcomes. In this way, both informants’ perceptions contribute to outcomes, but it is hypothesized that the meaning that emerging adults assign to their mother’s overprotection is the mechanism through which overprotection is related to coping and psychological distress.

Summary of the Present Study, Research Questions, and Hypotheses

This study was designed to investigate the experience of overprotective and overcontrolling parenting (overparenting) in emerging adult survivors of childhood cancer.

Previous research with healthy child populations has reported that overprotective parenting predicts children’s poor psychosocial development and psychological distress. Past studies, however, have failed to distinguish between parental overprotection and overcontrol, and the majority have been conducted with child or adolescent samples. The present study addresses important questions that have yet to be the focus of empirical research: does the association between overprotective parenting and psychological distress that is found in non-cancer populations exist in a sample of emerging adult survivors of childhood cancer, and are maternal overprotection and overcontrol related to psychological distress?

A secondary aim of this research was to uncover a mechanism linking overprotective parenting, and potentially overcontrolling parenting, to psychological distress. Strong support from theory and preliminary research implicates the role of a nonproductive coping style as a mediator between overprotective parenting and psychological distress, however, this has yet to

22 be examined in a population of emerging adult survivors of childhood cancer. A third feature of this research is the utilization of both mothers’ and emerging adults’ reports of mothers’ overprotection and overcontrol. Statistical models were used to assess emerging adults’ perceptions of their mothers’ overprotective and overcontrolling parenting as a mechanism through which overprotection and overcontrol (as reported by mothers) relates to nonproductive coping and psychological distress.

Research questions and hypotheses. The following research questions were posed in this study. Relevant hypotheses, based on prior research and theory, are stated below each research question. As there is little prior research to support specific predictions with regard to overcontrol, no hypotheses were generated. In this study, the overcontrol variable was analyzed analogously to overprotection, but in an exploratory manner.

1) How do levels of psychological distress in emerging adult survivors of childhood

cancer compare with general population norms?

H1: Emerging adult survivors of childhood cancer experience higher levels of anxiety

and depression than the general population.

2) How do mother-reported levels of overprotection compare in emerging adults who

score above and below clinical cutoffs for psychological distress?

H2: Emerging adults who score above clinical cutoffs for anxiety and depression have

higher mother-reported levels of overprotection than emerging adults who score below

clinical cutoffs for anxiety and depression.

3) How do perceived levels of overprotection compare in emerging adults who score

above and below clinical cutoffs for psychological distress?

4) H3: Emerging adults who score above clinical cutoffs for anxiety and depression have

higher perceived levels of overprotection than emerging adults who score below

clinical cutoffs for anxiety and depression.

5) Does mother-reported overprotection predict the use of productive coping styles (i.e.,

optimism, sharing, and dealing with the problem) and a nonproductive coping style?

H4: Mother-reported overprotection negatively predicts the use of productive coping

styles and positively predicts the use of a nonproductive coping style.

6) Is the effect of overprotection on anxiety symptoms mediated by emerging adults’

perceptions of overprotection and nonproductive coping?

H5: The effect of overprotection on anxiety symptoms is mediated by emerging

adults’ perceptions of overprotection and nonproductive coping.

7) Is the effect of overprotection on depression symptoms mediated by emerging adults’

perceptions of overparenting and nonproductive coping?

H6: The effect of overprotection on depression symptoms is mediated by emerging

adults’ perceptions of overprotection and nonproductive coping.

Method

Participants

Emerging adults qualified for study inclusion if they were between the ages of 18 and 30 years on the date of recruitment and had been diagnosed with cancer before age 18. Individuals were excluded from the study if they were not fluent in the English language, or if they were significantly cognitively impaired and therefore would have difficulty comprehending the study questions and responding in a meaningful manner. Emerging adults were asked to give permission for the researchers to contact their mothers for participation in the study, but were

23 24 excluded from the study if permission was refused or if the emerging adult was unable to provide their mother’s contact information.

One hundred and sixty seven emerging adults who satisfied the criteria for inclusion were approached for recruitment into this study. Of those individuals, 22 (13%) declined to participate. Of the 145 emerging adults who consented to participation, 16 (10%) withdrew prior to the first point of contact (the telephone interview). Reasons for declining or withdrawal included lack of interest, lack of time, and discomfort with participating in research. Of the individuals who participated in the telephone interview, 11 (9%) withdrew from the study prior to completing the first part of the measures. A total of 118 emerging adults completed the first part of the study measures. Of those individuals, 9 (8%) withdrew from the study prior to completing the second part of the study measures. Thus, a total of 109 emerging adults completed both parts of the study measures.

Of the 145 emerging adults who gave their consent to participate in this study, 9 (6%) of their mothers were not contacted because they were deceased or estranged. Of the remaining 136 mothers, 41 (30%) declined to participate. Reasons for refusal included limited interest, lack of time, and the desire to avoid memories of their family’s experience with cancer. Ninety-five mothers provided data for this study, but 5 of the mothers participated after their son or daughter withdrew from the study, therefore a total of 90 mothers had data included in this study. Five of the 90 mothers who participated had emerging adults who withdrew from the study prior to completing the second part of the measures.

Demographics. Demographic information for the emerging adult participants is listed in

Table 1. The emerging adults’ ages ranged from 18 to 30 years (M = 23.11, SD = 3.34). More females (60.2%) than males (39%) participated in this study. The majority of emerging adults

25 identified their ethnic origin as European (65.3%), and the remainder identified as Asian

(16.9%), of multiple origins (5.9%), Caribbean (4.2%), or Latin, Central, or of South American

(2.5%). Six participants (5.1%) identified their ethnicity as “other” and specified “Canadian”. In terms of religious affiliation, 34.7% of participants identified with the statement, “I am not religious”. The remainder of the emerging adults selected Catholic Christianity (35.6%),

Protestant Christianity (16.9%), Judaism (3.4%), other (i.e., Hinduism, Buddhism, Jehovah’s

Witness) (3.4%), Islam (2.5%), and Orthodox Christianity (2.5%).

More than half (52.5%) of the 118 emerging adults reported being in a committed, romantic relationship. Of the 62 participants in romantic relationships, 13.5% were married or engaged to be married, and 7.6% were cohabitating with their romantic partner. Of the 56 participants who identified as single, 62.5% indicated that they had never been in a committed romantic relationship. Five participants had children. The majority of participants were living in their parents’ home (64.4%), and the remainder were living independently, either with a partner or children (15.3%), one or more roommates (14.4%), or alone (5.9%).

Eighty-two percent of participants had completed some or all of a university or college program, while a minority indicated that their highest level of education was high school (18.6%) or elementary school (0.8%). Half of the sample (50.8%) reported that they were employed either full- or part-time, while the other half were students (39%), unemployed (5.1%) or other

(i.e., on maternity leave, students with part-time employment) (5.1%). The majority of emerging adults reported that their annual household income exceeded $60,000 (59.3%); however, when asked to report their personal income 67.8% of participants indicated no income or an income of under $10,000 per year and 19.5% reported a personal annual income of greater than $40,000 per year.

Table 1. Demographics of Emerging Adults

Variable Level n % Age 21-25 57 48 18-20 32 27 26-30 29 25 Sex Female 71 60.2 Male 46 39 Other: “Trans” 1 0.8 Ethnic origin European 77 65.3 Asian 20 16.9 Multiple origins 7 5.9 Other: “Canadian” 6 5.1 Caribbean 5 4.2 Latin, Central, or South American 3 2.5 Religion Catholic Christianity 42 35.6 Not religious 41 34.7 Protestant Christianity 20 16.9 Judaism 4 3.4 Other: “Hinduism,” “Buddhism,” “Jehovah’s Witnesses” 4 3.4 Islam 3 2.5 Orthodox Christianity 3 2.5 Relationship Single 56 47.5 status Committed relationship, not cohabitating 37 31.4 Married or engaged 16 13.5 Committed relationship, cohabitating 9 7.6 Number of 0 113 95.8 children 2 3 2.5 1 2 1.7 Living In the family home 76 64.4 arrangement Independent, with partner and/or children 18 15.3 Independent, with roommate(s) 17 14.4 Independent, alone 7 5.9 Education Completed college/university 40 33.9 Some college/university 38 32.2 Completed high school 22 18.6 Some or completed graduate/professional school 16 13.6 Completed elementary school 1 0.8 Occupational Student 46 39 status Employed full-time 45 38.1 Employed part-time 15 12.7 Unemployed 6 5.1 Other: “On maternity leave,” “Student and employed” 6 5.1 Household > $60,000 70 59.3 income $40,000-$59,999 22 18.6 $20,000-$39,999 12 10.2

< $9,999 6 5.1 $10,000-$19,000 5 4.2 Personal income None 75 63.6 > $60,000 12 10.2 $40,000-$59,999 11 9.3 $20,000-$39,999 7 5.9 < $9,999 5 4.2 $10,000-$19,000 3 2.5

Demographic information for the mothers who participated in this study, obtained from their children, is provided in Table 2. The emerging adults’ mothers’ ages ranged from 41 to 65 years (M = 52.58, SD = 5.26). The majority of the mothers were married (73.3%), while 22.2% were divorced or separated and 2.2% were reported as other (i.e., widowed, common-law). Five

(5.6%) of the mothers who were divorced had remarried. Close to half the mothers had two children (48.9%), while 26.7% had three children, 11.1% had one child, and 11.1% had four or more children. The majority of the mothers had completed some or all of a university or college degree (75.6%), while a minority had completed their education at high school (16.7%) or elementary school (7.8%).

Table 2. Demographics of Mothers

Variable Level n % Marital status Married 66 73.3 Divorced 17 18.9 Separated 3 3.3 Other: “Widowed,” “Common-law” 2 2.2 Education Completed college/university 45 50 Completed high school 15 16.7 Some college/university 14 15.6 Some or completed graduate/professional school 9 10 Some high school 5 5.6 Some or completed elementary school 2 2.2 Number of children 2 44 48.9 3 24 26.7 1 10 11.1 >3 10 11.1

Cancer-related demographics. Demographic information for the emerging adult participants concerning cancer history is presented in Table 3. The most common cancer diagnosis in this sample was leukemia (31.4%), followed by lymphoma (28%), Wilm’s tumour

(11.9%), sarcoma (9.3%), other (e.g., renal cell carcinoma, hepatoblastoma, nasopharyngeal carcinoma) (8.5%), neuroblastoma (7.6%), and germ cell tumour (3.4%). Participant’s age at diagnosis ranged from birth to 17 years (M = 6.91 years, SD = 4.73) and time since diagnosis ranged from 3 years to 30 years (M = 16.5 years, SD = 5.76). Almost all participants reported receiving chemotherapy (94.9%), while fewer reported surgery (excluding portacath insertion and removal) (50.8%), radiation therapy (41.5%), or bone marrow or stem cell transplant (7.6%).

The length of treatment ranged from less than 1 year to 8 years (M = 2.62 years, SD = 1.53). The distribution of the length of treatment variable was highly positively skewed with most participants reporting shorter treatment lengths. The time since treatment completion ranged from 3 years to 29 years (M = 14.91 years, SD = 5.59). Eleven emerging adults reported that they had experienced a recurrence of their original diagnosis (6.8%) or a secondary cancer (2.5%).

Only one participant (0.8%) reported a second recurrence of his or her original diagnosis.

Table 3. Cancer Demographics of Emerging Adults

Variable Level n % Cancer type Leukemia 37 31.4 Lymphoma 33 28 Wilm’s tumour 14 11.9 Sarcoma 11 9.3 Other: “Nasopharyngeal carcinoma,” 10 8.5 “Renal cell carcinoma,” “Hepatoblastoma,” “Carcinoid tumour,” “Skin cancer” Neuroblastoma 9 7.6 Germ cell tumour 4 3.4 Age at 3-6 33 28 diagnosis 7-11 31 26.3 0-2 28 23.7 12-18 26 22

Years since 11-20 70 59.3 diagnosis 21-30 28 23.7 6-10 12 10.2 3-5 3 2.5 Treatment: chemotherapy 112 94.9 Treatment: radiation 49 41.5 Treatment: surgery 60 50.8 Treatment: bone marrow or stem cell transplant 9 7.6 Treatment 1 year 35 29.7 length < 1 year 29 24.6 3 years 22 18.6 2 years 14 11.9 4 years 5 4.5 > 4 years 5 4.5 Years since 11-20 70 59.3 treatment 21-29 21 17.8 completion 6-10 20 16.9 3-5 3 2.5 Recurrence or secondary cancer 11 9.3

Procedure

The present study was part of a larger project designed to collect psychosocial and developmental information from emerging adult survivors of childhood cancer. Only those measures relevant to the present research will be discussed. Emerging adults were recruited from the waiting room of The Pediatric Cancer AfterCare Clinic at Princess Margaret Cancer Centre in Toronto, Canada. The Pediatric Cancer AfterCare Clinic at the Princess Margaret is one of seven sites of a provincial long-term follow-up program directed by the Pediatric Oncology

Group of Ontario (POGO). The AfterCare clinics provide survivors of childhood cancer with annual or biennial health surveillance for late effects of the disease or treatment, intervention in areas of identified risk, and education related to cancer survival and health promotion. All

Pediatric Cancer AfterCare Clinic patients at the Princess Margaret are at least 18 years old, were diagnosed with cancer before age 18, and completed cancer treatment a minimum of two years prior to their first visit to the clinic. Many of the patients had transitioned from the AfterCare

Clinic at the nearby Hospital for Sick Children. Although most patients lived within or just outside the Greater Toronto Area, some resided in remote areas of Ontario where specialized care is not available. None of the patients at the Princess Margaret AfterCare Clinic had a diagnosis of brain cancer, as a separate long-term follow-up clinic is dedicated to that patient population.

Clinic patients were approached by one of two doctoral students either prior to or following their appointments and were asked if they were interested in information about a research study currently being conducted with young adult survivors of childhood cancer.

Interested patients were given information about the purpose of the study, study procedures, potential risks, confidentiality, the right to withdraw, and compensation (see Appendix A for the recruitment script). If patients agreed to participate they were then given a consent form to read and sign (see Appendix B for the consent form) and were asked to provide their contact information and their mother’s contact information. A telephone interview was then scheduled.

As a component of the larger study and not included in the present research, trained undergraduate research assistants conducted telephone interviews where emerging adult participants were asked to identify significant memories and speak about the meaning derived from their experiences. Interview lengths ranged from 8 to 40 minutes (M = 18 minutes).

Following the interview, participants were emailed instructions to access a website where they could complete the first of two sets of measures, some of which were used in the present study

(see Appendix C for the email template). The measures were located on Qualtrics, an Internet survey platform (www.qualtrics.com). Upon completion of the first set of measures, participants were mailed a letter and $16 gift card (see Appendix D for the gift card letter template) and were emailed a second time with instructions to access the second set of measures (see Appendix E for

31 the second email template). Upon completion of the second set of measures, participants were mailed a letter and a $10 gift card (see Appendix F for the second gift card letter template). In total, the first set consisted of 9 measures, 2 of which were used in this study, and the second set consisted of 8 measures, 3 of which were used in this study. Mothers of the emerging adults were mailed a package that included a consent form, instructions for completing the measures, the measures, and a stamped and addressed return envelope (see Appendix G for the mother consent form and instructions). The mothers were given 4 measures, 1 was used in this study (see

Appendix H for the complete OPEAS). Follow-up telephone calls were made to emerging adults and mothers who did not complete their measures in a timely manner.

Measures

To address the main research questions of this study, 5 emerging adult measures and 1 mother measure were selected.

Demographics. Emerging adults completed a demographics questionnaire that included items about participants’ cancer history.

Overparenting. The Overparenting of Emerging Adults Scale (OPEAS) is a questionnaire developed for the purposes of this study. Information regarding the development and psychometric properties of the OPEAS can be found in the Results section. The OPEAS has two parallel forms: one version asks emerging adults to report on their mothers’ overparenting behaviors, and a second version asks mothers of emerging adults to report on their own overparenting behaviors. The OPEAS presents a list of overparenting behaviors and attitudes and asks the informant to report either the frequency of the behaviors or his or her agreement with the statement, respectively. Emerging adults responded on a 7-point Likert-type scale ranging from 1 (never happens; completely disagree) to 7 (happens all the time; completely agree) and

32 mothers responded on a 3-point Likert-type scale ranging from 1 (never happens; completely disagree) to 3 (happens all the time; completely agree).

The scale measures two aspects of overparenting, overprotection and overcontrol.

Overprotection is divided into four subscales that resulted from a factor analysis of the questionnaire items, presented in the Results section (reliability estimates are included in

Results): (1) infantilization (3 items): the mother treats the emerging adult as if he or she is a much younger developmental age, encouraging dependence (e.g., “My mother feels that I can’t look after myself without her help” [Emerging adult form]; “I feel that my child needs my help a lot of the time” [Mother form]); (2) medical management (2 items): the mother makes and attends the emerging adults’ appointments with health care professionals (e.g., “My mother likes to attend doctors’ appointments with me” [Emerging adult form]; “I like to attend doctors’ appointments with my child” [Mother form]); (3) parenting anxiety (3 items): the mother experiences excessive worry and anxiety in the parenting role, pertaining to the act of being a parent (e.g., “My mother blames herself when something bad happens to me” [Emerging adult form]; “I blame myself when something bad happens to my child” [Mother form]); and (4) harm reduction (2 items): the mother is exceptionally concerned about the possibility of the emerging adult engaging in behaviors that could compromise his or her health and safety (e.g., “My mother is more concerned than she needs to be about how much alcohol I am drinking” [Emerging adult form]; “I am very concerned about how much alcohol my child is drinking” [Mother form]).

