{"paper_id":"07b47a1d-07f0-4d57-be36-32d401f2f62a","body_text":"Mental Health of Children with Fontan Circulation: Associations with Maternal Psychopathology and Parenting Behavior | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Mental Health of Children with Fontan Circulation: Associations with Maternal Psychopathology and Parenting Behavior Jonas Markus Hemetsberger, Nina Nicklin, Katharina Louisa Göttlicher, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8648014/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Children with Fontan circulation face substantial long-term psychosocial challenges. Parental mental health and parenting behavior are known to influence psychosocial outcomes in children with congenital heart disease (CHD), yet data specific for Fontan families are scarce. This cross-sectional controlled study examined child psychopathology in relation to maternal psychopathology and parenting behavior. 31 mothers and their children with Fontan circulation (aged 4–16 years) were compared with a sex-, age- and socioeconomic status- (SES) matched control group. Standardized maternal self-report questionnaires assessed child psychopathology, maternal psychopathology, and parenting behavior. Children with Fontan circulation showed significantly higher psychopathology than controls ( F ( 1 , 58 ) = 6.38, p = .014, η p ² = .10). No group differences were found in maternal psychopathology or parenting behavior (all p > .24). No Group × Moderator interaction effects emerged (all p > .35). Significant main effects were observed for maternal total psychopathology, anxiety, and depression ( F ( 1 , 58 ) = 13.10, p < .001, η p ² = .19; F ( 1 , 58 ) = 9.94, p = .003, η p ² = .15; F ( 1 , 58 ) = 11.00, p = .002, η p ²= .16), and inconsistent parenting behavior ( F ( 1 , 58 ) = 19.20, p < .001, η p ² = .26), predicting higher child psychopathology across groups, underscoring the need of family-focused support in Fontan population. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Biological sciences/Psychology Social science/Psychology Fontan circulation congenital heart disease child psychopathology maternal psychopathology parenting behavior psychosocial adjustment Figures Figure 1 Introduction Congenital heart defects (CHDs) are among the most prevalent congenital malformations, with an estimated prevalence of eight cases per 1,000 live births. Approximately 1.5 per 1,000 newborns are affected by moderate to severe heart defects, most of which require early surgical intervention ( 1 ). Univentricular hearts can be considered complex heart defects, since they originate in cases in which a biventricular repair is impossible. Surgical treatment is usually carried out in multiple stages. The aim is to separate the pulmonary and systemic circulations in order to establish stable hemodynamics for a total cavopulmonary circulation (TCPC), often referred to as Fontan completion ( 2 ). Although it is life-saving, the Fontan circulation is associated with chronic venous pressure overload and long-term functional limitations ( 3 , 4 ). Due to medical advances and optimized care, the survival rate following Fontan completion has increased significantly ( 5 – 7 ). Today, more than 80% of patients reach 30-year survival, and more than 70,000 individuals worldwide are living with Fontan circulation - a number that continues to rise. Despite the considerable increase in life expectancy, Fontan circulation entails permanent somatic and psychosocial strain ( 4 ). Consequently, the growing population of survivors faces ongoing medical and psychological challenges, making issues of psychosocial adjustment and family stress increasingly relevant ( 8 ). Psychosocial development in children following Fontan completion As survival rates among children with CHD increase, mental health issues are becoming a central focus of research ( 9 ). Numerous studies have shown that children with CHD experience significant long-term physical, psychological, and psychosocial challenges, including elevated anxiety, depressive symptoms, and low self-esteem ( 5 , 10 ). Social isolation, frequent school absences, and difficulties interacting with peers exacerbate these challenges ( 11 , 12 ). As shown by Woolf-King, Arnold ( 13 ), children with complex CHD have an increased risk of emotional and behavioral problems, which cannot be explained by medical factors alone. Studies show that children with CHD perform worse across nearly all life domains, particularly in physical performance, social integration, and school participation ( 7 , 9 ). However, most studies focus on heterogeneous CHD populations, pooling different defect types. Evidence specifically addressing psychosocial outcomes in children with Fontan circulation remains scarce. To date, to the best of our knowledge, only one study has directly examined this group, reporting lower physical and psychosocial quality of life among adolescents and young adults compared to healthy peers ( 2 ). Thus, the psychosocial adjustment of children and adolescents with Fontan circulation remains insufficiently understood. Family burden The families of children with CHD experience considerable strain. A diagnosis of severe CHD is a critical life event for families ( 14 ). Compared to controls, affected parents report restrictions in daily life and higher stress levels ( 10 ), while increased medical complexity has been linked to an increased psychological burden ( 15 , 16 ). Mothers, who usually have primary responsibility for childcare and family organization, are particularly affected and experience higher levels of emotional distress ( 17 , 18 ). Studies consistently show that mothers experience higher levels of exhaustion, social isolation, anxiety, and depression than fathers ( 10 , 19 ). Major stressors include reduced leisure opportunities, limitations in family activities, and ongoing uncertainty about illness progression. Repeated hospitalizations, medical examinations, and invasive treatments can further disrupt family routines and long-term life plans ( 16 , 18 , 20 ). Many mothers report reduced well-being, particularly in terms of vitality and energy ( 15 ). Emotional symptoms such as guilt, hopelessness, and sadness are common, and can lead to chronic stress symptoms ( 13 , 14 , 21 ). This raises the question of how these impairments in mothers can influence their children's development. Maternal factors influencing the psychosocial development of affected children Maternal mental health : Numerous studies demonstrate a close association between parental mental health and the emotional and developmental outcomes of children with CHD ( 22 – 25 ). Maternal stress, anxiety, depressive symptoms and deficits in emotion regulation have been associated with childhood psychopathology in CHD affected children ( 23 , 26 – 29 ). There exists a considerable number of underlying potential mechanisms: Elevated levels of maternal stress have been demonstrated to reduce sensitivity and responsiveness toward the child, potentially hindering development ( 30 , 31 ). Family stress is associated with less warmth and support, depriving the child of stabilizing emotional feedback ( 32 ). The transfer of maternal fears to the child can impact the child's emotional development. While maternal stress has been identified as a risk factor for children with CHD, maternal emotional competence has been shown to function as a protective factor. Mothers who can regulate their emotions and respond empathetically can help their child to develop a stable self-image and emotion regulation abilities ( 33 ). Thus, maternal mental health represents a protective factor, while maternal psychopathology constitutes a risk factor for impaired mental health development in CHD affected children. Maternal Parenting behavior : It is evident that parenting behavior has a significant influence on psychosocial child development ( 34 ). A higher frequency of protective or permissive parenting styles has been observed in mothers of children affected by CHD ( 35 ). Excessive control and limited autonomy, defining overprotective behavior, have been associated with reduced self-esteem and independence in children ( 27 , 36 ). This dynamic may hinder the development of autonomy and resilience ( 37 , 38 ). Although acute stress typically declines as the child’s medical conditions stabilize, many mothers maintain a lasting “heart mom” identity that continues to shape their self-concept and parenting style ( 39 ). Study aims Despite substantial research on the psychosocial consequences of CHD, studies explicitly addressing these processes in Fontan populations remain scarce. Most existing evidence is based on mixed CHD samples, limiting generalisability to children with Fontan circulation. The present study therefore aims to address this gap by comparing children and adolescents with Fontan circulation and their mothers to a healthy control group in child psychopathology, maternal psychopathology and parenting behavior. In addition to the existing body of research, the present study examined the underlying mechanisms by addressing maternal psychopathology and parenting behavior as moderators of child psychopathology. Methods Participants and Study Design This study is part of a cross-sectional single-center project at Erlangen University Hospital, Germany, in a cooperation of the Departments of Pediatric Cardiology and Child and Adolescent Mental Health. The study population included patients between the ages of 4 and 18 years, which required a Fontan completion, as well as their parents, who were consulted in the outpatient center of Pediatric Cardiology. The unaffected control group was recruited from the general population via notices and information on the hospital's website. Data were collected using mother-rated digital standardized online questionnaires (SoSci Survey©) after written consent. In order to ensure the comparability of the cases, the CHD and control groups were matched on gender, and, within gender strata, according to age and socioeconomic status (SES) using the Mahalanobis distance-based nearest-neighbor matching method. Data collection in the Fontan group was conducted from March to July 2024. Data collection in the control group was conducted from September 2024 to October 2025. The total sample included n = 62 mothers with children between the ages of 4 and 16, comprising n = 31 mothers whose children underwent Fontan completion and a matched control group of n = 31 mothers with unaffected children. Data is complete except for one missing individual on two APQ scales. Group comparisons revealed no significant differences regarding child age ( t = − .16; p = .871) and gender (χ² = .00; p = 1.00) between the groups. However, significant differences were observed in SES, with higher values in the control group ( t = -2.10; p = .040). The demographic and socio-structural characteristics and goup difference statistics are shown in Table 1 . The study protocol was approved by the local ethics committee of the Medical Faculty of the University of Erlangen-Nürnberg (21–195_3-B), and was conducted in accordance with the Declaration of Helsinki. All mothers gave written informed consent for the study as well as for publication of the results Table 1 Descriptive data and Group differences in Fontan (n = 31) and control group (n = 31) Fontan Controls Statistics M/n SD/% range M/n SD/% range t/χ² p d/φ Child Age 10.14 3.04 4.42–15.58 10.27 2.85 5.00-15.42 − .16 .871 − 0.041 Child Sex f 13 42.9 13 42.9 .00 1.00 0.00 m 18 58.1 18 58.1 SES a 10.19 2.30 5–14 11.35 2.04 6–14 − 2.10 .040 − 0.532 Notes . Age in years. f = female, m = male. SES = Socioeconomic status: sum index maternal/paternal education level (< 9 [1], 9 [2], 10–12 [3] or 13 [4] years of education), monthly family income (< €1,000 [1], €1,000 - €2,000 [2], €2,000 - €3,000 [3], €3,000 - €4,000 [4], €4,000 - €5,000 [5], > €5,000 [6]), theoratical range 3–14. Measures The data collection was conducted online in standardized questionnaires, recording sociodemographic characteristics, child psychopathology, maternal psychopathology, and maternal parenting behavior. Sociodemographic characteristics : Child age and gender, maternal and paternal educational level, and family monthly net household income were assessed. Based on data regarding maternal and paternal educational level (four-tailed: school-attendance less than nine years [1], nine years [2], ten to twelve years [3], thirteen years or more [4]) and income (six-tailed: less than €1,000 [1], €1,000 to €2,000 [2], €2,000 to €3,000 [3], €3,000 to €4,000 [4], €4,000 to €5,000 [5], and more than €5,000 [6]), a composite sum-index of SES was calculated, with higher values indicating a higher SES and a theoretical range of 3 to 14. Child Psychopathology : The German parent version of the Strengths and Difficulties Questionnaire (SDQ; Goodman ( 40 ); German version: Woerner, Becker ( 41 ) was used to evaluate child psychopathology. The SDQ contains 25 items rated on a three-point Likert scale ranging from 0 (\"not applicable\") to 2 (\"definitely applicable\"). The SDQ has five subscales: emotional problems, behavioral problems, hyperactivity/inattention, problems with peers, and prosocial behavior. Adding the four problem-oriented subscales yields the total problem score (range 0–40), with higher scores indicating more/more serious problems. The internal consistency of the total problem score is good (Cronbach's α = .82; Woerner, Becker ( 41 )). In the present study the total problem score was used to operationalize child psychopathology. Maternal Psychopathology : The Brief Symptom Inventory (BSI; Derogatis ( 42 ), 1993; German version: Franke ( 43 )) self-report questionnaire was used to evaluate maternal psychopathology. This 53-item questionnaire is answered on a five-point scale ranging from 0 (\"not at all\") to 4 (\"very strongly\") and represents nine symptom dimensions, including depression and anxiety. In the present study, the depression (6 items) and anxiety (6 items) subscales, as well as the Global Severity Index (GSI, mean of 53 items), were evaluated. Subscale means and total mean were transformed into standardized T-values ( M = 50, SD = 10), with GSI values ≥ 63 considered clinically significant. The instrument demonstrates good to high internal consistency (sub-scales: α = .72–.88; GSI: α = .97) and good re-test reliability ( r = .64–.82) ( 44 ). Maternal Parenting Behavior : Parenting behavior was assessed in the mothers' self-reports using the German version of the Alabama Parenting Questionnaire (APQ; Shelton, Frick ( 45 ); German version: Reichle and Franiek ( 46 ). The 40-item instrument is using a five-point Likert scale ranging from 11(\"almost never\") to 5 (\"almost always\") and represents seven dimensions of parenting behavior. Three parenting dimensions were selected on a comprehensive review of the existing literature and on results from earlier research on parenting behaviors in CHD cohorts (Hemetsberger et al., 2024): The dimension of Inconsistency (6 items, e.g., “You find it difficult to be consistent in your parenting.”, “You threaten to punish the child, but then don't punish him/her after all.”) measures the extent to which parents apply rules or consequences inconsistently. The subscale Involvement (6 items, e.g., “You play together or do something fun with your child.”, “You ask your child how his/her day at school was.”) is designed to measure the active parental engagement in their child’s development through active parent participation in child activities. The Responsible Parenting Behavior subscale (6 items, e.g., “You discuss with your child what they could do in their free time.”, “You think about how your child should behave when interacting with other people.”) evaluates parental behavior, which is characterised by well-considered, non-impulsive, reliable, and planned actions in the context of everyday parenting. Subscale mean scores were calculated (range 0–4). Higher values indicate stronger expression of the corresponding behavior. Internal consistency ranges from α = .66 to .72, and scales show expected correlations with behavioral problems in children ( 46 ). Statistical analyses Statistical analyses were performed using IBM SPSS Statistics version 28.0 (IBM Corp., Armonk, NY, 2021) and chosen based on data level and