A Structural Equation Model of Psychological Adaptation in Caregivers of Children with Hematological Malignancies: The Role of Family Intimacy, Social Support, Cognitive Fusion and Coping

A Structural Equation Model of Psychological Adaptation in Caregivers of Children with Hematological Malignancies: The Role of Family Intimacy, Social Support, Cognitive Fusion and Coping | 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 Research Article A Structural Equation Model of Psychological Adaptation in Caregivers of Children with Hematological Malignancies: The Role of Family Intimacy, Social Support, Cognitive Fusion and Coping Imtiaz Alam, Wang Mengjia, Lei Jinjin, Fath Ur Rahman, Lalit Dzifa Kodzo, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9371422/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Caregivers of children with hematological malignancies frequently face intense emotional and psychological challenges that impair their mental health, well-being, and caregiving ability. Understanding the interaction of factors influencing psychological adaptation is essential for designing targeted interventions. However, limited research has explored these dynamics in the contexts of pediatric cancer. The aim of this study is to investigate psychological adaptation in caregivers of children with hematological malignancies. Methods A cross-sectional design was used with 214 primary caregiversrecruited from pediatric hematological oncology wards. Standardized scales measured psychological adaptation, family intimacy, social support, cognitive fusion and cognitive coping. Structural equation modeling (SEM) used to analyze the direct and indirect pathways among the variables. Results Family intimacy and social support were positively associated with psychological adaptation. Family intimacy was a significant negative predictor of cognitive fusion (β = − 0.167, p = 0.029), which was inversely associated with psychological adaptation (β = − 0.239, p = 0.001). Social support positively predicted the use of positive coping strategies (β = 0.283, p < 0.001), which in turn enhanced adaptation (β = 0.387, p = 0.001). Notably, indirect effects were observed for social support via positive coping (β = 0.112, p = 0.001), and family intimacy via cognitive fusion (β = 0.035, p = 0.057). Conclusion Family intimacy and social support promote psychological adaptation primarily through their impact on cognitive fusion and cognitive coping. Positive coping plays a key mediating role which underscoring the importance of interventions that enhance psychological adaptation and caregiving ability of caregivers. Psychological adaptation caregivers hematological malignancies family intimacy social support cognitive fusion cognitive coping structural equation modelling Figures Figure 1 Figure 2 1 Introduction Pediatric cancer affects approximately 400,000 children annually, with hematological malignancies being the most common subtype(Chhikara & Parang, 2023 ;Alhajori et al., 2023 ). In China, about 22,000 new cases are reported each year among children aged 0–14, with incidence rising by 2.5% annually(Li et al., 2021 ).Despite survival rates exceeding 80% due to therapeutic advances (Erdmann et al., 2021 ), the intensive nature of treatment places substantial physical, emotional, and financial burdens on family caregivers(Bekui et al., 2023 :Liu et al., 2022 ). Studies indicate that 52–94% of caregivers experience significant emotional distress following diagnosis(Karimi Moghaddam et al., 2023 ), and in China, rates of anxiety and depression reach 87.8% and 45.9%, respectively(Y. Wang et al., 2021 ). Although 20–30% of caregivers successfully adjust over time, the majority continue to experience poor psychological adaptation even years after the diagnosis (Jones et al., 2018 ). Understanding factors associated with healthy psychological adaptation is therefore critical for developing effective support strategies. Psychological adaptation refers to the cognitive and emotional adjustments individuals make to function effectively and alleviate distress in response to challenges(Rachmad, 2022 ;Avsec et al., 2022 ;Luo et al., 2021 ). For caregivers of children with cancer, such adaptation directly influences the child's quality of life and prognosis(Irwanto et al., 2020). Chinese caregivers of children with cancer report significantly lower psychological adaptability than those of healthy children(C. Wang et al., 2024 ), highlighting the need to identify key internal and external factors that shape adaptation outcomes(Katz et al., 2018 ;Teo et al., 2023 ). Cognitive coping strategies are mental processes used to interpret, reframe, and manage stress by changing perceptions of difficult situations(Bondarchuk et al., 2024 ;Ismael et al., 2024 ). In contrast, cognitive fusion involves becoming entangled with negative thoughts, which increases avoidance, rumination, and psychological distress (Gillanders et al., 2014 ). Among caregivers of pediatric cancer patients, high fusion intensifies fear of uncertainty and perceived burden, hindering emotional regulation and problem-solving(Barrera-Caballero et al., 2022 ). Effective coping, both problem-focused and emotion-focused is consistently linked to reduced distress and improved resilience (Gurtovenko et al., 2021 ;Prates et al., 2024 ), whereas negative coping strategies impair adaptation (Molzon et al., 2018 ). Family intimacy, characterized by strong emotional bonding, effective communication, and mutual support, helps maintain cohesion during pediatric cancer treatment(Deng et al., 2022 ;Oh et al., 2024 ). It promotes shared responsibility, emotional stability, and collaborative coping, thereby alleviating caregiving stress (Thomson et al., 2022 ). Beyond the family, social support from extended family, friends, and professional networks offers emotional relief and practical assistance(García-Carmona et al., 2021 ). Access to formal and informal resources reduces isolation, buffers chronic stress, and enhances caregiver well-being(Oshio & Kan, 2019 ;Tan et al., 2020 ;Smith et al., 2019 ).. Despite extensive literature on individual effects of these factors, studies exploring their combined and interactive impacts remain limited, particularly among caregivers of children with hematological malignancies. To address this gap, the present study examines both risk and protective factors from personal and environmental perspectives. 1.2 Theoretical Framework This study is grounded in social cognitive theory (SCT), developed by Albert Bandura (1986) which posits that human functioning emerges from the dynamic and reciprocal interaction of personal factors, environmental influences, and behaviors. Reciprocal determinism underscores how these three domains continually influence and modify one another(Martin et al., 2018 ). Applied to caregiving for children with hematological malignancies, SCT provides a strong framework for understanding how caregivers' cognitive and emotional responses are shaped by internal thoughts, behaviors, and the surrounding family and social environment. Supportive environments encourage effective coping and positive psychological adjustment, whereas restrictive environments with weak communication and minimal support impede adaptation (Abuhammad et al., 2025 ). Thus, using SCT as our conceptual model, we propose that personal factors (cognitive fusion, coping strategies) and environmental factors (family intimacy, social support) directly and indirectly influence caregivers' psychological adaptation. Specifically, personal factors are hypothesized to mediate the relationship between environmental influences and psychological adjustment (see Fig. 1 ). Using Structural Equation Modeling (SEM), this study aims to fill existing gaps by empirically testing a theory-based model of caregiver adaptation. 2 Method 2.1 Study Design A cross-sectional study useing a structural equation modeling (SEM) approach assessed the relationships among family intimacy, social support, cognitive fusion, cognitive coping and psychological adaptation. Participants were recruited by cluster sampling from pediatric cancer wards in five hospitals in Zhengzhou between November 2020 and January 2021. Caregivers who met the inclusion criteria were enrolled. A rough estimation method(Xiao, 2008 ) was used to estimate the sample size, with a target of 200–250 participants considered adequate for SEM based on the number of parameters to be estimated. 2.2 Participants Caregivers of children with hematological malignancies undergoing regular chemotherapy were recruited from pediatric cancer wards based on specific inclusion criteria derived from a detailed literature review. Inclusion criteria for children (1) pathologically diagnosed with hematological malignancies e.g leukemia, lymphoma, or myeloma (2) aged ≤ 16 years (3) diagnosed for ≥ 1 month and receiving regular chemotherapy. Inclusion criteria for caregivers (1) an immediate family member of the child (2) aged ≥ 22 years (3) able to comprehend, cooperate, and provide informed consent. Exclusion criteria included (1) children with severe organic brain syndromes or mental illnesses e.g cognitive impairment (2) children in critical or unstable condition needing intensive parental care. Informed consent was obtained from all individual participants included in the study. Participation was voluntary, and participants were informed about their right to withdraw at any time without penalty. 2.3 Procedure Investigators underwent standardized training prior to data collection to ensure consistency throughout across the study. Data were collected in coordination with hospital staff and study participants during the children's hospitalization for chemotherapy. Informed consent was obtained from each caregiver, and questionnaires were administered on-site in the pediatric hematology wards. To ensure data quality, all completed questionnaires were reviewed immediately, and any incomplete questionnaires were returned to participants for completion. Of the 252 eligible caregivers approached, all were living with and actively caring for a child with a hematological malignancy. A total of 214 participants consented and successfully completed the study within the specified timeframe. 2.4 Measures 2.4.1 General information questionnaire Demographic data were self-reported and included the child’s age, gender, type of health insurance, and caregiver characteristics such as age, gender, education, occupation, monthly household income, and medical insurance coverage. Clinical details including disease duration, type of onset and current treatment status were obtained from the child’s medical records. 2.4.2 Psychological adaptation The psychological adaptation scale (PAS)is a 20-item self-rating scale developed to measure caregivers’ adaptation to a disease(Biesecker et al., 2013 ). It evaluates four domains of adaptation (coping efficacy, self-esteem, social integration, and spiritual well-being). Each item is scored from 1 to 5, with higher scores reflecting better adaptation. The original scale has a Cronbach's α coefficient of 0.96, while the Chinese version has a Cronbach's α coefficient of 0.90.In current study,Cronbach’s α was 0.93. 2.4.3 Coping style The Simplified Coping Style Questionnaire (SCSQ) was used to assess coping styles(Xie, 1998 ). This 20-item scale measures two dimensions: positive coping (12 items) and negative coping (8 items), with responses rated on a 4-point Likert scale from 0 (“do not use”) to 3 (“often use”). In the original scale, Cronbach’s α was 0.89 for positive coping and 0.78 for negative coping. In this study, the Cronbach’s α was 0.83 for positive coping and 0.71 for negative coping. 2.4.4 Social support The Perceived Social Support Scale (PSSS) is a 12-item instrument comprising three subscales: support from family, friends, and other sources(Zimet et al., 1990 ). Each item is rated on a 7-point scale, with total scores ranging from 12 to 84. Higher scores indicating greater perceived social support. The Chinese version, revised by Jiang Qianjin in 1999, has shown strong reliability and validity. Cronbach's a coefficient of the total score of the original scale and the three subscales of family support, friend support, and other support were 0.88 and 0.87, 0.85 and 0.91, respectively. In this study, the Cronbach’s α coefficient for the total scale was 0.92. 2.4.5 Cognitive fusion The cognitive fusion questionnaire (CFQ) was developed by Gillanders(Gillanders et al., 2014 ).The Chinese version, translated by (W.-C. Zhang et al., 2014 )had good reliability and validity. The cognitive fusion scale has 9 items, using a 7-point scoring method, 1 = obviously inconsistent, 7 = obviously consistent. The higher the number, the higher the degree of cognitive fusion. The Cronbach's α coefficient of the Chinese version of the cognitive fusion scale was 0.92. The test-retest reliability was 0.67. The Cronbach's α coefficient of the scale in this study was 0.93. 2.4.6 Family relationship The family intimacy and adaptability scalewas used to evaluate the quality of family relationships(Olson et al., 1979 ). The original scale includes two subscales: intimacy and adaptability, rated on a 5-point scale (1 = “not”, 5 = “always”). In this study, only the intimacy subscale was used, with higher scores reflecting greater family intimacy. The scale demonstrated good reliability, with a Cronbach’s α of 0.85. 2.5 Statistical Analysis Data analyses were conducted using SPSS and AMOS version 26.0 (IBM Corporation, Armonk, NY). Categorical data were presented as frequencies and percentages, while continuous data were described using means and standard deviations (SD). Bivariate analyses were performed to explore the relationships between all variables. The model was constructed and evaluated using AMOS 26.0 statistical software. Structural Equation Modeling (SEM) was applied to explore both direct and indirect relationships among individual factors (positive coping, negative coping, cognitive fusion), family factors (family intimacy), social factors (social support), and psychological adaptation in caregivers of children with cancer. Mediation analysis was performed to examine whether positive coping strategies mediate the relationship between family intimacy and psychological adaptation, and whether cognitive fusion mediated the relationship between family intimacy and adaptation. Model Specification and Modification Statistical methods allowed the study to separate the complex interactions among the various factors that contribute to caregiver adaptation. The model was adjusted based on the initial parameter estimates, overall fit, and related model modification indices. The model fit was assessed using various model-fit indices, including relative chi-square (χ2/df) test 0.05), the goodness of fit index (GFI) > 0.90, the adjusted goodness of fit index (AGFI) > 0.90, the comparative fit index (CFI) > 0.90, normed fit index (NFI) > 0.90, the incremental fit index (IFI) > 0.90, the Tucker-Lewis index (TLI) > 0.90, and root mean squared error of approximation (RMSEA) < 0.06. Mediation focused on pathways with strong theoretical grounding in SCT. Specifically, we hypothesized that environmental factors (family intimacy, social support) would be associated with adaptation through personal factors (cognitive fusion, coping). Thus, we tested the indirect effects of (1) family intimacy on adaptation via cognitive fusion, and (2) social support on adaptation via positive coping. The mediation effect was examined using the deviation correction and percentage bootstrap method, with a sample size set to 5000 (iteration times) and a confidence interval set to 95%. Quality control measures were strictly implemented to evaluate test–retest reliability. 