Overcontrol is divided into three subscales that resulted from a factor analysis of the questionnaire items, presented in the Results section (reliability estimates are included in

Results): (1) problem solving intervention (4 items): the mother expects to solve problems for the emerging adult and intervene in his or her actions (e.g., “Sometimes when I am doing a task my

33 mother will just take over” [Emerging adult form]; “Sometimes I have to take over tasks that my child is doing improperly” [Mother form]); (2) intrusive decision making (3 items): the mother expects to have an influence on the emerging adult’s personal decisions (e.g., “My mother expects to have input about my job and/or direction in school” [Emerging adult form]; “I expect to have input about my child’s job/direction in school” [Mother form]); and (3) discounting of opinions/ideas (2 items): the mother does not respect the validity of the emerging adult’s independent thoughts and opinions (e.g., “It feels like my mother doesn’t want to hear my opinion about things” [Emerging adult form]; “I ask my child to contribute his/her opinion”

[reverse scored; Mother form]).

Psychological distress. Two domains of psychological distress were measured.

Depression. The Center for Epidemiologic Studies Depression Scale (CES-D; Radloff,

1977) is a 20-item self-report measure of depression symptoms. Emerging adults rated the frequency of their symptoms experienced in the past week on a 4-point Likert-type scale from 0

(rarely or none of the time) to 3 (most or all of the time). The CES-D yields four subscales: (1) depressed affect (5 items): the emotional symptoms of depression such as feelings of sadness, hopelessness, discouragement, or being "down in the dumps" (e.g., “I felt that I could not shake off the blues even with help from my family or friends”); (2) happy (4 items): positive affect and feelings of happiness (e.g., “I enjoyed life”); (3) somatic (6 items): the physical symptoms of depression such as irritability, poor appetite, psychomotor agitation, sleep disturbances, impaired concentration (e.g., “I did not feel like eating; my appetite was poor” “My sleep was restless”); and (4) interpersonal (2 items): oversensitivity to or misinterpretation of negative cues from others (e.g., “I felt that people disliked me” “People were unfriendly”). Subscale scores were created by averaging individual items. The measure also provides a CES-D total score, which is

34 a global assessment of depressive symptomatology across the four domains and is obtained by reverse-scoring items in the happy subscale and then summing across all items.

Radloff (1991) has reported an internal consistency reliability estimate of .87 for the

CES-D total score in the youth sample (ages 18-25). In the current study, the Cronbach’s alpha for the CES-D total score was .92. CES-D scores discriminate well between psychiatric inpatient and general population samples and correlate highly with other self-report measures of depression symptoms (Radloff, 1977).

Anxiety. The Multidimensional Anxiety Questionnaire (MAQ; Reynolds, 1999) is a 40- item self-report measure of anxiety symptoms. Emerging adults rated the frequency of their anxiety signs and symptoms in the past month on a 4-point Likert-type scale from 1 (almost never) to 4 (almost all the time). The MAQ yields four subscales: (1) physiological-panic (12 items): symptoms of panic attack and agoraphobia such as sudden physical symptoms, catastrophic misinterpretation of physical sensations, and worry or avoidance of places associated with panic (e.g., “I had heart palpitations” “I worried about having a panic attack”);

(2) social phobia (9 items): symptoms of social anxiety such as avoidance of people, performance anxiety, and fear of negative evaluation (e.g., “ I worried what others thought” “I was nervous with people”); (3) worry-fears (10 items): generalized and excessive, uncontrollable worry and fearfulness in daily life situations (e.g., “I felt afraid” “I worried about the future”); and (4) negative affectivity (9 items): the negative symptoms associated with anxiety, including difficulty sleeping, irritability, and somatic complaints (e.g., “I had difficulty concentrating” “I felt restless”). Subscale scores were created by converting raw scores to T-scores and then summing individual items. The measure also provides a MAQ total scale, which is a global assessment of anxiety symptomatology across the four domains and is obtained by summing

35 across all items and then converting the raw scores to T-scores.

Reynolds (1999) has reported an internal consistency reliability estimate of .96 for the

MAQ total scale. In the current study, Cronbach’s alpha for the MAQ total scale was .96. MAQ scores discriminate well between anxiety disorder, psychiatric inpatient, and community samples and correlate highly with other self-report measures of anxiety symptoms (Reynolds, 1999).

Coping style. The Coping Scale for Adults (CSA; Frydenberg & Lewis, 1997) is a 73- item measure of 19 strategies used by adults to cope with distress. Emerging adults rated the frequency with which they used strategies to cope with their various concerns or worries (e.g., work, studies, family, friends) on a 5-point Likert-type scale from 1 (not used at all) to 5 (used a great deal). The 19 CSA subscales are: (1) seek social support (4 items): sharing the problem with others and enlisting support in its management (e.g., “Talk to other people to help me sort it out”); (2) focus on solving the problem (5 items): reflecting on the problem, planning solutions, and tackling it systematically (e.g., “Develop a plan of action”); (3) work hard (5 items): commitment, ambition, and industry (e.g., “Keep up with work as required”); (4) worry (4 items): concern about the future in general terms or more specific concern with happiness in the future (e.g., “Worry about what is happening”); (5) improve relationships (6 items): engaging in a particular relationship (e.g., “Spend more time with husband/wife/boy/girl friend”); (6) wishful thinking (4 items): hoping for and anticipating a positive outcome (e.g., “Hope that the problem will sort itself out”); (7) tension reduction (4 items): attempting to make oneself feel better by releasing tension (e.g., “Cry or scream”); (8) social action (4 items): letting others know what is of concern and enlisting support by writing petitions or organizing an activity such as a meeting or rally (e.g., “Join with people who have the same concern”); (9) ignore the problem (3 items): consciously blocking out the problem (e.g., “Shut myself off from the problem so that I can

36 avoid it”); (10) self-blame (4 items): criticizing oneself for being responsible for the concern or worry (e.g., “Get annoyed at myself”); (11) keep to self (4 items): withdrawing from others and wanting to keep others from knowing about concerns (e.g., “Keep my feelings to myself”); (12) seek spiritual support (3 items): prayer and belief in the assistance of a spiritual leader or deity

(e.g., “Let the Lord take care of my worries”); (13) focus on the positive (5 items): having a positive or cheerful outlook on the current situation, including seeing the bright side of the circumstances and seeing oneself as fortunate or making meaning (e.g., “Look on the bright side of things and think of all that is good”); (14) seek professional help (4 items): the use of a professional adviser, such as a mentor or therapist (e.g., “Get professional help or counselling”);

(15) seek relaxing diversions (2 items): general relaxation and leisure activities such as reading and listening to music (e.g., “Make time for leisure activities”); (16) physical recreation (3 items): playing sports and keeping fit (e.g., “Go for a work-out at the gym”); (17) protect self (3 items): attempts to support one’s self-concept by constructive self-talk and looking after one’s appearance (e.g., “Improve my appearance”); (18) humor (3 items): being funny as a diversion

(e.g., “Try to be funny”); (19) not cope (3 items): an inability to cope resulting in the occurrence of psychosomatic illness (e.g., “I get sick”). Subscale scores were created by averaging across individual items.

Frydenberg and Lewis (1997) further group the 19 coping strategies into four distinct coping styles: (1) dealing with the problem (27 items): mean of the subscale scores of focus on solving the problem, work hard, improve relationships, seek relaxing diversions, physical recreation, protect self, and humor; (2) nonproductive (26 items): mean of the subscale scores of worry, wishful thinking, tension reduction, ignoring the problem, self blame, keep to self, and not cope; (3) optimism (14 items): mean of the subscale scores of wishful thinking, seek spiritual

support, focus on the positive, and seek relaxing diversions; and (4) sharing (16 items): mean of the subscale scores of seek social support, social action, seek professional help, and keep to self

(reverse scored).

Internal consistency reliability estimates of the 19 subscales reported by Frydenberg and

Lewis (1997) are .83 (focus on solving the problem), .78 (work hard), .77 (improve relationships), .76 (seek relaxing diversions), .78 (physical recreation), .71 (protect self), .87

(humor), .85 (worry), .75 (wishful thinking), .69 (tension reduction), .80 (ignore the problem),

.88 (self-blame), .82 (keep to self), .70 (not cope), .92 (seek spiritual support), .74 (focus on the positive), .79 (seek social support), .74 (social action), and .92 (seek professional help). In the present study, Cronbach’s alphas for the 19 subscales were .84 (focus on solving the problem),

.69 (work hard), .75 (improve relationships), .32 (seek relaxing diversions), .76 (physical recreation), .73 (protect self), .86 (humor), .89 (worry), .70 (wishful thinking), .81 (tension reduction), .80 (ignore the problem), .88 (self-blame), .90 (keep to self), .66 (not cope), .94 (seek spiritual support), .73 (focus on the positive), .83 (seek social support), .63 (social action), and

.88 (seek professional help). Cronbach’s alphas for the four coping styles in the present study were .87 (dealing with the problem), .92 (nonproductive coping), .81 (optimism), and .74

(sharing).

Results

The results of this study are presented in five sections. Preliminary analyses include descriptive statistics, data screening, and comparison of emerging adult participants with and without participating mothers. Second, the development and psychometric properties of the

OPEAS are described. Third, levels of psychological distress in emerging adult survivors of childhood cancer are presented and compared with the general population. In this section,

37 38 differences in levels of psychological distress are also explored according to both mother- reported and emerging adults’ perceptions of overparenting. Fourth, relations among mother- reported overparenting (both overprotection and overcontrol) and emerging adults’ coping styles are explored. Fifth, emerging adults’ perceptions of overparenting and nonproductive coping style are tested as mediators of the relation between mother-reported overparenting and psychological distress.

Preliminary Analyses

Descriptive statistics. Means, standard deviations, and ranges for study variables from previously validated measures, including the CES-D, MAQ, and CSA, are presented in Table 4.

Table 4. Descriptive Statistics for Study Variables from Previously Validated Measures

Scale Subscale N M SD Range Possible Range CES-D Total 109 12.11 9.41 0-36.00 0-60.00 Depressed affect 109 0.53 .55 0-2.40 0-3.00 Happy 109 2.30 .69 0.70-3.00 0-3.00 Somatic 109 0.75 .55 0-2.13 0-3.00 Interpersonal 109 0.43 .57 0-2.00 0-3.00 MAQ Total 117 65.65 17.61 36.00-116.00 36.00-138.00 Physiological-panic 117 68.31 23.40 44.00-136.00 44.00-175.00 Social phobia 117 65.67 14.59 38.00-102.00 38.00-107.00 Worry/fears 117 70.30 21.98 41.00-125.00 41.00-145.00 Negative affectivity 117 53.44 10.31 34.00-83.00 34.00-92.00 CSA Dealing with the 109 3.34 .50 1.95-4.49 1.00-5.00 problem Nonproductive 109 2.58 .66 1.07-4.56 1.00-5.00 Optimism 109 3.01 .60 1.71-4.55 1.00-5.00 Sharing 109 2.57 .49 1.50-4.13 1.00-5.00

Data screening. Prior to data analysis, all variables were screened for outliers by examining box-plots and standardized scores. Nine cases with z scores above 3.3 and an obvious distance from a hinge of the box were identified as outliers, and 6 of those cases were outliers on more than one variable. In order to minimize harm to statistical inference while keeping these

39 cases in the data set, identified outliers were truncated by recoding their values to just greater than or less than the next highest or lowest score, respectively, for that variable. In total, 25 outlier scores were truncated.

Normality of the variable distributions was then examined by testing the skewness and kurtosis of each variable. When the skewness values were divided by their standard errors, 6 variables did not conform to normality, with z scores for skewness greater than 3.3. Four variables showed moderate, positive skewness; those were three variables from the CES-D

(CES-D total score, depressed affect, and interpersonal), and the MAQ physiological-panic subscale. Square root transformations were applied to each of the 4 variables, and for all variables this method was successful in achieving satisfactory normality.

Comparison of participants with participating and nonparticipating mothers. Of the

118 emerging-adult participants in this study, 28 of their mothers did not participate; therefore, these cases were missing mother-report data on the overparenting measure. In order to examine potential group differences between the emerging adults whose mothers participated versus those whose mothers did not, independent samples t-tests were conducted using all study variables as test variables, and a grouping variable that coded mother data present as 1 and mother data absent as 2. Several of these tests were statistically significant. Emerging adults whose mothers did not participate in the study reported higher scores than those whose mothers did participate on most CES-D subscales (CES-D total score, t(29.96) = -2.96, p < .01; depressed affect, t(29.40) = -2.40, p < .05; and somatic, t(30.29) = -3.72, p < .01), and lower scores on the CES-D happy subscale, t(107) = 2.09, p < .05. These emerging adults also reported higher scores on all

MAQ subscales (MAQ total scale, t(115) = -2.98, p < .01; physiological-panic, t(35.65) = -2.42,

40 p < .05; social phobia, t(115) = -2.30, p < .05; worry-fears, t(115) = -2.70, p < .01; and negative affectivity, t(115) = -2.57, p < .05).

Development and Psychometric Properties of the Overparenting of Emerging Adults Scale

(OPEAS)

Factor analysis. Four separate factor analyses were conducted to create the emerging adult-reported and mother-reported OPEAS subscales. First, emerging adult-reported overprotection items were analyzed, second, emerging adult-report overcontrol items were analyzed, third, mother-reported overprotection items were analyzed, and fourth, mother- reported overcontrol items were analyzed.

Emerging adult-reported items. A principal component analysis (PCA) with orthogonal varimax rotation was conducted on the 10 emerging adult-reported maternal overprotection items. The Kaiser-Meyer-Olkin measure verified the sampling adequacy of the analysis, KMO =

.72 (good adequacy, according to Hutcheson & Sofroniou, 1999). Bartlett’s test of sphericity,

χ2(45) = 374.42, p < .001, indicated that correlations between items were sufficiently large for

PCA. An initial analysis was run to obtain eigenvalues for each component of the data. Four components had eigenvalues over Kaiser’s criterion of 1 and were retained for analysis. In combination the 4 components explained 74.65% of the variance. Table 5 presents the factor loadings, eigenvalues, and percentages of variance after rotation, as well as commonalities and

Cronbach’s alphas. Items are ordered and grouped by size of loading to facilitate interpretation.

Loadings under .45 (20% variance overlap between item and component) are not reported.

Interpretive labels for the components suggest 4 maternal overprotection subscales of infantilization, medical management, parenting anxiety, and harm reduction. Adequate internal

41 consistencies were found for all 4 subscales; Cronbach’s alphas were .78 (intrusive decision making), .75 (medical management), .74 (parenting anxiety), and .74 (harm reduction).

A second PCA with orthogonal varimax rotation was conducted on the 9 emerging adult- reported maternal overcontrol items. The Kaiser-Meyer-Olkin measure verified the sampling adequacy of the analysis, KMO = .76 (good adequacy, according to Hutcheson & Sofroniou,

1999). Bartlett’s test of sphericity χ2(36) = 336.16, p < .001, indicated that correlations between items were sufficiently large for PCA. An initial analysis was run to obtain eigenvalues for each component of the data. Three components had eigenvalues over Kaiser’s criterion of 1 and were retained for analysis. In combination the 3 components explained 68.73% of the variance. Table

6 presents the factor loadings, eigenvalues, and percentages of variance after rotation, as well as commonalities and Cronbach’s alphas. Items are ordered and grouped by size of loading to facilitate interpretation. Loadings under .40 are not reported. One item (“My mother doesn’t like it when I make a change and/or try something new without consulting her first”) cross loaded; based on prior theory this item was assigned to the second component. Interpretive labels for the components suggest 3 maternal overcontrol subscales of problem solving intervention, intrusive decision making, and discounting of opinions/ideas. Adequate internal consistencies were found for all three subscales; Cronbach’s alphas were .76 (problem solving intervention), .67 (intrusive decision making), and .81 (discounting of opinions/ideas).

Table 5. Maternal Overprotection Measure, Emerging Adult Version (N = 109)

a Item F1 F2 F3 F4 Communalities My mother feels that I can’t look after myself without her .87 .78 help. My mother wants me to depend on her even when I don’t .79 .70 need it. Sometimes my mother treats me like I’m still a child. .69 .65

My mother likes to attend doctors’ appointments with me. .90 .87

My mother likes to make my doctors’ appointments. .82 .85 My mother blames herself when something bad happens to .87 .80 me. My mother worries about whether she is a good mother. .79 .67

My mother gets very upset when I tell her about bad things .58 .55 that have happened to me. My mother is more concerned than she needs to be about .88 .81 how much alcohol I am drinking. My mother is more concerned than she needs to be about .86 .80 whether I am smoking cigarettes. Percent of variance 21.87 15.74 20.47 16.58 Eigenvalues 2.18 1.57 2.05 1.66 Cronbach’s α .78 .75 .74 .74 aFactor labels: F1 Infantilization F2 Medical management F3 Parenting anxiety F4 Harm reduction

Table 6. Maternal Overcontrol Measure, Emerging Adult Version (N = 109)

a Item F1 F2 F3 Communalities Sometimes when I am doing a task my mother will just take over. .86 .74

My mother likes to do things for me even when I can do them on my .77 .60 own. If my mother really doesn’t care for one of my friends or someone I’m .64 .56 dating she will try to get me to stop seeing him/her. When I have a problem, my mother expects me to do what she says. .55 .60

My mother expects to have input about my job and/or direction in .85 .77 school. My mother wants me to tell her everything about my friends and close .78 .66 colleagues. My mother doesn’t like it when I make a change and/or try something .66 .42 .62 new without consulting her first. It feels like my mother doesn’t want to hear my opinion about things. .89 .83 My mother discourages me from expressing my point of view. .89 .82

Percent of variance 28.43 21.26 19.04

Eigenvalues 2.56 1.91 1.71 Cronbach’s α .76 .67 .81 aFactor labels: F1 Problem solving intervention F2 Intrusive decision making F3 Discounting of opinions/ideas

Mother reported-items. The initial PCA on the 10 emerging adult-reported maternal overprotection items was applied to the 10 mother-reported maternal overprotection items. The

Kaiser-Meyer-Olkin measure verified the sampling adequacy of the analysis, KMO = .68

(moderate adequacy, according to Hutcheson & Sofroniou, 1999). Bartlett’s test of sphericity

χ2(45) = 247.61, p < .001, indicated that correlations between items were sufficiently large for

PCA. In order to emulate the initial emerging adult PCA as closely as possible, 4 components were specified a priori. The factor structure from the PCA of the emerging adult-reported measure was replicated. Table 7 presents the factor loadings, eigenvalues, and percentages of variance after rotation, as well as commonalities and Cronbach’s alphas. Items are ordered and grouped by size of loading to facilitate interpretation. Loadings under .45 (20% variance overlap between item and factor) are not reported. Adequate internal consistencies were found for all 4 subscales; Cronbach’s alphas were .68 (intrusive decision making), .77 (medical management),

.71 (parenting anxiety), and .75 (harm reduction).