distribution characteristics of the variables. Outlier analysis indicated that all outcome measures were situated within ± 2.5 standard deviations of the respective sample means, expect for one individual maternal anxiety score (BSI Anxiety; T = 80), which fell within 3.5 standard deviations; analyses were run without this case with no differences in significance, why the mother was included in all claculations. Potential confounding variables (child gender, child age, SES), were examined beforehand and included as covariates in the inferential statistical models if necessary. The significance threshold was set at p < .05 (two-tailed), results with p ≤ .10 were interpreted as trends. Effect sizes were reported as absolute values and classified according to Cohen (2013) as follows: η p ² ≥ .01 = small, ≥ .06 = medium, ≥ .14 = large effect; d ≥ .20 = small, ≥ .50 = medium, ≥ .80 = large; and φ ≥ .10 = weak, ≥ .30 = medium, ≥ .50 = strong. First, descriptive statistics (means with standard deviations, frequencies with percentages, minimum and maximum) were calculated. Group differences in sociodemographic characteristics between the Fontan and control group were examined using t-tests for independent samples (age and SES) and chi-square tests (gender). Associations of outcome measures and potential influencing factors were analyzed in bivariate Pearson’s correlations (age, SES) or t-Tests for independent groups (gender). For hypotheses testing, analyses of covariance (ANCOVA) were performed to identify group differences, with affected versus unaffected mothers/children as the group factor and the following variables as outcomes: child psychopathology (SDQ total problem score), maternal psychopathology (BSI subscales: anxiety, depression; GSI total score), and parenting behavior (APQ subscales: Responsible Parenting Behavior, Involvement, Inconsistency). In the analyses, child age and family SES were considered as covariates when a significant correlation was found with the outcome measure in bivariate Pearson's correlations. To identify moderator effects of maternal psychopathology or maternal parenting behavior on child psychopathology group differences, additional ANCOVAs were calculated. Maternal psychopathology and parenting behavior variables were dichotomized in the total sample using median splits: maternal total psychopathology: Md = 51 (in the lower group), n = 35 low, n = 27 high; maternal anxiety: Md = 49 (in the lower group), n = 37 low, n = 25 high; maternal depressive symptoms: Md = 51 (in the higher group), n = 30 low, n = 32 high; Responsible Parenting Behavior: Md = 3.33 (in the lower group), n = 31 low, n = 30 high; inkonsistency: Md = 2.1667 (in the lower group), n = 32 low, n = 29 high; Involvement: Md = 4.00 (in the lower group), n = 33 low, n = 29 high. Dichotomized group variables were included as factors, in addition to the affected vs. unaffected group factor, in ANCOVA analyses. Child age and family SES were considered as covariates when a significant correlation was found in bivariate Pearson's correlations. Group x maternal psychopathology/maternal parenting behavior interaction effects were interpreted. Results Descriptive data Table 3 presents descriptive statistics for all outcome variables. Table 2 summarizes bivariate associations between potential confounders and outcome measures. Correlational analyses revealed two significant associations: Higher SES was related to higher maternal anxiety symptoms ( r = .301, p = .018), and higher child age was associated with lower levels of Responsible Parenting Behavior ( r = –.267, p = .038). No associations emerged for child gender. Because of the wide age range and a significant group difference in SES, both variables were included as covariates in all ANCOVA analyses. Table 2 Bivariate Associations Between Child and Mother Outcomes, and Potential Influencing Factors (Age, SES, Sex) Correlation r (p) t-Test (p) SES Age Sex Child Psychopathology .017 (.893) –.026 (.838) –0.89 (.378) Maternal Psychopathology Depression –.015 (.908) .046 (.723) –1.56 (.125) Anxiety .301* (.018) –.033 (.797) –1.03 (.308) Global Severity Index .040 (.758) .019 (.881) –1.08 (.286) Maternal Parenting Behavior Responsible Parenting .082 (.529) –.267* (.038) –0.38 (.703) Involvement .151 (.243) –.139 (.280) –0.36 (.719) Inconsistency –.049 (.707) –.164 (.207) –0.54 (.591) Notes. Child psychopathology: SDQ total score (Goodman, 2001); Maternal psychopathology: BSI subscales Anxiety, Depression, and total psychopathology (GSI) (Franke, 2017). Maternal parenting behavior: APQ subscales Responsible Parenting Behavior, Involvement, and Inconsistency (Reichle & Franiek, 2009). * p < .05. Table 3 ANCOVA group main effects on Child Psychopathology, Maternal Psychopathology, and Parenting Behavior controlled for age and SES (df 1/58) Group main effect Fontan n = 31 Controls n = 31 F p η p 2 M SD M SD Child Psychopathology 6.38 .014* .099 14.23 7.04 10.03 6.50 Maternal Psychopathology Depression 0.89 .348 .015 50.42 8.57 48.45 7.92 Anxiety 1.36 .248 .023 50.35 9.74 49.23 9.17 Global Severity Index 0.27 .607 .005 51.16 9.87 50.16 9.08 Parenting Behavior Responsible Parenting a 0.15 .704 .003 3.51 .59 3.45 .66 Involvement 0.10 .749 .002 3.89 .67 3.98 .60 Inconsistency a 1.13 .292 .019 2.45 .64 2.24 .67 Notes . Child Psychopathology: SDQ total score (Goodman, 2001); Maternal Psychopathology: BSI subscales Anxiety, Depression, and total psychopathology (GSI) (Franke, 2017). Maternal Parenting Behavior: APQ subscales Responsible Parenting Behavior, Involvement, and Inconsistency (Reichle & Franiek, 2009). * p < .05; a n = 30 in Fontan group, df 1/57. Table 3 ANCOVA group main effects on Child Psychopathology, Maternal Psychopathology, and Parenting Behavior under control of age and SES (df 1/58) Group main effect Fontan n = 31 Controls n = 31 F p η p 2 M SD M SD Child Psychopathology 6.38 .014* .099 14.23 7.04 10.03 6.50 Maternal Psychopathology Depression 0.89 .348 .015 50.42 8.57 48.45 7.92 Anxiety 1.36 .248 .023 50.35 9.74 49.23 9.17 Global Severity Index 0.27 .607 .005 51.16 9.87 50.16 9.08 Parenting Behavior Responsible Parenting a 0.15 .704 .003 3.51 .59 3.45 .66 Involvement 0.10 .749 .002 3.89 .67 3.98 .60 Inconsistency a 1.13 .292 .019 2.45 .64 2.24 .67 Notes . Child Psychopathology: SDQ total score (Goodman, 2001); Maternal Psychopathology: BSI subscales Anxiety, Depression, and total psychopathology (GSI) (Franke, 2017). Maternal Parenting Behavior: APQ subscales Responsible Parenting Behavior, Involvement, and Inconsistency (Reichle & Franiek, 2009). * p < .05; a n = 30 in Fontan group, df 1/57. Group differences in child psychopathology, maternal psychopathology, and parenting behavior ANCOVA results are presented in Table 3 and Fig. 1 . Child psychopathology : A significant main effect of group on child psychopathology was identified, with a medium effect size [ F ( 1 , 58 ) = 6.36, p = .014, η p ² = .099]. Consequently, children in the Fontan group exhibited significantly higher levels of psychopathology compared to children in the control group. Maternal psychopathology : No significant group effects were observed for maternal psychopathology [depression: F ( 1 , 58 ) = 0.89, p = .348, η p ² = .015; anxiety: F ( 1 , 58 ) = 1.36, p = .248, η p ² = .023; total psychopathology: F ( 1 , 58 ) = 0.27, p = .607, η p ² = .005]. Mothers in both groups reported comparable levels of mental health. Maternal parenting behavior : Similarly, no significant group effects were found for parenting behavior [Responsible Parenting Behavior: F ( 1 , 57 ) = 0.15, p = .704, η p ² = .003; Involvement: F ( 1 , 57 ) = 0.10, p = .749, η p 2 = .002 ; Inconsistency: F ( 1 , 57 ) = 1.13, p = .292, η p 2 = ..019]. Parenting practices appeared comparable between groups. Moderating effects of maternal characteristics on child psychopathology Table 4 and Fig. 1 present the ANCOVA moderator analyses results testing whether maternal psychopathology and parenting behavior moderated group differences in child psychopathology. Table 4 ANCOVA Results for median-splitted Moderator Main Effects (Maternal Psychopathology and Parenting Behavior) and Group × Moderator Interaction Effects on Child Psychopathology controlling for age and SES (df 1/58) Child psychopatholgy Fontan Controls Moderators (median) F p η p 2 M SD M SD Maternal depression ( 51 ) Group x moderator interaction 0.05 .820 .001 High 16.44 6.82 13.07 7.61 Moderator main effect 11.0 .002* .164 Low 11.15 6.38 7.53 4.17 Maternal anxiety ( 49 ) Group x moderator interaction 0.37 .545 .007 High 17.64 6.23 12.91 7.92 Moderator main effect 9.94 .003* .151 Low 11.41 6.55 8.45 5.12 Maternal Global Severity Index ( 51 ) Group x moderator interaction 0.06 .810 .001 High 17.71 6.66 13.23 7.67 Moderator main effect 13.1 < .001** .189 Low 11.35 6.13 7.72 4.42 Responsible Parenting Behavior a (3.33) Group x moderator interaction 0.44 .511 .008 High 14.73 7.41 10.47 7.21 Moderator main effect 0.07 .789 .001 Low 13.53 7.08 9.63 5.97 Involvement (4.00) Group x moderator interaction 0.06 .809 .001 High 15.00 6.49 10.68 6.07 Moderator main effect 0.87 .356 .015 Low 13.29 7.80 9.33 7.07 Inconsistency a (2.17) Group x moderator interaction 0.86 .358 .015 High 16.35 5.45 15.25 7.06 Moderator main effect 19.2 < .001** .258 Low 11.23 8.23 6.74 3.21 Notes . Child psychopathology: SDQ total score (Goodman, 2001), score range 0–40; Maternal psychopathology: BSI subscales Anxiety (T-Scores M = 50, SD = 10), Depression (T-Scores M = 50, SD = 10), and total psychopathology (GSI, T-Scores M = 50, SD = 10) (Franke, 2017). Maternal parenting behavior: APQ subscales Responsible Parenting Behavior, Involvement, and Inconsistency (Reichle & Franiek, 2009), scale range 0–5. * p < .01; ** p < .001; a n = 30 in Fontan group, df 1/57. Maternal psychopathology Across all maternal psychopathology measures (total symptoms, anxiety, and depression), no significant Group × Moderator interaction effects emerged (all p > .54), indicating that the association between maternal psychopathology and child psychopathology did not differ between the Fontan and control group. At the same time, each of the maternal psychopathology measures demonstrated a robust and statistically significant main effect on child psychopathology, with high effect sizes. Higher levels of maternal depression [ F ( 1 , 58 ) = 11.00, p = .002, η p ² = .16], maternal anxiety [ F ( 1 , 58 ) = 9.94, p = .003, η p ² = .15] and maternal total psychopathology [ F ( 1 , 58 ) = 13.10, p < .001, η p ² = .19], were consistently associated with substantially elevated child psychopathology scores across both groups. Maternal parenting behavior For the parenting variables, no significant Group × Moderator interaction effects were found (all p > .35), indicating that parenting behaviors did not differentially affect child outcomes in the Fontan and control group. Responsible Parenting Behavior [ F ( 1 , 58 ) = 0.07, p = .789] and Involvement [ F ( 1 , 58 ) = 0.87, p = .356] showed no significant main effects on child psychopathology. In contrast, Inconsistency demonstrated a strong and significant main effect, at high effect size [ F ( 1 , 58 ) = 19.20, p < .001, η p ² = .26]. Children of mothers reporting high Inconsistency in parenting exhibited markedly higher psychopathology scores compared with those whose mothers reported low Inconsistency, irrespective of group membership. Discussion Child psychopathology The findings of this study indicate that mothers of children with Fontan circulation reported significantly higher levels of child psychopathology compared to mothers of healthy controls. This result substantiates the hypothesis of elevated psychosocial vulnerability in this patient cohort and aligns with previous studies reporting increased anxiety, depressive symptoms, and social difficulties in children with complex congenital heart defects ( 2 , 5 , 9 , 10 , 24 ). Our results further demonstrate that these differences persist even after controlling for age and socioeconomic status, underscoring the robustness of this group difference. Psychosocial impairments thus extend beyond the medical course of the disease, highlighting the importance of psychosocial factors in coping with chronic cardiac conditions. Maternal psychopathology No significant differences were observed between mothers in the Fontan group and the control group with respect to depressive symptoms, anxiety, or overall psychopathology. This finding stands in contrast to previous studies which described increased psychological vulnerability in parents of children with CHD ( 10 , 16 , 19 ). However, in line with our results, a recent meta-analysis by Wang, Ma ( 47 ) showed no significant differences in mental health, physical functioning, vitality, or pain between mothers of children with CHD and a general population sample. One potential explanation for this discrepancy may be found in the sample charateristics. The present study focuses exclusively on mothers of children with Fontan circulation, a homogeneous and clearly defined subgroup. In contrast, many earlier studies combined a variety of heart defects of varying severity. Furthermore, the temporal context differs from prior studies. While earlier research often examined acute phases of stress immediately following diagnosis or surgery ( 14 , 17 ), in the current sample, surgical procedures usually took place years ago. Our results suggest that, despite elevated child psychopathology in the Fontan group, many mothers appear to have achieved successful psychological adjustment over time, possibly due to stability in daily life, coping mechanisms, and supportive environments. As time since surgery increases, adaptation and coping processes become more effective. Such mechanisms have been shown to reduce parental stress ( 48 , 49 ). Psychosocial protective factors—including partner support, self-efficacy, and a strong sense of coherence ( 50 ) —may also have facilitated adjustment in the long-term. Parents who perceive their situation as manageable and meaningful tend to demonstrate long-term resilience ( 51 , 52 ). The present findings emphasize that maternal psychological stability may be reached despite caring for a chronically ill child. Future longitudinal research should examine how maternal well-being develops over time and how it relates to child outcomes at different phases of the disease. Maternal parenting behavior Consistent with previous studies showing no major deficits in basic parenting dimensions ( 27 , 34 , 37 ), the present study found no significant group differences in parenting behavior. This may indicate that many mothers display parenting competence and adaptability despite heightened stress. Differences may be more evident in specific parenting domains, such as expectations or beliefs regarding control ( 34 ), which were not the focus of the present study. Parents often report increased self-efficacy and personal growth following successful coping with the child's illness ( 51 ). These adaptive processes may help stabilize parenting behavior ( 49 ), and psychosocial stress does not necessarily result in dysfunctional parenting styles; coping strategies and resilience may buffer negative effects ( 53 , 54 ). However, our moderation analyses indicate that inconsistent parenting—rather than other parenting dimensions—was strongly associated with elevated child psychopathology across both groups. This underscores the need to examine parenting behavior at a more fine-grained level rather than relying solely on broad parenting constructs. Future studies should investigate developmental trajectories of parenting behaviors and the influence of contextual factors such as family resources, disease burden, and parental coping strategies. Maternal psychopathology and parenting behavior as moderators of child psychopathology The moderation analyses showed no significant Group × Moderator interaction effects for either maternal psychopathology or parenting behavior, indicating that these factors did not differentially influence child psychopathology in the Fontan and control groups. Instead, the data revealed clear and consistent main effects across the entire sample: higher maternal total psychopathology, anxiety, and depression, as well as more inconsistent parenting, were each robustly associated with higher child psychopathology. In contrast, Responsible