3 Results 3.1 Sociodemographic and clinical characteristics of the study sample The mean age of caregivers was 34.6 years, with 51 fathers (23.8%) and 163 mothers (76.2%) and the mean age of children with cancer was 6.91 ± 3.75 years, with 133 males (62.1%) and 81 females (37.9%) see Table 1 . Table 1 The sociodemographic and clinical characteristics of the participants(N = 214). Gender N (%) Male Female 133(62.1) 81(37.9) Type of cancer ALL AML Lymphoma Myelodysplastic disease Others 124(57.9) 29(13.6) 20(9.3) 17(7.9) 24(11.2) Age (year) <6 6~ 12~ 85(39.7) 98(45.8) 31(14.5) Duration of hematologic malignancies (month) 0–3 4–6 7–12 13~ 70(32.7) 47(22.0) 52(24.3) 45(21.0) Caregiver characteristics Relationship with the child Father Mother 51(23.8) 163(76.2) Age (year) ≤ 30 31~ 40~ 60(28.0) 109(50.9) 45(21.0) Location Urban Rural 55(25.7) 159(74.3) Education level of primary caregivers Junior high school and less High school/ technical secondary school College education or more 103(48.1) 64(29.9) 47(22.0) Monthly household income 5000 56(26.2) 97(45.3) 40(18.7) 21(9.8) Note: ALL,Acute lymphoblastic leukemia; AML,Acute myeloid leukemia 3.2 Descriptive Statistics and Bivariate Correlations Analyses of the Main Variables In our sample, the mean score of psychological adaptation was 69.17 (SD = 12.27). The mean scores for other variables were: cognitive fusion was 40.47 (SD = 10.77), family intimacy was 64.37 (SD = 11.70), social support was 54.13 (SD = 12.45), positive coping was 19.81 (SD = 6.40), and negative coping was 9.43 (SD = 4.37). Table 2 presents bivariate correlations. Psychological adaptation was positively associated with positive coping (r = 0.444, p < 0.01), negative coping (r = 0.174, p < 0.05), social support (r = 0.141, p < 0.05), and family intimacy (r = 0.223, p < 0.01). Psychological adaptation was negatively associated with cognitive fusion (r=-0.154, p < 0.05). Table 2 Zero Order Correlations of the Study Variables 1. psychological adaptation 1 2 3 4 5 6 1.00 2. positive coping 0.444** 1.00 3. negative coping 0.174* 0.174** 1.00 4. family intimacy 0.223** 0.226** -0.160* 1 5. social support 0.141* 0.347** -0.152* 0.492** 1 6. cognitive fusion -0.154* -0.142* 0.393** -0.208** -0.159* 1 Note : *P <0.05 **P <0.01 3.3 Structural Equation Modeling Structural equation modeling was used to explore the pathways of how variables of social support and family intimacy could influence psychological adaptation through positive coping, negative coping, and cognitive fusion. The data were fitted by the maximum likelihood method, which revealed a poor fit (CMIN) = 73.147, DF = 3, p < 0.001; root mean square error of approximation (RMSEA) = 0.331 (95% Confidence Interval (CI): 0.268, 0.399); comparative fit index (CFI) = 0.691; standardized root mean residual (SRMR) = 0.111). The path of the structural equation model that was not statistically significant has been eliminated. And then using standardized residuals to identify potential areas of model misfit, several model modifications were made using a stepwise approach. The final measurement model had substantially better fit (CMIN = 1.349 DF = 1, p = 0.246; RMSEA = 0.04 (95% CI: 0.000, 0.192); CFI = 0.998; SRMR = 0.020). see Fig. 2 . The coefficients (b) and standardized coefficients (β) of all the direct and indirect relationships in the final model can be found in Table 3 , Social support was a positive predictor of positive coping (β = 0.283, p < 0.001). Social support also indirectly influenced psychological adaptation through positive coping (β = 0.112, p = 0.001). Family intimacy was a negative predictor of cognitive fusion (β = -0.167, p = 0.029). Family intimacy also indirectly influenced psychological adaptation through cognitive fusion (β = 0.035, p = 0.057), this effect was not statistically significant because the P value is slightly above the common threshold for significance (0.05) It might exist, but we can’t be confident based on the data. Cognitive fusion (β = -0.239, p = 0.001), positive coping (β = 0.387, p = 0.001), and negative coping (β = 0.245, p = 0.001) had direct effects on psychological adaptation. Table 3 Parameter estimates of the direct and indirect paths in the final model (N = 214). Structural path b 95% CI β P Lower Upper Direct Paths Cognitive fusion Family intimacy →cognitive fusion -0.154 -0.305 -0.013 -0.167 0.029 Positive coping Social support → positive coping 0.146 0.134 0.418 0.283 <0.001 Psychological adaptation Cognitive fusion →Psychological adaptation -0.271 -0.352 -0.128 -0.239 0.001 Positive coping →Psychological adaptation 0.739 0.288 0.489 0.387 0.001 Negative coping →Psychological adaptation 0.669 0.120 0.357 0.245 0.001 Indirect paths family intimacy →cognitive fusion → psychological adaptation 0.036 -0.037 0.110 0.035 0.057 Social support →positive coping → psychological adaptation 0.110 0.039 0.202 0.112 0.001 Note: b regression coefficient; β. standardized regression coefficient; 95%CI, 95% confidence intervals 4 Discussion Recognizing and enhancing the factors associated to psychological adaptation are essential for improving the wellbeing and outcomes of caregivers of children with hematological malignancies. This study used structural equation modeling (SEM) to examine how personal factors (cognitive fusion, positive and negative coping) and environmental factors (family intimacy and social support) are collectively associated with psychological adaptation in caregivers of children with hematological malignancies. The analysis revealed key interrelationships, showing that family intimacy and social support impact psychological well-being both directly and indirectly through their relationships with cognitive fusion and positive coping. These insights can guide targeted interventions aimed at enhancing social support and family intimacy to promote positive coping, reduce cognitive fusion, and improve caregivers' psychological adaptation. Perceived social support is an individual’s belief that help and cooperation are available from others. Support from sources such as extended family, friends, and community networks plays a crucial role in facilitating caregiver adaptation. In our model, perceived social support emerged as an indirect rather than direct determinant of caregivers’ psychological adaptation, highlighting its role as a resource-enabling factor rather than a symptom reliever. It facilitated positive coping, which in turn contributed to improve psychological adaptation, yielding a statistically reliable indirect effect. So after we considered proactive coping, support by itself no longer had any effect. However, support is helpful mostly because it gives caregivers the mental skills and coping strategies they need to deal with the stress of a child’s cancer.this patteren is consisted with studies finding complete mediation by positive coping in caregivers of children with cancer(Chung et al., 2022 ), and with longitudinal research demonstrating that the prospective association between baseline support and later distress became non-significant after accounting for changes in coping self-efficacy(García-Torres et al., 2020 ). This significant indirect pathway from social support to psychological adaptation via positive coping aligns with prior findings that social networks can bolster caregivers’ capacity for adaptive coping (Long et al., 2021 ).Social support, a well-documented variable has been shown to alleviate caregiver distress, enhance autonomy(Xu et al., 2024 ), and more effective coping. For caregivers of children with illnesses, support from family, friends, and the community is a vital resource associated with reduce negative emotions and greater resilience(Alon, 2019 ). A meta-analysis of pediatric oncology caregivers in china found that 60–75% of the overall effect of social support on mental health outcomes was mediated through coping mechanisms, resilience, and interpersonal factors(Mao et al., 2022 ). Another study has showed that caregivers of children with chronic illness often shift between adaptive and maladaptive strategies, depending on illness severity and perceived resources(Wong et al., 2020 ). These evidence syntheses align with the lens of social cognitive theory. The findings suggest that interventions should go beyond simply enhancing caregivers' sense of support, and should instead focus on teaching caregivers how to actively mobilize that support into adaptive coping strategies. Coping strategies have been identified as key mediators in caregivers’ psychological adaptation. They reflect a form of determination or capability including enhanced problem-solving confidence, reduced negative emotions, and improved management of stressful situations(Weigold et al., 2024 ).The study result highlighted the complex dual role of coping, such as positive coping strategies significantly associated with better psychological adaptation,consistent with prior research(Spaggiari et al., 2024 ;Rosenblat & Li, 2021 ), while negative coping inconsistently showed a direct positive association with psychological adaptation in the SEM. The positive association between negative coping and psychological adaptation initially appears counterintuitive, as maladaptive strategies are typically negatively associated with quality of life(Fairfax et al., 2019 ). However, our analysis clarified that this finding is a statistical artifact. When considered alongside positive coping, negative coping acted as a suppressor variable, removing noise from the positive coping-adaptation relationship. This interpretation is supported by the hierarchical regression, where the inclusion of negative coping increased the beta coefficient for positive coping. Therefore, the positive coefficient for negative coping in the SEM should not be interpreted as evidence that strategies such as giving up or avoidance are beneficial. Rather, it underscores the importance of interpreting path coefficients within the full multivariate context. Clinically, this reinforces the need to focus on enhancing positive, approach-oriented coping strategies rather than assuming any form of coping is adaptive. Consistent with prior research, Caregivers who engage in proactive coping strategies such as seeking information, emotional expression, and maintaining optimism are better equipped to manage caregiving demands(Marrakchi et al., 2024 ). In our model where social support and positive coping are controlled the residual component of negative coping (brief emotional venting or controlled denial) provide short-term relief, thereby explaining its positive association with psychological adaptation. From a theoretical perspective, these findings align with the core principles of Social Cognitive Theory (SCT), which emphasizes that adaptive cognitive behavioral responses are crucial for navigating stressful life situations(Bandura, 2001 ). The results highlight the significance and practical benefit of incorporating coping strategy training such as problem-solving and emotional regulation into interventions designed to enhance caregiver adaptation. Beyond moderating cognitive fusion, family intimacy also directly benefits caregiver psychological adaptation by raising a supportive environment in which members offer emotional and practical assistance when difficulties arise (Lei & Kantor, 2022 ;W. Zhang et al., 2024 ) and helps caregivers cope with the strains of caring for an ill child (Aduful et al., 2023 ).In our study, higher levels of family intimacy were significantly associated with lower cognitive fusion, suggesting that caregivers from more cohesive families are less entangled with negative thoughts. In turn, lower cognitive fusion was linked to improved psychological adaptation. However, the indirect effect of family intimacy on adaptation through cognitive fusion was small and not statistically significant. Similarly, prior research showing that strong family functioning reduces parental distress(Kurz et al., 2025 ), while cognitive fusion hampers psychological flexibility and contributes to emotional distress(Bodenlos et al., 2020 ). Close family bonds provide direct support along with protecting caregivers from maladaptive cognitive processes and thetendency to get “stuck” in negative thoughts. This complements evidence from acceptance and commitment therapy (ACT) frameworks, which target cognitive fusion as a core barrier to well-being(Gayatridevi, 2025 ;Van Hout et al., 2024 ). By buffering against cognitive fusion, family intimacy appears to help caregivers maintain healthier cognitive coping, thereby enhancing their ability to adjust as their child’s health status changes. Our findings are consistent with global research highlighting the importance of family-centered interventions such as family counseling, communication skills training, and emotional support programs that reinforce family cohesion and promote caregivers’ psychological well-being. This study provides a new perspective on how the family environment affects psychological adjustment not only through direct support but also indirectly by shaping coping styles and cognitive fusion. The indirect pathway from family intimacy to psychological adaptation through reduced cognitive fusion provides a nuanced understanding of how family systems indirectly promote psychological adjustment. Cognitive fusion, a tendency to get stuck in negative thoughts and inversely related to family intimacy, had a significant negative impact on psychological adaptation. The model confirmed that caregivers with higher levels of cognitive fusion exhibited poorer psychological adaptation, suggesting that strong family bonds safeguard against maladaptive cognitive processes. Our study bridges the gap between the family environment and caregivers’ internal cognitive coping, showing that the closer and more supportive a family is, the less caregivers get stuck in negative thoughts. This finding links the family’s influence with how caregivers manage their own thinking. Therefore, incorporating ACT principles into caregiver support programs could be beneficial in promoting adaptive psychological functioning. Additionally, the results of this study showed a significant positive correlation between family intimacy and psychological adaptation as well as its various dimensions i.e the higher the family intimacy of caregivers lowers the cognitive fusion, which in turnimproves the psychological adaptation of caregivers and vice versa. High family intimacy and lower cognitive fusion enhance the ability of caregivers to change their cognition according to the child’s health condition. Regression analysis also indicated that family intimacy is an important predictor of caregivers’ psychological adaptation. 