Next, the second PCA on the 9 emerging adult-reported maternal overcontrol items was applied to the 9 mother-reported maternal overcontrol items. The Kaiser-Meyer-Olkin measure verified the sampling adequacy of the analysis, KMO = .66 (moderate adequacy, according to

Hutcheson & Sofroniou, 1999). Bartlett’s test of sphericity χ2(36) = 108.92, p < .001, indicated that correlations between items were sufficiently large for PCA. Again, in order to emulate the original emerging adult PCA as closely as possible, 3 components were specified a priori. The factor structure from the PCA of the emerging adult reported measure was replicated. Table 8 presents the factor loadings, eigenvalues, and percentages of variance after rotation, as well as commonalities and Cronbach’s alphas. Items are ordered and grouped by size of loading to facilitate interpretation. Loadings under .45 (20% variance overlap between item and factor) are not reported. The internal consistencies of the 3 subscales were relatively low but mostly

45 acceptable; Cronbach’s alphas were .61 (problem solving intervention), .62 (intrusive decision making), and .45 (discounting of opinions/ideas).

Table 7. Maternal Overprotection Measure, Mother Version (N = 90)

a Item F1 F2 F3 F4 Communalities I feel that my child needs my help a lot of the time. .89 .83

Sometimes I treat my child a little young for his/her age. .70 .62

I really like when my child depends on me. .56 .55

I like to make my child’s doctors’ appointments. .86 .79

I like to attend doctors’ appointments with my child. .84 .81

I worry about whether I am a good mother. .78 .65

I blame myself when something bad happens to my child. .76 .72

I get very upset when my child tells me about bad things that have happened .76 .64 to him/her. I am very concerned about whether my child is smoking cigarettes. .92 .84

I am very concerned about how much alcohol my child is drinking. .79 .79

Percent of variance 18.01 18.03 20.18 16.07 Eigenvalues 1.80 1.80 2.02 1.61 Cronbach’s α .68 .77 .71 .75 aFactor labels: F1 Infantilization F2 Medical management F3 Parenting anxiety F4 Harm reduction

Table 8. Maternal Overprotection Measure, Mother Version (N = 90)

a Item F1 F2 F3 Communalities If I really don’t care for one of my child’s friends or someone he/she is .74 .55 dating, I will attempt to get my child to stop seeing that person. Sometimes I have to take over tasks that my child is doing improperly. .69 .52

When my child has a problem, I expect he/she will do what I say. .65 .47 I like to do things for my child, even things he/she could do alone. .61 .43

I expect to have input about my child’s job/direction in school. .82 .68

I want my child to tell me everything about his/her friends and close .71 .53 colleagues. I dislike when my child makes a change and/or tries something new .62 .51 without consulting me first. I tend to prefer when my child keeps his/her point of view to .82 .71 him/herself. I ask my child to contribute his/her opinion. (reverse scored) .76 .61

Percent of variance 21.80 19.23 14.81 Eigenvalues 1.96 1.73 1.33 Cronbach’s α .61 .62 .45

aFactor labels: F1 Problem solving intervention F2 Intrusive decision making F3 Discounting of opinions/ideas

Computing factor scores. Factor scores were computed in two steps. First, item scores were weighted by multiplying each raw score by its factor loading. The purpose of this step was to ensure that items with the strongest loadings would have the largest effects on their respective factor scores, and, that items with weak loadings would have lesser contributions to their respective factor scores. Once scores were weighted, means composed of all items loading on a factor were calculated using the weighted item scores. The method of averaging the scores was chosen over summing the scores in order to retain the scale metric. This allows for ease of interpretation and for comparisons across factors, given that not all factors contain equal numbers of items. The descriptive statistics (means, standard deviations, and ranges) for the factor scores can be found in Table 9.

Table 9. Descriptive Statistics of the OPEAS Factor Scores

Informant Factor N M SD Range Infantilization 109 2.51 1.15 0.78-5.48 Medical management 109 3.11 1.54 0.86-6.02 Parenting anxiety 109 2.14 1.11 0.75-5.23 Harm reduction 109 2.20 1.48 0.87-6.09 Emerging Problem solving 109 2.12 .92 0.71-4.94 adult intervention Intrusive decision making 109 1.97 .90 0.68-4.08 Discounting of 109 1.63 1.06 0.89-6.23 opinions/ideas Infantilization 90 1.18 .38 0.72-2.15 Medical management 90 1.62 .54 0.85-2.55 Parenting anxiety 90 1.52 .33 1.02-2.30 Harm reduction 90 1.63 .53 0.86-2.57 Mother Problem solving 90 1.14 .30 0.67-2.02 intervention Intrusive decision making 90 1.67 .36 0.72-2.15 Discounting of 90 1.00 .30 0.79-1.96 opinions/ideas

Psychological Distress in Emerging Adult Survivors of Childhood Cancer

Research question 1: How do levels of psychological distress in emerging adult survivors of childhood cancer compare with general population norms?

Depression. The CES-D cutoff score for clinically significant symptoms of depression is

16 (Radloff, 1977), which corresponds to the 80th percentile for depression in community samples (Radloff & Locke, 1986). In the present sample, 28.4% of participants scored at or above 16 on the CES-D. This can be compared to 29.4% of the youth community sample (ages

18-25 years), and 18% of the adult community sample (age 26 years and above) (Radloff, 1991).

More recent research has reported similar results, with 24% of a United States general adult population sample scoring 16 or higher on the CES-D (Choi, Schalet, Cook, & Cella, 2014).

Epidemiological research with American adults ages 18 to 64 years has reported a 15.4% lifetime prevalence of a single major depressive episode, and has noted a rising prevalence in more recent cohorts (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012).

In order to compare the CES-D means of the present sample to population norms, the values reported by Radloff (1991) from the community samples were again consulted. The CES-

D total and subscale mean scores of emerging adult survivors of childhood cancer were all within one standard deviation of both youth (ages 18-25 years) and adult (age 26 years and above) community sample mean scores.

Anxiety. For the MAQ total scale, the cutoff for clinically significant anxiety symptoms is a T-score at or above 64, which is approximately 1.5 standard deviations above the mean in the standardization sample (Reynolds, 1999). In the present sample, 48% of participants scored at or above 64T on the MAQ total scale. This can be compared to 10% of the community standardization sample. Epidemiological research with American adults ages 18 to 64 years has

50 reported lifetime prevalence rates of 13.8% for specific phobia, 13% for social anxiety disorder,

6.2% for generalized anxiety disorder, 5.2% for panic disorder, and 2.7% for obsessive- compulsive disorder, and has noted a rising prevalence in more recent cohorts (Kessler et al.,

2012).

An alternate method of scoring the MAQ total scale using a T-score at or above 71 has been used to identify individuals with more severe anxiety symptoms (Reynolds, 1999). In the present sample, 32% of participants scored at or above 71T on the MAQ total scale. This can be compared to just 4% of the community standardization sample.

In order to compare the MAQ means of the present sample with population norms, the values reported by Reynolds (1999) from the community standardization sample were consulted.

All MAQ scale mean scores of the present sample (with the exception of the negative affectivity subscale) fell well above 1 standard deviation from the non-referred, community adult sample mean scores (N = 600). In addition, all MAQ scale mean scores of the present sample (again, with the exception of the negative affectivity subscale) fell well within 1 standard deviation of the MAQ mean scores of the anxiety disorders sample (obsessive-compulsive disorder, n = 44; panic disorder, n = 53; social anxiety disorder, n = 51; generalized anxiety disorder, n =30).

Summary. The mean depression symptom scores reported by emerging adult survivors of childhood cancer, as well as the percentages of participants who fell above clinical cutoffs, did not differ significantly from estimates found in the general population. In contrast, the percentages of participants who fell above clinical cutoffs for anxiety (both standard and severe cutoffs) were markedly higher than estimates found in the general population. In addition, the anxiety symptom scores reported by emerging adult survivors of childhood cancer were more than 1 standard deviation higher than the anxiety symptom scores reported in the general

51 population, and more closely resembled those reported in clinical populations. Percentages of participants scoring above clinical cutoffs for both depression and anxiety are higher than recent lifetime prevalence estimates from epidemiological research.

Research question 2: How do mother-reported levels of overparenting compare in emerging adults who score above and below clinical cutoffs for psychological distress?

Depression. Independent samples t-tests were conducted to compare scores on each of the seven mother-reported OPEAS subscales in emerging adults who scored at or above the

CES-D clinical cutoff of 16 and below the CES-D clinical cutoff of 16. There were no differences in mother-reported infantilization, medical management, parenting anxiety, harm reduction, problem solving intervention, intrusive decision making, or discounting of opinions/ideas, based on the emerging adult depression cutoff score of 16 (t(24.16) = -1.65, ns, d

= -.43, t(39.19) = -0.07, ns, d = -.02, t(83) = -1.01, ns, d = -.27, t(83) = -1.21, ns, d = -.32, t(83)

= -1.25, ns, d = -.33, t(83) = 0.14, ns, d = .04, and t(83) = -0.52, ns, d = -.14, respectively).

Anxiety. Independent samples t-tests were conducted to compare scores on each of the seven mother-reported reported OPEAS subscales in emerging adults who scored at or above the

MAQ total scale clinical cutoff T-score of 64 and below the MAQ total scale clinical cutoff T- score of 64. Emerging adults who scored at or above 64T had mothers who reported significantly more harm reduction than emerging adults who scored below 64T (t(81) = -2.04, p < .05, d = -

.46). There were no differences in mother-reported infantilization, medical management, parenting anxiety, problem solving intervention, intrusive decision making, or discounting of opinions/ideas, based on the emerging adult total anxiety cutoff score of 64T (t(81) = -1.64, ns, d

= -.37, t(81) = -1.31, ns, d = -.29, t(81) = -1.39, ns, d = -.31, t(81) = -1.89, ns, d = -.42, t(81) = -

1.30, ns, d = -.29, and t(81) = 0.03, ns, d = .01, respectively).

Independent samples t-tests were also conducted to compare scores on each of the seven mother-reported OPEAS subscales in emerging adults who scored at or above the MAQ total scale clinical severity cutoff T-score of 71 and below the MAQ total scale clinical severity cutoff

T-score of 71. There were no differences in mother-reported infantilization, medical management, parenting anxiety, harm reduction, problem solving intervention, intrusive decision making, or discounting of opinions/ideas, based on the emerging adult severe anxiety cutoff score of 71T (t(32.89) = -1.65, ns, d = -.40, t(81) = 0.33, ns, d = .08, t(81) = -0.27, ns, d = -.07, t(81) = -0.81, ns, d = -.02, t(81) = 0.12, ns, d = .03, t(81) = -0.22, ns, d = -.05, and t(81) = 0.34, ns, d = .08, respectively).

Summary. Mother-reported levels of overparenting did not differ for any overparenting subscale based on whether emerging adults scored at or above versus below clinical cutoffs for depression, anxiety, or severe anxiety, with the exception of one overprotection subscale, mother-reported harm reduction, being higher for emerging adults who scored at or above 64T than those who scored below 64T on the MAQ total scale.

Research question 3: How do perceived levels of overparenting compare in emerging adults who score above and below clinical cutoffs for psychological distress?

Depression. Independent samples t-tests were conducted to compare scores on each of the seven emerging adult-reported OPEAS subscales in emerging adults who scored at or above the CES-D clinical cutoff of 16 and below the CES-D clinical cutoff of 16. In terms of overprotection, emerging adults who scored at or above 16 perceived that their mothers displayed significantly more infantilization and parenting anxiety than emerging adults who scored below 16 (t(107) = -2.43, p < .05, d = -.52, and t(107) = -3.20, p < .01, d = -.69, respectively). Mothers’ levels of medical management and harm reduction as perceived by the

53 emerging adults did not differ based on the cutoff score of 16 (t(107) = -1.60, ns, d = -.34, and t(44.88) = -1.60, ns, d = -.34, respectively). In terms of overcontrol, emerging adults who scored at or above 16 perceived that their mothers displayed significantly more problem solving intervention, intrusive decision making, and discounting of opinions/ideas than emerging adults who scored below 16 (t(107) = -2.58, p < .05, d = -.55, t(107) = -2.83, p < .01, d = -.61, and t(38.67) = -2.87, p < .01, d = -.62, respectively).

Anxiety. Independent samples t-tests were conducted to compare scores on each of the seven emerging-adult reported OPEAS subscales in emerging adults who scored at or above the

MAQ total scale clinical cutoff T-score of 64 and below the MAQ total scale clinical cutoff T- score of 64. In terms of overprotection, emerging adults who scored at or above 64T perceived that their mothers displayed significantly more infantilization and parenting anxiety than emerging adults who scored below 64T (t(107) = -3.52, p < .01, d = -.71, and t(107) = -3.04, p <

.01, d = -.61, respectively). Mothers’ levels of medical management and harm reduction as perceived by the emerging adults did not differ based on the cutoff score of 64T (t(107) = -0.76, ns, d = -.15, and t(107) = -0.67, ns, d = -.13, respectively). In terms of overcontrol, emerging adults who scored at or above 64T perceived that their mothers displayed significantly more problem solving intervention, intrusive decision making, and discounting of opinions/ideas than emerging adults who scored below 64T (t(107) = -2.98, p < .01, d = -.60, and t(107) = -3.73, p <

.001, d = -.75, and t(89.89) = -2.61, p < .05, d = -.52, respectively).

Independent samples t-tests were also conducted to compare scores on each of the seven emerging adult-reported OPEAS subscales in emerging adults who scored at or above the MAQ total scale clinical severity cutoff of 71T and below the MAQ clinical severity cutoff of 71T. In terms of overprotection, emerging adults who scored at or above 71T perceived that their

54 mothers displayed significantly more infantilization and parenting anxiety than emerging adults who scored below the clinical severity cutoff of 71T (t(107) = -2.60, p < .05, d = -.56, and t(82.39) = -2.83, p < .01, d = -.61, respectively). Mothers’ levels of medical management and harm reduction as perceived by the emerging adults did not differ based on the cutoff score of

71T (t(107) = -1.58, ns, d = -.34, and t(107) = -0.60, ns, d = -.13, respectively). In terms of overcontrol, emerging adults who scored at or above 71T perceived that their mothers displayed significantly more problem solving intervention, intrusive decision making, and discounting of opinions/ideas than emerging adults who scored below the clinical severity cutoff of 71T (t(107)

= -2.07, p < .05, d = -.44, t(107) = -2.97, p < .01, d = -.64, and t(107) = -2.20, p < .05, d = -.47, respectively).

Summary. Perceived levels of two of the four overprotection subscales, infantilization and parenting anxiety, and the three overcontrol subscales, problem solving intervention, intrusive decision making, and discounting of opinions/ideas, were higher for emerging adults who scored above the clinical cutoff of 16 for depression than below 16. Perceived levels of two of the four overprotection subscales, infantilization and parenting anxiety, and the three overcontrol subscales, problem solving intervention, intrusive decision making, and discounting of opinions/ideas, were higher for emerging adults who scored above the clinical cutoff of 64T for anxiety than below 64T. When the anxiety cutoff was raised to a more severe level of 71T, the groups above and below the cutoff continued to differ in perceived levels of infantilization, parenting anxiety, problem solving intervention, intrusive decision making, and discounting of opinions/ideas.

The Effect of Overparenting on Coping Style

Research question 4: Does mother-reported overparenting predict the use of productive coping styles and a nonproductive coping style? Intercorrelations among the mother-reported overparenting subscales and the emerging-adult reported coping styles are presented in Table 10. Hierarchical multiple linear regressions were used to test the hypothesis that mothers’ overprotective parenting would negatively predict emerging adults’ productive coping styles (dealing with the problem, sharing, and optimism coping styles), and positively predict emerging adults’ nonproductive coping style. To avoid the problem of multicolinearity that could result from the conceptual and empirical interrelations among the overparenting subscales, each subscale was tested in a separate regression equation as a predictor. For all regressions, at the first step four control variables were entered: emerging adult’s sex, age, age of diagnosis, and education. At the second step one of each of the seven mother-reported overparenting factors was entered as a predictor variable. Outcome variables were the four coping styles.

Table 10. Intercorrelations among Mother-Reported Overparenting and Emerging-Adult Coping Styles

Dealing with Sharing Optimism Non the problem productive Infantilization -.22* .16 .16 .09 Medical management -.10 -.06 .06 .05 Parenting anxiety -.01 .11 .08 .08 Harm reduction .21 -.02 .22* .21 Problem solving intervention .11 .08 .21 .27* Intrusive decision making .07 .06 .08 .10 Discounting of opinions/ideas .07 -.19 .18 .18 Dealing with the problem -- Sharing .21* -- Optimism .52*** .21* -- Nonproductive .13 .02 .30** -- Note. *p < .05, **p < .01, ***p < .001.

Dealing with the problem. The results of the seven regression models are presented in

Table 11. None of the mother-reported overparenting subscales significantly predicted the emerging adult coping strategy of dealing with the problem. Emerging adult sex was a significant predictor of dealing with the problem in all seven regressions, indicating that being male predicted dealing with the problem coping style.

Sharing. The results of the seven regressions are presented in Table 12. None of the mother-reported overparenting subscales significantly predicted the emerging adult coping style of sharing.

Optimism. The results of the seven regressions are presented in Table 13. Mother- reported harm reduction and problem solving intervention significantly and positively predicted the emerging adult coping style of optimism. Beyond the variance in optimism accounted for by sex, age, education, and age of diagnosis, harm reduction and problem solving intervention accounted for an additional 7% and 5%, respectively, of the variance in optimism.