Parenting Behavior and nvolvement showed no significant associations with child outcomes. These results align with previous research demonstrating that maternal psychopathology may represent an additional stressor that compounds an already heightened risk profile, even if the underlying mechanisms of influence are comparable to those in healthy peers. Maternal anxiety and depression may impair parent–child interactions through emotional overinvolvement, heightened worry, or reduced emotional availability ( 28 , 33 ), while nonspecific stressors such as exhaustion or overload can affect family functioning more broadly ( 34 , 55 ). Likewise, inconsistent parenting has been repeatedly linked to heightened internalizing and externalizing symptoms ( 56 , 57 ). Taken together, the findings indicate that maternal psychopathology and inconsistent parenting operate as general, but modifiable risk factors for child psychopathology, rather than as CHD-specific mechanisms. However, the clinical implications for children with Fontan circulation remain substantial: although they were not statistically more sensitive to these parental factors, they exhibited significantly higher baseline levels of psychopathology. Within a vulnerability–stress framework, this suggests that children with Fontan circulation face an accumulation of non-modifiable stressors—including chronic physiological burden, ongoing medical uncertainty, and developmental challenges—that elevate their vulnerability relative to healthy peers. Against this background, reducing modifiable familial risk factors becomes especially important for this population. While maternal psychopathology and parenting Inconsistency are problematic for any child, they may constitute a particularly consequential additional stressor when layered on top of the existing medical and psychosocial load associated with Fontan physiology. Interventions that alleviate maternal psychopathology and promote consistent, predictable parenting may therefore help meaningfully reduce the overall risk burden in CHD families. Ultimately, such efforts may support psychosocial adjustment in children with Fontan circulation to a degree that narrows the gap to their healthy peers. Although statistically non-significant, small effect sizes for a slightly higher maternal anxiety and depression scores in the Fontan group could be shown. This pattern might indicate that caregiving in the context of complex congenital heart disease is often associated with elevated emotional strain and sustained vigilance ( 17 , 52 ). Even subclinical internalizing symptoms in mothers can influence family functioning through reduced emotional availability or heightened worry ( 28 ), suggesting that these subtle differences—despite their small magnitude—fit within a broader evidence base highlighting increased caregiver burden in CHD. These results underscore the importance of integrating routine psychosocial screening, parental support services, and targeted interventions into comprehensive CHD care. Future longitudinal research is needed to clarify how these modifiable parental factors interact with disease-related stressors over time and to identify protective processes that can buffer the heightened vulnerability associated with single-ventricle physiology. The Importance of the Association of Maternal Psychopathology and Parenting Behavior The findings indicated a strong association between maternal psychopathology and parenting behavior: higher maternal total psychopathology (GSI) was associated with higher Inconsistency ( r = .276; p = .031) and lower Involvement ( r = − .245; p = .055). These patterns mirror previous findings indicating that depressive symptoms are linked with reduced sensitivity and emotional availability ( 58 – 60 ), while maternal anxiety is associated with greater control or intrusiveness ( 61 , 62 ). In light of the present results, these correlations gain additional relevance: maternal psychopathology and inconsistent parenting each showed strong main effects on child psychopathology, independent of group membership. This convergence of correlational and multivariate findings underscores the close interplay between parental distress and parenting behavior and highlights their combined influence on children’s psychosocial development. Overall, these results emphasize the necessity of integrative approaches that consider both parental stress and parenting behavior when examining child adjustment, particularly in the context of chronic pediatric illness. Future research should investigate how these interconnected factors unfold over time to inform targeted interventions aimed at enhancing family resilience and supporting positive developmental trajectories in children with Fontan circulation. Strengths, Limitations and Implications for Future Research A significant methodological limitation of this study is that data were collected only from the mothers' perspective. The single-informant approach carries the risk of subjective bias, particularly when the mothers are experiencing psychological distress. Previous studies have shown that stressed mothers tend to perceive their children's behavior as more noticeable ( 26 , 27 ). Therefore, future studies should adopt a multi-informant design that considers maternal assessments, children's self-reports, paternal perspectives, and other caregivers, if applicable. Including behavioral observations in addition to questionnaire surveys would also increase the validity of the findings. Furthermore, the rarity of Fontan heart defects limited the sample size, which restricts the generalizability of the results. Since the survey was conducted at only one point in time, no conclusions can be drawn about changes over time. Longitudinal designs are necessary to more accurately capture the reciprocal influences between maternal stress and child psychopathology. The wide age range of the children represents a methodological limitation but also allows for a broader view of parental stress patterns across different developmental phases. One of the study's strengths is its specific focus on children with Fontan circulation, a clinically relevant yet underrepresented group. The design with a matched control group enabled better control of potential confounding variables. Additionally, combining key psychosocial dimensions — maternal stress, parenting behavior, and child psychopathology — provides insight into family dynamics in chronic childhood illness. Conclusion Children with Fontan circulation exhibited substantially higher levels of psychopathology than matched healthy controls, confirming their elevated psychosocial vulnerability. Maternal psychopathology and inconsistent parenting were identified as general risk factors for higher levels of child psychopathology in both groups, suggesting that these influences are not unique to the Fontan population. However, given that children with Fontan circulation already face increased medical and developmental challenges, it is particularly important to integrate psychosocial support for parents into the care structures for families of children with CHD. Interventions that strengthen parental emotional stability and promote consistent parenting practices may contribute to improved long-term psychosocial outcomes for affected children and their families. Declarations Ethics statement The studies involving humans were approved by Ethics Committee of the Erlangen University Hospital, Friedrich-Alexander-Universität Erlangen-Nürnberg (21–195_3-B). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided. Competing interests The authors declare no competing interests. Funding Declaration This study was conducted without any external founding. Author Contribution AE, IS, OK contributed to the conception and design of the study, as well as supervision and project administration. JMH, JG, LH, NN contributed to the data aquisition and data curation. JMH, KLG, AE, NN, JG contributed to data analysis. JMH and NN drafted the article. All authors reviewed and edited the manuscript and approved the submitted version. Acknowledgement We would like to thank all participating parents for taking part in this study. Data Availability The datasets analyzed during the current study are available from the corresponding author on reasonable request. References Bouma, B. J. & Mulder, B. J. Changing Landscape of Congenital Heart Disease. Circul. Res. 120 (6), 908–922 (2017). Marshall, K. H. et al. 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The impact of early surgical ventricular septal defect repair on parenting behavior and mother-child relationship: a prospective longitudinal study. Front. Pead. ; 12 . (2024). Carey, L. K., Nicholson, B. C. & Fox, R. A. Maternal factors related to parenting young children with congenital heart disease. J. Pediatr. Nurs. 17 (3), 174–183 (2002). Dandy, S., Wittkowski, A. & Murray, C. Parenting a Child with a Functionally Univentricular Heart: Mothers’ Experiences of Role and Identity. J. Child Fam. stud. 33 (8), 2401–2414 (2024). Goodman, R. The Strengths and Difficulties Questionnaire: a research note. J. Child Psychol. Psychiatry Allied Discip. 38 (5), 581–586 (1997). Woerner, W. et al. [Normal values and evaluation of the German parents' version of Strengths and DIfficulties Questionnaire (SDQ): Results of a representative field study]. Z. fur Kinder- und Jugendpsychiatrie und Psychother. 30 (2), 105–112 (2002). Derogatis, L. Brief Symptom Inventory (BSI), administration, scoring, and procedures manual, 3rd edition.: Minneapolis: National Camputer Services.; (1993). Franke, G. H. Brief symptom inventory (BSI) von LR Derogatis:(Kurzform der SCL-90-R) (Beltz Test, 2000). Franke, G. H. BSCL: Brief-Symptom-Checklist: Manual (Hogrefe, 2017). Shelton, K. K., Frick, P. J. & Wootton, J. The assessment of parenting practices in families of elementary school-aged children. J. Clin. Child Psychol. 25 , 317–327 (1996). Reichle, B. & Franiek, S. Self-reported parenting style - German extended version of the Alabama Parenting Questionnaire for elementary school age children. Z. für Entwicklungspsychologie und Pädagogische Psychologie . 41 , 12–25 (2009). Wang, Y. et al. Health-related quality of life and influencing factors in parents of children with congenital heart disease: a systematic review and meta-analysis. Front. public. health . 13 , 1622491 (2025). Gerlach, J. et al. Long-Term Effects of Child Early Surgical Ventricular Septal Defect Repair on Maternal Stress. Children 10 (12), 1832 (2023). Marshall, K. H. et al. Wellbeing and quality of life among parents of individuals with Fontan physiology. Qual. life research: Int. J. Qual. life aspects Treat. care rehabilitation . 34 (5), 1419–1431 (2025). Eriksson, M. & Lindström, B. Antonovsky's sense of coherence scale and its relation with quality of life: a systematic review. J. Epidemiol. Commun. Health . 61 (11), 938–944 (2007). Brosig, C. L., Mussatto, K., Kuhn, E. M. & Tweddell, J. S. Psychosocial outcomes for preschool children and families after surgery for complex congenital heart disease. Pediatr. Cardiol. ; 28 . (2007). Woolf-King, S. E., Anger, A., Arnold, E. A., Weiss, S. J. & Teitel, D. Mental Health Among Parents of Children With Critical Congenital Heart Defects: A Systematic Review. J. Am. Heart Assoc. ; 6 (2). (2017). Uzark, K. & Jones, K. Parenting stress and children with heart disease. J. Pediatr. Health Care . 17 (4), 163–168 (2003). Brudy, L. et al. Perceived Parental Style Is Better in Adults with Congenital Heart Disease than Healthy Controls—But There Is Work Left to Do in Specific Subgroups. J. Vascular Dis. 3 , 58–66 (2024). Goldbeck, L. & Melches, J. Quality of life in families of children with congenital heart disease. Qual. life research: Int. J. Qual. life aspects Treat. care rehabilitation . 14 (8), 1915–1924 (2005). Lempers, J. D., Clark-Lempers, D. & Simons, R. L. Economic hardship, parenting, and distress in adolescence. Child Dev. 60 (1), 25–39 (1989). Carrasco, M. Á., Holgado-Tello, F. P. & RodrÍguez Serrano, M. Á. Intraparental Inconsistency: The Influence of Parenting Behaviors on Aggression and Depression in Children. Fam. Relat. 64 (5), 621–634 (2015). Campbell, S. B. Behavior Problems in Preschool Children: A Review of Recent Research. J. Child Psychol. Psychiatry . 36 , 113–149 (1995). Feldman, R. Maternal versus child risk and the development of parent-child and family relationships in five high-risk populations. Dev. Psychopathol. 19 (2), 293–312 (2007). Murray, L., Halligan, S. L., Goodyer, I. & Herbert, J. Disturbances in early parenting of depressed mothers and cortisol secretion in offspring: a preliminary study. J. Affect. Disord . 122 (3), 218–223 (2010). Apetroaia, A., Hill, C. & Creswell, C. Parental responsibility beliefs: associations with parental anxiety and behaviours in the context of childhood anxiety disorders. J. Affect. Disord . 188 , 127–133 (2015). Reeves, J., Reynolds, S., Coker, S. & Wilson, C. An experimental manipulation of responsibility in children: A test of the inflated responsibility model of obsessive-compulsive disorder. J. Behav. Ther. Exp. Psychiatry . 41 (3), 228–233 (2010). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8648014\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Article\",\"associatedPublications\":[],\"authors\":[{\"id\":585781351,\"identity\":\"d32aa744-503b-4f5f-9c58-a61a061dee84\",\"order_by\":0,\"name\":\"Jonas Markus 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1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":85986,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSee image above for figure legend\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure1InfluenceofmaternalpsychopathologyandparentingInconsistencyonchildpsychopathology.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8648014/v1/14155abd13b063b3759e2c99.jpg\"},{\"id\":102180666,\"identity\":\"90762982-14aa-4de5-98ef-f61381b17446\",\"added_by\":\"auto\",\"created_at\":\"2026-02-09 07:13:26\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1543070,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8648014/v1/fb4ede69-df2d-4da6-80ba-52afb78ffbe4.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Mental Health of Children with Fontan Circulation: Associations with Maternal Psychopathology and Parenting Behavior\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eCongenital heart defects (CHDs) are among the most prevalent congenital malformations, with an estimated prevalence of eight cases per 1,000 live births. Approximately 1.5 per 1,000 newborns are affected by moderate to severe heart defects, most of which require early surgical intervention (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). Univentricular hearts can be considered complex heart defects, since they originate in cases in which a biventricular repair is impossible. Surgical treatment is usually carried out in multiple stages. The aim is to separate the pulmonary and systemic circulations in order to establish stable hemodynamics for a total cavopulmonary circulation (TCPC), often referred to as Fontan completion (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). Although it is life-saving, the Fontan circulation is associated with chronic venous pressure overload and long-term functional limitations (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). Due to medical advances and optimized care, the survival rate following Fontan completion has increased significantly (\\u003cspan additionalcitationids=\\\"CR6\\\" citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e). Today, more than 80% of patients reach 30-year survival, and more than 70,000 individuals worldwide are living with Fontan circulation - a number that continues to rise. Despite the considerable increase in life expectancy, Fontan circulation entails permanent somatic and psychosocial strain (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). Consequently, the growing population of survivors faces ongoing medical and psychological challenges, making issues of psychosocial adjustment and family stress increasingly relevant (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003ch3\\u003ePsychosocial development in children following Fontan completion\\u003c/h3\\u003e\\n\\u003cp\\u003eAs survival rates among children with CHD increase, mental health issues are becoming a central focus of research (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). Numerous studies have shown that children with CHD experience significant long-term physical, psychological, and psychosocial challenges, including elevated anxiety, depressive symptoms, and low self-esteem (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). Social isolation, frequent school absences, and difficulties interacting with peers exacerbate these challenges (\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). As shown by Woolf-King, Arnold (\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e), children with complex CHD have an increased risk of emotional and behavioral problems, which cannot be explained by medical factors alone. Studies show that children with CHD perform worse across nearly all life domains, particularly in physical performance, social integration, and school participation (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). However, most studies focus on heterogeneous CHD populations, pooling different defect types. Evidence specifically addressing psychosocial outcomes in children with Fontan circulation remains scarce. To date, to the best of our knowledge, only one study has directly examined this group, reporting lower physical and psychosocial quality of life among adolescents and young adults compared to healthy peers (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). Thus, the psychosocial adjustment of children and adolescents with Fontan circulation remains insufficiently understood.