4.1 Limitation Several limitations should be considered when interpreting these findings. First, the cross-sectional design prevents causal inferences, limiting the ability to determine the temporal sequence of observed relationships. However, longitudinal studies are necessary to assess changes in coping, family dynamics, and psychological adaptation over time. Second, the study was conducted in a specific geographic region using a cluster sampling approach, which limits the generalizability of the findings to other populations or healthcare settings. Although we identified significant associations and mediating pathways, prospective studies are needed to examine changes in coping, family dynamics and psychological adaptation over time. Third, reliance on self-reported data introduces potential for recall and social desirability biases. Additionally, the psychometric tools used, although validated, were largely adapted from Western contexts and may not fully capture culturally specific caregiving experiences or emotional expressions. Fourth, while we tested specific theoretically derived mediation pathways, we did not test all possible indirect effects. Although this approach reduces the risk of Type I error, it may have overlooked other meaningful relationships. Future research with larger samples should explore a more comprehensive set of mediators. Finally, other potentially relevant variables, such as illness severity, caregiving duration, financial stress, and healthcare access, were not examined and should be included in future research to develop a more comprehensive model of caregiver adaptation. 4.2 Clinical implications This study provides a conceptual framework that can inform the development of psychosocial interventions aimed at enhancing the psychological adaptation of caregivers of children with hematological malignancies. For Oncology nurses and healthcare professionals, the findings underscore the importance of routinely assessing family intimacy and perceived social support as part of psychosocial screening. Early identification of caregivers with low family cohesion or inadequate social networks should prompt referral to structured interventions, such as family-based counseling, peer support groups, community linkage services and training on emotion regulation and problem solving strategies. Incorporating coping skills training into routine caregiver support programs such as cognitive behavioral therapy, acceptance and commitment therapy, or mindfulness-based stress reduction promote adaptive coping and alleviate psychological distress. Nurses are ideally positioned to deliver brief, structured training on emotion regulation, cognitive de-fusion, and problem-solving strategies, either individually or in group settings. Strengthening the caregiving environment through targeted education and psychological support could ultimately improve caregiver well-being and the quality of care delivered to children undergoing cancer treatment. 5 Conclusion This study contributes to the growing body of literature on psychosocial determinants of caregiver well-being by identifying key pathways through which family intimacy, social support, cognitive fusion and cognitive coping influence psychological adaptation in caregivers of children with hematological malignancies. Grounded in Social Cognitive Theory, the research employed a cross-sectional design and utilized SEM to extricate direct and indirect effects within this multifaceted framework. The findings demonstrate that supportive environmental factors enhance psychological adaptation by facilitating adaptive coping and reducing cognitive fusion. Notably, social support indirectly promoted adaptation via positive coping, while family intimacy reduced maladaptive cognitive fusion, which was associated with better psychological outcomes. These findings highlight the importance of addressing both internal (cognitive strategies) and external (family and social) factors when designing interventions to support caregivers. For oncology nursing practice, integrating family-focused and coping-enhancement strategies into standard care can play a pivotal role in improving caregiver mental health and sustaining quality care for pediatric oncology patients.Future research should employ longitudinal designs and culturally sensitive tools to further explore these dynamics and test the effectiveness of multi component interventions. Declarations Ethical approval Ethical approval was obtained from the Life Science Ethics Committee of the University, approval number ZZUIRB2023-083. Funding: This research received no external funding and was conducted as part of academic requirements. Author Contribution Author Contribution Statement: Imtiaz Alam: Conceptualization, methodology, formal analysis, investigation, writing – original draft, writing – review and editing, project administration. Wang Mengjia: Data curation, investigation, validation, writing – review and editing. Lei Jinjin: Software, formal analysis, visualization, writing – review and editing. Fath Ur Rahman: Investigation, data curation, resources, writing – review and editing. Lalit Dzifa Kodzo: Validation, formal analysis, writing – review and editing. Zhang Ruixing: Conceptualization, supervision, methodology, writing – review and editing, corresponding author. All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work. Acknowledgement AcknowledgmentWe would like to express our sincere gratitude to the dedicated nursing staff for their invaluable support and collaboration throughout the course of this study. Their professionalism, compassion, and commitment to patient care were instrumental in the successful execution of this research.We are also deeply thankful to all the research participants who generously gave their time and shared their experiences. Their willingness to contribute to this study is not only appreciated but essential to the advancement of healthcare knowledge and practice.This work would not have been possible without the contributions of each individual involved. References Abuhammad, S., Hamaideh, S., Alhawatmeh, H., Almaaitah, R., Abu Ghosh, A., & Kiewan, R. (2025). Parental Quality of Life in Childhood Cancer: Social Support as a Predictor and the Limited Association of Father Involvement. Journal of Multidisciplinary Healthcare , 18 , 6607–6616. https://doi.org/10.2147/JMDH.S541541 Aduful, A. K., Boamah-Mensah, F., Nyarko, M. Y., Neizer, M. L., Brew, Y. N., Williams, L. A., Calys-Tagoe, B. N., Ackun, H. K., & Tette, E. M. (2023). Family needs assessment of patients with cerebral palsy attending two hospitals in Accra. Ghana Children , 10 (8), 1313. Alhajori, F. S., Makkawi, M. H., Alasmari, S. Z., Shaikh, A. A., & Baig, M. A. (2023). Estimating the prevalence of pediatric hematological malignancies in Al-Madinah Al-Munawwarah, Saudi Arabia. Saudi Medical Journal , 44 (5), 504. Alon, R. (2019). Social support and post-crisis growth among mothers of children with autism spectrum disorder and mothers of children with down syndrome. Research in Developmental Disabilities , 90 , 22–30. Avsec, A., Eisenbeck, N., Carreno, D. F., Kocjan, G. Z., & Kavčič, T. (2022). Coping styles mediate the association between psychological inflexibility and psychological functioning during the COVID-19 pandemic: A crucial role of meaning-centered coping. Journal of Contextual Behavioral Science , 26 , 201–209. Bandura, A. (2001). Social cognitive theory: An agentic perspective. Annual Review of Psychology , 52 (1), 1–26. Barrera-Caballero, S., Romero-Moreno, R., Vara-García, C., Olmos, R., Márquez-González, M., & Losada-Baltar, A. (2022). Cognitive fusion and treatment response to depression in caregivers of relatives with dementia. Journal of Contextual Behavioral Science , 26 , 234–240. Bekui, B. A., Ohene, L. A., Badzi, C., Ampomah, M. O., & Aziato, L. (2023). Physical and socioeconomic burden of caregiving on family caregivers of children with cancer at a tertiary Hospital in Ghana. Nursing Open , 10 (2), 915–925. Biesecker, B. B., Erby, L. H., Woolford, S., Adcock, J. Y., Cohen, J. S., Lamb, A., Lewis, K. V., Truitt, M., Turriff, A., & Reeve, B. B. (2013). Development and validation of the Psychological Adaptation Scale (PAS): Use in six studies of adaptation to a health condition or risk. Patient Education and Counseling , 93 (2), 248–254. Bodenlos, J. S., Hawes, E. S., Burstein, S. M., & Arroyo, K. M. (2020). Association of cognitive fusion with domains of health. Journal of Contextual Behavioral Science , 18 , 9–15. Bondarchuk, O., Balakhtar, V., Pinchuk, N., Pustovalov, I., & Pavlenok, K. (2024). Coping with stressfull situations using coping strategies and their impact on mental health. Multidisciplinary Reviews , 7 . Chhikara, B. S., & Parang, K. (2023). Global Cancer Statistics 2022: The trends projection analysis. Chemical Biology Letters , 10 (1), 451–451. Chung, J. O. K., LI, W. H. C., Cheung, A. T., Ho, L. L. K., & Chan, G. C. F. (2022). Association of resilience with psychological well-being and quality of life for parents of children with cancer . Deng, X., Lin, M., Zhang, L., Li, X., & Gao, Q. (2022). Relations between family cohesion and adolescent-parent’s neural synchrony in response to emotional stimulations. Behavioral and Brain Functions , 18 (1), 11. https://doi.org/10.1186/s12993-022-00197-1 Erdmann, F., Frederiksen, L. E., Bonaventure, A., Mader, L., Hasle, H., Robison, L. L., & Winther, J. F. (2021). Childhood cancer: Survival, treatment modalities, late effects and improvements over time. Cancer Epidemiology , 71 , 101733. Fairfax, A., Brehaut, J., Colman, I., Sikora, L., Kazakova, A., Chakraborty, P., Potter, B. K., & Canadian Inherited Metabolic Diseases Research Network. (2019). A systematic review of the association between coping strategies and quality of life among caregivers of children with chronic illness and/or disability. BMC Pediatrics , 19 , 1–16. García-Carmona, M., García‐Torres, F., Jacek Jabłoński, M., Gomez Solis, A., Jaén‐Moreno, M. J., Moriana, J. A., Moreno‐Díaz, M. J., & Aranda, E. (2021). The influence of family social support on quality of life of informal caregivers of cancer patients. Nursing Open , 8 (6), 3411–3419. García-Torres, F., Jacek Jabłoński, M., Gómez Solís, Á., Moriana, J. A., Jaén‐Moreno, M. J., Moreno‐Díaz, M. J., & Aranda, E. (2020). Social support as predictor of anxiety and depression in cancer caregivers six months after cancer diagnosis: A longitudinal study. Journal of Clinical Nursing , 29 (5–6), 996–1002. Gayatridevi, S. (2025). Acceptance and Commitment Therapy and Psychological Well-Being: A Narrative Review. Cureus , 17 (1). Gillanders, D. T., Bolderston, H., Bond, F. W., Dempster, M., Flaxman, P. E., Campbell, L., Kerr, S., Tansey, L., Noel, P., & Ferenbach, C. (2014). The development and initial validation of the cognitive fusion questionnaire. Behavior Therapy , 45 (1), 83–101. Gurtovenko, K., Fladeboe, K. M., Galtieri, L. R., King, K., Friedman, D., Compas, B., Breiger, D., Lengua, L., Keim, M., & Kawamura, J. (2021). Stress and psychological adjustment in caregivers of children with cancer. Health Psychology , 40 (5), 295. Irwanto, Ratwita, M., Prihaningtyas, R. A., & Mustakim, M. R. D. (2020). Impact of Caregiver’s Psychological Aspects towards Quality of Life of Children with Acute Lymphoblastic Leukemia (ALL). Asian Pacific Journal of Cancer Prevention: APJCP , 21 (9), 2683–2688. https://doi.org/10.31557/APJCP.2020.21.9.2683 Ismael, N., Jaber, A., Malkawi, S., Awady, A., S., & Ismael, T. (2024). Exploring coping strategies among caregivers of children who have survived paediatric cancer in Jordan. BMJ Paediatrics Open , 8 (1), e002453. https://doi.org/10.1136/bmjpo-2023-002453 Jones, B., Currin-Mcculloch, J., Pelletier, W., Sardi-Brown, V., Brown, P., & Wiener, L. (2018). Psychosocial standards of care for children with cancer and their families: A national survey of pediatric oncology social workers. Social Work in Health Care , 57 (4), 221–249. Karimi Moghaddam, Z., Rostami, M., Zeraatchi, A., Mohammadi Bytamar, J., Saed, O., & Zenozian, S. (2023). Caregiving burden, depression, and anxiety among family caregivers of patients with cancer: An investigation of patient and caregiver factors. Frontiers in Psychology , 14 , 1059605. https://doi.org/10.3389/fpsyg.2023.1059605 Katz, L. F., Fladeboe, K., King, K., Gurtovenko, K., Kawamura, J., Friedman, D., Compas, B., Gruhn, M., Breiger, D., & Lengua, L. (2018). Trajectories of child and caregiver psychological adjustment in families of children with cancer. Health Psychology , 37 (8), 725. Kurz, H., Paul, V., Nasse, M. L., Krauth, K. A., Kandels, D., Rutkowski, S., Escherich, G., Inhestern, L., & Bergelt, C. (2025). Beyond Treatment: Prevalence, Predictors, and Changes in Anxiety and Depression Among Parents of Childhood Cancer Survivors. Psycho-Oncology , 34 (3), e70115. https://doi.org/10.1002/pon.70115 Lei, X., & Kantor, J. (2022). Social support and family quality of life in Chinese families of children with autism spectrum disorder: The mediating role of family cohesion and adaptability. International Journal of Developmental Disabilities , 68 (4), 454–461. Li, Z., Zheng, R., Xu, X., Liu, Y., Jia, C., Feng, G., Zhang, X., Li, X., Bai, G., & Ni, X. (2021). Pediatric cancer surveillance in China: A hospital-based introduction. Pediatric Investigation , 5 (2), 81–85. https://doi.org/10.1002/ped4.12279 Liu, Y., Ma, L., Mo, L., Shen, X., & Zhong, D. (2022). The demands of caregivers of children with acute lymphoblastic leukaemia in different therapy stages and the exploration of possible interventions: A longitudinal investigation survey at a Tertiary Medical Institution. Nursing Open , 10 (4), 2273–2281. https://doi.org/10.1002/nop2.1481 Long, N. X., Ngoc, N. B., Phung, T. T., Linh, D. T. D., Anh, T. N., Hung, N. V., Thang, N. T., Lan, N. T. M., Trang, V. T., Thuong, N. H., Hieu, N. V., Minh, H. V., Long, N. X., Ngoc, N. B., Phung, T. T., Linh, D. T. D., Anh, T. N., Hung, N. V., Thang, N. T., & Minh, H. V. (2021). Coping strategies and social support among caregivers of patients with cancer: A cross-sectional study in Vietnam. AIMS Public Health , 8 (1). https://doi.org/10.3934/publichealth.2021001 . Article publichealth-08-01-001. Luo, Y. H., Xia, W., He, X. L., Zhang, J. P., & Li, H. C. W. (2021). Psychological interventions for enhancing resilience in parents of children with cancer: A systematic review and meta-analysis. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer , 29 (11), 7101–7110. https://doi.org/10.1007/s00520-021-06344-0 Mao, P., Yang, X., Tan, M., Luo, A., Jiang, S., Guo, J., Su, J., Wiley, J., Xu, P., & Chen, J. L. (2022). The roles of parental absence, life skills and personality traits in mental health status among adolescents in rural China. Journal of Pediatric Nursing , 64 , e15–e23. Marrakchi, A., Chakit, M., Elmorabit, N., Kababri, M. E., Hessni, A. E., & Mesfioui, A. (2024). Psychological distress and coping strategies in parents of children receiving cancer therapy in Morocco – a correlational study. Contemporary Oncology , 28 (3), 260–266. https://doi.org/10.5114/wo.2024.144134 Martin, C. A., Rivera, D. E., Hekler, E. B., Riley, W. T., Buman, M. P., Adams, M. A., & Magann, A. B. (2018). Development of a control-oriented model of social cognitive theory for optimized mHealth behavioral interventions. IEEE Transactions on Control Systems Technology , 28 (2), 331–346. Molzon, E. S., Mullins, L. L., Cushing, C. C., Chaney, J. M., McNall, R., & Mayes, S. (2018). The relationship between barriers to care, caregiver distress, and child health-related quality of life in caregivers of children with cancer: A structural equation modeling approach. Children’s Health Care , 47 (1), 1–15. Oh, S. J., Min, H., Choi, S., Hwang, H., & Kim, S. (2024). Experiences of Pediatric Palliative Care Among Bereaved Parents Who Lost a Child With Leukemia in South Korea. Journal of Hospice & Palliative Nursing , 26 (2), E74–E82. Olson, D. H., Sprenkle, D. H., & Russell, C. S. (1979). Circumplex model of marital and family systems: I. Cohesion and adaptability dimensions, family types, and clinical applications. Family Process , 18 (1), 3–28. Oshio, T., & Kan, M. (2019). Does social participation accelerate psychological adaptation to health shocks? Evidence from a national longitudinal survey in Japan. Quality of Life Research , 28 , 2125–2133. Prates, P. E. G., Correa-Júnior, A. J. S., Russo, T. M. da, Paraizo-Horvath, S., Teles, C. M. S., A. A., & Sonobe, H. M. (2024). Effectiveness of Family Coping Interventions in Improving Problem-Solving Skills in the Care of Children and Adolescent Cancer Survivors during and after Treatment: A Scoping Review. Nursing Reports , 14 (3), Article 3. https://doi.org/10.3390/nursrep14030161 Rachmad, Y. E. (2022). Psychological Adaptation Theory . Rosenblat, J. D., & Li, M. (2021). Is ketamine a litmus test for capacity in assisted dying with depression? Psycho-Oncology , 30 (3). Smith, V. A., Lindquist, J., Miller, K. E., Shepherd-Banigan, M., Olsen, M., Campbell-Kotler, M., Henius, J., Kabat, M., & Van Houtven, C. H. (2019). Comprehensive family caregiver support and caregiver well-being: Preliminary evidence from a pre-post-survey study with a non-equivalent control group. Frontiers in Public Health , 7 , 122. Spaggiari, S., Calignano, G., Montanaro, M., Zaffani, S., Cecinati, V., Maffeis, C., & Di Riso, D. (2024). Examining Coping Strategies and Their Relation with Anxiety: Implications for Children Diagnosed with Cancer or Type 1 Diabetes and Their Caregivers. International Journal of Environmental Research and Public Health , 21 (1), 77. Tan, R., Koh, S., Wong, M. E., Rui, M., & Shorey, S. (2020). Caregiver stress, coping strategies, and support needs of mothers caring for their children who are undergoing active cancer treatments. Clinical Nursing Research , 29 (7), 460–468. Teo, I., Ng, S., Bundoc, F. G., Malhotra, C., Ozdemir, S., Steel, J. L., Finkelstein, E. A., & COMPASS Group. (2023). A prospective study of psychological distress among patients with advanced cancer and their caregivers. Cancer Medicine , 12 (8), 9956–9965. Thompson, B., Tickle,Anna,and, & Dillon, G. (2021). Discovery awareness for staff supporting individuals with intellectual disabilities and challenging behaviour: Is it helpful and does it increase self-efficacy? International Journal of Developmental Disabilities , 67 (1), 44–57. https://doi.org/10.1080/20473869.2019.1599605 Thomson, M. D., Genderson, M. W., & Siminoff, L. A. (2022). Understanding cancer caregiver burden over time: Dyadic assessments of family cohesion, conflict and communication. Patient Education and Counseling , 105 (6), 1545–1551. Van Hout, E., Contreras, M., Mioshi, E., & Kishita, N. (2024). The role of experiential avoidance and cognitive fusion in the development of anxiety symptoms among family carers of people with dementia. Journal of Behavioral and Cognitive Therapy , 34 (1), 100482. Wang, C., Zhao, B., & Fang, P. (2024). Evaluation of the Effect of Social Care Collaboration on the Psychological State of the Parents of Children with Leukemia. SAGE Open , 14 (3), 21582440241279568. https://doi.org/10.1177/21582440241279568 Wang, Y., Yan, J., Chen, J., Wang, C., Lin, Y., Wu, Y., & Hu, R. (2021). Comparison of the anxiety, depression and their relationship to quality of life among adult acute leukemia patients and their family caregivers: A cross-sectional study in China. Quality of Life Research , 30 , 1891–1901. Weigold, I. K., Weigold, A., Dykema, S. A., Drakeford, N. M., & Ethridge, E. T. (2024). Personal Growth Initiative: Relation to Coping Styles, Strategies, and Self-Efficacy. Journal of Happiness Studies , 25 (6), 80. https://doi.org/10.1007/s10902-024-00782-3 Wong, C. L., Choi, K. C., Lau, M. N., Lam, K. L., & So, W. K. W. (2020). Caregiving burden and sleep quality amongst family caregivers of Chinese male patients with advanced cancer: A cross-sectional study. European Journal of Oncology Nursing , 46 , 101774. Xiao, S. (2008). Clinical research design . Peking University Medical Publishing House. Xie, Y. (1998). Reliability and validity of the simplified coping style questionnaire. Chinese Journal of Clinical Psychology . Xu, Q., Ma, J., Zhang, Y., & Gan, J. (2024). Family resilience and social support as mediators of caregiver burden and capacity in stroke caregivers: A cross-sectional study. Frontiers in Psychology , 15 . https://doi.org/10.3389/fpsyg.2024.1435867 Zhang, W., Gao, Y. J., Ye, M. M., & Zhou, L. S. (2024). Post-stroke family resilience is correlated with family functioning among stroke survivors: The mediating role of patient’s coping and self-efficacy. Nursing Open , 11 (7), e2230. https://doi.org/10.1002/nop2.2230 Zhang, W. C., Ji, Y., Li, X., Guo, H. N., & Zhu, Z. H. (2014). Reliability and validity of the Chinese version of the Cognitive Fusion Questionnaire. Chinese Mental Health Journal . Zimet, G. D., Powell, S. S., Farley, G. K., Werkman, S., & Berkoff, K. A. (1990). Psychometric characteristics of the multidimensional scale of perceived social support. Journal of Personality Assessment , 55 (3–4), 610–617. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 28 Apr, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviewers invited by journal 23 Apr, 2026 Editor assigned by journal 20 Apr, 2026 Submission checks completed at journal 16 Apr, 2026 First submitted to journal 09 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-9371422","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":631197836,"identity":"fd97ab98-ee5f-4d25-ab5d-ff4516f638e9","order_by":0,"name":"Imtiaz Alam","email":"","orcid":"","institution":"Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Imtiaz","middleName":"","lastName":"Alam","suffix":""},{"id":631197839,"identity":"5f391780-2584-48de-94f7-506e7f02363d","order_by":1,"name":"Wang Mengjia","email":"","orcid":"","institution":"Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Wang","middleName":"","lastName":"Mengjia","suffix":""},{"id":631197843,"identity":"8cbc94ff-8b08-4e27-b00a-66d1d0d1b1f6","order_by":2,"name":"Lei Jinjin","email":"","orcid":"","institution":"First Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Jinjin","suffix":""},{"id":631197846,"identity":"70ccb787-f3db-463d-ac55-52fc74d3f5a1","order_by":3,"name":"Fath Ur Rahman","email":"","orcid":"","institution":"Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Fath","middleName":"Ur","lastName":"Rahman","suffix":""},{"id":631197854,"identity":"b1fed3b2-e6d7-4c9e-b2a8-42c42f896650","order_by":4,"name":"Lalit Dzifa Kodzo","email":"","orcid":"","institution":"Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Lalit","middleName":"Dzifa","lastName":"Kodzo","suffix":""},{"id":631197861,"identity":"036885f1-0d7f-4075-9268-ea4823601cf1","order_by":5,"name":"Zhang Ruixing","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYDACCQjFw8AMJD9AOAbEa2GcQYoWMGDmIUaL/OzmZw+/7jksY3Cc9/Brmz91iQ3szdskGGru4NTCOOeYubHMs8M8ks18adY5PGyJDTzHyiQYjj3DqYVZIsFMWuLAYR5+Zh4z4xwJnsQGiRwzCcaGwzi1sEmkfwNrYQNpsTCQSGyQf4NfCw/QTMkPEFuMHzMkGABt4cGvRUIip0ya4UA60C88Zow9BxKM23jSii0SjuHWIj8jfZvkjwPW9gbnzxh/+PGnTraf/fDGGx9qcGsBBwEPzF9gEkQk4NUADOgfUK0fCCgcBaNgFIyCEQoAupRJOWupq9sAAAAASUVORK5CYII=","orcid":"","institution":"Zhengzhou University","correspondingAuthor":true,"prefix":"","firstName":"Zhang","middleName":"","lastName":"Ruixing","suffix":""}],"badges":[],"createdAt":"2026-04-09 17:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9371422/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9371422/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108819719,"identity":"47a9fc4a-e573-4a13-93fb-43aec9bc6fc3","added_by":"auto","created_at":"2026-05-08 16:38:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":32079,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual model with hypotheses.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9371422/v1/55eb64b164591969ffe92033.png"},{"id":108819995,"identity":"2010d976-cc4d-4d02-9b7f-61e3ae7497ae","added_by":"auto","created_at":"2026-05-08 16:39:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":87739,"visible":true,"origin":"","legend":"\u003cp\u003eThe final model of psychological adaptation among caregivers of children withcancer\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9371422/v1/59b883f701d428089480cf44.png"},{"id":108821978,"identity":"a70eea0b-79c3-4697-8a82-d27c6238047a","added_by":"auto","created_at":"2026-05-08 16:47:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":545697,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9371422/v1/94dc008f-7b28-4c26-9943-8d5784c45687.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Structural Equation Model of Psychological Adaptation in Caregivers of Children with Hematological Malignancies: The Role of Family Intimacy, Social Support, Cognitive Fusion and Coping","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003ePediatric cancer affects approximately 400,000 children annually, with hematological malignancies being the most common subtype(Chhikara \u0026amp; Parang, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e;Alhajori et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In China, about 22,000 new cases are reported each year among children aged 0\u0026ndash;14, with incidence rising by 2.5% annually(Li et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).Despite survival rates exceeding 80% due to therapeutic advances (Erdmann et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), the intensive nature of treatment places substantial physical, emotional, and financial burdens on family caregivers(Bekui et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e:Liu et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Studies indicate that 52\u0026ndash;94% of caregivers experience significant emotional distress following diagnosis(Karimi Moghaddam et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and in China, rates of anxiety and depression reach 87.8% and 45.9%, respectively(Y. Wang et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Although 20\u0026ndash;30% of caregivers successfully adjust over time, the majority continue to experience poor psychological adaptation even years after the diagnosis (Jones et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Understanding factors associated with healthy psychological adaptation is therefore critical for developing effective support strategies.\u003c/p\u003e \u003cp\u003ePsychological adaptation refers to the cognitive and emotional adjustments individuals make to function effectively and alleviate distress in response to challenges(Rachmad, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2022\u003c/span\u003e;Avsec et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e;Luo et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). For caregivers of children with cancer, such adaptation directly influences the child's quality of life and prognosis(Irwanto et al., 2020). Chinese caregivers of children with cancer report significantly lower psychological adaptability than those of healthy children(C. Wang et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), highlighting the need to identify key internal and external factors that shape adaptation outcomes(Katz et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2018\u003c/span\u003e;Teo et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCognitive coping strategies are mental processes used to interpret, reframe, and manage stress by changing perceptions of difficult situations(Bondarchuk et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e;Ismael et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In contrast, cognitive fusion involves becoming entangled with negative thoughts, which increases avoidance, rumination, and psychological distress (Gillanders et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Among caregivers of pediatric cancer patients, high fusion intensifies fear of uncertainty and perceived burden, hindering emotional regulation and problem-solving(Barrera-Caballero et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Effective coping, both problem-focused and emotion-focused is consistently linked to reduced distress and improved resilience (Gurtovenko et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e;Prates et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), whereas negative coping strategies impair adaptation (Molzon et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFamily intimacy, characterized by strong emotional bonding, effective communication, and mutual support, helps maintain cohesion during pediatric cancer treatment(Deng et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e;Oh et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). It promotes shared responsibility, emotional stability, and collaborative coping, thereby alleviating caregiving stress (Thomson et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Beyond the family, social support from extended family, friends, and professional networks offers emotional relief and practical assistance(Garc\u0026iacute;a-Carmona et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Access to formal and informal resources reduces isolation, buffers chronic stress, and enhances caregiver well-being(Oshio \u0026amp; Kan, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2019\u003c/span\u003e;Tan et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2020\u003c/span\u003e;Smith et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2019\u003c/span\u003e)..