Nonproductive. The results of the seven regressions are presented in Table 14. Harm reduction, problem solving intervention, and discounting of opinions/ideas significantly and positively predicted the emerging adult coping nonproductive coping strategy. Beyond the variance in nonproductive coping accounted for by sex, age, education, and age of diagnosis, harm reduction, problem solving intervention, and discounting of opinions/ideas accounted for an additional 5%, 5%, and 5%, of the variance in nonproductive coping. Emerging adult age of diagnosis was also a significant predictor of nonproductive coping in all seven regressions, indicating that older age of diagnosis predicted nonproductive coping.

Summary. Mothers’ reports of overparenting differentially affected the four coping styles of emerging adult survivors of childhood cancer. Dealing with the problem and sharing were not

57 predicted by mother-reported overparenting. A third productive coping strategy, optimism, was positively predicted by one overprotection subscale, mothers’ harm reduction, and one overcontrol subscale, problem solving intervention, with mothers who were high in harm reduction and problem solving intervention having children who were more likely to engage in optimism coping. Nonproductive coping was positively predicted by one overprotection subscale, mothers’ harm reduction, and two overcontrol subscales, problem solving intervention and discounting of opinions/ideas, with mothers who were high in harm reduction, problem solving intervention, and discounting of opinions/ideas having children who were more likely to engage in nonproductive coping.

58 Table 11. Summary of Linear Regression Analyses for the Prediction of Dealing with the Problem Coping Style from Mother-Reported Overparenting Step 1 Step 2 Predictors B SE B β B SE B β Sex -.26 .11 -.26* -.25 .11 -.25* Age -.01 .02 -.09 -.01 .02 -.10 Education .13 .07 .26 .12 .07 .23 Age of diagnosis -.01 .01 -.11 -.01 .01 -.07 Infantilization -.19 .15 -.15 Notes. *p <.05; R2 = .12 for Step 1 (p < .05); ΔR2 = .02 for Step 2 (ns); f2 = .02. Sex -.26 .11 -.26* -.27 .11 -.26* Age -.01 .02 -.09 -.02 .02 -.11 Education .13 .07 .26 .13 .07 .25 Age of diagnosis -.01 .01 -.11 -.01 .01 -.10 Medical management -.05 .11 -.06 Notes. *p <.05; R2 = .12 for Step 1 (p < .05); ΔR2 = .00 for Step 2 (ns); f2 = .00. Sex -.26 .11 -.26* -.26 .11 -.26* Age -.01 .02 -.09 -.01 .02 -.09 Education .13 .07 .26 .13 .07 .26 Age of diagnosis -.01 .01 -.11 -.01 .01 -.11 Parenting anxiety .01 .17 .01 Notes. *p <.05; R2 = .12 for Step 1 (p < .05); ΔR2 = .00 for Step 2 (ns); f2 = .00. Sex -.26 .11 -.26* -.23 .11 -.23* Age -.01 .02 -.09 -.01 .02 -.07 Education .13 .07 .26 .13 .07 .26 Age of diagnosis -.01 .01 -.11 -.01 .01 -.12 Harm reduction .18 .10 .19 Notes. *p <.05; R2 = .12 for Step 1 (p < .05); ΔR2 = .03 for Step 2 (ns); f2 = .04. Sex -.26 .11 -.26* -.25 .11 -.24* Age -.01 .02 -.09 -.01 .02 -.06 Education .13 .07 .26 .13 .07 .26 Age of diagnosis -.01 .01 -.11 -.02 .01 -.14 Problem solving .23 .19 .14 intervention Notes. *p <.05; R2 = .12 for Step 1 (p < .05); ΔR2 = .02 for Step 2 (ns); f2 = .02. Sex -.26 .11 -.26* -.25 .11 -.25* Age -.01 .02 -.09 -.01 .02 -.07 Education .13 .07 .26 .13 .07 .26 Age of diagnosis -.01 .01 -.11 -.01 .01 -.12 Intrusive decision making .07 .16 .05 Notes. *p <.05; R2 = .12 for Step 1 (p < .05); ΔR2 = .00 for Step 2 (ns); f2 = .00. Sex -.26 .11 -.26* -.26 .11 -.26* Age -.01 .02 -.09 -.02 .02 -.10 Education .13 .07 .26 .14 .07 .27 Age of diagnosis -.01 .01 -.11 -.01 .01 -.11 Discounting of .12 .18 .07 opinions/ideas Notes. *p <.05; R2 = .12 for Step 1 (p < .05); ΔR2 = .01 for Step 2 (ns); f2 = .01.

59 Table 12. Summary of Linear Regression Analyses for the Prediction of Sharing Coping Style from Mother-Reported Overparenting Step 1 Step 2 Predictors B SE B β B SE B β Sex .18 .12 .18 .17 .12 .16 Age -.00 .02 -.01 .00 .02 .01 Education .05 .07 .09 .07 .07 .14 Age of diagnosis -.01 .01 -.13 -.02 .01 -.19 Infantilization .30 .15 .22 Notes. R2 = .05 for Step 1 (ns); ΔR2 = .04 for Step 2 (ns); f2 = .05. Sex .18 .12 .18 .19 .12 .18 Age -.00 .02 -.01 .00 .02 .01 Education .05 .07 .09 .05 .08 .10 Age of diagnosis -.01 .01 -.13 -.02 .01 -.14 Medical management .04 .12 .04 Notes. R2 = .05 for Step 1 (ns); ΔR2 = .00 for Step 2 (ns); f2 = .00. Sex .18 .12 .18 .20 .12 .19 Age -.00 .02 -.01 .00 .02 .03 Education .05 .07 .09 .05 .07 .10 Age of diagnosis -.01 .01 -.13 -.02 .01 -.16 Parenting anxiety .25 .17 .17 Notes. R2 = .05 for Step 1 (ns); ΔR2 = .03 for Step 2 (ns); f2 = .03. Sex .18 .12 .18 .19 .12 .18 Age -.00 .02 -.01 .00 .02 -.00 Education .05 .07 .09 .05 .07 .09 Age of diagnosis -.01 .01 -.13 -.01 .01 -.13 Harm reduction .02 .11 .02 Notes. R2 = .05 for Step 1 (ns); ΔR2 = .00 for Step 2 (ns); f2 = .00. Sex .18 .12 .18 .20 .12 .20 Age -.00 .02 -.01 .00 .02 .03 Education .05 .07 .09 .04 .07 .09 Age of diagnosis -.01 .01 -.13 -.02 .01 -.17 Problem solving .26 .20 .15 intervention Notes. R2 = .05 for Step 1 (ns); ΔR2 = .02 for Step 2 (ns); f2 = .02. Sex .18 .12 .18 .21 .12 .20 Age -.00 .02 -.01 .01 .02 .04 Education .05 .07 .09 .04 .07 .08 Age of diagnosis -.01 .01 -.13 -.02 .01 -.15 Intrusive decision making .19 .16 .14 Notes. R2 = .05 for Step 1 (ns); ΔR2 = .02 for Step 2 (ns); f2 = .02. Sex .18 .12 .18 .18 .12 .17 Age -.00 .02 -.01 .01 .02 .03 Education .05 .07 .09 .04 .07 .07 Age of diagnosis -.01 .01 -.13 -.01 .01 -.14 Discounting of -.32 .18 -.19 opinions/ideas Notes. R2 = .05 for Step 1 (ns); ΔR2 = .04 for Step 2 (ns); f2 = .04.

60 Table 13. Summary of Linear Regression Analyses for the Prediction of Optimism Coping Style from Mother-Reported Overparenting Step 1 Step 2 Predictors B SE B β B SE B β Sex .17 .14 .14 .16 .14 .13 Age -.02 .03 -.10 -.02 .02 -.09 Education .13 .09 .22 .16 .09 .26 Age of diagnosis .01 .01 .09 .01 .01 .05 Infantilization .28 .18 .18 Notes. R2 = .07 for Step 1 (ns); ΔR2 = .03 for Step 2 (ns); f2 = .03. Sex .17 .14 .14 .19 .14 .16 Age -.02 .03 -.10 -.01 .03 -.06 Education .13 .09 .22 .15 .09 .25 Age of diagnosis .01 .01 .09 .01 .01 .06 Medical management .15 .14 .14 Notes. R2 = .07 for Step 1 (ns); ΔR2 = .01 for Step 2 (ns); f2 = .02. Sex .17 .14 .14 .19 .14 .15 Age -.02 .03 -.10 -.01 .03 -.08 Education .13 .09 .22 .14 .09 .22 Age of diagnosis .01 .01 .09 .01 .01 .08 Parenting anxiety .19 .20 .11 Notes. R2 = .07 for Step 1 (ns); ΔR2 = .01 for Step 2 (ns); f2 = .01. Sex .17 .14 .14 .23 .13 .18 Age -.02 .03 -.10 -.01 .02 -.07 Education .13 .09 .22 .13 .08 .22 Age of diagnosis .01 .01 .09 .01 .01 .08 Harm reduction .20 .12 .26* Notes. *p < .05; R2 = .07 for Step 1 (ns); ΔR2 = .07 for Step 2 (ns); f2 = .08. Sex .17 .14 .14 .21 .13 .17 Age -.02 .03 -.10 -.01 .02 -.05 Education .13 .09 .22 .13 .08 .21 Age of diagnosis .01 .01 .09 .00 .01 .03 Problem solving intervention .48 .22 .24* Notes. *p < .05; R2 = .07 for Step 1 (ns); ΔR2 = .05 for Step 2 (ns); f2 = .06. Sex .17 .14 .14 .21 .14 .17 Age -.02 .03 -.10 -.01 .03 -.06 Education .13 .09 .22 .13 .09 .21 Age of diagnosis .01 .01 .09 .01 .01 .08 Intrusive decision making .22 .19 .13 Notes. R2 = .07 for Step 1 (ns); ΔR2 = .02 for Step 2 (ns); f2 = .02. Sex .17 .14 .14 .18 .13 .15 Age -.02 .03 -.10 -.03 .02 -.14 Education .13 .09 .22 .15 .09 .24 Age of diagnosis .01 .01 .09 .01 .01 .09 Discounting of opinions/ideas .38 .21 .19 Notes. R2 = .07 for Step 1 (ns); ΔR2 = .04 for Step 2 (ns); f2 = .04.

61 Table 14. Summary of Linear Regression Analyses for the Prediction of Nonproductive Coping Style from Mother-Reported Overparenting Step 1 Step 2 Predictors B SE B β B SE B β Sex .22 .14 .17 .22 .14 .17 Age -.05 .03 -.26 -.05 .03 -.26 Education .14 .09 .21 .14 .09 .21 Age of diagnosis .03 .01 .24* .03 .01 .23* Infantilization .05 .19 .03 Notes. *p < .05; R2 = .14 for Step 1 (p < .05); ΔR2 = .00 for Step 2 (ns); f2 = .00. Sex .22 .14 .17 .22 .14 .17 Age -.05 .03 -.26 -.05 .03 -.26 Education .14 .09 .21 .13 .09 .20 Age of diagnosis .03 .01 .24* .03 .02 .24* Medical management -.02 .14 -.01 Notes. *p < .05; R2 = .14 for Step 1 (p < .05); ΔR2 = .00 for Step 2 (ns); f2 = .00. Sex .22 .14 .17 .23 .14 .17 Age -.05 .03 -.26 -.05 .03 -.25 Education .14 .09 .21 .14 .09 .21 Age of diagnosis .03 .01 .24* .03 .01 .23* Parenting anxiety .09 .21 .05 Notes. *p < .05; R2 = .14 for Step 1 (p < .05); ΔR2 = .00 for Step 2 (ns); f2 = .00. Sex .22 .14 .17 .27 .14 .21 Age -.05 .03 -.26 -.04 .03 -.23 Education .14 .09 .21 .14 .09 .21 Age of diagnosis .03 .01 .24* .03 .01 .23* Harm reduction .28 .13 .23* Notes. *p < .05; R2 = .14 for Step 1 (p < .05); ΔR2 = .05 for Step 2 (p < .05); f2 = .06. Sex .22 .14 .17 .26 .14 .20 Age -.05 .03 -.26 -.04 .03 -.21 Education .14 .09 .21 .13 .09 .20 Age of diagnosis .03 .01 .24* .02 .01 .18 Problem solving .52 .23 .24* intervention Notes. *p < .05; R2 = .14 for Step 1 (p < .05); ΔR2 = .05 for Step 2 (p < .05); f2 = .06. Sex .22 .14 .17 .24 .14 .19 Age -.05 .03 -.26 -.04 .03 -.23 Education .14 .09 .21 .13 .09 .20 Age of diagnosis .03 .01 .24* .03 .01 .23* Intrusive decision making .15 .20 .09 Notes. *p < .05; R2 = .14 for Step 1 (p < .05); ΔR2 = .01 for Step 2 (ns); f2 = .01. Sex .22 .14 .17 .23 .14 .18 Age -.05 .03 -.26 -.06 .03 -.30* Education .14 .09 .21 .15 .09 .23 Age of diagnosis .03 .01 .24* .03 .01 .24* Discounting of .27 .22 .22* opinions/ideas Notes. *p < .05; R2 = .14 for Step 1 (p < .05); ΔR2 = .05 for Step 2 (ns); f2 = .06.

Perceptions of Overparenting and Nonproductive Coping as Mediators of the Relation between Overparenting and Psychological Distress

Research questions 5 and 6 address the possibility of mediation, where emerging adults’ perceptions of overparenting and nonproductive coping are conceptualized as serial multiple mediators between mother-reported overparenting and emerging adults’ psychological distress.

The other three coping styles (i.e., dealing with the problem, sharing, and optimism) were not tested as mediators because, according to theory and past findings, there is no reason to expect the use of productive coping styles to be linked to overprotective parenting or psychological distress.

Table 15 presents the intercorrelations among overparenting subscales (both mother- and emerging adult-report), nonproductive coping, and the psychological distress outcomes.

Table 15. Intercorrelations among Variables of Interest

2 3 4 5 1. Infantilization M-R .40*** .09 .18 .27* 2. Infantilization EA-R -- .29** .29** .20* 3. Nonproductive coping -- .71*** .63*** 4. Anxiety -- .79*** 5. Depression -- 2 3 4 5 1. Medical management M-R .49*** .05 .05 .09 2. Medical management EA-R -- .18 .16 .19* 3. Nonproductive coping -- .71*** .63*** 4. Anxiety -- .79*** 5. Depression -- 2 3 4 5 1. Parenting anxiety M-R .41*** .08 .09 .14 2. Parenting anxiety EA-R -- .30** .28** .31**

3. Nonproductive coping -- .71*** .63*** 4. Anxiety -- .79*** 5. Depression -- 2 3 4 5 1. Harm reduction M-R .32** .21 .17 .12 2. Harm reduction EA-R -- .14 .14 .21* 3. Nonproductive coping -- .71*** .63*** 4. Anxiety -- .79*** 5. Depression -- 2 3 4 5 1. Problem solving intervention M-R .36** .27* .17 .23* 2. Problem solving intervention EA-R -- .31** .31** .28** 3. Nonproductive coping -- .71*** .63*** 4. Anxiety -- .79*** 5. Depression -- 2 3 4 5 1. Intrusive decision making M-R .29** .10 .12 .03 2. Intrusive decision making EA-R -- .34*** .35*** .32** 3. Nonproductive coping -- .71*** .63*** 4. Anxiety -- .79*** 5. Depression -- 2 3 4 5 1. Discounting of opinions/ideas M-R .16 .17 .31** .31** 2. Discounting of opinions/ideas EA-R -- .18 .06 .02 3. Nonproductive coping -- .71*** .63*** 4. Anxiety -- .79*** 5. Depression -- Notes. *p < .05, **p < .01, ***p < .001. M-R = Mother-report, EA-R = Emerging adult-report.

Research question 5: Is the effect of overparenting on anxiety symptoms mediated by emerging adults’ perceptions of overparenting and nonproductive coping? A series of serial multiple mediation models were estimated using an ordinary least squares (OLS) regression-based path analysis framework (for more information on PROCESS for SPSS, see

Hayes, 2013). Serial multiple mediation models were selected because, in our hypotheses, two mediators were presumed to be somehow casually prior to each other while also affecting all variables later in the sequence. The aim of a serial multiple mediation model was to investigate the direct and indirect effects of mother-reported overparenting on anxiety while modeling a process in which mother-reported overparenting relates to emerging adult-reported overparenting, which in turn relates to nonproductive coping, concluding with anxiety as the final consequent.

Separate mediation models were tested for each mother-reported overparenting subscale as predictors. Figure 1 presents the statistical model for these analyses. In all models, emerging adult sex, age, age of diagnosis, and education were included as control variables. This model tested three specific indirect effects and one direct effect (c') of the overparenting predictor on anxiety symptoms. The three indirect effects were estimated as the product of the regression weights linking the overparenting predictor to anxiety symptoms through at least one of the two mediators. As illustrated in Figure 1, the specific indirect effect of the overparenting predictor on anxiety symptoms through only emerging adults’ perceptions of the overparenting predictor was a1b1, the specific indirect effect through only nonproductive coping was a2b2, and the specific indirect effect through both emerging adults’ perceptions of the overparenting predictor and nonproductive coping in serial was a1db2.

eM1 eM2

1 1

Emerging adult-report d overparenting Nonproductive coping predictor eY a b2 1 1

b1 a2

Mother-report Anxiety symptoms overparenting c' predictor

Age of diagnosis

Age

Sex Education

Figure 1. Statistical diagram of serial multiple mediation model 1, anxiety symptoms as outcome.