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eFamily burden\\u003c/h2\\u003e \\u003cp\\u003eThe families of children with CHD experience considerable strain. A diagnosis of severe CHD is a critical life event for families (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e). Compared to controls, affected parents report restrictions in daily life and higher stress levels (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e), while increased medical complexity has been linked to an increased psychological burden (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e). Mothers, who usually have primary responsibility for childcare and family organization, are particularly affected and experience higher levels of emotional distress (\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e). Studies consistently show that mothers experience higher levels of exhaustion, social isolation, anxiety, and depression than fathers (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). Major stressors include reduced leisure opportunities, limitations in family activities, and ongoing uncertainty about illness progression. Repeated hospitalizations, medical examinations, and invasive treatments can further disrupt family routines and long-term life plans (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). Many mothers report reduced well-being, particularly in terms of vitality and energy (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e). Emotional symptoms such as guilt, hopelessness, and sadness are common, and can lead to chronic stress symptoms (\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e). This raises the question of how these impairments in mothers can influence their children's development.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eMaternal factors influencing the psychosocial development of affected children\\u003c/h3\\u003e\\n\\u003cp\\u003e \\u003cspan type=\\\"Underline\\\" class=\\\"Underline\\\" name=\\\"Emphasis\\\"\\u003eMaternal mental health\\u003c/span\\u003e: Numerous studies demonstrate a close association between parental mental health and the emotional and developmental outcomes of children with CHD (\\u003cspan additionalcitationids=\\\"CR23 CR24\\\" citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e). Maternal stress, anxiety, depressive symptoms and deficits in emotion regulation have been associated with childhood psychopathology in CHD affected children (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR27 CR28\\\" citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e). There exists a considerable number of underlying potential mechanisms: Elevated levels of maternal stress have been demonstrated to reduce sensitivity and responsiveness toward the child, potentially hindering development (\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e). Family stress is associated with less warmth and support, depriving the child of stabilizing emotional feedback (\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e). The transfer of maternal fears to the child can impact the child's emotional development. While maternal stress has been identified as a risk factor for children with CHD, maternal emotional competence has been shown to function as a protective factor. Mothers who can regulate their emotions and respond empathetically can help their child to develop a stable self-image and emotion regulation abilities (\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e). Thus, maternal mental health represents a protective factor, while maternal psychopathology constitutes a risk factor for impaired mental health development in CHD affected children.\\u003c/p\\u003e \\u003cp\\u003e \\u003cspan type=\\\"Underline\\\" class=\\\"Underline\\\" name=\\\"Emphasis\\\"\\u003eMaternal Parenting behavior\\u003c/span\\u003e: It is evident that parenting behavior has a significant influence on psychosocial child development (\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e). A higher frequency of protective or permissive parenting styles has been observed in mothers of children affected by CHD (\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e). Excessive control and limited autonomy, defining overprotective behavior, have been associated with reduced self-esteem and independence in children (\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e). This dynamic may hinder the development of autonomy and resilience (\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e). Although acute stress typically declines as the child\\u0026rsquo;s medical conditions stabilize, many mothers maintain a lasting \\u0026ldquo;heart mom\\u0026rdquo; identity that continues to shape their self-concept and parenting style (\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003ch3\\u003eStudy aims\\u003c/h3\\u003e\\n\\u003cp\\u003eDespite substantial research on the psychosocial consequences of CHD, studies explicitly addressing these processes in Fontan populations remain scarce. Most existing evidence is based on mixed CHD samples, limiting generalisability to children with Fontan circulation. The present study therefore aims to address this gap by comparing children and adolescents with Fontan circulation and their mothers to a healthy control group in child psychopathology, maternal psychopathology and parenting behavior. In addition to the existing body of research, the present study examined the underlying mechanisms by addressing maternal psychopathology and parenting behavior as moderators of child psychopathology.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eParticipants and Study Design\\u003c/h2\\u003e \\u003cp\\u003eThis study is part of a cross-sectional single-center project at Erlangen University Hospital, Germany, in a cooperation of the Departments of Pediatric Cardiology and Child and Adolescent Mental Health. The study population included patients between the ages of 4 and 18 years, which required a Fontan completion, as well as their parents, who were consulted in the outpatient center of Pediatric Cardiology. The unaffected control group was recruited from the general population via notices and information on the hospital's website. Data were collected using mother-rated digital standardized online questionnaires (SoSci Survey\\u0026copy;) after written consent. In order to ensure the comparability of the cases, the CHD and control groups were matched on gender, and, within gender strata, according to age and socioeconomic status (SES) using the Mahalanobis distance-based nearest-neighbor matching method. Data collection in the Fontan group was conducted from March to July 2024. Data collection in the control group was conducted from September 2024 to October 2025. The total sample included \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;62 mothers with children between the ages of 4 and 16, comprising \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;31 mothers whose children underwent Fontan completion and a matched control group of \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;31 mothers with unaffected children. Data is complete except for one missing individual on two APQ scales. Group comparisons revealed no significant differences regarding child age (\\u003cem\\u003et\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;\\u0026minus;\\u0026thinsp;.16; \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.871) and gender (χ\\u0026sup2; = .00; \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;1.00) between the groups. However, significant differences were observed in SES, with higher values in the control group (\\u003cem\\u003et\\u003c/em\\u003e = -2.10; \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.040). The demographic and socio-structural characteristics and goup difference statistics are shown in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e The study protocol was approved by the local ethics committee of the Medical Faculty of the University of Erlangen-N\\u0026uuml;rnberg (21\\u0026ndash;195_3-B), and was conducted in accordance with the Declaration of Helsinki. All mothers gave written informed consent for the study as well as for publication of the results\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eDescriptive data and Group differences in Fontan (n\\u0026thinsp;=\\u0026thinsp;31) and control group (n\\u0026thinsp;=\\u0026thinsp;31)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"12\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c8\\\" colnum=\\\"8\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c9\\\" colnum=\\\"9\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c10\\\" colnum=\\\"10\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c11\\\" colnum=\\\"11\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c12\\\" colnum=\\\"12\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c6\\\" namest=\\\"c4\\\"\\u003e \\u003cp\\u003eFontan\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c9\\\" namest=\\\"c7\\\"\\u003e \\u003cp\\u003eControls\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c12\\\" namest=\\\"c10\\\"\\u003e \\u003cp\\u003eStatistics\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM/n\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSD/%\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003erange\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eM/n\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003eSD/%\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003erange\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003et/χ\\u0026sup2;\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003ep\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003ed/φ\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c3\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eChild Age\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e10.14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.04\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e4.42\\u0026ndash;15.58\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e10.27\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2.85\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e5.00-15.42\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003e\\u0026minus;\\u0026thinsp;.16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003e.871\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e\\u0026minus;\\u0026thinsp;0.041\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eChild Sex\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ef\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e42.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e42.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003e.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003e1.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e0.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003em\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e58.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e58.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c3\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eSES\\u003csup\\u003ea\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e10.19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e2.30\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e5\\u0026ndash;14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e11.35\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2.04\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e6\\u0026ndash;14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003e\\u0026minus;\\u0026thinsp;2.10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003e.040\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e\\u0026minus;\\u0026thinsp;0.532\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"12\\\"\\u003e\\u003cem\\u003eNotes\\u003c/em\\u003e. Age in years. f\\u0026thinsp;=\\u0026thinsp;female, m\\u0026thinsp;=\\u0026thinsp;male. SES = Socioeconomic status: sum index maternal/paternal education level (\\u0026lt;\\u0026thinsp;9 [1], 9 [2], 10\\u0026ndash;12 [3] or 13 [4] years of education), monthly family income (\\u0026lt; \\u0026euro;1,000 [1], \\u0026euro;1,000 - \\u0026euro;2,000 [2], \\u0026euro;2,000 - \\u0026euro;3,000 [3], \\u0026euro;3,000 - \\u0026euro;4,000 [4], \\u0026euro;4,000 - \\u0026euro;5,000 [5], \\u0026gt; \\u0026euro;5,000 [6]), theoratical range 3\\u0026ndash;14.\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eMeasures\\u003c/h2\\u003e \\u003cp\\u003eThe data collection was conducted online in standardized questionnaires, recording sociodemographic characteristics, child psychopathology, maternal psychopathology, and maternal parenting behavior.\\u003c/p\\u003e \\u003cp\\u003e \\u003cspan type=\\\"Underline\\\" class=\\\"Underline\\\" name=\\\"Emphasis\\\"\\u003eSociodemographic characteristics\\u003c/span\\u003e: Child age and gender, maternal and paternal educational level, and family monthly net household income were assessed. Based on data regarding maternal and paternal educational level (four-tailed: school-attendance less than nine years [1], nine years [2], ten to twelve years [3], thirteen years or more [4]) and income (six-tailed: less than \\u0026euro;1,000 [1], \\u0026euro;1,000 to \\u0026euro;2,000 [2], \\u0026euro;2,000 to \\u0026euro;3,000 [3], \\u0026euro;3,000 to \\u0026euro;4,000 [4], \\u0026euro;4,000 to \\u0026euro;5,000 [5], and more than \\u0026euro;5,000 [6]), a composite sum-index of SES was calculated, with higher values indicating a higher SES and a theoretical range of 3 to 14.\\u003c/p\\u003e \\u003cp\\u003e \\u003cspan type=\\\"Underline\\\" class=\\\"Underline\\\" name=\\\"Emphasis\\\"\\u003eChild Psychopathology\\u003c/span\\u003e: The German parent version of the Strengths and Difficulties Questionnaire (SDQ; Goodman (\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e); German version: Woerner, Becker (\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e) was used to evaluate child psychopathology. The SDQ contains 25 items rated on a three-point Likert scale ranging from 0 (\\\"not applicable\\\") to 2 (\\\"definitely applicable\\\"). The SDQ has five subscales: emotional problems, behavioral problems, hyperactivity/inattention, problems with peers, and prosocial behavior. Adding the four problem-oriented subscales yields the total problem score (range 0\\u0026ndash;40), with higher scores indicating more/more serious problems. The internal consistency of the total problem score is good (Cronbach's α\\u0026thinsp;=\\u0026thinsp;.82; Woerner, Becker (\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e)). In the present study the total problem score was used to operationalize child psychopathology.