\u003c/p\u003e \u003cp\u003eDespite extensive literature on individual effects of these factors, studies exploring their combined and interactive impacts remain limited, particularly among caregivers of children with hematological malignancies. To address this gap, the present study examines both risk and protective factors from personal and environmental perspectives.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Theoretical Framework\u003c/h2\u003e \u003cp\u003eThis study is grounded in social cognitive theory (SCT), developed by Albert Bandura (1986) which posits that human functioning emerges from the dynamic and reciprocal interaction of personal factors, environmental influences, and behaviors. Reciprocal determinism underscores how these three domains continually influence and modify one another(Martin et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Applied to caregiving for children with hematological malignancies, SCT provides a strong framework for understanding how caregivers' cognitive and emotional responses are shaped by internal thoughts, behaviors, and the surrounding family and social environment. Supportive environments encourage effective coping and positive psychological adjustment, whereas restrictive environments with weak communication and minimal support impede adaptation (Abuhammad et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThus, using SCT as our conceptual model, we propose that personal factors (cognitive fusion, coping strategies) and environmental factors (family intimacy, social support) directly and indirectly influence caregivers' psychological adaptation. Specifically, personal factors are hypothesized to mediate the relationship between environmental influences and psychological adjustment (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Using Structural Equation Modeling (SEM), this study aims to fill existing gaps by empirically testing a theory-based model of caregiver adaptation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"2 Method","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design\u003c/h2\u003e \u003cp\u003eA cross-sectional study useing a structural equation modeling (SEM) approach assessed the relationships among family intimacy, social support, cognitive fusion, cognitive coping and psychological adaptation. Participants were recruited by cluster sampling from pediatric cancer wards in five hospitals in Zhengzhou between November 2020 and January 2021. Caregivers who met the inclusion criteria were enrolled. A rough estimation method(Xiao, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) was used to estimate the sample size, with a target of 200\u0026ndash;250 participants considered adequate for SEM based on the number of parameters to be estimated.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participants\u003c/h2\u003e \u003cp\u003eCaregivers of children with hematological malignancies undergoing regular chemotherapy were recruited from pediatric cancer wards based on specific inclusion criteria derived from a detailed literature review.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInclusion criteria for children\u003c/strong\u003e \u003cp\u003e(1) pathologically diagnosed with hematological malignancies e.g leukemia, lymphoma, or myeloma (2) aged\u0026thinsp;\u0026le;\u0026thinsp;16 years (3) diagnosed for \u0026ge;\u0026thinsp;1 month and receiving regular chemotherapy.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInclusion criteria for caregivers\u003c/strong\u003e \u003cp\u003e(1) an immediate family member of the child (2) aged\u0026thinsp;\u0026ge;\u0026thinsp;22 years (3) able to comprehend, cooperate, and provide informed consent.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExclusion criteria included\u003c/strong\u003e \u003cp\u003e(1) children with severe organic brain syndromes or mental illnesses e.g cognitive impairment (2) children in critical or unstable condition needing intensive parental care. Informed consent was obtained from all individual participants included in the study. Participation was voluntary, and participants were informed about their right to withdraw at any time without penalty.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Procedure\u003c/h2\u003e \u003cp\u003eInvestigators underwent standardized training prior to data collection to ensure consistency throughout across the study. Data were collected in coordination with hospital staff and study participants during the children's hospitalization for chemotherapy. Informed consent was obtained from each caregiver, and questionnaires were administered on-site in the pediatric hematology wards. To ensure data quality, all completed questionnaires were reviewed immediately, and any incomplete questionnaires were returned to participants for completion. Of the 252 eligible caregivers approached, all were living with and actively caring for a child with a hematological malignancy. A total of 214 participants consented and successfully completed the study within the specified timeframe.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Measures\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.4.1 General information questionnaire\u003c/h2\u003e \u003cp\u003eDemographic data were self-reported and included the child\u0026rsquo;s age, gender, type of health insurance, and caregiver characteristics such as age, gender, education, occupation, monthly household income, and medical insurance coverage. Clinical details including disease duration, type of onset and current treatment status were obtained from the child\u0026rsquo;s medical records.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.4.2 Psychological adaptation\u003c/h2\u003e \u003cp\u003eThe psychological adaptation scale (PAS)is a 20-item self-rating scale developed to measure caregivers\u0026rsquo; adaptation to a disease(Biesecker et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). It evaluates four domains of adaptation (coping efficacy, self-esteem, social integration, and spiritual well-being). Each item is scored from 1 to 5, with higher scores reflecting better adaptation. The original scale has a Cronbach's α coefficient of 0.96, while the Chinese version has a Cronbach's α coefficient of 0.90.In current study,Cronbach\u0026rsquo;s α was 0.93.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.4.3 Coping style\u003c/h2\u003e \u003cp\u003eThe Simplified Coping Style Questionnaire (SCSQ) was used to assess coping styles(Xie, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). This 20-item scale measures two dimensions: positive coping (12 items) and negative coping (8 items), with responses rated on a 4-point Likert scale from 0 (\u0026ldquo;do not use\u0026rdquo;) to 3 (\u0026ldquo;often use\u0026rdquo;). In the original scale, Cronbach\u0026rsquo;s α was 0.89 for positive coping and 0.78 for negative coping. In this study, the Cronbach\u0026rsquo;s α was 0.83 for positive coping and 0.71 for negative coping.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e2.4.4 Social support\u003c/h2\u003e \u003cp\u003eThe Perceived Social Support Scale (PSSS) is a 12-item instrument comprising three subscales: support from family, friends, and other sources(Zimet et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e1990\u003c/span\u003e). Each item is rated on a 7-point scale, with total scores ranging from 12 to 84. Higher scores indicating greater perceived social support. The Chinese version, revised by Jiang Qianjin in 1999, has shown strong reliability and validity. Cronbach's a coefficient of the total score of the original scale and the three subscales of family support, friend support, and other support were 0.88 and 0.87, 0.85 and 0.91, respectively. In this study, the Cronbach\u0026rsquo;s α coefficient for the total scale was 0.92.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e2.4.5 Cognitive fusion\u003c/h2\u003e \u003cp\u003eThe cognitive fusion questionnaire (CFQ) was developed by Gillanders(Gillanders et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).The Chinese version, translated by (W.-C. Zhang et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2014\u003c/span\u003e)had good reliability and validity. The cognitive fusion scale has 9 items, using a 7-point scoring method, 1\u0026thinsp;=\u0026thinsp;obviously inconsistent, 7\u0026thinsp;=\u0026thinsp;obviously consistent. The higher the number, the higher the degree of cognitive fusion. The Cronbach's α coefficient of the Chinese version of the cognitive fusion scale was 0.92. The test-retest reliability was 0.67. The Cronbach's α coefficient of the scale in this study was 0.93.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e2.4.6 Family relationship\u003c/h2\u003e \u003cp\u003eThe family intimacy and adaptability scalewas used to evaluate the quality of family relationships(Olson et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e1979\u003c/span\u003e). The original scale includes two subscales: intimacy and adaptability, rated on a 5-point scale (1 = \u0026ldquo;not\u0026rdquo;, 5 = \u0026ldquo;always\u0026rdquo;). In this study, only the intimacy subscale was used, with higher scores reflecting greater family intimacy. The scale demonstrated good reliability, with a Cronbach\u0026rsquo;s α of 0.85.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical Analysis\u003c/h2\u003e \u003cp\u003eData analyses were conducted using SPSS and AMOS version 26.0 (IBM Corporation, Armonk, NY). Categorical data were presented as frequencies and percentages, while continuous data were described using means and standard deviations (SD). Bivariate analyses were performed to explore the relationships between all variables. The model was constructed and evaluated using AMOS 26.0 statistical software.\u003c/p\u003e \u003cp\u003eStructural Equation Modeling (SEM) was applied to explore both direct and indirect relationships among individual factors (positive coping, negative coping, cognitive fusion), family factors (family intimacy), social factors (social support), and psychological adaptation in caregivers of children with cancer. Mediation analysis was performed to examine whether positive coping strategies mediate the relationship between family intimacy and psychological adaptation, and whether cognitive fusion mediated the relationship between family intimacy and adaptation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eModel Specification and Modification\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStatistical methods allowed the study to separate the complex interactions among the various factors that contribute to caregiver adaptation. The model was adjusted based on the initial parameter estimates, overall fit, and related model modification indices. The model fit was assessed using various model-fit indices, including relative chi-square (χ2/df) test\u0026thinsp;\u0026lt;\u0026thinsp;2 (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), the goodness of fit index (GFI)\u0026thinsp;\u0026gt;\u0026thinsp;0.90, the adjusted goodness of fit index (AGFI)\u0026thinsp;\u0026gt;\u0026thinsp;0.90, the comparative fit index (CFI)\u0026thinsp;\u0026gt;\u0026thinsp;0.90, normed fit index (NFI)\u0026thinsp;\u0026gt;\u0026thinsp;0.90, the incremental fit index (IFI)\u0026thinsp;\u0026gt;\u0026thinsp;0.90, the Tucker-Lewis index (TLI)\u0026thinsp;\u0026gt;\u0026thinsp;0.90, and root mean squared error of approximation (RMSEA)\u0026thinsp;\u0026lt;\u0026thinsp;0.06. Mediation focused on pathways with strong theoretical grounding in SCT. Specifically, we hypothesized that environmental factors (family intimacy, social support) would be associated with adaptation through personal factors (cognitive fusion, coping). Thus, we tested the indirect effects of (1) family intimacy on adaptation via cognitive fusion, and (2) social support on adaptation via positive coping. The mediation effect was examined using the deviation correction and percentage bootstrap method, with a sample size set to 5000 (iteration times) and a confidence interval set to 95%. Quality control measures were strictly implemented to evaluate test\u0026ndash;retest reliability.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Sociodemographic and clinical characteristics of the study sample\u003c/h2\u003e \u003cp\u003eThe mean age of caregivers was 34.6 years, with 51 fathers (23.8%) and 163 mothers (76.2%) and the mean age of children with cancer was 6.91\u0026thinsp;\u0026plusmn;\u0026thinsp;3.75 years, with 133 males (62.1%) and 81 females (37.9%) see Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\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\u003eThe sociodemographic and clinical characteristics of the participants(N\u0026thinsp;=\u0026thinsp;214).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e133(62.1)\u003c/p\u003e \u003cp\u003e81(37.9)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eALL\u003c/p\u003e \u003cp\u003eAML\u003c/p\u003e \u003cp\u003eLymphoma\u003c/p\u003e \u003cp\u003eMyelodysplastic disease\u003c/p\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e124(57.9)\u003c/p\u003e \u003cp\u003e29(13.6)\u003c/p\u003e \u003cp\u003e20(9.3)\u003c/p\u003e \u003cp\u003e17(7.9)\u003c/p\u003e \u003cp\u003e24(11.