Overprotection - Infantilization. Mother-reported infantilization was indirectly related to anxiety through its relation to emerging adults’ perceptions of infantilization, which, in turn, related to nonproductive coping. Mother-reported infantilization impacted perceptions (a1 = 1.21, t(79) = 3.61, p < .001), perceptions impacted nonproductive coping (d = 0.18, t(78) = 3.04, p <

.01), and nonproductive coping impacted anxiety (b2 = 16.12, t(77) = 7.28, p < .001). A bias- corrected bootstrap confidence interval for the indirect effect (a1db2 = 3.52) based on 10,000 bootstrap samples was entirely above zero (1.36 to 8.47). There was no evidence of simple mediation models, where mother-reported infantilization would relate to anxiety through either perceptions or nonproductive coping (a1b1 = 2.73, CI = -0.31 to 6.87, and a2b2 = -2.73, CI = -9.29 to 2.99, respectively). The direct (unmediated) effect of mother-reported infantilization on anxiety when controlling for the two mediators was nonsignificant (cʹ = 1.98, p = .60), providing further evidence for mediation.

Overprotection - Medical management. Mother-reported medical management was not indirectly related to anxiety through perceptions of medical management and nonproductive coping, either through serial multiple mediation (a1db2 = 0.81, CI = -0.50 to 3.93), or through simple mediation (a1b1 = 0.47, CI = -1.07 to 2.84; a2b2 = -1.08, CI = -6.18 to 3.90).

Overprotection - Parenting anxiety. Mother-reported parenting anxiety was indirectly related to anxiety through its relation to emerging adults’ perceptions of parenting anxiety, which, in turn, was related to nonproductive coping. Mother-reported parenting anxiety impacted perceptions (a1 = 1.44, t(79) = 4.01, p < .001), perceptions impacted nonproductive coping at trend level (d = 0.11, t(78) = 1.75, p = .08), and nonproductive coping impacted anxiety (b2 =

17.22, t(77) = 7.84, p < .001). A bias-corrected bootstrap confidence interval for the indirect effect (a1db2 = 2.81) based on 10,000 bootstrap samples was entirely above zero (0.05 to 7.92).

There was no evidence of simple mediation models, where mother-reported parenting anxiety would impact anxiety through either perceptions or nonproductive coping (a1b1 = 1.15, CI = -

2.61 to 5.35, and a2b2 = -1.20, CI = -8.04 to 6.17, respectively). The direct (unmediated) effect of mother-reported parenting anxiety on anxiety when controlling for the two mediators was nonsignificant (cʹ = 0.42, p = .92), providing further evidence for mediation.

Overprotection - Harm reduction. Although for the relation of mother-reported harm reduction to anxiety there was no evidence of serial multiple mediation, mother-reported harm reduction was indirectly related to anxiety through its effect on nonproductive coping. Mother- reported harm reduction impacted nonproductive coping (a2 = 0.28, t(78) = 2.10, p < .05), and nonproductive coping impacted anxiety (b2 = 17.27, t(77) = 7.87, p < .001). A bias-corrected bootstrap confidence interval for the indirect effect (a2b2 = 4.83) based on 10,000 bootstrap samples was entirely above zero (0.44 to 9.19). The direct (unmediated) effect of mother- reported harm reduction on anxiety when controlling for the two mediators was nonsignificant

(cʹ = 0.08, p = .98), providing further evidence for mediation.

Overcontrol - Problem solving intervention. Although for the relation of mother- reported problem solving intervention to anxiety there was no evidence of serial multiple mediation, mother-reported problem solving intervention was indirectly related to anxiety through its effect on perceptions of problem solving intervention. Mother-reported problem solving intervention impacted perceptions (a2 = 1.03, t(79) = 3.07, p < .01), and perceptions impacted anxiety at trend level (b2 = 2.94, t(77) = 1.93, p = .06). A bias-corrected bootstrap confidence interval for the indirect effect (a2b2 = 3.01) based on 10,000 bootstrap samples was entirely above zero (0.09 to 8.27). The direct (unmediated) effect of mother-reported problem

68 solving intervention on anxiety when controlling for the two mediators was nonsignificant (cʹ = -

2.91, p = .55), providing further evidence for mediation.

Overcontrol - Intrusive decision making. Mother-reported intrusive decision making was not indirectly related to anxiety through perceptions of intrusive decision making and nonproductive coping, either through serial multiple mediation (a1db2 = 1.29, CI = -0.12 to 4.25), or through simple mediation (a1b1 = 1.15, CI = -0.09 to 3.76; a2b2 = -1.54, CI = -5.68 to 2.92).

Overcontrol - Discounting of opinions/ideas. Although for the relation of mother- reported discounting of opinions/ideas to anxiety there was no evidence of serial multiple mediation, mother-reported discounting of opinions/ideas was indirectly related to anxiety through its effect on nonproductive coping. Mother-reported discounting of opinions/ideas impacted nonproductive coping at trend level (a2 = 0.43, t(78) = 1.92, p = .05), and nonproductive coping impacted anxiety (b2 = 17.02, t(77) = 8.14, p < .001). A bias-corrected bootstrap confidence interval for the indirect effect (a2b2 = 7.25) based on 10,000 bootstrap samples was entirely above zero (1.40 to 14.49). The direct (unmediated) effect of mother- reported discounting of opinions/ideas on anxiety when controlling for the two mediators was nonsignificant (cʹ = -5.38, p = .20), providing further evidence for mediation.

Overprotection summary. Serial multiple mediation of the association between mother- reported overprotection and anxiety was found for two overprotection subscales. Specifically, mother-reported infantilization and parenting anxiety were indirectly related to anxiety through a link to emerging adults’ perceptions of the overparenting, which, in turn, related to nonproductive coping. For mother-reported harm reduction, relations to anxiety were mediated by nonproductive coping only, and not emerging adults’ perceptions of harm reduction. Mother-

69 reported medical management was not indirectly related to anxiety through multiple mediation or simple mediation.

Overcontrol summary. Serial multiple mediation of the relation between mother-reported overcontrol and anxiety was not found for any overcontrol subscale. For mother-reported discounting of opinions/ideas, relations to anxiety were mediated by nonproductive coping only, and not emerging adults’ perceptions of the overparenting. For mother-reported problem solving intervention, its relation to anxiety was mediated by emerging adults’ perceptions of problem solving intervention only, and not nonproductive coping. Mother-reported intrusive decision making was not indirectly related to anxiety through multiple mediation or simple mediation.

Research question 6: Is the effect of overparenting on depression symptoms mediated by emerging adults’ perceptions of overparenting and nonproductive coping?

Analogous to the analyses conducted in research question 5, a series of serial multiple mediation models were estimated using an OLS regression-based path analysis framework (Hayes, 2013).

Again, serial multiple mediation models were selected because, in our hypotheses, two mediators were presumed to be somehow casually prior to each other while also affecting all variables later in the sequence. The aim of a serial multiple mediation model was to investigate the direct and indirect effects of mother-reported overparenting on depression while modeling a process in which mother-reported overparenting relates to emerging adult-reported overparenting, which in turn relates to nonproductive coping, concluding with depression as the final consequent.

Separate mediation models were tested for each mother-reported overparenting subscale as predictors. Figure 2 presents the statistical model for these analyses. In all models, emerging adult sex, age, age of diagnosis, and education were included as control variables. This model tested three specific indirect effects and one direct effect (c') of the overparenting predictor on

70 depression symptoms. The three indirect effects were estimated as the product of the regression weights linking the overparenting predictor to depression symptoms through at least one of the two mediators. As illustrated in Figure 1, the specific indirect effect of the overparenting predictor on depression symptoms through only emerging adults’ perceptions of the overparenting predictor was a1b1, the specific indirect effect through only nonproductive coping was a2b2, and the specific indirect effect through both emerging adults’ perceptions of the overparenting predictor and nonproductive coping in serial was a1db2.

eM1 eM2

1 1

Emerging adult-report d overparenting Nonproductive coping predictor eY b a1 2 1

b1 a2 Mother-report overparenting Depression symptoms c' predictor

Age of diagnosis

Age

Sex Education

Figure 2. Statistical diagram of serial multiple mediation model 2, depression symptoms as outcome.

Overprotection - Infantilization. Mother-reported infantilization was indirectly related to depression through its relation to emerging adults’ perceptions of infantilization, which, in turn, related to nonproductive coping. Mother-reported infantilization impacted perceptions (a1 = 1.21, t(79) = 3.61, p < .001), perceptions impacted nonproductive coping (d = 0.18, t(78) = 3.04, p <

.01), and nonproductive coping impacted depression (b2 = 1.36, t(77) = 6.54, p < .001). A bias- corrected bootstrap confidence interval for the indirect effect (a1db2 = 0.30) based on 10,000 bootstrap samples was entirely above zero (0.10 to 0.71). There was no evidence of simple mediation models, where mother-reported infantilization would impact depression through either perceptions or nonproductive coping (a1b1 = -0.11, CI = -0.45 to 0.17, and a2b2 = -0.23, CI = -

0.85 to 0.23, respectively). The direct (unmediated) effect of mother-reported infantilization on depression when controlling for the two mediators was significant (cʹ = 0.77, p < .05).

Overprotection - Medical management. For the relation of mother-reported medical management to depression through emerging adults’ perceptions of medical management and nonproductive coping there was no evidence of serial multiple mediation (a1db2 = 0.06, CI = -

0.05 to 0.27) or simple mediation (a1b1 = 0.07, CI = -0.09 to 0.34; a2b2 = -0.08, CI = -0.52 to

0.29).

Overprotection - Parenting anxiety. Mother-reported parenting anxiety was indirectly related to depression through its effect on emerging adults’ perceptions of parenting anxiety, which, in turn, related to nonproductive coping. Mother-reported parenting anxiety impacted perceptions (a1 = 1.44, t(79) = 4.01, p < .001), perceptions impacted nonproductive coping at trend level (d = 0.11, t(78) = 1.75, p = .08), and nonproductive coping impacted depression (b2 =

1.25, t(77) = 6.18, p < .001). A bias-corrected bootstrap confidence interval for the indirect effect

(a1db2 = 0.20) based on 10,000 bootstrap samples was entirely above zero (0.02 to 0.57). There

73 was no evidence of simple mediation models, where mother-reported parenting anxiety would impact depression through either perceptions or nonproductive coping (a1b1 = 0.24, CI = -0.07 to

0.72, and a2b2 = -0.09, CI = -0.69 to 0.44, respectively). The direct (unmediated) effect of parenting anxiety on depression when controlling for the two mediators was nonsignificant (cʹ =

0.07, p = .87), providing further evidence for mediation.

Overprotection - Harm reduction. Although for the relation of mother-reported harm reduction to depression there was no evidence of serial multiple mediation, mother-reported harm reduction was indirectly related to depression through its relation to perceptions of harm reduction. Mother-reported harm reduction impacted perceptions (a2 = 0.73, t(79) = 2.59, p <

.05), and perceptions impacted depression at trend level (b2 = 0.18, t(77) = 1.95, p = .05). A bias- corrected bootstrap confidence interval for the indirect effect (a2b2 = 0.13) based on 10,000 bootstrap samples was entirely above zero (0.02 to 0.38). Mother-reported harm reduction was also indirectly related to depression through its effect on nonproductive coping. Mother-reported harm reduction impacted nonproductive coping (a2 = 0.28, t(78) = 2.10, p < .05), and nonproductive coping impacted depression (b2 = 1.31, t(77) = 6.47, p < .001). A bias-corrected bootstrap confidence interval for the indirect effect (a2b2 = 0.37) based on 10,000 bootstrap samples was entirely above zero (0.07 to 0.76). The direct (unmediated) effect of mother- reported harm reduction on anxiety when controlling for the two mediators was nonsignificant

(cʹ = -0.14, p = .57), providing further evidence for mediation.

Overcontrol - Problem solving intervention. Mother-reported problem solving intervention was not indirectly related to depression through perceptions of problem solving intervention and nonproductive coping, either through serial multiple mediation (a1db2 = 0.13, CI

= -0.04 to 0.58), or through simple mediation (a1b1 = 0.17, CI = -0.14 to 0.62; a2b2 = 0.51, CI = -

0.13 to 1.23).

Overcontrol - Intrusive decision making. Mother-reported intrusive decision making was indirectly related to depression through its relation to emerging adults’ perceptions of intrusive decision making, which, in turn, related to nonproductive coping. Mother-reported intrusive decision making impacted perceptions (a1 = 0.57, t(79) = 2.01, p < .05), perceptions impacted nonproductive coping (d = 0.24, t(78) = 3.15, p < .01), and nonproductive coping impacted depression (b2 = 1.19, t(77) = 5.68, p < .001). A bias-corrected bootstrap confidence interval for the indirect effect (a1db2 = 0.16) based on 10,000 bootstrap samples was entirely above zero

(0.02 to 0.47). There was also evidence of a simple mediation model, where mother-reported intrusive decision making was related to depression through perceptions. Mother-reported intrusive decision making impacted perceptions (a1 = 0.57, t(79) = 2.01, p < .05), and perceptions impacted depression at trend level (b2 = 0.27, t(77) = 1.83, p = .07). A bias-corrected bootstrap confidence interval for the indirect effect (a2b2 = 0.15) based on 10,000 bootstrap samples was entirely above zero (0.01 to 0.46). There was no evidence for a simple mediation model where mother-reported intrusive decision making impacted depression through nonproductive coping

(a1b1 = 0.02, CI = -0.46 to 0.53). The direct (unmediated) effect of mother-reported intrusive decision making on depression when controlling for the two mediators was nonsignificant (cʹ = -

0.29, p = .42), providing further evidence for mediation.

Overcontrol - Discounting of opinions/ideas. Although for the effect of mother-reported discounting of opinions/ideas on depression there was no evidence of serial multiple mediation, mother-reported discounting of opinions/ideas was indirectly related to depression through its relation to on nonproductive coping. Mother-reported discounting of opinions/ideas impacted

nonproductive coping at trend level (a2 = 0.43, t(78) = 1.92, p = .05), and nonproductive coping impacted depression (b2 = 1.30, t(77) = 6.49, p < .001). A bias-corrected bootstrap confidence interval for the indirect effect (a2b2 = 0.56) based on 10,000 bootstrap samples was entirely above zero (0.09 to 1.21). The direct (unmediated) effect of mother-reported discounting of opinions/ideas on anxiety when controlling for the two mediators was nonsignificant (cʹ = -0.57, p = .16), providing further evidence for mediation.

Overprotection summary. Serial multiple mediation of the relation of mother-reported overprotection to depression was found for two overprotection subscales. Specifically, mother- reported infantilization and parenting anxiety were indirectly related to depression through their relation to emerging adults’ perceptions of the overparenting, which, in turn, was linked to nonproductive coping. For mother-reported harm reduction, the relation to depression was mediated by emerging adults’ perceptions of harm reduction and nonproductive coping, although only the indirect effects of each mediator alone were significant, and not in serial. Mother- reported medical management was not indirectly related to depression through multiple mediation or simple mediation.

Overcontrol summary. Serial multiple mediation of the relation of mother-reported overcontrol to depression was found for one overcontrol subscale. Specifically, mother-reported intrusive decision making was indirectly related to depression through its link to emerging adults’ perceptions of intrusive decision making, which, in turn, related to nonproductive coping.

In addition, the relation of mother-reported intrusive decision making to depression was mediated by emerging adults’ perceptions of intrusive decision making only, and not nonproductive coping in serial. For mother-reported discounting of opinions/ideas, relations to depression were mediated by nonproductive coping only, and not emerging adults’ perceptions

of discounting of opinions/ideas. Mother-reported problem solving intervention was not indirectly related to depression through multiple mediation or simple mediation.

Discussion

Existing research examining the psychological health of emerging adult survivors of childhood cancer is contentious, with findings that are not well understood. Those who posit increased psychological distress in survivors of childhood cancer often do not provide much more than speculation about the influences of that distress. In contrast with a strong tradition of parenting research with healthy populations, to our knowledge, the role of parents in the psychosocial development of survivors of childhood cancer specifically in the emerging adulthood developmental period has not been the focus of empirical research. The primary aim of this study was to examine the relation between the experience of parental overprotection and the psychological distress of emerging adult survivors of childhood cancer.

Psychological Distress in Emerging Adult Survivors of Childhood Cancer

Anxiety and depression symptoms. The first research question asked how levels of psychological distress in emerging adult survivors of childhood cancer compared with general population norms. Based on prior research and theory, it was predicted that emerging adult survivors of childhood cancer would experience higher levels of anxiety and depression than individuals in the general population. With regard to depression, the mean symptom scores reported by emerging adult survivors of childhood cancer, as well as the percentages of participants who fell above clinical cutoffs, did not differ significantly from estimates found in the general population. In contrast, with regard to anxiety, the percentages of participants who fell above clinical cutoffs were markedly higher than estimates found in the general population.

In fact, the mean anxiety symptom scores of participants were more than one standard deviation

76 77 higher than the general population scores, and more closely resembled those reported by clinical samples, specifically, individuals diagnosed with generalized anxiety disorder, social anxiety disorder, panic disorder, and obsessive-compulsive disorder.

One can also compare the percentages of participants who fell above clinical cutoffs to the lifetime prevalence rates reported in epidemiological studies. For both depression and anxiety, lifetime prevalence rates were lower than the percentage of participants in this study who reported clinical symptom levels. It is difficult to make direct comparisons, however, due to the fact that this research considers only the participants’ number of symptoms, whereas epidemiological studies take into account other diagnostic criteria such as the length of time that the symptoms have been present for. For example, the CES-D asks participants to report their depressive symptoms across the past week, whereas the diagnostic criteria for a major depressive episode specify that an individual must experience the symptoms for a period of two weeks or more. It is therefore possible that some participants’ symptoms could abate before meeting the two-week diagnostic criterion, therefore potentially explaining the discrepancy in the percentage of participants who fell above the CES-D cutoff and the lifetime prevalence of a major depressive episode. Similar explanations can be offered for the discrepancy between participants who fell above MAQ cutoffs and estimates of the lifetime prevalence of anxiety disorders, however, it should also be noted that the number of participants who experienced clinical levels of anxiety symptoms in this sample was much higher than for depression symptoms.