\\u003c/p\\u003e \\u003cp\\u003e \\u003cspan type=\\\"Underline\\\" class=\\\"Underline\\\" name=\\\"Emphasis\\\"\\u003eMaternal Psychopathology\\u003c/span\\u003e: The Brief Symptom Inventory (BSI; Derogatis (\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e), 1993; German version: Franke (\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e)) self-report questionnaire was used to evaluate maternal psychopathology. This 53-item questionnaire is answered on a five-point scale ranging from 0 (\\\"not at all\\\") to 4 (\\\"very strongly\\\") and represents nine symptom dimensions, including depression and anxiety. In the present study, the depression (6 items) and anxiety (6 items) subscales, as well as the Global Severity Index (GSI, mean of 53 items), were evaluated. Subscale means and total mean were transformed into standardized T-values (\\u003cem\\u003eM\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;50, \\u003cem\\u003eSD\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;10), with GSI values\\u0026thinsp;\\u0026ge;\\u0026thinsp;63 considered clinically significant. The instrument demonstrates good to high internal consistency (sub-scales: α\\u0026thinsp;=\\u0026thinsp;.72\\u0026ndash;.88; GSI: α\\u0026thinsp;=\\u0026thinsp;.97) and good re-test reliability (\\u003cem\\u003er\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.64\\u0026ndash;.82) (\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e\\u003cspan type=\\\"Underline\\\" class=\\\"Underline\\\" name=\\\"Emphasis\\\"\\u003eMaternal Parenting Behavior\\u003c/span\\u003e: Parenting behavior was assessed in the mothers' self-reports using the German version of the Alabama Parenting Questionnaire (APQ; Shelton, Frick (\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e); German version: Reichle and Franiek (\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e). The 40-item instrument is using a five-point Likert scale ranging from 11(\\\"almost never\\\") to 5 (\\\"almost always\\\") and represents seven dimensions of parenting behavior. Three parenting dimensions were selected on a comprehensive review of the existing literature and on results from earlier research on parenting behaviors in CHD cohorts (Hemetsberger et al., 2024): The dimension of Inconsistency (6 items, e.g., \\u0026ldquo;You find it difficult to be consistent in your parenting.\\u0026rdquo;, \\u0026ldquo;You threaten to punish the child, but then don't punish him/her after all.\\u0026rdquo;) measures the extent to which parents apply rules or consequences inconsistently. The subscale Involvement (6 items, e.g., \\u0026ldquo;You play together or do something fun with your child.\\u0026rdquo;, \\u0026ldquo;You ask your child how his/her day at school was.\\u0026rdquo;) is designed to measure the active parental engagement in their child\\u0026rsquo;s development through active parent participation in child activities. The Responsible Parenting Behavior subscale (6 items, e.g., \\u0026ldquo;You discuss with your child what they could do in their free time.\\u0026rdquo;, \\u0026ldquo;You think about how your child should behave when interacting with other people.\\u0026rdquo;) evaluates parental behavior, which is characterised by well-considered, non-impulsive, reliable, and planned actions in the context of everyday parenting. Subscale mean scores were calculated (range 0\\u0026ndash;4). Higher values indicate stronger expression of the corresponding behavior. Internal consistency ranges from α\\u0026thinsp;=\\u0026thinsp;.66 to .72, and scales show expected correlations with behavioral problems in children (\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e).\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eStatistical analyses\\u003c/h3\\u003e\\n\\u003cp\\u003eStatistical analyses were performed using IBM SPSS Statistics version 28.0 (IBM Corp., Armonk, NY, 2021) and chosen based on data level and distribution characteristics of the variables. Outlier analysis indicated that all outcome measures were situated within \\u0026plusmn;\\u0026thinsp;2.5 standard deviations of the respective sample means, expect for one individual maternal anxiety score (BSI Anxiety; T\\u0026thinsp;=\\u0026thinsp;80), which fell within 3.5 standard deviations; analyses were run without this case with no differences in significance, why the mother was included in all claculations. Potential confounding variables (child gender, child age, SES), were examined beforehand and included as covariates in the inferential statistical models if necessary. The significance threshold was set at \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;.05 (two-tailed), results with \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026le;\\u0026thinsp;.10 were interpreted as trends. Effect sizes were reported as absolute values and classified according to Cohen (2013) as follows: \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u0026sup2; \\u0026ge; .01\\u0026thinsp;=\\u0026thinsp;small, \\u0026ge; .06\\u0026thinsp;=\\u0026thinsp;medium, \\u0026ge; .14\\u0026thinsp;=\\u0026thinsp;large effect; \\u003cem\\u003ed\\u003c/em\\u003e\\u0026thinsp;\\u0026ge;\\u0026thinsp;.20\\u0026thinsp;=\\u0026thinsp;small, \\u0026ge; .50\\u0026thinsp;=\\u0026thinsp;medium, \\u0026ge; .80\\u0026thinsp;=\\u0026thinsp;large; and \\u003cem\\u003eφ\\u003c/em\\u003e\\u0026thinsp;\\u0026ge;\\u0026thinsp;.10\\u0026thinsp;=\\u0026thinsp;weak, \\u0026ge; .30\\u0026thinsp;=\\u0026thinsp;medium, \\u0026ge; .50\\u0026thinsp;=\\u0026thinsp;strong. First, descriptive statistics (means with standard deviations, frequencies with percentages, minimum and maximum) were calculated. Group differences in sociodemographic characteristics between the Fontan and control group were examined using t-tests for independent samples (age and SES) and chi-square tests (gender). Associations of outcome measures and potential influencing factors were analyzed in bivariate Pearson\\u0026rsquo;s correlations (age, SES) or t-Tests for independent groups (gender). For hypotheses testing, analyses of covariance (ANCOVA) were performed to identify group differences, with affected versus unaffected mothers/children as the group factor and the following variables as outcomes: child psychopathology (SDQ total problem score), maternal psychopathology (BSI subscales: anxiety, depression; GSI total score), and parenting behavior (APQ subscales: Responsible Parenting Behavior, Involvement, Inconsistency). In the analyses, child age and family SES were considered as covariates when a significant correlation was found with the outcome measure in bivariate Pearson's correlations. To identify moderator effects of maternal psychopathology or maternal parenting behavior on child psychopathology group differences, additional ANCOVAs were calculated. Maternal psychopathology and parenting behavior variables were dichotomized in the total sample using median splits: maternal total psychopathology: \\u003cem\\u003eMd\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;51 (in the lower group), \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;35 low, \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;27 high; maternal anxiety: \\u003cem\\u003eMd\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;49 (in the lower group), \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;37 low, \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;25 high; maternal depressive symptoms: \\u003cem\\u003eMd\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;51 (in the higher group), \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;30 low, \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;32 high; Responsible Parenting Behavior: \\u003cem\\u003eMd\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;3.33 (in the lower group), \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;31 low, \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;30 high; inkonsistency: \\u003cem\\u003eMd\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;2.1667 (in the lower group), \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;32 low, \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;29 high; Involvement: \\u003cem\\u003eMd\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;4.00 (in the lower group), \\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;33 low, n\\u0026thinsp;=\\u0026thinsp;29 high. Dichotomized group variables were included as factors, in addition to the affected vs. unaffected group factor, in ANCOVA analyses. Child age and family SES were considered as covariates when a significant correlation was found in bivariate Pearson's correlations. Group x maternal psychopathology/maternal parenting behavior interaction effects were interpreted.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eDescriptive data\\u003c/h2\\u003e \\u003cp\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e presents descriptive statistics for all outcome variables. Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e summarizes bivariate associations between potential confounders and outcome measures. Correlational analyses revealed two significant associations: Higher SES was related to higher maternal anxiety symptoms (\\u003cem\\u003er\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.301, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.018), and higher child age was associated with lower levels of Responsible Parenting Behavior (\\u003cem\\u003er\\u003c/em\\u003e = \\u0026ndash;.267, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.038). No associations emerged for child gender. Because of the wide age range and a significant group difference in SES, both variables were included as covariates in all ANCOVA analyses.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eBivariate Associations Between Child and Mother Outcomes, and Potential Influencing Factors (Age, SES, Sex)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003eCorrelation r (p)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003et-Test (p)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSES\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAge\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eSex\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChild Psychopathology\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e.017 (.893)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u0026ndash;.026 (.838)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026ndash;0.89 (.378)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMaternal Psychopathology\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDepression\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026ndash;.015 (.908)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.046 (.723)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026ndash;1.56 (.125)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAnxiety\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e.301* (.018)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u0026ndash;.033 (.797)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026ndash;1.03 (.308)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGlobal Severity Index\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e.040 (.758)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.019 (.881)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026ndash;1.08 (.286)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMaternal Parenting Behavior\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eResponsible Parenting\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e.082 (.529)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u0026ndash;.267* (.038)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026ndash;0.38 (.703)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInvolvement\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e.151 (.243)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u0026ndash;.139 (.280)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026ndash;0.36 (.719)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInconsistency\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026ndash;.049 (.707)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u0026ndash;.164 (.207)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026ndash;0.54 (.591)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003e\\u003cem\\u003eNotes.\\u003c/em\\u003e Child psychopathology: SDQ total score (Goodman, 2001); Maternal psychopathology: BSI subscales Anxiety, Depression, and total psychopathology (GSI) (Franke, 2017). Maternal parenting behavior: APQ subscales Responsible Parenting Behavior, Involvement, and Inconsistency (Reichle \\u0026amp; Franiek, 2009). * \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;.05.\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eANCOVA group main effects on Child Psychopathology, Maternal Psychopathology, and Parenting Behavior controlled for age and SES (df 1/58)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"8\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c8\\\" colnum=\\\"8\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c4\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003eGroup main effect\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c6\\\" namest=\\\"c5\\\"\\u003e \\u003cp\\u003eFontan\\u003c/p\\u003e \\u003cp\\u003e\\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;31\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c8\\\" namest=\\\"c7\\\"\\u003e \\u003cp\\u003eControls\\u003c/p\\u003e \\u003cp\\u003e\\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;31\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eF\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u003csup\\u003e\\u003cem\\u003e2\\u003c/em\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eM\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eSD\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eM\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eSD\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChild Psychopathology\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6.38\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.014*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.099\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e14.23\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e7.04\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e10.03\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e6.50\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMaternal Psychopathology\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDepression\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.89\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.348\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.015\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e50.42\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e8.57\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e48.45\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e7.92\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAnxiety\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1.36\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.248\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e50.35\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e9.74\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e49.23\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e9.17\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGlobal Severity Index\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.27\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.607\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.005\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e51.16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e9.87\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e50.16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e9.08\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eParenting Behavior\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eResponsible Parenting\\u003csup\\u003ea\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.704\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.003\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.51\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e.59\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e3.45\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e.66\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInvolvement\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.749\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.002\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.89\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e.67\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e3.98\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e.60\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInconsistency\\u003csup\\u003ea\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1.13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.292\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.019\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e2.45\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e.64\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e2.24\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e.67\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"8\\\"\\u003e\\u003cem\\u003eNotes\\u003c/em\\u003e. Child Psychopathology: SDQ total score (Goodman, 2001); Maternal Psychopathology: BSI subscales Anxiety, Depression, and total psychopathology (GSI) (Franke, 2017). Maternal Parenting Behavior: APQ subscales Responsible Parenting Behavior, Involvement, and Inconsistency (Reichle \\u0026amp; Franiek, 2009). * \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;.05; \\u003csup\\u003ea\\u003c/sup\\u003en = 30 in Fontan group, df 1/57.