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;6\u003c/p\u003e \u003cp\u003e6~\u003c/p\u003e \u003cp\u003e12~\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85(39.7)\u003c/p\u003e \u003cp\u003e98(45.8)\u003c/p\u003e \u003cp\u003e31(14.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of hematologic malignancies (month)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003cp\u003e4\u0026ndash;6\u003c/p\u003e \u003cp\u003e7\u0026ndash;12\u003c/p\u003e \u003cp\u003e13~\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70(32.7)\u003c/p\u003e \u003cp\u003e47(22.0)\u003c/p\u003e \u003cp\u003e52(24.3)\u003c/p\u003e \u003cp\u003e45(21.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiver characteristics\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelationship with the child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFather\u003c/p\u003e \u003cp\u003eMother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51(23.8)\u003c/p\u003e \u003cp\u003e163(76.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003cp\u003e31~\u003c/p\u003e\u003cp\u003e40~\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60(28.0)\u003c/p\u003e \u003cp\u003e109(50.9)\u003c/p\u003e \u003cp\u003e45(21.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55(25.7)\u003c/p\u003e \u003cp\u003e159(74.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level of primary caregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJunior high school and less\u003c/p\u003e \u003cp\u003eHigh school/ technical secondary school\u003c/p\u003e \u003cp\u003eCollege education or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103(48.1)\u003c/p\u003e \u003cp\u003e64(29.9)\u003c/p\u003e \u003cp\u003e47(22.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonthly household income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;1000\u003c/p\u003e \u003cp\u003e1000~\u003c/p\u003e \u003cp\u003e3000~\u003c/p\u003e \u003cp\u003e\u0026gt;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56(26.2)\u003c/p\u003e \u003cp\u003e97(45.3)\u003c/p\u003e \u003cp\u003e40(18.7)\u003c/p\u003e \u003cp\u003e21(9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: ALL,Acute lymphoblastic leukemia; AML,Acute myeloid leukemia\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Descriptive Statistics and Bivariate Correlations Analyses of the Main Variables\u003c/h2\u003e \u003cp\u003eIn our sample, the mean score of psychological adaptation was 69.17 (SD\u0026thinsp;=\u0026thinsp;12.27). The mean scores for other variables were: cognitive fusion was 40.47 (SD\u0026thinsp;=\u0026thinsp;10.77), family intimacy was 64.37 (SD\u0026thinsp;=\u0026thinsp;11.70), social support was 54.13 (SD\u0026thinsp;=\u0026thinsp;12.45), positive coping was 19.81 (SD\u0026thinsp;=\u0026thinsp;6.40), and negative coping was 9.43 (SD\u0026thinsp;=\u0026thinsp;4.37).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents bivariate correlations. Psychological adaptation was positively associated with positive coping (r\u0026thinsp;=\u0026thinsp;0.444, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), negative coping (r\u0026thinsp;=\u0026thinsp;0.174, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), social support (r\u0026thinsp;=\u0026thinsp;0.141, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and family intimacy (r\u0026thinsp;=\u0026thinsp;0.223, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Psychological adaptation was negatively associated with cognitive fusion (r=-0.154, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\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\u003eZero Order Correlations of the Study Variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1. psychological adaptation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. positive coping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.444**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.00\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. negative coping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.174*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.174**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. family intimacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.223**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.226**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.160*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.141*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.347**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.152*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.492**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. cognitive fusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.154*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.142*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.393**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.208**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.159*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cb\u003eNote\u003c/b\u003e: \u003cem\u003e*P\u003c/em\u003e\u0026lt;0.05\u003cem\u003e**P\u003c/em\u003e\u0026lt;0.01\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Structural Equation Modeling\u003c/h2\u003e \u003cp\u003eStructural equation modeling was used to explore the pathways of how variables of social support and family intimacy could influence psychological adaptation through positive coping, negative coping, and cognitive fusion. The data were fitted by the maximum likelihood method, which revealed a poor fit (CMIN)\u0026thinsp;=\u0026thinsp;73.147, DF\u0026thinsp;=\u0026thinsp;3, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; root mean square error of approximation (RMSEA)\u0026thinsp;=\u0026thinsp;0.331 (95% Confidence Interval (CI): 0.268, 0.399); comparative fit index (CFI)\u0026thinsp;=\u0026thinsp;0.691; standardized root mean residual (SRMR)\u0026thinsp;=\u0026thinsp;0.111). The path of the structural equation model that was not statistically significant has been eliminated. And then using standardized residuals to identify potential areas of model misfit, several model modifications were made using a stepwise approach. The final measurement model had substantially better fit (CMIN\u0026thinsp;=\u0026thinsp;1.349 DF\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;=\u0026thinsp;0.246; RMSEA\u0026thinsp;=\u0026thinsp;0.04 (95% CI: 0.000, 0.192); CFI\u0026thinsp;=\u0026thinsp;0.998; SRMR\u0026thinsp;=\u0026thinsp;0.020). see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe coefficients (b) and standardized coefficients (β) of all the direct and indirect relationships in the final model can be found in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Social support was a positive predictor of positive coping (β\u0026thinsp;=\u0026thinsp;0.283, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Social support also indirectly influenced psychological adaptation through positive coping (β\u0026thinsp;=\u0026thinsp;0.112, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). Family intimacy was a negative predictor of cognitive fusion (β = -0.167, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029). Family intimacy also indirectly influenced psychological adaptation through cognitive fusion (β\u0026thinsp;=\u0026thinsp;0.035, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.057), this effect was not statistically significant because the P value is slightly above the common threshold for significance (0.05) It \u003cem\u003emight\u003c/em\u003e exist, but we can\u0026rsquo;t be confident based on the data. Cognitive fusion (β = -0.239, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), positive coping (β\u0026thinsp;=\u0026thinsp;0.387, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), and negative coping (β\u0026thinsp;=\u0026thinsp;0.245, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) had direct effects on psychological adaptation.\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\u003eParameter estimates of the direct and indirect paths in the final model (N\u0026thinsp;=\u0026thinsp;214).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStructural path\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect Paths\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive fusion\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily intimacy \u0026rarr;cognitive fusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.029\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive coping\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial support \u0026rarr; positive coping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.418\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychological adaptation\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive fusion \u0026rarr;Psychological adaptation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.352\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive coping \u0026rarr;Psychological adaptation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.739\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.489\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.387\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative coping \u0026rarr;Psychological adaptation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.669\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.357\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndirect paths\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efamily intimacy \u0026rarr;cognitive fusion \u0026rarr; psychological adaptation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.057\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial support \u0026rarr;positive coping \u0026rarr; psychological adaptation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: b regression coefficient; β. standardized regression coefficient; 95%CI, 95% confidence intervals\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eRecognizing and enhancing the factors associated to psychological adaptation are essential for improving the wellbeing and outcomes of caregivers of children with hematological malignancies. This study used structural equation modeling (SEM) to examine how personal factors (cognitive fusion, positive and negative coping) and environmental factors (family intimacy and social support) are collectively associated with psychological adaptation in caregivers of children with hematological malignancies. The analysis revealed key interrelationships, showing that family intimacy and social support impact psychological well-being both directly and indirectly through their relationships with cognitive fusion and positive coping. These insights can guide targeted interventions aimed at enhancing social support and family intimacy to promote positive coping, reduce cognitive fusion, and improve caregivers' psychological adaptation.\u003c/p\u003e \u003cp\u003ePerceived social support is an individual\u0026rsquo;s belief that help and cooperation are available from others. Support from sources such as extended family, friends, and community networks plays a crucial role in facilitating caregiver adaptation. In our model, perceived social support emerged as an indirect rather than direct determinant of caregivers\u0026rsquo; psychological adaptation, highlighting its role as a resource-enabling factor rather than a symptom reliever. It facilitated positive coping, which in turn contributed to improve psychological adaptation, yielding a statistically reliable indirect effect. So after we considered proactive coping, support by itself no longer had any effect. However, support is helpful mostly because it gives caregivers the mental skills and coping strategies they need to deal with the stress of a child\u0026rsquo;s cancer.this patteren is consisted with studies finding complete mediation by positive coping in caregivers of children with cancer(Chung et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), and with longitudinal research demonstrating that the prospective association between baseline support and later distress became non-significant after accounting for changes in coping self-efficacy(Garc\u0026iacute;a-Torres et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This significant indirect pathway from social support to psychological adaptation via positive coping aligns with prior findings that social networks can bolster caregivers\u0026rsquo; capacity for adaptive coping (Long et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).Social support, a well-documented variable has been shown to alleviate caregiver distress, enhance autonomy(Xu et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), and more effective coping. For caregivers of children with illnesses, support from family, friends, and the community is a vital resource associated with reduce negative emotions and greater resilience(Alon, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). A meta-analysis of pediatric oncology caregivers in china found that 60\u0026ndash;75% of the overall effect of social support on mental health outcomes was mediated through coping mechanisms, resilience, and interpersonal factors(Mao et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Another study has showed that caregivers of children with chronic illness often shift between adaptive and maladaptive strategies, depending on illness severity and perceived resources(Wong et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These evidence syntheses align with the lens of social cognitive theory. The findings suggest that interventions should go beyond simply enhancing caregivers' sense of support, and should instead focus on teaching caregivers how to actively mobilize that support into adaptive coping strategies.\u003c/p\u003e \u003cp\u003eCoping strategies have been identified as key mediators in caregivers\u0026rsquo; psychological adaptation. They reflect a form of determination or capability including enhanced problem-solving confidence, reduced negative emotions, and improved management of stressful situations(Weigold et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).The study result highlighted the complex dual role of coping, such as positive coping strategies significantly associated with better psychological adaptation,consistent with prior research(Spaggiari et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2024\u003c/span\u003e;Rosenblat \u0026amp; Li, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), while negative coping inconsistently showed a direct positive association with psychological adaptation in the SEM.