In general, our findings that this sample experienced markedly higher levels of anxiety than the general population, but similar levels of depression, were both supportive of and discrepant from past research. For example, a study that followed the prescription psychoactive medication use of adult survivors of childhood cancer across 13 years found that, at baseline,

78 survivors were 1.64 times more likely than their siblings to use anxiolytics, sedatives, and hypnotics, especially if they had a history of cancer recurrence (Brinkman et al., 2013). At follow-up, survivors were 1.71 times more likely than their siblings to use anticonvulsants, a class of medication commonly prescribed as mood stabilizers. Female survivors and those diagnosed at older ages were also more likely then their siblings to use antidepressants and to report new antidepressant and anxiolytic use at follow-up. A study of adult survivors’ suicidal ideation reported that survivors were 1.79 times more likely to report having thoughts of ending their life than their siblings were (Recklitis et al., 2010). This past research suggests that both anxiety and depression symptoms in this population are higher than siblings or other controls.

When one considers survivors’ antidepressant/anticonvulsant use and increased suicidal ideation, our finding that emerging adult survivors of childhood cancer were no more depressed than the average individual is somewhat surprising. However, an explanation is offered by

Brinkman et al. (2013), who speculate that many of the survivors may have been prescribed antidepressants and anticonvulsants for pain management, rather than depressed mood. Indeed,

Recklitis et al. (2010) reported that the strongest correlate of increased suicidal ideation in adult survivors of childhood cancer was the survivors’ current physical health, including disabled status and chronic cancer-related pain. Therefore, increased antidepressant/anticonvulsant use and suicidal ideation alone do not necessarily indicate that emerging adult survivors of childhood cancer experience higher levels of depression symptoms than individuals who are not survivors of childhood cancer do. It is also possible that our sample was relatively healthy compared to other samples of survivors of childhood cancer, and this may somewhat account for the lower levels of depression.

Overparenting and survivors’ psychological distress.

Mother-reported overparenting. The second research question asked how mother- reported levels of overparenting compared in emerging adult survivors of childhood cancer who scored above and below the clinical cutoffs for psychological distress. It was predicted that emerging adults who had more anxiety and depression symptoms would have higher mother- reported levels of overprotection. The hypothesis was not well supported; mother-reported levels of overprotection, for the most part, did not differ based on whether emerging adults displayed depression or anxiety symptoms above or below clinical cutoffs. One exception was that mother- reported levels of harm reduction were higher for emerging adults who reported anxiety symptoms above the clinical cutoff than for those who reported anxiety symptoms below the clinical cutoff. In terms of overcontrol, similar to overprotection, mother-reported levels of overcontrol on all subscales also did not differ based on whether emerging adults reported depression or anxiety symptoms above or below clinical cutoffs. A potential explanation for this lack of findings could be that the variance in mothers’ responses was constrained due to the 3- point measurement scale, and therefore may not have been sensitive enough to differentiate between the behaviors of mothers of emerging adults above and below specific cutoffs.

Emerging adult-reported overparenting. Another potential explanation for the lack of difference in mother-reported overprotection behaviors in emerging adults who scored above and below psychological distress clinical cutoffs could be that mothers are not entirely accurate informants of their own overprotection. Indeed, past research has found that mothers reporting on their own parenting tend to provide socially desirable responses, or simply do not have the same perceptions of their parenting as their children do (see, for example, Schwartz, Barton-

Henry, & Pruzinsky, 1985; Yahav, 2006). In order to test this possibility, a third research

80 question asked how emerging adults’ perceived levels of overprotection compared in emerging adults who scored above and below psychological distress clinical cutoffs, with the hypotheses that emerging adults who experienced anxiety and depression symptoms above clinical cutoffs would perceive higher levels of overprotection than those who were below clinical cutoffs.

Our hypothesis was partially supported. Perceived levels of the overprotection subscales of infantilization and parenting anxiety were higher for emerging adults who reported both anxiety and depression symptoms above clinical cutoffs. Perceived levels of medical management and harm reduction were not higher for emerging adults who reported anxiety or depression symptoms above clinical cutoffs. Interestingly, in terms of overcontrol, perceived levels of problem solving intervention, intrusive decision making, and discounting of opinions/ideas were all higher for emerging adults who reported both anxiety and depression symptoms above clinical cutoffs.

When emerging adults reported on their perceptions of their mothers’ overparenting, it appears that survivors who displayed more symptoms of anxiety and depression experienced higher levels of both parental overprotection and overcontrol on all but two subscales than survivors who displayed fewer symptoms of anxiety and depression. One potential explanation, as compared to the relative lack of significant findings when mother-reported levels of overparenting were examined, could be that mothers’ reports are inaccurate or skewed. However, this does not preclude the possibility that emerging adults’ reports could also be somewhat inaccurate. For example, respondent bias and common method variance are both factors that increase the likelihood of attaining significant results when a single informant reports on all variables. The debate between mother- and emerging adult-reports is an issue that was revisited, with a proposed solution, later in the data analyses. These results are discussed below.

The Effect of Overparenting on Coping Style

Once it was established that anxiety and depression symptoms may be higher in emerging adult survivors of childhood cancer who experience overprotection, the next step of this research was to uncover a potential mechanism linking overprotection to psychological distress. Emerging adults’ coping styles were this proposed mechanism. Specifically, we examined one nonproductive coping style and three productive coping styles: dealing with the problem, optimism, and sharing. Thus, the fourth research question of this study asked whether mother- reported overprotection predicted the use of productive and nonproductive coping strategies. It was further hypothesized that overprotection would be positively related to productive coping styles, and negative related to nonproductive coping style.

Results of hierarchical multiple regressions showed that both overprotective and overcontrolling behaviors, as reported by mothers, differentially affected the four coping styles.

In the regression equations, emerging adult sex, age, education level, and age of diagnosis were held constant. Two productive coping styles, dealing with the problem and sharing, were not predicted by any mother-reported overprotection or overcontrol subscale. A third productive coping style, optimism, was positively predicted by one overprotection subscale, mother’s harm reduction, and one overcontrol subscale, mother’s problem solving intervention, with mothers who were high in harm reduction and problem solving intervention having emerging adults who were more likely to engage in the optimism coping style. Nonproductive coping was positively predicted by one overprotection subscale, mother’s harm reduction, and two overcontrol subscales, mother’s problem solving intervention and discounting of opinions/ideas, with mothers who were high in harm reduction, problem solving intervention, and discounting of

82 opinions/ideas having emerging adults who were more likely to engage in a nonproductive coping style.

With regard to the original hypothesis, three observations are made from these results. The first observation involves the hypothesis that mother-reported overprotection would be predictive of all coping styles. In fact, only one overprotection subscale, mother’s harm reduction, positively predicted both the optimism coping style and the nonproductive coping style. One potential explanation for the relative lack of significant overprotection findings may again be the limitations imposed by asking mothers to report on their own parenting behaviors, particularly behaviors that are not always desirable or socially acceptable. Therefore, in the statistical models created to address the fifth and sixth research questions, attempts were made to account for the possibility that mothers may have underreported their overparenting behaviors, while recognizing the importance of acknowledging emerging adults’ perceptions of, or experience of, overparenting. Those statistical models will be explained further below.

Second, while no prior hypotheses were made about overcontrol, it should be noted that one overcontrol subscale, mother’s problem solving intervention, was positively predictive of both the optimism coping style and the nonproductive coping style, and a second overcontrol subscale, mother’s discounting of opinions/ideas, was positively predictive of the nonproductive coping style. This provides some preliminary evidence that the experience of inappropriate parenting in the control domain may be associated with emerging adult’s development of a nonproductive coping style. Perhaps having limited opportunities to perform difficult tasks and solve problems independently lowers the emerging adult’s confidence in his or her ability to successfully solve novel problems independently. If emerging adults are rarely allowed the opportunity to resolve and cope with developmentally appropriate challenges, these skills may

83 not develop. Without a sense of mastery and agency, individuals are left to resort to passive and avoidance coping strategies such as ignoring the problem and hoping it will go away, or worrying excessively without forming an action plan. This appears to be the experience of the emerging adult survivors of childhood cancer whose mothers reported specific overcontrolling parenting behaviors.

Finally, the finding that emerging adult optimism coping style is predicted by mother’s harm reduction and problem solving intervention seems counterintuitive. Why would inappropriate parenting practices predict productive coping in emerging adult survivors of childhood cancer? One potential explanation is that optimism coping style may not be as positive or productive as the name implies. Indeed, upon closer examination of the individual coping strategies that form the optimism coping style–wishful thinking, seek spiritual support, focus on the positive, and seek relaxing diversions–some of these strategies may actually represent individuals’ attempts to avoid stressors. Avoidance of distress and disengagement from stressors has been well established as a nonproductive coping strategy. In a comprehensive survey of the literature conducted by Compas and colleagues (2001), it was found that 28 of the 30 relevant studies reported statistically significant associations between disengagement coping (defined by strategies such as avoidance, denial, and wishful thinking) and symptoms of anxiety, depression, and somatic symptoms. In addition, while this study found that optimism coping style was positively and significantly correlated with the other two productive coping styles, the same positive and significant correlation existed with the nonproductive coping style. Some of these correlations may be due, in part, to the shared items between the optimism and dealing with the problem coping styles (2 of the 14 optimism items) and the optimism and nonproductive coping styles (4 of the 14 optimism items). However, there are enough other items in all three coping

84 styles to assume that the correlations exist above and beyond the covariance from the shared items. Therefore, when one no longer conceptualizes Frydenberg and Lewis’s (1997) definition of “optimism” as a purely productive coping style, its positive associations with mothers’ harm reduction and problem solving intervention practices are better understood.

Perceptions of Overparenting and Nonproductive Coping as Mediators of the Relation between Overparenting and Psychological Distress

Serial multiple mediation findings. The final two research questions asked if the relation between overprotection and psychological distress is mediated by emerging adults’ perceptions of the overprotection and emerging adults’ nonproductive coping style. Specifically, research question five examined anxiety as the psychological distress outcome variable, while research question six examined depression as the psychological distress outcome variable.

Answering these questions involved testing a series of multiple mediation models, where relations between each mother-reported overparenting subscale, emerging adults’ perceptions of that type of overparenting, emerging adults’ nonproductive coping style, and emerging adults’ symptoms of psychological distress were tested in serial. In these models, emerging adult sex, age, education, and age of diagnosis were held constant (see Figures 1 and 2).

Our hypotheses were partially supported. For the models with anxiety symptoms as an outcome, it was found that two overprotection subscales, mother-reported infantilization and parenting anxiety, were indirectly related to emerging adult anxiety through emerging adults’ perceptions of the infantilization and parenting anxiety, which, in turn, related to emerging adult nonproductive coping style. None of the overcontrol subscales were significantly related to emerging adult anxiety symptoms through serial multiple mediation. For the models that tested depression symptoms as an outcome, similar results were found, with some key differences.

Again, the same two overprotection subscales, mother-reported infantilization and parenting anxiety, were indirectly related to emerging adult depression through emerging adults’ perceptions of the infantilization and parenting anxiety, which, in turn, related to emerging adult nonproductive coping style. However, in contrast to the results for anxiety, one overcontrol subscale, intrusive decision making, was also indirectly related to emerging adult depression through emerging adults’ perceptions of the intrusive decision making, which, in turn, related to emerging adult nonproductive coping style.

These results provide evidence that for two forms of overprotection, infantilization and parenting anxiety, and one form of overcontrol, intrusive decision making, there is a link between mothers’ reports of exercising these parenting practices and emerging adults’ symptoms of anxiety and depression. Furthermore, the link between these overparenting variables and emerging adult psychological distress appears to operate through two serial mediators, emerging adults’ perceptions of their mothers’ overparenting, and emerging adults’ nonproductive coping style. These results therefore allow for the conclusion that emerging adults whose mothers display increased infantilization and parenting anxiety, and who perceive that their mothers parent in this way, practice a nonproductive coping style, and thus experience greater symptoms of anxiety and depression. In addition, emerging adults whose mothers display increased intrusive decision making, and who perceive that their mothers parent in this way, practice a nonproductive coping style, and thus experience greater symptoms of depression.

One interpretation of these results is that, of the four forms of overprotection and three forms of overcontrol studied in this research, maternal infantilization and intrusive decision making are the two most impactful forms of miscarried helping for the nonproductive coping and subsequent psychological distress of emerging adult survivors of childhood cancer. Miscarried

86 helping is a term used by Anderson and Coyne (1991; 1993) to describe the behaviors exhibited by parents of ill children aimed at promoting the child’s health, while inadvertently preventing the child from developing normative autonomy skills. In this research we observed miscarried helping that occurs beyond childhood, long after the cessation of cancer treatment, and during a developmental period where autonomy and independence are paramount. It is therefore not surprising that a mother who infantilizes, including believing that her child frequently needs her help, treating her child as younger than his or her chronological age, and encouraging her child to depend on her, has an emerging adult who exercises a nonproductive coping style in the face of distress. Similarly, a mother who intrusively makes decisions for her emerging adult, including soliciting information and making decisions about her emerging adult’s job, direction in school, and potential changes, also has an emerging adult whose coping skills are poorly developed.

Both infantilization and intrusive decision making share the quality of teaching emerging adults to depend on others for assistance, which limits their opportunities to confront difficult situations independently, and acquire a sense of mastery over their coping abilities. Over time, the emerging adult’s nonproductive coping strategies are detrimental to his or her mental health, and contribute to increased psychological distress.

It should also be noted that infantilization was related to emerging adults’ anxiety and depression symptoms, whereas intrusive decision making was related only to emerging adults’ symptoms of depression. Why might intrusive decision making relate to depression, and not anxiety? Depression is thought to develop when an individual chronically perceives a lack of agency over his or her actions, eventually learning a sense of helplessness (Seligman, &

Peterson, 1986). Depressed individuals also hold a biased, negative view of the self, others, and the future (Beck, 1963), which hinders the development of supportive social relationships and

87 renders individuals unable to effectively challenge their ruminative, negative thoughts (Bandura,

1997). Self-determination theory proposes that emerging adults who experience intrusive decision making are prevented from developing internalized motivations for their behaviors; they cannot base their actions on personal interests, values, and goals, but rather, are controlled by external forces (Deci & Ryan, 2000). Therefore, in accord with the domain-specific approach to socialization, it naturally follows that overcontrolling parenting, where the emerging adult does not learn to internalize motivations, is linked to symptoms of depression, but not symptoms of anxiety.

Parenting anxiety was a third overparenting subscale that was related to emerging adults’ anxiety and depression symptoms through serial multiple mediation. Parenting anxiety involves a mother excessively worrying about her capability as a parent, blaming herself for her child’s misfortunes, and becoming overly distressed upon learning about her child’s misfortunes. While we have proposed that infantilization and intrusive problem solving are related to emerging adults’ coping style and subsequent psychological distress through the “miscarried helping” phenomenon–limiting independence and mastery of productive coping strategies–it is possible that mothers’ parenting anxiety operates in another way to relate to coping and psychological distress. Specifically, mothers high in parenting anxiety are likely also high in trait anxiety.

Rather than limiting emerging adults’ independence to master productive coping abilities, parenting anxiety may transmit poor coping strategies and psychological distress more directly.

Specifically, continually observing an anxious mother as a model teaches the emerging adult that the world is a dangerous and threatening place, and may also promote the adoption of negative schemas about the self, the world, and the future. In fact, mothers with anxiety disorders have been found to be less warm and positive in their interactions with their 7 to 14 year-old children,

88 and catastrophized and criticized more in comparison with control mothers (Whaley, Pinto, &

Sigman, 1999). The anxious mother also naturally models her own coping strategies, which are then familiar and readily accessible to the emerging adult in times of distress. Nonproductive coping strategies such as worrying, blaming oneself, crying, avoidance, keeping to oneself, or a complete lack of coping attempts, can all be adopted by the emerging adult through observational learning. Parenting anxiety, then, is proposed to relate to nonproductive coping and psychological distress in a somewhat different manner than infantilization and intrusive problem solving.

Simple mediation findings. Other than the statistically significant serial multiple mediations, several other significant simple mediations are of note. The first concerns the overprotective parenting practice of a mother’s harm reduction, which involves excessive concern about her emerging adult’s use of tobacco and alcohol. Harm reduction was not found to relate to emerging adults’ psychological distress through serial multiple mediation, however, mother-reported harm reduction was significantly related to emerging adult anxiety and depression symptoms through simple mediation, with nonproductive coping as a mediator. In addition, mother-reported harm reduction was significantly related to emerging adult depression symptoms through simple mediation, with the emerging adults’ perceptions of mothers’ harm reduction practices as a mediator. We can therefore conclude that mothers’ harm reduction practices are related to emerging adults’ nonproductive coping, which is then related to anxiety and depression symptoms. For harm reduction, emerging adults’ perceptions of the practice appear to be unimportant for their adoption of nonproductive coping strategies, although emerging adults’ perceptions of their mothers as higher in harm reduction are related to greater depression symptoms, without coping style as a mediator.

Harm reduction, or more specifically, concern about emerging adults’ alcohol and tobacco use, is a sensitive issue for many mothers of individuals who have survived childhood cancer. It is well known that tobacco use, and to a somewhat lesser extent, alcohol consumption, are risky health behaviors. Tobacco use has been linked with cancer recurrence (e.g., Stevens,

Gardner, Parkin, & Johnson, 1983) and alcohol use and abuse have been found to predict poorer long-term survival following cancer treatment (e.g., Deleyiannis, Thomas, Vaughan, & Davis,

1996). However, experimenting with tobacco and alcohol consumption is a normative developmental event in the emerging adulthood period. Mothers of emerging adult survivors of childhood cancer walk a fine line between encouraging their children to respect their health histories while safely participating in social activities, and limiting their emerging adults’ social development by being overprotective. This adds context to the findings that mother-reported harm reduction relates to emerging adults’ anxiety and depression through nonproductive coping, and that mother-reported harm reduction relates to emerging adults’ depression through their perceptions of their mothers’ overprotective harm avoidance.