\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eANCOVA group main effects on Child Psychopathology, Maternal Psychopathology, and Parenting Behavior under control of age and SES (df 1/58)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"8\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c8\\\" colnum=\\\"8\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c4\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003eGroup main effect\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c6\\\" namest=\\\"c5\\\"\\u003e \\u003cp\\u003eFontan\\u003c/p\\u003e \\u003cp\\u003e\\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;31\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c8\\\" namest=\\\"c7\\\"\\u003e \\u003cp\\u003eControls\\u003c/p\\u003e \\u003cp\\u003e\\u003cem\\u003en\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;31\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eF\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u003csup\\u003e\\u003cem\\u003e2\\u003c/em\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eM\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eSD\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eM\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eSD\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChild Psychopathology\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6.38\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.014*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.099\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e14.23\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e7.04\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e10.03\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e6.50\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMaternal Psychopathology\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDepression\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.89\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.348\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.015\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e50.42\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e8.57\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e48.45\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e7.92\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAnxiety\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1.36\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.248\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e50.35\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e9.74\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e49.23\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e9.17\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGlobal Severity Index\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.27\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.607\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.005\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e51.16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e9.87\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e50.16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e9.08\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eParenting Behavior\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eResponsible Parenting\\u003csup\\u003ea\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.704\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.003\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.51\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e.59\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e3.45\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e.66\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInvolvement\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.749\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.002\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.89\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e.67\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e3.98\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e.60\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInconsistency\\u003csup\\u003ea\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1.13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.292\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.019\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e2.45\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e.64\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e2.24\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e.67\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"8\\\"\\u003e\\u003cem\\u003eNotes\\u003c/em\\u003e. Child Psychopathology: SDQ total score (Goodman, 2001); Maternal Psychopathology: BSI subscales Anxiety, Depression, and total psychopathology (GSI) (Franke, 2017). Maternal Parenting Behavior: APQ subscales Responsible Parenting Behavior, Involvement, and Inconsistency (Reichle \\u0026amp; Franiek, 2009). * \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;.05; \\u003csup\\u003ea\\u003c/sup\\u003en = 30 in Fontan group, df 1/57.\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eGroup differences in child psychopathology, maternal psychopathology, and parenting behavior\\u003c/h2\\u003e \\u003cp\\u003eANCOVA results are presented in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e and Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003cspan type=\\\"Underline\\\" class=\\\"Underline\\\" name=\\\"Emphasis\\\"\\u003eChild psychopathology\\u003c/span\\u003e: A significant main effect of group on child psychopathology was identified, with a medium effect size [\\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;6.36, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.014, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u003cem\\u003e\\u0026sup2;\\u003c/em\\u003e= .099]. Consequently, children in the Fontan group exhibited significantly higher levels of psychopathology compared to children in the control group.\\u003c/p\\u003e \\u003cp\\u003e \\u003cspan type=\\\"Underline\\\" class=\\\"Underline\\\" name=\\\"Emphasis\\\"\\u003eMaternal psychopathology\\u003c/span\\u003e: No significant group effects were observed for maternal psychopathology [depression: \\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;0.89, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.348, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u003cem\\u003e\\u0026sup2;\\u003c/em\\u003e = .015; anxiety: \\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;1.36, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.248, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u003cem\\u003e\\u0026sup2;\\u003c/em\\u003e = .023; total psychopathology: \\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;0.27, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.607, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u003cem\\u003e\\u0026sup2;\\u003c/em\\u003e = .005]. Mothers in both groups reported comparable levels of mental health.\\u003c/p\\u003e \\u003cp\\u003e \\u003cspan type=\\\"Underline\\\" class=\\\"Underline\\\" name=\\\"Emphasis\\\"\\u003eMaternal parenting behavior\\u003c/span\\u003e: Similarly, no significant group effects were found for parenting behavior [Responsible Parenting Behavior: \\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;0.15, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.704, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u003cem\\u003e\\u0026sup2;\\u003c/em\\u003e = .003; Involvement: \\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;0.10, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.749, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u003csup\\u003e\\u003cem\\u003e2\\u003c/em\\u003e\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;.002 ; Inconsistency: \\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;1.13, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.292, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u003csup\\u003e\\u003cem\\u003e2\\u003c/em\\u003e\\u003c/sup\\u003e = ..019]. Parenting practices appeared comparable between groups.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eModerating effects of maternal characteristics on child psychopathology\\u003c/h2\\u003e \\u003cp\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab5\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e and Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e present the ANCOVA moderator analyses results testing whether maternal psychopathology and parenting behavior moderated group differences in child psychopathology.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab5\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eANCOVA Results for median-splitted Moderator Main Effects (Maternal Psychopathology and Parenting Behavior) and Group \\u0026times; Moderator Interaction Effects on Child Psychopathology controlling for age and SES (df 1/58)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"9\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c8\\\" colnum=\\\"8\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c9\\\" colnum=\\\"9\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"5\\\" nameend=\\\"c5\\\" namest=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c9\\\" namest=\\\"c6\\\"\\u003e \\u003cp\\u003eChild psychopatholgy\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"5\\\" nameend=\\\"c5\\\" namest=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c7\\\" namest=\\\"c6\\\"\\u003e \\u003cp\\u003eFontan\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c9\\\" namest=\\\"c8\\\"\\u003e \\u003cp\\u003eControls\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eModerators (median)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eF\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u003csup\\u003e\\u003cem\\u003e2\\u003c/em\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eM\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eSD\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eM\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eSD\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMaternal depression\\u003c/b\\u003e (\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGroup x moderator interaction\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.05\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.820\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eHigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e16.44\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e6.82\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e13.07\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e7.61\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eModerator main effect\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e11.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.002*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.164\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eLow\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e11.15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e6.38\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e7.53\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e4.17\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMaternal anxiety\\u003c/b\\u003e (\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGroup x moderator interaction\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.37\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.545\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.007\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eHigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e17.64\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e6.23\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e12.91\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e7.92\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eModerator main effect\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e9.94\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.003*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.151\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eLow\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e11.41\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e6.55\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e8.45\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e5.12\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c3\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMaternal Global Severity Index\\u003c/b\\u003e (\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGroup x moderator interaction\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.06\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.810\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eHigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e17.71\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e6.66\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e13.23\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e7.67\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eModerator main effect\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e13.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;.001**\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.189\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eLow\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e11.35\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e6.13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e7.72\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e4.42\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c3\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eResponsible Parenting Behavior\\u003c/b\\u003e \\u003csup\\u003ea\\u003c/sup\\u003e (3.33)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGroup x moderator interaction\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.44\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.511\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.008\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eHigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e14.73\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e7.41\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e10.47\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e7.21\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eModerator main effect\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.07\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.789\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eLow\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e13.53\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e7.08\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e9.63\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e5.97\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eInvolvement\\u003c/b\\u003e (4.00)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGroup x moderator interaction\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.06\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.809\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eHigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e15.