\u003c/p\u003e \u003cp\u003eThe positive association between negative coping and psychological adaptation initially appears counterintuitive, as maladaptive strategies are typically negatively associated with quality of life(Fairfax et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). However, our analysis clarified that this finding is a statistical artifact. When considered alongside positive coping, negative coping acted as a suppressor variable, removing noise from the positive coping-adaptation relationship. This interpretation is supported by the hierarchical regression, where the inclusion of negative coping increased the beta coefficient for positive coping. Therefore, the positive coefficient for negative coping in the SEM should not be interpreted as evidence that strategies such as giving up or avoidance are beneficial. Rather, it underscores the importance of interpreting path coefficients within the full multivariate context. Clinically, this reinforces the need to focus on enhancing positive, approach-oriented coping strategies rather than assuming any form of coping is adaptive.\u003c/p\u003e \u003cp\u003eConsistent with prior research, Caregivers who engage in proactive coping strategies such as seeking information, emotional expression, and maintaining optimism are better equipped to manage caregiving demands(Marrakchi et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In our model where social support and positive coping are controlled the residual component of negative coping (brief emotional venting or controlled denial) provide short-term relief, thereby explaining its positive association with psychological adaptation. From a theoretical perspective, these findings align with the core principles of Social Cognitive Theory (SCT), which emphasizes that adaptive cognitive behavioral responses are crucial for navigating stressful life situations(Bandura, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). The results highlight the significance and practical benefit of incorporating coping strategy training such as problem-solving and emotional regulation into interventions designed to enhance caregiver adaptation.\u003c/p\u003e \u003cp\u003eBeyond moderating cognitive fusion, family intimacy also directly benefits caregiver psychological adaptation by raising a supportive environment in which members offer emotional and practical assistance when difficulties arise (Lei \u0026amp; Kantor, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e;W. Zhang et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and helps caregivers cope with the strains of caring for an ill child (Aduful et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).In our study, higher levels of family intimacy were significantly associated with lower cognitive fusion, suggesting that caregivers from more cohesive families are less entangled with negative thoughts. In turn, lower cognitive fusion was linked to improved psychological adaptation. However, the indirect effect of family intimacy on adaptation through cognitive fusion was small and not statistically significant. Similarly, prior research showing that strong family functioning reduces parental distress(Kurz et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), while cognitive fusion hampers psychological flexibility and contributes to emotional distress(Bodenlos et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Close family bonds provide direct support along with protecting caregivers from maladaptive cognitive processes and thetendency to get \u0026ldquo;stuck\u0026rdquo; in negative thoughts. This complements evidence from acceptance and commitment therapy (ACT) frameworks, which target cognitive fusion as a core barrier to well-being(Gayatridevi, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e;Van Hout et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). By buffering against cognitive fusion, family intimacy appears to help caregivers maintain healthier cognitive coping, thereby enhancing their ability to adjust as their child\u0026rsquo;s health status changes.\u003c/p\u003e \u003cp\u003eOur findings are consistent with global research highlighting the importance of family-centered interventions such as family counseling, communication skills training, and emotional support programs that reinforce family cohesion and promote caregivers\u0026rsquo; psychological well-being. This study provides a new perspective on how the family environment affects psychological adjustment not only through direct support but also indirectly by shaping coping styles and cognitive fusion. The indirect pathway from family intimacy to psychological adaptation through reduced cognitive fusion provides a nuanced understanding of how family systems indirectly promote psychological adjustment. Cognitive fusion, a tendency to get stuck in negative thoughts and inversely related to family intimacy, had a significant negative impact on psychological adaptation. The model confirmed that caregivers with higher levels of cognitive fusion exhibited poorer psychological adaptation, suggesting that strong family bonds safeguard against maladaptive cognitive processes. Our study bridges the gap between the family environment and caregivers\u0026rsquo; internal cognitive coping, showing that the closer and more supportive a family is, the less caregivers get stuck in negative thoughts. This finding links the family\u0026rsquo;s influence with how caregivers manage their own thinking. Therefore, incorporating ACT principles into caregiver support programs could be beneficial in promoting adaptive psychological functioning.\u003c/p\u003e \u003cp\u003eAdditionally, the results of this study showed a significant positive correlation between family intimacy and psychological adaptation as well as its various dimensions i.e the higher the family intimacy of caregivers lowers the cognitive fusion, which in turnimproves the psychological adaptation of caregivers and vice versa. High family intimacy and lower cognitive fusion enhance the ability of caregivers to change their cognition according to the child\u0026rsquo;s health condition. Regression analysis also indicated that family intimacy is an important predictor of caregivers\u0026rsquo; psychological adaptation.\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Limitation\u003c/h2\u003e \u003cp\u003eSeveral limitations should be considered when interpreting these findings. First, the cross-sectional design prevents causal inferences, limiting the ability to determine the temporal sequence of observed relationships. However, longitudinal studies are necessary to assess changes in coping, family dynamics, and psychological adaptation over time.\u003c/p\u003e \u003cp\u003eSecond, the study was conducted in a specific geographic region using a cluster sampling approach, which limits the generalizability of the findings to other populations or healthcare settings. Although we identified significant associations and mediating pathways, prospective studies are needed to examine changes in coping, family dynamics and psychological adaptation over time.\u003c/p\u003e \u003cp\u003eThird, reliance on self-reported data introduces potential for recall and social desirability biases. Additionally, the psychometric tools used, although validated, were largely adapted from Western contexts and may not fully capture culturally specific caregiving experiences or emotional expressions.\u003c/p\u003e \u003cp\u003eFourth, while we tested specific theoretically derived mediation pathways, we did not test all possible indirect effects. Although this approach reduces the risk of Type I error, it may have overlooked other meaningful relationships. Future research with larger samples should explore a more comprehensive set of mediators.\u003c/p\u003e \u003cp\u003eFinally, other potentially relevant variables, such as illness severity, caregiving duration, financial stress, and healthcare access, were not examined and should be included in future research to develop a more comprehensive model of caregiver adaptation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Clinical implications\u003c/h2\u003e \u003cp\u003eThis study provides a conceptual framework that can inform the development of psychosocial interventions aimed at enhancing the psychological adaptation of caregivers of children with hematological malignancies. For Oncology nurses and healthcare professionals, the findings underscore the importance of routinely assessing family intimacy and perceived social support as part of psychosocial screening. Early identification of caregivers with low family cohesion or inadequate social networks should prompt referral to structured interventions, such as family-based counseling, peer support groups, community linkage services and training on emotion regulation and problem solving strategies.\u003c/p\u003e \u003cp\u003eIncorporating coping skills training into routine caregiver support programs such as cognitive behavioral therapy, acceptance and commitment therapy, or mindfulness-based stress reduction promote adaptive coping and alleviate psychological distress. Nurses are ideally positioned to deliver brief, structured training on emotion regulation, cognitive de-fusion, and problem-solving strategies, either individually or in group settings. Strengthening the caregiving environment through targeted education and psychological support could ultimately improve caregiver well-being and the quality of care delivered to children undergoing cancer treatment.\u003c/p\u003e \u003c/div\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eThis study contributes to the growing body of literature on psychosocial determinants of caregiver well-being by identifying key pathways through which family intimacy, social support, cognitive fusion and cognitive coping influence psychological adaptation in caregivers of children with hematological malignancies. Grounded in Social Cognitive Theory, the research employed a cross-sectional design and utilized SEM to extricate direct and indirect effects within this multifaceted framework. The findings demonstrate that supportive environmental factors enhance psychological adaptation by facilitating adaptive coping and reducing cognitive fusion.\u003c/p\u003e \u003cp\u003eNotably, social support indirectly promoted adaptation via positive coping, while family intimacy reduced maladaptive cognitive fusion, which was associated with better psychological outcomes. These findings highlight the importance of addressing both internal (cognitive strategies) and external (family and social) factors when designing interventions to support caregivers.\u003c/p\u003e \u003cp\u003eFor oncology nursing practice, integrating family-focused and coping-enhancement strategies into standard care can play a pivotal role in improving caregiver mental health and sustaining quality care for pediatric oncology patients.Future research should employ longitudinal designs and culturally sensitive tools to further explore these dynamics and test the effectiveness of multi component interventions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical approval\u003c/h2\u003e\n\u003cp\u003eEthical approval was obtained from the Life Science Ethics Committee of the University, approval number ZZUIRB2023-083.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eThis research received no external funding and was conducted as part of academic requirements.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAuthor Contribution Statement: Imtiaz Alam: Conceptualization, methodology, formal analysis, investigation, writing \u0026ndash; original draft, writing \u0026ndash; review and editing, project administration. Wang Mengjia: Data curation, investigation, validation, writing \u0026ndash; review and editing. Lei Jinjin: Software, formal analysis, visualization, writing \u0026ndash; review and editing. Fath Ur Rahman: Investigation, data curation, resources, writing \u0026ndash; review and editing. Lalit Dzifa Kodzo: Validation, formal analysis, writing \u0026ndash; review and editing. Zhang Ruixing: Conceptualization, supervision, methodology, writing \u0026ndash; review and editing, corresponding author. All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eAcknowledgmentWe would like to express our sincere gratitude to the dedicated nursing staff for their invaluable support and collaboration throughout the course of this study. Their professionalism, compassion, and commitment to patient care were instrumental in the successful execution of this research.We are also deeply thankful to all the research participants who generously gave their time and shared their experiences. Their willingness to contribute to this study is not only appreciated but essential to the advancement of healthcare knowledge and practice.This work would not have been possible without the contributions of each individual involved.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbuhammad, S., Hamaideh, S., Alhawatmeh, H., Almaaitah, R., Abu Ghosh, A., \u0026amp; Kiewan, R. (2025). Parental Quality of Life in Childhood Cancer: Social Support as a Predictor and the Limited Association of Father Involvement. \u003cem\u003eJournal of Multidisciplinary Healthcare\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e, 6607\u0026ndash;6616. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/JMDH.S541541\u003c/span\u003e\u003cspan address=\"10.2147/JMDH.S541541\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAduful, A. K., Boamah-Mensah, F., Nyarko, M. Y., Neizer, M. L., Brew, Y. N., Williams, L. A., Calys-Tagoe, B. N., Ackun, H. K., \u0026amp; Tette, E. M. (2023). Family needs assessment of patients with cerebral palsy attending two hospitals in Accra. \u003cem\u003eGhana Children\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(8), 1313.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlhajori, F. S., Makkawi, M. H., Alasmari, S. Z., Shaikh, A. A., \u0026amp; Baig, M. A. (2023). Estimating the prevalence of pediatric hematological malignancies in Al-Madinah Al-Munawwarah, Saudi Arabia. \u003cem\u003eSaudi Medical Journal\u003c/em\u003e, \u003cem\u003e44\u003c/em\u003e(5), 504.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlon, R. (2019). Social support and post-crisis growth among mothers of children with autism spectrum disorder and mothers of children with down syndrome. \u003cem\u003eResearch in Developmental Disabilities\u003c/em\u003e, \u003cem\u003e90\u003c/em\u003e, 22\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAvsec, A., Eisenbeck, N., Carreno, D. F., Kocjan, G. Z., \u0026amp; Kavčič, T. (2022). Coping styles mediate the association between psychological inflexibility and psychological functioning during the COVID-19 pandemic: A crucial role of meaning-centered coping. \u003cem\u003eJournal of Contextual Behavioral Science\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e, 201\u0026ndash;209.