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IX. ’ . .1 I. . 4 - . ah.’ .. .. .{LX‘I‘ISII h.- \t. 1'5552‘giigti . -. 2.5!... ail-E... Etiucz; {£25. .5522515 K. (la? i. 5,.--.,:i....1>;t.i§t.t£:a§:rlllllxl.l 3...}... 5-..... Slit..- list. . . . . . . 1.9». 5...... z . ..-..:...lx.).?5( xvtiistigiu.s.+f . . is... . ...;.I.\\.J........, . .1... ..... THE ROLE OF FAMILY DYNAMICS IN PSYCHOSOMATIC AND CHRONIC ILLNESS IN CHILDHOOD By E1izabeth Klopper A DISSERTATION Submitted to Michigan State University in partiaI fquiIIment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of PsychoIogy Fall 1982 ABSTRACT THE ROLE OF FAMILY DYNAMICS IN PSYCHOSOMATIC AND CHRONIC ILLNESS IN CHILDHOOD By Elizabeth Klopper This study proposed to clarify the role of family function- ing in relation to childhood psychosomatic illness. Maladaptive family functioning is thought by some to be characteristic of families with psychosomatically ill children. Others propose that any chronically ill child can produce such family dynamics. Fami- lies of children with psychogenic abdominal pain, asthma, and leukemia were compared on dimensions of adjustment, adaptability and cohesion. It was hypothesized that families with a psychoso- matically ill child would show the most disturbed child and family adjustment. Measures of psychosomaticism for asthmatics only were used to define a subgroup of asthmatics expected to show disturbed family functioning. Leukemics were expected to have moderate levels of adjustment. Fifteen families with an ill child comprised each of three illness groups: Leukemia, Asthma, and Abdominal Pain. Families were enlisted through local specialty clinics and private pediatri- cians. Children ranged in age from six to thirteen. The families were seen in their homes and filled out questionnaires. The Family Adaptability and Cohesion Evaluation Scales (FACES) (Olson, Elizabeth Klopper Sprenkle, and Russell, l979) measured family cohesion and adaptabi- lity. The Spanier Dyadic Adjustment Scale (Spanier, l976) and the Achenbach Child Behavior Checklist (Achenbach, l980) measured marital and child adjustment, respectively. For asthmatic subjects only, psychosomaticism was measured by the Asthma Precipitant Survey, filled out by the mother, and a physician rating. As hypothesized, children in the Abdominal Pain Group showed more characteristics of emotionally disturbed children than did those in the Asthma and Leukemia Groups. However, predicted family patterns were not found. Rather, mothers were found to be more rigid than fathers in all three groups. As a whole, the sample scored as more rigid and more enmeshed than the population norms. In the Asthma Group, psychosomatic prone asthmatics reported more behavior problems and lower marital satisfaction than non-psychoso- matic asthmatics. The hypothesis that psychosomatic symptoms in children are related to patterns of family functioning was rejected. It was concluded that families with an ill child show similar family dynamics and are more connected and structured than typical families. DEDICATION To the ill children and their families, that they may live happily. ii ACKNOWLEDGMENTS I extend my sincere appreciation, first, to the families who shared of themselves to make this project possible. Many thanks to my committee: Professor Lucy Ferguson, Committee Chair, for her guidance throughout not only this project, but also my entire graduate program; Professor Charles Hanley, for assuming the respon- sibilities of chairman, for his statistical and editorial assistance, and for sharing interesting conversation; and to Professors Martha Karson and Elizabeth Seagull, a special heartfelt thanks for their respect and friendship. The assistance of many medical professionals is responsible for the successful completion of this study. For their time and help in contacting families with ill children, I extend my thanks to Patricia Peek, R.N., M.A.; and Sara LeeRoy, R.N. from Michigan State University Clinical Center; Mary Haskerwitz, R.N., P.N.P., from Mott Children's Hospital, Ann Arbor;and Dr. Ronald Holmes, Beaumont Hospital, Detroit, Michigan. Finally, I wish to acknowledge Dr. Richard Honicky, pedia- tric pulmonary specialist at Michigan State University Clinical Center, for his help in conceptualizing and implementing this study. I especially appreciate his openness, sharing and willingness to see ill children as whole human beings in the context of their families. Thank you all. TABLE OF CONTENTS LIST OF FIGURES. LIST OF TABLES . INTRODUCTION. LITERATURE REVIEW . Psychosomatics . Psychosomatic Disorders in Childhood. Asthma . . . Recurrent Abdominal Pain . The Effect of Chronic Illness on Families STATEMENT OF PROBLEM AND HYPOTHESES . METHODS Subjects . Definitions of Terms Instruments Procedures. RESULTS DISCUSSION Implications of Significant Findings . Family Adaptability and Cohesion Evaluation Scales Intercorrelations of Variables . Conclusions and Recommendations for Further Research. APPENDICES Appendix A - Consent to Be Contacted . Appendix B - Letter to Families. Appendix C - Informed Consent Form. . Appendix D - Family Adaptability and Cohesion Evaluation Scales . . . Appendix E - Family Wellness Scale. iv Page vi 60 64 66 74 Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix REFERENCES. 