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e6.49\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e10.68\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e6.07\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eModerator main effect\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.87\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.356\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.015\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eLow\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e13.29\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e7.80\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e9.33\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e7.07\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eInconsistency\\u003c/b\\u003e\\u003csup\\u003e\\u003cb\\u003ea\\u003c/b\\u003e\\u003c/sup\\u003e (2.17)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGroup x moderator interaction\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.86\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e.358\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.015\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eHigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e16.35\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e5.45\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e15.25\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e7.06\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eModerator main effect\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e19.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;.001**\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e.258\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eLow\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e11.23\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e8.23\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e6.74\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e3.21\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"9\\\"\\u003e\\u003cem\\u003eNotes\\u003c/em\\u003e. Child psychopathology: SDQ total score (Goodman, 2001), score range 0\\u0026ndash;40; Maternal psychopathology: BSI subscales Anxiety (T-Scores M\\u0026thinsp;=\\u0026thinsp;50, SD\\u0026thinsp;=\\u0026thinsp;10), Depression (T-Scores M\\u0026thinsp;=\\u0026thinsp;50, SD\\u0026thinsp;=\\u0026thinsp;10), and total psychopathology (GSI, T-Scores M\\u0026thinsp;=\\u0026thinsp;50, SD\\u0026thinsp;=\\u0026thinsp;10) (Franke, 2017). Maternal parenting behavior: APQ subscales Responsible Parenting Behavior, Involvement, and Inconsistency (Reichle \\u0026amp; Franiek, 2009), scale range 0\\u0026ndash;5. * \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;.01; \\u003cem\\u003e** p\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001; \\u003csup\\u003ea\\u003c/sup\\u003en = 30 in Fontan group, df 1/57.\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eMaternal psychopathology\\u003c/h2\\u003e \\u003cp\\u003eAcross all maternal psychopathology measures (total symptoms, anxiety, and depression), no significant Group \\u0026times; Moderator interaction effects emerged (all \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026gt;\\u0026thinsp;.54), indicating that the association between maternal psychopathology and child psychopathology did not differ between the Fontan and control group. At the same time, each of the maternal psychopathology measures demonstrated a robust and statistically significant main effect on child psychopathology, with high effect sizes. Higher levels of maternal depression [\\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;11.00, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.002, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u0026sup2; = .16], maternal anxiety [\\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;9.94, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.003, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u0026sup2; = .15] and maternal total psychopathology [\\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;13.10, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u0026sup2; = .19], were consistently associated with substantially elevated child psychopathology scores across both groups.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eMaternal parenting behavior\\u003c/h2\\u003e \\u003cp\\u003eFor the parenting variables, no significant Group \\u0026times; Moderator interaction effects were found (all \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026gt;\\u0026thinsp;.35), indicating that parenting behaviors did not differentially affect child outcomes in the Fontan and control group. Responsible Parenting Behavior [\\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;0.07, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.789] and Involvement [\\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;0.87, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.356] showed no significant main effects on child psychopathology. In contrast, Inconsistency demonstrated a strong and significant main effect, at high effect size [\\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;19.20, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u0026sup2; = .26]. Children of mothers reporting high Inconsistency in parenting exhibited markedly higher psychopathology scores compared with those whose mothers reported low Inconsistency, irrespective of group membership.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eChild psychopathology\\u003c/h2\\u003e \\u003cp\\u003eThe findings of this study indicate that mothers of children with Fontan circulation reported significantly higher levels of child psychopathology compared to mothers of healthy controls. This result substantiates the hypothesis of elevated psychosocial vulnerability in this patient cohort and aligns with previous studies reporting increased anxiety, depressive symptoms, and social difficulties in children with complex congenital heart defects (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e). Our results further demonstrate that these differences persist even after controlling for age and socioeconomic status, underscoring the robustness of this group difference. Psychosocial impairments thus extend beyond the medical course of the disease, highlighting the importance of psychosocial factors in coping with chronic cardiac conditions.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec18\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eMaternal psychopathology\\u003c/h2\\u003e \\u003cp\\u003eNo significant differences were observed between mothers in the Fontan group and the control group with respect to depressive symptoms, anxiety, or overall psychopathology. This finding stands in contrast to previous studies which described increased psychological vulnerability in parents of children with CHD (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). However, in line with our results, a recent meta-analysis by Wang, Ma (\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e) showed no significant differences in mental health, physical functioning, vitality, or pain between mothers of children with CHD and a general population sample. One potential explanation for this discrepancy may be found in the sample charateristics. The present study focuses exclusively on mothers of children with Fontan circulation, a homogeneous and clearly defined subgroup. In contrast, many earlier studies combined a variety of heart defects of varying severity. Furthermore, the temporal context differs from prior studies. While earlier research often examined acute phases of stress immediately following diagnosis or surgery (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e), in the current sample, surgical procedures usually took place years ago. Our results suggest that, despite elevated child psychopathology in the Fontan group, many mothers appear to have achieved successful psychological adjustment over time, possibly due to stability in daily life, coping mechanisms, and supportive environments. As time since surgery increases, adaptation and coping processes become more effective. Such mechanisms have been shown to reduce parental stress (\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e). Psychosocial protective factors\\u0026mdash;including partner support, self-efficacy, and a strong sense of coherence (\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e) \\u0026mdash;may also have facilitated adjustment in the long-term. Parents who perceive their situation as manageable and meaningful tend to demonstrate long-term resilience (\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThe present findings emphasize that maternal psychological stability may be reached despite caring for a chronically ill child. Future longitudinal research should examine how maternal well-being develops over time and how it relates to child outcomes at different phases of the disease.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec19\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eMaternal parenting behavior\\u003c/h2\\u003e \\u003cp\\u003eConsistent with previous studies showing no major deficits in basic parenting dimensions (\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e), the present study found no significant group differences in parenting behavior. This may indicate that many mothers display parenting competence and adaptability despite heightened stress. Differences may be more evident in specific parenting domains, such as expectations or beliefs regarding control (\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e), which were not the focus of the present study. Parents often report increased self-efficacy and personal growth following successful coping with the child's illness (\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e). These adaptive processes may help stabilize parenting behavior (\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e), and psychosocial stress does not necessarily result in dysfunctional parenting styles; coping strategies and resilience may buffer negative effects (\\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e). However, our moderation analyses indicate that inconsistent parenting\\u0026mdash;rather than other parenting dimensions\\u0026mdash;was strongly associated with elevated child psychopathology across both groups. This underscores the need to examine parenting behavior at a more fine-grained level rather than relying solely on broad parenting constructs. Future studies should investigate developmental trajectories of parenting behaviors and the influence of contextual factors such as family resources, disease burden, and parental coping strategies.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec20\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eMaternal psychopathology and parenting behavior as moderators of child psychopathology\\u003c/h2\\u003e \\u003cp\\u003eThe moderation analyses showed no significant Group \\u0026times; Moderator interaction effects for either maternal psychopathology or parenting behavior, indicating that these factors did not differentially influence child psychopathology in the Fontan and control groups. Instead, the data revealed clear and consistent main effects across the entire sample: higher maternal total psychopathology, anxiety, and depression, as well as more inconsistent parenting, were each robustly associated with higher child psychopathology. In contrast, Responsible Parenting Behavior and nvolvement showed no significant associations with child outcomes.\\u003c/p\\u003e \\u003cp\\u003eThese results align with previous research demonstrating that maternal psychopathology may represent an additional stressor that compounds an already heightened risk profile, even if the underlying mechanisms of influence are comparable to those in healthy peers. Maternal anxiety and depression may impair parent\\u0026ndash;child interactions through emotional overinvolvement, heightened worry, or reduced emotional availability (\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e), while nonspecific stressors such as exhaustion or overload can affect family functioning more broadly (\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e). Likewise, inconsistent parenting has been repeatedly linked to heightened internalizing and externalizing symptoms (\\u003cspan citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eTaken together, the findings indicate that maternal psychopathology and inconsistent parenting operate as general, but modifiable risk factors for child psychopathology, rather than as CHD-specific mechanisms. However, the clinical implications for children with Fontan circulation remain substantial: although they were not statistically more sensitive to these parental factors, they exhibited significantly higher baseline levels of psychopathology. Within a vulnerability\\u0026ndash;stress framework, this suggests that children with Fontan circulation face an accumulation of non-modifiable stressors\\u0026mdash;including chronic physiological burden, ongoing medical uncertainty, and developmental challenges\\u0026mdash;that elevate their vulnerability relative to healthy peers.\\u003c/p\\u003e \\u003cp\\u003eAgainst this background, reducing modifiable familial risk factors becomes especially important for this population. While maternal psychopathology and parenting Inconsistency are problematic for any child, they may constitute a particularly consequential additional stressor when layered on top of the existing medical and psychosocial load associated with Fontan physiology. Interventions that alleviate maternal psychopathology and promote consistent, predictable parenting may therefore help meaningfully reduce the overall risk burden in CHD families. Ultimately, such efforts may support psychosocial adjustment in children with Fontan circulation to a degree that narrows the gap to their healthy peers.\\u003c/p\\u003e \\u003cp\\u003eAlthough statistically non-significant, small effect sizes for a slightly higher maternal anxiety and depression scores in the Fontan group could be shown. This pattern might indicate that caregiving in the context of complex congenital heart disease is often associated with elevated emotional strain and sustained vigilance (\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e). Even subclinical internalizing symptoms in mothers can influence family functioning through reduced emotional availability or heightened worry (\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e), suggesting that these subtle differences\\u0026mdash;despite their small magnitude\\u0026mdash;fit within a broader evidence base highlighting increased caregiver burden in CHD.\\u003c/p\\u003e \\u003cp\\u003eThese results underscore the importance of integrating routine psychosocial screening, parental support services, and targeted interventions into comprehensive CHD care. Future longitudinal research is needed to clarify how these modifiable parental factors interact with disease-related stressors over time and to identify protective processes that can buffer the heightened vulnerability associated with single-ventricle physiology.