Second, mothers’ discounting of ideas and opinions was not found to relate to emerging adults’ psychological distress through serial multiple mediation, however, mother-reported discounting of opinions and ideas was significantly related to emerging adult anxiety and depression symptoms through nonproductive coping style. We can therefore conclude that mothers’ discounting of opinions and ideas is related to emerging adult nonproductive coping, which is then associated with higher anxiety and depression symptoms, although emerging adults’ perceptions of the practice appear to be unrelated to their adoption of nonproductive coping strategies.

Discounting of opinions and ideas is perhaps the harshest form of overparenting measured in this study, as it involves the mother actively discouraging the emerging adult from expressing his or her point of view, or conveying the message that she does not want to hear the emerging adult’s opinions. It is possible that discounting of opinions and ideas shares its features with psychological control, a construct that involves parents’ attempts to control their children’s behaviors thorough their emotions (Barber, 2002). Psychological control commonly involves a combination of guilt induction, withdrawal of love, and intrusiveness, although Barber (1996) has defined constraining verbal expression as a characteristic of psychological control, which involves parents preventing, interfering with, or showing disinterest in their child’s speech by actions such as changing the subject, interrupting, speaking for the child, ignoring the child’s comments, or physically turning or looking away. Psychological control is harmful because it is insensitive to the needs of the child, and has been associated with higher levels of anxiety and depression in children (Barber & Harmon, 2002). Therefore, while the discounting of opinions/ideas subscale was not intended to be a proxy for psychological control, the present findings do support past psychological control research, with emerging adult survivors of childhood cancer whose mothers report discounting of opinions and ideas experiencing more anxiety and depression symptoms, through a nonproductive coping style.

A third finding involves mothers’ medical management, which was the only overparenting subscale that was consistently unrelated to emerging adults’ symptoms of anxiety and depression, either through serial multiple mediation or through simple mediation. It appears that mothers who make their emerging adults’ medical appointments and attend those appointments with them are not influencing their emerging adults’ symptoms of psychological distress, at least not through emerging adults’ perceptions of this practice or through a

91 nonproductive coping style. This result is surprising, as one can imagine how medical management could be perceived by an emerging adult as inappropriate or excessive, and could promote the development of poor coping abilities. However, within the context of a family who has experienced cancer diagnosis and treatment, these practices may be more normative and accepted. In fact, having one’s mother manage and support medical care may actually be comforting and helpful for an emerging adult who has survived childhood cancer, rather than stifling and overprotective. In this way, the burden and stress of the ongoing medical management is shared, as it always has been since childhood, providing the emerging adult with more time and energy for other aspects of their developing lives. Indeed, Kadan-Lottick and colleagues (2002) found that most survivors of childhood cancer were not able to accurately report information about their treatment to their physician, and had a very limited understanding of their risk of late effects. When Kinahan and colleagues (2008) conducted interviews with adult survivors of childhood cancer who attended a long-term follow-up clinic, and their parents, they found that 50% of parents were currently involved with their adult child’s healthcare. The parents reported thinking and talking about cancer more than their children did, and were more concerned with their children’s health status than the adult survivors themselves were.

Furthermore, Doshi and colleagues (2014) reported that, when mothers were asked why they accompanied their emerging adult children to follow-up clinics, their most frequent responses included concern for their child’s health and well-being and to provide practical support, both motivations that are consistent across their child’s development from childhood to emerging adulthood, and may account for survivors’ relative lack of knowledge of or interest in their cancer treatment and long-term effects.

Finally, problem solving intervention involves a mother actively intervening in her emerging adult’s actions, activities, relationships, and problems. Mother-reported problem solving intervention was the only overparenting subscale to relate to emerging adult anxiety symptoms through the emerging adults’ perceptions of the problem solving intervention, with no relation to emerging adults’ nonproductive coping style. Mothers’ problem solving intervention was unrelated to emerging adults’ depression symptoms. In general, survivors of childhood cancer tend to have somewhat impaired social development in comparison to healthy controls

(Stam et al., 2006). It is therefore possible that some mothers of survivors of childhood cancer increase their overcontrol in the domain of problem solving intervention in order to assist their emerging adults with the social skills that they are lacking. But emerging adults who are aware of the assistance that their mothers provide them with may be more likely to feel anxious about their own ability and resources to handle problems, regardless of whether they indeed possess the ability to problem solve on their own or not. While mothers’ problem solving intervention may not hinder emerging adults’ development of productive coping skills, it may still engender anxiety in emerging adults by making them keenly aware of their own limitations in this area, and the assistance that their mothers routinely provide for them.

Overall Summary of Findings

In this sample of emerging adult survivors of childhood cancer, self-reported anxiety symptoms were greater than one standard deviation above general populations means, while depression symptoms were similar to those reported in the general population. Mother-reported levels of overprotection and overcontrol, other than mothers’ harm reduction, did not differ based on whether emerging adults’ displayed depression or anxiety symptoms above or below clinical cutoffs. When emerging adults’ perceptions of overparenting were examined, perceived

93 levels of infantilization, parenting anxiety, problem solving intervention, intrusive decision making, and discounting of opinions/ideas were all higher for emerging adults who reported both anxiety and depression symptoms above clinical cutoffs than for those who reported psychological distress below clinical cutoffs.

Two productive coping styles, dealing with the problem and sharing, were not predicted by any mother-reported overprotection or overcontrol subscale. A third productive coping style, optimism, was positively predicted by mother’s harm reduction and mother’s problem solving intervention. Nonproductive coping was positively predicted by mother’s harm reduction, mother’s problem solving intervention, and mother’s discounting of opinions/ideas.

Mother-reported infantilization and parenting anxiety were indirectly related to emerging adult anxiety symptoms through emerging adults’ perceptions of the infantilization and parenting anxiety, which, in turn, was related to emerging adult nonproductive coping style. None of the overcontrol subscales were significantly related to emerging adult anxiety symptoms through serial multiple mediation. Mother-reported infantilization and parenting anxiety were also indirectly related to emerging adult depression through emerging adults’ perceptions of the infantilization and parenting anxiety, which, in turn, was related to emerging adult nonproductive coping style. Intrusive decision making was also indirectly related to emerging adult depression through emerging adults’ perceptions of the intrusive decision making, which, in turn, was related to emerging adult nonproductive coping style.

Mother-reported harm reduction was indirectly related to emerging adult anxiety and depression symptoms through nonproductive coping, and was indirectly related to emerging adult depression symptoms through emerging adults’ perceptions of mothers’ harm reduction.

Mother-reported discounting of opinions and ideas was indirectly related to emerging adult

94 anxiety and depression symptoms through nonproductive coping style. Mother-reported medical management was the only overparenting subscale that was consistently unrelated to emerging adults’ symptoms of anxiety and depression, either through serial multiple mediation, or through simple mediation. Finally, mother-reported problem solving intervention was the only overparenting subscale to relate to emerging adult anxiety symptoms through the emerging adults’ perceptions of the problem solving intervention, with no relation to emerging adults’ nonproductive coping style.

Strengths and Contributions

The present study makes several contributions to our understanding of the mental health of emerging adult survivors of childhood cancer. First, it adds to the body of research that raises concerns about the levels of psychological distress of survivors of childhood cancer, by confirming that this population does indeed struggle with symptoms of anxiety. However, it is also encouraging that our sample did not endorse significant concerns with symptoms of depressed mood. Second, this research confirmed that specific overprotective and overcontrolling parenting practices are related to psychological distress in emerging adult survivors of childhood cancer. In addition, we provided one explanation for how overprotective and overcontrolling parenting practices influence psychological distress by testing emerging adults’ perceptions of the parenting and the adoption of a nonproductive coping style as serial mediators.

The findings of this study may be used to inform clinical practice in survivors’ long-term care. At after-care clinic appointments, emerging adult survivors can be asked to report on their mothers’ infantilization, parenting anxiety, and intrusive decision making. Those who score above OPEAS means can be identified as potential targets of further intervention to develop and

95 enhance productive coping styles, and decrease reliance on nonproductive coping strategies. At these appointments, parents and survivors can also be educated on when psychological treatment may be warranted, and the benefits and goals of working with a mental health professional.

Furthermore, this research can be extended to the families of children currently in cancer treatment, or who have recently completed treatment. Those children’s parents can be educated on the potential risks of overprotective and overcontrolling parenting, as well as given support and strategies for how to socialize productive coping styles. Future directions include applying these findings to work in developing or adapting research-based parenting interventions specifically for use with the childhood cancer populations. The Surviving Cancer Competently

Intervention Program (SCCIP) is an example of one of the few evidence-based, manualized interventions (Kazak et al., 2004). The SCCIP integrates family therapy and cognitive behavioural therapy techniques to reduce post-traumatic stress symptoms and cancer-related anxiety, and improve child and family coping. The SCCIP may benefit from the addition of an overparenting education component, as well as being adapted for emerging adult participants.

The ultimate purpose of incorporating this research into clinical practice would be to aid in preventing or decreasing the anxiety symptoms experienced by emerging adult survivors of childhood cancer, in addition to assisting survivors in developing productive strategies to cope with their distress.

One notable strength of this study is the creation of the OPEAS, which included items designed to assess the established overprotection dimensions of infantilization and parenting anxiety, with the addition of two overprotection dimensions specific to this study’s sample of survivors of childhood cancer: medical management and harm reduction. This scale also included items designed to measure the overcontrol dimensions of problem solving intervention,

96 intrusive decision making, and discounting of opinions/ideas. We opted to create a new measure, rather than utilize existing measures of parental overprotection, for several reasons. The first was simply because all validated measures of parental overprotection were developmentally inappropriate, designed to assess overprotective behaviors in much younger samples. To date, no other empirical research exists that has examined parental overprotection of emerging adults, and the closest construct, helicopter parenting, was not appropriate for the current research. We also included some items that were particularly relevant for survivors of childhood cancer, which may be of less interest for the study of emerging adults who have not experienced a significant health event. The second reason for creating a novel measure was to circumvent, and potentially create a solution for, the current lack of clarity and consistency in the literature about the construct of overprotection, including the lack of specificity about the similarities and differences between overprotection and overcontrol. Our solution was based on the domain-specific approach to socialization, which makes a clear distinction between the control domain and the protection domain in terms of the parenting practices of each, their mechanisms of socialization, and resulting child outcomes. The OPEAS, then, was not intended to solely assess maternal overprotection, but to separately assess dimensions of maternal overprotection and overcontrol.

As our study was the first to conceptualize overprotection and overcontrol as empirically distinct constructs, hypotheses about the relations of overcontrol to emerging adults’ coping styles and symptoms of psychological distress were exploratory. The results of our research provide preliminary evidence that one form of overcontrol, intrusive decision making, operates through similar mechanisms as the overprotective practices of infantilization and parenting anxiety do to relate to emerging adult survivors’ depression symptoms. This is somewhat inconsistent with the domain-specific approach to socialization, which would suggest that

97 overcontrol would be unrelated to coping style. Nevertheless, this study has provided us with the important knowledge that specific dimensions of both overprotection and overcontrol are related to psychological distress in emerging adult survivors of childhood cancer.

The methodology of this research is an additional strength. The serial multiple mediation models allowed for the inclusion of both mother-reports and emerging adult-reports in the same analysis. In this way, both informants’ perceptions contributed to outcomes, but it was hypothesized that the meaning that emerging adults assigned to their mother’s overprotection and overcontrol was the mechanism through which the mothers’ parenting influenced emerging adults’ coping and psychological distress. This was in line with the work of Youniss (1989), who has argued that both parents’ and children’s perceptions of family processes provide valid data, despite disagreements, because they are meaningful to all of the individuals who are involved in the dynamic. The inclusion of reports from two informants in the same model was also intended to resolve some of the limitations of single-informant approaches, such as common method variance, and biased reporting due to social desirability and respondent bias.

Limitations and Future Directions

While the creation of the OPEAS is a notable strength of this study, it is also somewhat of a limitation. Though we made an effort to present data on internal consistency and included reports from two informants, we have yet to determine the test-retest reliability, or convergent and discriminant validity of the OPEAS. In addition, while the Cronbach’s alphas of the majority of the overparenting subscales were adequate or better, the mother-reported discounting of opinions/ideas subscale had a relatively low Cronbach’s alpha, which could limit the reliability of the measure. However, the results of the OPEAS are mostly quite promising, and a validation

98 study with a larger sample is the next step in confirming that the results of this study are sound and generalizable.

Our sample was relatively homogeneous with regard to ethnicity and level of education.

It would appear that the emerging adults who attend The Pediatric Cancer AfterCare Clinic at

Princess Margaret Cancer Centre are primarily of European origin, and are well educated, which is not necessarily reflective of the demographics of the populations of survivors of childhood cancer in other geographic locations. Caution should be exercised when generalizing the results of this study, as parenting practices, and children’s reactions to these practices, are known to differ by culture, ethnicity, and socio-economic status (e.g., Deater-Deckard & Dodge, 1997;

Conger et al., 1992). In addition, compared to larger, multi-site samples of survivors of childhood cancer (see the Childhood Cancer Survivor Study; e.g., Gurney et al., 2009; Zeltzer et al., 2009; Stuber et al., 2011), fewer of our participants had experienced a secondary cancer or recurrence, which indicates that our sample may be relatively healthier, and potentially more motivated and higher functioning than emerging adult survivors of childhood cancer as a whole.

Therefore, caution should also be used when generalizing these results to emerging adult survivors of childhood cancer who do not fit a similar demographic profile.

A third limitation concerns the correlational nature of our data. While the statistical methods allow for some degree of prediction of the outcomes, all of the data were collected at a single time point, therefore limiting inferences about causality or change over time. There are also questions about the directionality of effects. The assumption in this study has been that overparenting produces psychological distress. However, it must also be recognized that socialization is a complex process, often involving dynamic bidirectional processes of influence

(Bell, 1968; Sameroff, 1975). For example, Whaley, Pinto, and Sigman (1999) found that

99 mothers who were high in anxiety and who had similarly anxious children were less autonomy granting than anxious and non-anxious mothers were with non-anxious children. Hudson, Doyle, and Gar (2009) had mothers of children with anxiety disorders prepare the children of other mothers to perform a speech. They found that when those mothers worked with children who had anxiety disorders, they were more involved and negative than they were with children who did not have anxiety disorders. They were also more involved and negative than mothers of non- anxious children were with anxious and non-anxious children. These findings suggest that mothers’ behaviors with their anxious children may be at least partly influenced by the child’s anxiety. The present study did not consider how the emerging adults’ anxiety and depression symptoms or their use of a non-productive coping style might have elicited their mothers’ overprotective and overcontrolling parenting behaviors. In addition, while we proposed that some of the emerging adults’ anxiety symptoms may have been related to direct modelling of the mothers’ parenting anxiety, we did not account for the heritability of anxiety symptoms. Future research on overprotection and overcontrol of survivors of childhood cancer should take into account, or control for, genetic influences on survivors’ symptoms of psychological distress, as well as how these symptoms may elicit overparenting.

Finally, we chose not to include fathers in this research for practical reasons. Fathers are important agents of socialization, however, and it would be particularly interesting to examine differences in overprotection and overcontrol in mothers and fathers of emerging adult survivors of childhood cancer. Efforts should be made to include fathers in future research.

Future directions may also include measures of relevant constructs for the assessment of appropriate parenting in the protection and control domains. In particular, attachment style and the emerging adult’s perception of his or her autonomy are two variables that could provide

100 insight into processes involved in parental overprotection and overcontrol. According to attachment theory and self-determination theory, attachment style and autonomy may predict emerging adults’ perceptions of overprotective and overcontrolling parenting as well as emerging adults’ psychological distress and coping abilities. These are interesting and promising avenues for expanding the current findings.

Conclusion

The present study makes a contribution to our knowledge of how mothers’ parenting relates to emerging adult childhood cancer survivors’ psychological health. We found that a substantial portion of our sample reported clinically significant levels of anxiety symptoms.

Further analyses found that mother-reported overprotective behaviors of infantilization and parenting anxiety were indirectly related to emerging adult anxiety and depression symptoms through serial multiple mediation. Specifically, the mediators were emerging adults’ perceptions of the infantilization and parenting anxiety, which, in turn, related to emerging adult nonproductive coping style. None of the overcontrol subscales were significantly related to emerging adult anxiety symptoms through serial multiple mediation, but intrusive decision making was indirectly related to emerging adult depression through emerging adults’ perceptions of the intrusive decision making, which, in turn, related to emerging adult nonproductive coping style. It is hoped that these findings will inform how health care professionals identify and manage overprotective and overcontrolling parenting of survivors of childhood cancer, including educating those parents about the socialization of productive coping styles.

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Appendices

A. Emerging Adult Participants’ Recruitment Script

B. Emerging Adult Participants’ Consent Form

C. Template for First Email to Emerging Adult Participants

D. Template for First Letter to Emerging Adult Participants

E. Template for Second Email to Emerging Adult Participants

F. Template for Second Letter to Emerging Adult Participants

G. Mother Participants’ Consent Form and Instructions

H. The Overparenting of Emerging Adults Scale (OPEAS)

116 117

Appendix A

Emerging Adult Participants’ Recruitment Script

Hi. My name is ______and I am a PhD student working with Dr. Norma D’Agostino, who is a clinical psychologist here at Princess Margaret Cancer Centre, in the Department of Psychosocial Oncology. We are currently conducting a research study with young adults who had childhood cancer. I’m wondering if you might be interested in hearing a bit more about the study?

[If no] Ok, thank you for your time.

[If yes] Ok, great! So in this study we are interested in exploring some factors that might contribute to the psychological and social adjustment of young adult survivors of childhood cancer. The study involves filling out two sets of questionnaires online and a telephone interview that will take about 30 minutes or less. We will also ask you for your mother’s contact information so that we can send her a few questionnaires.

The questionnaires ask about a lot of different things, but mainly we are interested in how you were parented, your thoughts and feelings, and your personality. The interview asks you to tell us stories about important events in your life. There are no potential risks to participating in the study, and everything you tell us will be kept completely anonymous and confidential. You can also withdraw from the study at any time. For your participation in the study you will receive two gift cards.