3 I" KID—1:011 "UOZ Spanier Dyadic Adjustment Scale. Child Behavior Checklist . Asthma Precipitant Survey. Consent to Contact Physician. Physician Rating of Asthmatic Patients Circumplex Model for the Family Adaptabi- lity and Cohesion Evaluation Scales . Family Functioning Typologies for Mothers and Fathers by Illness Group. . Summary of Chi- -Square of Moderate and Extreme Family Functioning for Mothers and Fathers . FACES Scatterplots . T- Tests for Difference Between Sample Means and Normative Means. . Significant Correlations Between Variables 96 97 102 104 107 LIST OF FIGURES FIGURE Page 1 Sixteen Possible Types of Family Systems Derived From the Circumplex Model With Cutting Points. . . 92 2 FACES Plot on Fathers. . . . . . . . . . . 98 3 FACES Plot on Mothers. . . . . . . . . . . 99 4 FACES Plot on Mothers and Fathers Combined. . . . lOO vi TABLE 10 ll 12 l3 14 LIST OF TABLES Psychoanalytic Theories of Psychosomatic Illness. Theories of Psychosomatic Illness in Childhood Theories Consistent with Minuchin's Proposed Psychosomatic Family Dynamics . . . . . Early Studies of the Asthmatic Personality and Mother- Child Relationship . Mean Values on Demographic Variables for Three Illness Groups . . . . . . . . Distributions of Sex of Patient Child and Religious Affiliation for Three Illness Groups. . . Means and Standard Deviations of Dependent Measures by Illness Group . . . . . . . . . Parents Adaptability and Marital Adjustment Scores: Analysis of Variance Results . . . Significant Differences Between Illness Groups from Analysis of Variance on Scores on the Achenbach Child Behavior Checklist . . . . T-tests of Differences in Mean Scores on Dependent Variables for Psychosomatic and Non-Psychosomatic Asthmatics . . . . . . . . . . Mother and Father Placements on the Family Adaptabi- lity and Cohesion Evaluation Scales . . . Chi- -Squares for Moderate and Extreme FACES Scores by Illness Group for Mothers and Fathers T-tests of Differences Between Sample Means and Normative Population Means . . . . . Significant Correlations Between Dependent Variables vii Page 10 I4 32 32 41 42 44 45 94 96 102 104 TABLE Page 15 Significant Intercorrelations Between Demographic Characteristics and Dependent Variables. . . . . lOS viii INTRODUCTION The role of family dynamics in psychosomatic disorders of childhood was the subject of this study. The study of family dynamics in relation to psychosomatics represents the move away from purely psychoanalytic and physiological consideration of symptoms to the exploration of the interaction of psycho-social factors influencing psychophysiological functioning. Minuchin, Rosman and Baker (1978) have proposed that families of psychoso— matic children show chronic unresolved stress, rigidity, enmeshment, and use the child's illness to detour marital conflict. Litera- ture on chronic illness in childhood suggests that the dynamics proposed to encourage psychosomatic symptoms in children may be the result of the stress generated by having any chronically ill child in the family. Yet another theory suggests that the adjust— ment of the child and family to any illness, psychosomatic included, depends on variables related to pre—illness adjustment and adapt- ability. This study explored whether family dynamics which have been identified as characteristic of children with psychosomatic illness are neurotic family patterns which produce a symptomatic child, rather than the effect of coping with a chronically ill child. Families with a child diagnosed as having psychogenic recurrent abdominal pain (irritable bowel syndrome), families with an 1 asthmatic child, and families with a child who had leukemia parti- cipated in the study. These three illnesses were chosen since they represent different degrees of psychosomaticism. Recurrent abdomi- nal pain has no known organic etiology and is thought to be pri- marily psychogenic. Asthma traditionally has been thought of as a psychosomatic disease. Now, it is known to have organic etiology with morphological changes, but its course is highly influenced by emotional factors. Leukemia is a chronic disease rarely considered to be psychosomatic. Before discussing specific hypotheses regarding the role of the family in the etiology of these childhood illnesses, literature relevant to the study will be reviewed. A brief historical review of the study of psychosomatics and summaries of theory and research in childhood asthma, recurrent abdominal pain, leukemia, and the effect on families of chronic illness in children will follow. LITERATURE REVIEW Psychosomatics The modern study of psychosomatics derives from the ancient consideration of the relationship between the human mind and the body. The discipline as we know it grew from two major trends in the early 20th century: the psychoanalytical and the psychophysiological. The former was primarily influenced by Freud‘s revolutionary theories about unconscious mental processes and their effect on behavior. The latter grew from Pavlov's demonstra- tions that external stimuli could affect functional patterns of internal behavior. The psychodynamic school of thought in psychosomatics relied on psychoanalytic concepts and methods of making observations. The focus of the approach was to identify the specific factors in per- sonality which determine susceptibility to particular diseases, and to identify the particular intrapsychic mechanisms and psycho- logical factors determining choice of disease organ or function. These early theories are summarized in Table l. They are largely based on observations of psychiatric patients and are not supported by empirical studies. 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