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec21\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eThe Importance of the Association of Maternal Psychopathology and Parenting Behavior\\u003c/h2\\u003e \\u003cp\\u003eThe findings indicated a strong association between maternal psychopathology and parenting behavior: higher maternal total psychopathology (GSI) was associated with higher Inconsistency (\\u003cem\\u003er\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.276; \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.031) and lower Involvement (\\u003cem\\u003er\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;\\u0026minus;\\u0026thinsp;.245; \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.055). These patterns mirror previous findings indicating that depressive symptoms are linked with reduced sensitivity and emotional availability (\\u003cspan additionalcitationids=\\\"CR59\\\" citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e), while maternal anxiety is associated with greater control or intrusiveness (\\u003cspan citationid=\\\"CR61\\\" class=\\\"CitationRef\\\"\\u003e61\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR62\\\" class=\\\"CitationRef\\\"\\u003e62\\u003c/span\\u003e). In light of the present results, these correlations gain additional relevance: maternal psychopathology and inconsistent parenting each showed strong main effects on child psychopathology, independent of group membership. This convergence of correlational and multivariate findings underscores the close interplay between parental distress and parenting behavior and highlights their combined influence on children\\u0026rsquo;s psychosocial development. Overall, these results emphasize the necessity of integrative approaches that consider both parental stress and parenting behavior when examining child adjustment, particularly in the context of chronic pediatric illness. Future research should investigate how these interconnected factors unfold over time to inform targeted interventions aimed at enhancing family resilience and supporting positive developmental trajectories in children with Fontan circulation.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec22\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStrengths, Limitations and Implications for Future Research\\u003c/h2\\u003e \\u003cp\\u003eA significant methodological limitation of this study is that data were collected only from the mothers' perspective. The single-informant approach carries the risk of subjective bias, particularly when the mothers are experiencing psychological distress. Previous studies have shown that stressed mothers tend to perceive their children's behavior as more noticeable (\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e). Therefore, future studies should adopt a multi-informant design that considers maternal assessments, children's self-reports, paternal perspectives, and other caregivers, if applicable. Including behavioral observations in addition to questionnaire surveys would also increase the validity of the findings. Furthermore, the rarity of Fontan heart defects limited the sample size, which restricts the generalizability of the results. Since the survey was conducted at only one point in time, no conclusions can be drawn about changes over time. Longitudinal designs are necessary to more accurately capture the reciprocal influences between maternal stress and child psychopathology. The wide age range of the children represents a methodological limitation but also allows for a broader view of parental stress patterns across different developmental phases. One of the study's strengths is its specific focus on children with Fontan circulation, a clinically relevant yet underrepresented group. The design with a matched control group enabled better control of potential confounding variables. Additionally, combining key psychosocial dimensions \\u0026mdash; maternal stress, parenting behavior, and child psychopathology \\u0026mdash; provides insight into family dynamics in chronic childhood illness.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eChildren with Fontan circulation exhibited substantially higher levels of psychopathology than matched healthy controls, confirming their elevated psychosocial vulnerability. Maternal psychopathology and inconsistent parenting were identified as general risk factors for higher levels of child psychopathology in both groups, suggesting that these influences are not unique to the Fontan population. However, given that children with Fontan circulation already face increased medical and developmental challenges, it is particularly important to integrate psychosocial support for parents into the care structures for families of children with CHD. Interventions that strengthen parental emotional stability and promote consistent parenting practices may contribute to improved long-term psychosocial outcomes for affected children and their families.\\u003c/p\\u003e \"},{\"header\":\"Declarations\",\"content\":\"\\u003cdiv id=\\\"Sec25\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eEthics statement\\u003c/h2\\u003e \\u003cp\\u003eThe studies involving humans were approved by Ethics Committee of the Erlangen University Hospital, Friedrich-Alexander-Universit\\u0026auml;t Erlangen-N\\u0026uuml;rnberg (21\\u0026ndash;195_3-B). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003ch2\\u003eCompeting interests\\u003c/h2\\u003e \\u003cp\\u003eThe authors declare no competing interests.\\u003c/p\\u003e \\u003ch2\\u003eFunding Declaration\\u003c/h2\\u003e \\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eThis study was conducted without any external founding.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eAE, IS, OK contributed to the conception and design of the study, as well as supervision and project administration. JMH, JG, LH, NN contributed to the data aquisition and data curation. JMH, KLG, AE, NN, JG contributed to data analysis. JMH and NN drafted the article. All authors reviewed and edited the manuscript and approved the submitted version.\\u003c/p\\u003e\\u003ch2\\u003eAcknowledgement\\u003c/h2\\u003e\\u003cp\\u003e We would like to thank all participating parents for taking part in this study.\\u003c/p\\u003e\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\u003cp\\u003eThe datasets analyzed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eBouma, B. J. \\u0026amp; Mulder, B. J. Changing Landscape of Congenital Heart Disease. \\u003cem\\u003eCircul. Res.\\u003c/em\\u003e \\u003cb\\u003e120\\u003c/b\\u003e (6), 908\\u0026ndash;922 (2017).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMarshall, K. H. et al. Health-Related Quality of Life in Children, Adolescents, and Adults With a Fontan Circulation: A Meta-Analysis. \\u003cem\\u003eJ. Am. Heart Assoc.\\u003c/em\\u003e \\u003cb\\u003e9\\u003c/b\\u003e (6), e014172 (2020).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGewillig, M. The Fontan circulation. \\u003cem\\u003eHeart (British Cardiac Society)\\u003c/em\\u003e. \\u003cb\\u003e91\\u003c/b\\u003e (6), 839\\u0026ndash;846 (2005).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRychik, J. et al. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. \\u003cem\\u003eCirculation\\u003c/em\\u003e \\u003cb\\u003e140\\u003c/b\\u003e (6), e234\\u0026ndash;e84 (2019).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKarsdorp, P. A., Everaerd, W., Kindt, M. \\u0026amp; Mulder, B. J. Psychological and cognitive functioning in children and adolescents with congenital heart disease: a meta-analysis. \\u003cem\\u003eJ. Pediatr. Psychol.\\u003c/em\\u003e \\u003cb\\u003e32\\u003c/b\\u003e (5), 527\\u0026ndash;541 (2007).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMcCrindle, B. W. et al. Relationship of patient and medical characteristics to health status in children and adolescents after the Fontan procedure. \\u003cem\\u003eCirculation\\u003c/em\\u003e \\u003cb\\u003e113\\u003c/b\\u003e (8), 1123\\u0026ndash;1129 (2006).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eUzark, K. et al. Assessment of Quality of Life in Young Patients with Single Ventricle after the Fontan Operation. \\u003cem\\u003eJ. Pediatr.\\u003c/em\\u003e ;\\u003cb\\u003e170\\u003c/b\\u003e: (2016). 166\\u0026thinsp;\\u0026ndash;\\u0026thinsp;72.e1.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSchilling, C. et al. The Fontan epidemic: Population projections from the Australia and New Zealand Fontan Registry. \\u003cem\\u003eInt. J. Cardiol.\\u003c/em\\u003e \\u003cb\\u003e219\\u003c/b\\u003e, 14\\u0026ndash;19 (2016).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLadak, L. A., Hasan, B. S., Gullick, J. \\u0026amp; Gallagher, R. Health-related quality of life in congenital heart disease surgery in children and young adults: a systematic review and meta-analysis. \\u003cem\\u003eArch. Dis. Child.\\u003c/em\\u003e \\u003cb\\u003e104\\u003c/b\\u003e (4), 340\\u0026ndash;347 (2019).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLiu, H. C., Chaou, C. H., Lo, C. W., Chung, H. T. \\u0026amp; Hwang, M. S. Factors Affecting Psychological and Health-Related Quality-of-Life Status in Children and Adolescents with Congenital Heart Diseases. \\u003cem\\u003eChild. (Basel)\\u003c/em\\u003e ;\\u003cb\\u003e9\\u003c/b\\u003e(4). (2022).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCasey, F. A., Sykes, D. H., Craig, B. G., Power, R. \\u0026amp; Mulholland, H. C. Behavioral adjustment of children with surgically palliated complex congenital heart disease. \\u003cem\\u003eJ. Pediatr. Psychol.\\u003c/em\\u003e \\u003cb\\u003e21\\u003c/b\\u003e (3), 335\\u0026ndash;352 (1996).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHorner, T., Liberthson, R. \\u0026amp; Jellinek, M. S. Psychosocial profile of adults with complex congenital heart disease. Mayo Clin Proc. ;75(1):31\\u0026thinsp;\\u0026ndash;\\u0026thinsp;6. (2000).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWoolf-King, S. E., Arnold, E., Weiss, S. \\u0026amp; Teitel, D. There's no acknowledgement of what this does to people: A qualitative exploration of mental health among parents of children with critical congenital heart defects. \\u003cem\\u003eJ. Clin. Nurs.\\u003c/em\\u003e \\u003cb\\u003e27\\u003c/b\\u003e (13\\u0026ndash;14), 2785\\u0026ndash;2794 (2018).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDale, M. T. et al. Mothers of infants with congenital heart defects: well-being from pregnancy through the child's first six months. \\u003cem\\u003eQual. life research: Int. J. Qual. life aspects Treat. care rehabilitation\\u003c/em\\u003e. \\u003cb\\u003e21\\u003c/b\\u003e (1), 115\\u0026ndash;122 (2012).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eArafa, M. A., Zaher, S. R., El-Dowaty, A. A. \\u0026amp; Moneeb, D. E. Quality of life among parents of children with heart disease. \\u003cem\\u003eHealth Qual. Life Outcomes\\u003c/em\\u003e. \\u003cb\\u003e6\\u003c/b\\u003e, 91 (2008).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWray, J. et al. 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Disord\\u003c/em\\u003e. \\u003cb\\u003e122\\u003c/b\\u003e (3), 218\\u0026ndash;223 (2010).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eApetroaia, A., Hill, C. \\u0026amp; Creswell, C. Parental responsibility beliefs: associations with parental anxiety and behaviours in the context of childhood anxiety disorders. \\u003cem\\u003eJ. Affect. Disord\\u003c/em\\u003e. \\u003cb\\u003e188\\u003c/b\\u003e, 127\\u0026ndash;133 (2015).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eReeves, J., Reynolds, S., Coker, S. \\u0026amp; Wilson, C. An experimental manipulation of responsibility in children: A test of the inflated responsibility model of obsessive-compulsive disorder. \\u003cem\\u003eJ. Behav. Ther. Exp. Psychiatry\\u003c/em\\u003e. \\u003cb\\u003e41\\u003c/b\\u003e (3), 228\\u0026ndash;233 (2010).\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"scientific-reports\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"scirep\",\"sideBox\":\"Learn more about [Scientific Reports](http://www.nature.com/srep/)\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"Scientific Reports\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Scientific Reports\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Fontan circulation, congenital heart disease, child psychopathology, maternal psychopathology, parenting behavior, psychosocial adjustment\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8648014/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8648014/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eChildren with Fontan circulation face substantial long-term psychosocial challenges. Parental mental health and parenting behavior are known to influence psychosocial outcomes in children with congenital heart disease (CHD), yet data specific for Fontan families are scarce. This cross-sectional controlled study examined child psychopathology in relation to maternal psychopathology and parenting behavior. 31 mothers and their children with Fontan circulation (aged 4\\u0026ndash;16 years) were compared with a sex-, age- and socioeconomic status- (SES) matched control group. Standardized maternal self-report questionnaires assessed child psychopathology, maternal psychopathology, and parenting behavior. Children with Fontan circulation showed significantly higher psychopathology than controls (\\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;6.38, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.014, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u0026sup2; = .10). No group differences were found in maternal psychopathology or parenting behavior (all \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026gt;\\u0026thinsp;.24). No Group \\u0026times; Moderator interaction effects emerged (all \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026gt;\\u0026thinsp;.35). Significant main effects were observed for maternal total psychopathology, anxiety, and depression (\\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;13.10, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u0026sup2; = .19; \\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;9.94, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.003, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u0026sup2; = .15; \\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;11.00, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;.002, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u0026sup2;= .16), and inconsistent parenting behavior (\\u003cem\\u003eF\\u003c/em\\u003e(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)\\u0026thinsp;=\\u0026thinsp;19.20, \\u003cem\\u003ep\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001, \\u003cem\\u003eη\\u003c/em\\u003e\\u003csub\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/sub\\u003e\\u0026sup2; = .26), predicting higher child psychopathology across groups, underscoring the need of family-focused support in Fontan population.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Mental Health of Children with Fontan Circulation: Associations with Maternal Psychopathology and Parenting Behavior\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-02-09 07:11:42\",\"doi\":\"10.21203/rs.3.rs-8648014/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-03-31T02:01:30+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"7471767624957919278196208304215108663\",\"date\":\"2026-03-27T03:16:43+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"112490649381346487185103748758613637181\",\"date\":\"2026-03-23T16:43:59+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-02-03T08:32:28+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-01-23T18:36:02+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-01-22T02:57:24+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-01-22T02:56:07+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Scientific Reports\",\"date\":\"2026-01-20T09:37:17+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"scientific-reports\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"scirep\",\"sideBox\":\"Learn more about [Scientific Reports](http://www.nature.com/srep/)\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"Scientific Reports\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Scientific Reports\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"721d39b4-ab9c-498e-bf35-dd6d4e63746a\",\"owner\":[],\"postedDate\":\"February 9th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[{\"id\":62321608,\"name\":\"Health sciences/Diseases\"},{\"id\":62321609,\"name\":\"Health sciences/Health care\"},{\"id\":62321610,\"name\":\"Health sciences/Medical research\"},{\"id\":62321611,\"name\":\"Biological sciences/Psychology\"},{\"id\":62321612,\"name\":\"Social science/Psychology\"}],\"tags\":[],\"updatedAt\":\"2026-02-09T07:11:46+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-02-09 07:11:42\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8648014\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8648014\",\"identity\":\"rs-8648014\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}