Does this sound like something you’d be interested in?

[If no] Ok, thank you for your time. May I ask you briefly why it is that you are not interested? [Record the patient’s information and reason on the Declined to Participate Record]

[If yes] Fantastic! So now we’ll quickly go over this consent form together and then we will schedule a time for your telephone interview.

[Give the consent form to the participant. Ensure he/she reads it] Please let me know if you have any questions about anything on there. [After answering any questions have participant sign the form. Give participant a copy] Now I will ask you to fill out this sheet with your contact information and your mother’s contact information, so that we can call you for the phone interview, mail you the gift cards, and mail your mother some information about the study. [Give contact sheet to participant to fill out]

So, when is a good time, in the next week or so, for your phone interview? We can work around your schedule. [Coordinate an interview time, write the time down for the participant] As soon as you complete the interview we will email you a link for the first set of online questionnaires.

That is everything for today. Thank you so much for agreeing to participate! Talk to you soon.

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Appendix B

Emerging Adult Participants’ Consent Form

CONSENT TO PARTICIPATE IN A RESEARCH STUDY

Title Parenting Predictors of Autonomy and Identity Development in Young Adult Survivors of Childhood Cancer

Investigator Dr. Norma D’Agostino, Psychologist, Princess Margaret Cancer Centre

Co-Investigators Ms. Maria Chaparro, PhD Candidate, University of Toronto Department of Psychology

Ms. Amanda Sherman, PhD Candidate, University of Toronto Department of Psychology

Dr. David Hodgson, Radiation Oncologist, Princess Margaret Cancer Centre

Introduction

You are being asked to take part in a research study. Please read this explanation about the study and its risks and benefits before you decide if you would like to take part. You should take as much time as you need to make your decision. You should ask the study doctor or study staff to explain anything that you do not understand and make sure that all of your questions have been answered before signing this consent form. Before you make your decision, feel free to talk about this study with anyone you wish. Participation in this study is voluntary.

Background and Purpose

You are being asked to consider participating in this study because you are a young adult survivor of childhood cancer. This study aims to understand why some survivors of childhood cancer experience issues with anxiety and depression, while others experience positive social and emotional outcomes. We want to know what factors contribute to or protect against

119 psychological distress in young adult survivors of childhood cancer in order to assist families currently experiencing childhood cancer.

About 100 people from Princess Margaret Cancer Centre Pediatric Oncology Long-term Follow-Up Clinic will be in the study.

Study Design

This study is intended to be finished in about a two-week time frame. There are three parts to this study: a telephone interview, an online questionnaire, and permission to contact your mother to complete a questionnaire.

We will schedule a telephone interview in the upcoming week. You will be asked to complete your online questionnaire within one week following the interview.

Study Procedures

Interview: You will participate in one telephone interview (you may also choose to complete the interview face to face at the hospital) that will take about 20 minutes. In this interview you will be asked to respond to general questions about significant periods in your life.

Questionnaire Package: You will complete an online survey that will take about 45 minutes. The survey will be done in two parts. This survey contains various questionnaires that will give us information about things like your personality, your view of the world, and the way you handle certain situations. You will be emailed a link to the online questionnaires only after your have completed the interview.

Mother’s Contact Information. You will also be asked to give the contact information of your mother so that we may ask her to complete a questionnaire package that will take about 20 minutes to complete. Please do not discuss your responses to interview or survey questions with your mother.

Risks Related to Being in the Study

There are no medical risks if you take part in this study, but being in this study may make you feel uncomfortable. You may refuse to answer questions or stop the interview at any time if there is any discomfort.

Benefits to Being in the Study

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You will not receive direct benefit from being in this study. Information learned from this study may help other pediatric cancer patients and their families in the future.

Voluntary Participation

Your participation in this study is voluntary. You may decide not to be in this study, or to be in the study now and then change your mind later. You may leave the study at any time without affecting your care. You may refuse to answer any question you do not want to answer, or not answer an interview question by saying “pass”.

We will give you new information that is learned during the study that might affect your decision to stay in the study.

Confidentiality

If you agree to join this study, the study doctor and his/her study team will look at your personal health information and collect only the information they need for the study. Personal health information is any information that could be used to identify you and includes your: • name, • address, • date of birth, • new or existing medical records, that includes types, dates and results of medical tests or procedures.

The information that is collected for the study will be kept in a locked and secure area by the study doctor for 5 years after the end of the study. Only the study team or the people or groups listed below will be allowed to look at your records. Your participation in this study also may be recorded in your medical record at this hospital.

Representatives of the University Health Network Research Ethics Board may look at the study records and at your personal health information to check that the information collected for the study is correct and to make sure the study followed proper laws and guidelines.

All information collected during this study, including your personal health information, will be kept confidential and will not be shared with anyone outside the study unless required by law. You will not be named in any reports, publications, or presentations that may come from this study.

If you decide to leave the study, the information about you that was collected before you left the study will still be used. No new information will be collected without your permission.

Expenses Associated with Participating in the Study

You will not have to pay for any of the procedures involved with this study. As a token of our appreciation you will be sent two gift cards, one for $16 and another for $10. If you

121 decide to withdraw early from the study you will still be given a $16 gift card for your partial participation in the study.

Conflict of Interest

This research will have professional benefit to Ms. Chaparro and Ms. Sherman, serving as their doctoral dissertation projects. These individuals have an interest in completing this study. Their interests should not influence your decision to participate in this study. You should not feel pressured to join this study.

Questions About the Study

If you have any questions, concerns or would like to speak to the study team for any reason, please call: Dr. Norma D’Agostino at 416-946-4525 or Amanda Sherman/Maria Chaparro at 416-978-5373.

If you have any questions about your rights as a research participant or have concerns about this study, call the Chair of the University Health Network Research Ethics Board (REB) or the Research Ethics office number at 416-581-7849. The REB is a group of people who oversee the ethical conduct of research studies. These people are not part of the study team. Everything that you discuss will be kept confidential.

Consent

This study has been explained to me and any questions I had have been answered. I know that I may leave the study at any time. I agree to take part in this study.

Print Study Participant’s Name Signature Date

(You will be given a signed copy of this consent form)

My signature means that I have explained the study to the participant named above. I have answered all questions.

Print Name of Person Signature Date Obtaining Consent

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Appendix C

Template for First Email to Emerging Adult Participants

[Subject line: UofT Study Questionnaire Part 1] Dear [Participant’s name] ,

Thank you so much for agreeing to participate in this study! As I mentioned on the phone, this email provides you with the link to the first set of questionnaires. This set of questionnaires should take you about 30-45 minutes to complete. It is best if you try to put aside a block of time to complete these all at once and in private. As soon as you complete this questionnaire we will mail you the first gift card and send you the link to the second set of questionnaires.

Please note that if, while completing the questionnaires, you need to stop for a period of time you must complete all the questions displayed on the current page before you can click "NEXT”. Although there is no “SAVE” button, your answers are periodically saved once you click the "NEXT" button. If you wish to stop at some point and continue later, you can just close the window. You can re-open the same link later (the original one sent to your email) but if you want to access your saved answers you have to access them from the same computer. However, we recommend doing the complete survey in one session.

To access your questionnaires, please go to this website address: https://survey.qualtrics.com/SE/?SID=SV_aVtT7tUqqloSHvm. You will be prompted for your Participant ID# and you will be shown a set of instructions. Please enter [participant #] and click "Next". The study will then begin.

If you have any questions, please contact one of the following people at the Social Development Lab (phone number: 416-978-5373): Maria Chaparro: [email protected] Amanda Sherman: [email protected] Becky Crawford (study manager): [email protected]

Thank you again for your participation, it is very valuable to us!

[Interviewer’s name] -- Social Development Lab Department of Psychology University of Toronto

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Appendix D

Template for First Letter to Emerging Adult Participants

Department of Psychology

UNIVERSITY OF TORONTO, TORONTO, ONTARIO, CANADA M5S 3G3

[Date]

Dear [Participant’s name] ,

Thank you for taking the time to complete Part A of the questionnaires! Our research would not be possible without you.

As a token of our appreciation, please find enclosed a $16 gift card to Tim Hortons.

You should have already received an email with the link to Part B of the online questionnaire. We sincerely hope that you have had a chance to begin or complete those surveys.

If you have any specific questions, concerns, or comments about this study, please do not hesitate to contact PhD students Maria Chaparro and/or Amanda Sherman, or the study manager Becky Crawford, by email at [email protected], or by telephone at 416-978-5373.

Sincerely,

Maria Chaparro, MA

Amanda Sherman, MA

Joan Grusec, PhD

Norma D’Agostino, PhD, CPsych

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Appendix E

Template for Second Email to Emerging Adult Participants

[Subject: UofT Study Questionnaire Part 2] Dear [Participant’s name] ,

Thank you for successfully completing the first set of questionnaires! This email provides you with the link to the second set of questionnaires. This set of questionnaires should take you about 30-40 to complete. It is best if you try to put aside a block of time to complete these all at once and in private. As soon as you complete this questionnaire we will mail you a second gift card as a token of our appreciation.

To access your questionnaires, please go to this website address: https://survey.qualtrics.com/SE/?SID=SV_bdflnyqL3sgBMQ4. You will be shown a set of instructions and will be prompted for your Participant ID#. Please remember to enter [participant #] and click "Next". The study will then begin.

Thank you again for your participation, it is very valuable to us!

Becky Crawford -- Social Development Lab Department of Psychology University of Toronto

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Appendix F

Template for Second Letter to Emerging Adult Participants

Department of Psychology

UNIVERSITY OF TORONTO, TORONTO, ONTARIO, CANADA M5S 3G3

[Date]

Dear [Participant’s name] ,

Thank you very much for completing Part B of the online questionnaires! Your participation in our study is now complete. Your contribution has been very valuable for our research on cancer survivors.

As a token of our appreciation, please find enclosed a $10 gift card to the iTunes store. We hope that you find this card useful in purchasing apps, music, or renting movies.

As always, if you have any specific questions, concerns, or comments about this study, please do not hesitate to contact PhD students Maria Chaparro and/or Amanda Sherman, or the study manager Becky Crawford, by email at [email protected], or by telephone at 416-978-5373.

Thanks again!

Sincerely,

Maria Chaparro, MA Amanda Sherman, MA Joan Grusec, PhD Norma D’Agostino, PhD, CPsych

126

Appendix G

Mother Participants’ Consent Form and Instructions

[Date]

Dear [Mother’s name] ,

Your [son/daughter] [Participant’s name] is currently participating in a research study at Princess Margaret Cancer Centre. [He/she] has agreed for us to contact you to request your participation in this study. Please find attached a consent form that will further explain the details of our research, and a short questionnaire. Your participation would be a great asset to our study, and we hope that you find that it appeals to you. Thank you very much!

Sincerely,

Dr. Norma D’Agostino Psychologist Princess Margaret Cancer Centre

Ms. Maria Chaparro PhD Candidate University of Toronto Department of Psychology

Ms. Amanda Sherman PhD Candidate University of Toronto Department of Psychology

Dr. David Hodgson Radiation Oncologist Princess Margaret Cancer Centre

127

Parenting Predictors of Autonomy and Identity Development in Young Adult Survivors of Childhood Cancer

You are being asked to take part in a research study because you are the mother of a survivor of childhood cancer who is also participating in this study.

While we know that the experience of childhood cancer can influence how well survivors adjust to the demands of young adulthood, less is known about the influence of mothers on the psychosocial adjustment of young adult survivors of childhood cancer. This study aims to understand why some survivors of childhood cancer experience issues with anxiety and depression, while others experience positive social and emotional outcomes. We want to know what factors contribute to or protect against psychological distress in young adult survivors of childhood cancer in order to assist families currently experiencing childhood cancer.

The package will take about 20 minutes to complete. The package is composed of various self- report questionnaires and a short essay that will provide us with information about things like your personality, your view of the world, your parenting style, and the way you handle certain situations. You will return your questionnaire package through the mail (prepaid postage) one week after you have received it.

You will not receive any direct benefit from being in this study. Your participation in this study is voluntary. You may decide not to be in this study, or to be in the study now, and then change your mind later. You may leave the study at any time without affecting your child’s care. You have the right to refuse participation in this study or not complete the study in its entirety.

All information obtained during the study will be held in strict confidence. Representatives of the University Health Network Research Ethics Board may look at the study records to check that the information collected for the study is correct and to make sure the study followed proper laws and guidelines. All information collected during this study will be kept confidential and will not be shared with anyone outside the study unless required by law. You will not be named in any reports, publication or presentations that may come from this study.

If you have any questions, concerns or would like to speak to the study team for any reason, please call: Dr. Norma D’Agostino at 416-946-4525 or Amanda Sherman/Maria Chaparro at 416-978-5373.

128

By completing this questionnaire you are agreeing to participate in the study.

Instructions

Please set aside approximately 20 minutes to complete these questionnaires, preferably in a quiet place where you will be able to concentrate and will not be interrupted. Please do your best to complete every question.

At the beginning of each section you will find a set of instructions. Please be sure to read them carefully. If you have any questions or unsure of what you are being asked, please telephone Maria or Amanda at 416-978-5373.

We would greatly appreciate if you could please return this questionnaire to us within one week after you receive it. We have included an addressed, stamped envelope for your convenience. Thank you very much for your help!

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Appendix H

The Overparenting of Emerging Adults Scale (OPEAS)

Emerging Adult Form

The following items are about your mother’s current behaviors, and may or may not apply to her. Please use the scale below each item to indicate how well it describes your mother, in the present time.

1. My mother wants me to completely …….. …….. neither …….. …….. completely depend on her even when I disagree agree agree nor disagree don’t need it.

2. My mother feels that I completely …….. …….. neither …….. …….. completely can’t look after myself disagree agree agree without her help. nor disagree

3. Sometimes my mother never …….. …….. happens …….. …….. happens all treats me like I’m still a happens sometimes the time child.

4. My mother likes to attend never …….. …….. happens …….. …….. happens all doctors’ appointments with happens sometimes the time me.

5. My mother likes to make never …….. …….. happens …….. …….. happens all my doctors’ appointments. happens sometimes the time

6. My mother worries about never …….. …….. happens …….. …….. happens all whether she is a good happens sometimes the time mother.

7. My mother blames herself never …….. …….. happens …….. …….. happens all when something bad happens sometimes the time happens to me (e.g., an injury).

8. My mother is more completely …….. …….. neither …….. …….. completely concerned than she needs disagree agree agree to be about how much nor disagree alcohol I am drinking.

9. My mother is more completely …….. …….. neither …….. …….. completely concerned than she needs disagree agree agree to be about whether I am nor disagree smoking cigarettes.

130

10. My mother gets very upset never …….. …….. happens …….. …….. happens all when I tell her about bad happens sometimes the time things that have happened to me. (e.g., A break up with a romantic partner, losing a job).

11. When I have a problem, completely …….. …….. neither …….. …….. completely my mother expects me to disagree agree agree do what she says. nor disagree

12. If my mother really completely …….. …….. neither …….. …….. completely doesn’t care for one of my disagree agree agree friends or someone I’m nor disagree dating she will try to get me to stop seeing him/her.

13. My mother likes to do never …….. …….. happens …….. …….. happens all things for me even when I happens sometimes the time can do them on my own.

14. Sometimes when I am never …….. …….. happens …….. …….. happens all doing a task my mother happens sometimes the time will just take over.

15. My mother doesn’t like it completely …….. …….. neither …….. …….. completely when I make a change disagree agree agree and/or try something new nor disagree without consulting her first.

16. My mother wants me to completely …….. …….. neither …….. …….. completely tell her everything about disagree agree agree my friends and close nor disagree colleagues.

17. My mother expects to have completely …….. …….. neither …….. …….. completely input about my job and/or disagree agree agree nor disagree direction in school.

18. It feels like my mother never …….. …….. happens …….. …….. happens all doesn’t want to hear my happens sometimes the time opinion about things.

19. My mother discourages me never …….. …….. happens …….. …….. happens all from expressing my point happens sometimes the time of view.

131

Mother Form

The following items are about your current behaviors with your child (the child participating in this study), and may or may not apply to you. Please circle the statement beside each item to indicate how well each item describes you.

1. I really like when my child depends on me. completely neither agree completely disagree nor disagree agree

2. I feel that my child needs my help a lot of the time. completely neither agree completely disagree nor disagree agree

3. Sometimes I treat my child a little young for his/her Never happens happens all age. happens sometimes the time

4. I like to attend doctors’ appointments with my never happens happens all child. happens sometimes the time

5. I like to make my child’s doctors’ appointments. never happens happens all happens sometimes the time

6. I worry about whether I am a good mother. never happens happens all happens sometimes the time

7. I blame myself when something bad happens to my never happens happens all child (e.g., an injury). happens sometimes the time

8. I am very concerned about how much alcohol my completely neither agree completely child is drinking. disagree nor disagree agree

9. I am very concerned about whether my child is completely neither agree completely smoking cigarettes. disagree nor disagree agree

10. I get very upset when my child tells me about bad never happens happens all things that have happened to him/her (e.g., A break happens sometimes the time up with a romantic partner, losing a job).

11. When my child has a problem, I expect that he/she completely neither agree completely will do what I say. disagree nor disagree agree

12. If I really don’t care for one of my child’s friends or completely neither agree completely someone he/she is dating, I will attempt to get my disagree nor disagree agree child to stop seeing that person.

13. I like to do things for my child, even things he/she never happens happens all could do alone. happens sometimes the time

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14. Sometimes I have to take over tasks that my child is never happens happens all doing improperly. happens sometimes the time

15. I dislike when my child makes a change and/or tries completely neither agree completely something new without consulting me first. disagree nor disagree agree

16. I want my child to tell me everything about his/her completely neither agree completely friends and close colleagues. disagree nor disagree agree

17. I expect to have input about my child’s completely neither agree completely job/direction in school. disagree nor disagree agree

18. I ask my child to contribute his/her opinion. never happens happens all happens sometimes the time

19. I tend to prefer when my child keeps his/her point never happens happens all of view to him/herself. happens sometimes the time