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBandura, A. (2001). Social cognitive theory: An agentic perspective. \u003cem\u003eAnnual Review of Psychology\u003c/em\u003e, \u003cem\u003e52\u003c/em\u003e(1), 1\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarrera-Caballero, S., Romero-Moreno, R., Vara-Garc\u0026iacute;a, C., Olmos, R., M\u0026aacute;rquez-Gonz\u0026aacute;lez, M., \u0026amp; Losada-Baltar, A. (2022). Cognitive fusion and treatment response to depression in caregivers of relatives with dementia. \u003cem\u003eJournal of Contextual Behavioral Science\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e, 234\u0026ndash;240.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBekui, B. A., Ohene, L. A., Badzi, C., Ampomah, M. O., \u0026amp; Aziato, L. (2023). Physical and socioeconomic burden of caregiving on family caregivers of children with cancer at a tertiary Hospital in Ghana. \u003cem\u003eNursing Open\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(2), 915\u0026ndash;925.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBiesecker, B. B., Erby, L. H., Woolford, S., Adcock, J. Y., Cohen, J. S., Lamb, A., Lewis, K. V., Truitt, M., Turriff, A., \u0026amp; Reeve, B. B. (2013). Development and validation of the Psychological Adaptation Scale (PAS): Use in six studies of adaptation to a health condition or risk. \u003cem\u003ePatient Education and Counseling\u003c/em\u003e, \u003cem\u003e93\u003c/em\u003e(2), 248\u0026ndash;254.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBodenlos, J. S., Hawes, E. S., Burstein, S. M., \u0026amp; Arroyo, K. M. (2020). Association of cognitive fusion with domains of health. \u003cem\u003eJournal of Contextual Behavioral Science\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e, 9\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBondarchuk, O., Balakhtar, V., Pinchuk, N., Pustovalov, I., \u0026amp; Pavlenok, K. (2024). Coping with stressfull situations using coping strategies and their impact on mental health. \u003cem\u003eMultidisciplinary Reviews\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChhikara, B. S., \u0026amp; Parang, K. (2023). Global Cancer Statistics 2022: The trends projection analysis. \u003cem\u003eChemical Biology Letters\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(1), 451\u0026ndash;451.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChung, J. O. K., LI, W. H. C., Cheung, A. T., Ho, L. L. K., \u0026amp; Chan, G. C. F. (2022). \u003cem\u003eAssociation of resilience with psychological well-being and quality of life for parents of children with cancer\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeng, X., Lin, M., Zhang, L., Li, X., \u0026amp; Gao, Q. (2022). Relations between family cohesion and adolescent-parent\u0026rsquo;s neural synchrony in response to emotional stimulations. \u003cem\u003eBehavioral and Brain Functions\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(1), 11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12993-022-00197-1\u003c/span\u003e\u003cspan address=\"10.1186/s12993-022-00197-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErdmann, F., Frederiksen, L. E., Bonaventure, A., Mader, L., Hasle, H., Robison, L. L., \u0026amp; Winther, J. F. (2021). Childhood cancer: Survival, treatment modalities, late effects and improvements over time. \u003cem\u003eCancer Epidemiology\u003c/em\u003e, \u003cem\u003e71\u003c/em\u003e, 101733.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFairfax, A., Brehaut, J., Colman, I., Sikora, L., Kazakova, A., Chakraborty, P., Potter, B. K., \u0026amp; Canadian Inherited Metabolic Diseases Research Network. (2019). A systematic review of the association between coping strategies and quality of life among caregivers of children with chronic illness and/or disability. \u003cem\u003eBMC Pediatrics\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e, 1\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarc\u0026iacute;a-Carmona, M., Garc\u0026iacute;a‐Torres, F., Jacek Jabłoński, M., Gomez Solis, A., Ja\u0026eacute;n‐Moreno, M. J., Moriana, J. A., Moreno‐D\u0026iacute;az, M. J., \u0026amp; Aranda, E. (2021). The influence of family social support on quality of life of informal caregivers of cancer patients. \u003cem\u003eNursing Open\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(6), 3411\u0026ndash;3419.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarc\u0026iacute;a-Torres, F., Jacek Jabłoński, M., G\u0026oacute;mez Sol\u0026iacute;s, \u0026Aacute;., Moriana, J. A., Ja\u0026eacute;n‐Moreno, M. J., Moreno‐D\u0026iacute;az, M. J., \u0026amp; Aranda, E. (2020). Social support as predictor of anxiety and depression in cancer caregivers six months after cancer diagnosis: A longitudinal study. \u003cem\u003eJournal of Clinical Nursing\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(5\u0026ndash;6), 996\u0026ndash;1002.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGayatridevi, S. (2025). Acceptance and Commitment Therapy and Psychological Well-Being: A Narrative Review. \u003cem\u003eCureus\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGillanders, D. T., Bolderston, H., Bond, F. W., Dempster, M., Flaxman, P. E., Campbell, L., Kerr, S., Tansey, L., Noel, P., \u0026amp; Ferenbach, C. (2014). The development and initial validation of the cognitive fusion questionnaire. \u003cem\u003eBehavior Therapy\u003c/em\u003e, \u003cem\u003e45\u003c/em\u003e(1), 83\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGurtovenko, K., Fladeboe, K. M., Galtieri, L. R., King, K., Friedman, D., Compas, B., Breiger, D., Lengua, L., Keim, M., \u0026amp; Kawamura, J. (2021). Stress and psychological adjustment in caregivers of children with cancer. \u003cem\u003eHealth Psychology\u003c/em\u003e, \u003cem\u003e40\u003c/em\u003e(5), 295.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIrwanto, Ratwita, M., Prihaningtyas, R. A., \u0026amp; Mustakim, M. R. D. (2020). Impact of Caregiver\u0026rsquo;s Psychological Aspects towards Quality of Life of Children with Acute Lymphoblastic Leukemia (ALL). \u003cem\u003eAsian Pacific Journal of Cancer Prevention: APJCP\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(9), 2683\u0026ndash;2688. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.31557/APJCP.2020.21.9.2683\u003c/span\u003e\u003cspan address=\"10.31557/APJCP.2020.21.9.2683\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsmael, N., Jaber, A., Malkawi, S., Awady, A., S., \u0026amp; Ismael, T. (2024). Exploring coping strategies among caregivers of children who have survived paediatric cancer in Jordan. \u003cem\u003eBMJ Paediatrics Open\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(1), e002453. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjpo-2023-002453\u003c/span\u003e\u003cspan address=\"10.1136/bmjpo-2023-002453\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones, B., Currin-Mcculloch, J., Pelletier, W., Sardi-Brown, V., Brown, P., \u0026amp; Wiener, L. (2018). Psychosocial standards of care for children with cancer and their families: A national survey of pediatric oncology social workers. \u003cem\u003eSocial Work in Health Care\u003c/em\u003e, \u003cem\u003e57\u003c/em\u003e(4), 221\u0026ndash;249.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarimi Moghaddam, Z., Rostami, M., Zeraatchi, A., Mohammadi Bytamar, J., Saed, O., \u0026amp; Zenozian, S. (2023). Caregiving burden, depression, and anxiety among family caregivers of patients with cancer: An investigation of patient and caregiver factors. \u003cem\u003eFrontiers in Psychology\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e, 1059605. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyg.2023.1059605\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2023.1059605\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatz, L. F., Fladeboe, K., King, K., Gurtovenko, K., Kawamura, J., Friedman, D., Compas, B., Gruhn, M., Breiger, D., \u0026amp; Lengua, L. (2018). Trajectories of child and caregiver psychological adjustment in families of children with cancer. \u003cem\u003eHealth Psychology\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e(8), 725.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKurz, H., Paul, V., Nasse, M. L., Krauth, K. A., Kandels, D., Rutkowski, S., Escherich, G., Inhestern, L., \u0026amp; Bergelt, C. (2025). Beyond Treatment: Prevalence, Predictors, and Changes in Anxiety and Depression Among Parents of Childhood Cancer Survivors. \u003cem\u003ePsycho-Oncology\u003c/em\u003e, \u003cem\u003e34\u003c/em\u003e(3), e70115. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/pon.70115\u003c/span\u003e\u003cspan address=\"10.1002/pon.70115\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLei, X., \u0026amp; Kantor, J. (2022). Social support and family quality of life in Chinese families of children with autism spectrum disorder: The mediating role of family cohesion and adaptability. \u003cem\u003eInternational Journal of Developmental Disabilities\u003c/em\u003e, \u003cem\u003e68\u003c/em\u003e(4), 454\u0026ndash;461.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi, Z., Zheng, R., Xu, X., Liu, Y., Jia, C., Feng, G., Zhang, X., Li, X., Bai, G., \u0026amp; Ni, X. (2021). Pediatric cancer surveillance in China: A hospital-based introduction. \u003cem\u003ePediatric Investigation\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(2), 81\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ped4.12279\u003c/span\u003e\u003cspan address=\"10.1002/ped4.12279\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu, Y., Ma, L., Mo, L., Shen, X., \u0026amp; Zhong, D. (2022). The demands of caregivers of children with acute lymphoblastic leukaemia in different therapy stages and the exploration of possible interventions: A longitudinal investigation survey at a Tertiary Medical Institution. \u003cem\u003eNursing Open\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(4), 2273\u0026ndash;2281. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/nop2.1481\u003c/span\u003e\u003cspan address=\"10.1002/nop2.1481\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLong, N. X., Ngoc, N. B., Phung, T. T., Linh, D. T. D., Anh, T. N., Hung, N. V., Thang, N. T., Lan, N. T. M., Trang, V. T., Thuong, N. H., Hieu, N. V., Minh, H. V., Long, N. X., Ngoc, N. B., Phung, T. T., Linh, D. T. D., Anh, T. N., Hung, N. V., Thang, N. T., \u0026amp; Minh, H. V. (2021). Coping strategies and social support among caregivers of patients with cancer: A cross-sectional study in Vietnam. \u003cem\u003eAIMS Public Health\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3934/publichealth.2021001\u003c/span\u003e\u003cspan address=\"10.3934/publichealth.2021001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Article publichealth-08-01-001.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo, Y. H., Xia, W., He, X. L., Zhang, J. P., \u0026amp; Li, H. C. W. (2021). Psychological interventions for enhancing resilience in parents of children with cancer: A systematic review and meta-analysis. \u003cem\u003eSupportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(11), 7101\u0026ndash;7110. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00520-021-06344-0\u003c/span\u003e\u003cspan address=\"10.1007/s00520-021-06344-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMao, P., Yang, X., Tan, M., Luo, A., Jiang, S., Guo, J., Su, J., Wiley, J., Xu, P., \u0026amp; Chen, J. L. (2022). The roles of parental absence, life skills and personality traits in mental health status among adolescents in rural China. \u003cem\u003eJournal of Pediatric Nursing\u003c/em\u003e, \u003cem\u003e64\u003c/em\u003e, e15\u0026ndash;e23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarrakchi, A., Chakit, M., Elmorabit, N., Kababri, M. E., Hessni, A. E., \u0026amp; Mesfioui, A. (2024). Psychological distress and coping strategies in parents of children receiving cancer therapy in Morocco \u0026ndash; a correlational study. \u003cem\u003eContemporary Oncology\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(3), 260\u0026ndash;266. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5114/wo.2024.144134\u003c/span\u003e\u003cspan address=\"10.5114/wo.2024.144134\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin, C. A., Rivera, D. E., Hekler, E. B., Riley, W. T., Buman, M. P., Adams, M. A., \u0026amp; Magann, A. B. (2018). Development of a control-oriented model of social cognitive theory for optimized mHealth behavioral interventions. \u003cem\u003eIEEE Transactions on Control Systems Technology\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(2), 331\u0026ndash;346.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMolzon, E. S., Mullins, L. L., Cushing, C. C., Chaney, J. M., McNall, R., \u0026amp; Mayes, S. (2018). The relationship between barriers to care, caregiver distress, and child health-related quality of life in caregivers of children with cancer: A structural equation modeling approach. \u003cem\u003eChildren\u0026rsquo;s Health Care\u003c/em\u003e, \u003cem\u003e47\u003c/em\u003e(1), 1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOh, S. J., Min, H., Choi, S., Hwang, H., \u0026amp; Kim, S. (2024). Experiences of Pediatric Palliative Care Among Bereaved Parents Who Lost a Child With Leukemia in South Korea. \u003cem\u003eJournal of Hospice \u0026amp; Palliative Nursing\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e(2), E74\u0026ndash;E82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlson, D. H., Sprenkle, D. H., \u0026amp; Russell, C. S. (1979). Circumplex model of marital and family systems: I. Cohesion and adaptability dimensions, family types, and clinical applications. \u003cem\u003eFamily Process\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(1), 3\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOshio, T., \u0026amp; Kan, M. (2019). Does social participation accelerate psychological adaptation to health shocks? Evidence from a national longitudinal survey in Japan. \u003cem\u003eQuality of Life Research\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e, 2125\u0026ndash;2133.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrates, P. E. G., Correa-J\u0026uacute;nior, A. J. S., Russo, T. M. da, Paraizo-Horvath, S., Teles, C. M. S., A. A., \u0026amp; Sonobe, H. M. (2024). Effectiveness of Family Coping Interventions in Improving Problem-Solving Skills in the Care of Children and Adolescent Cancer Survivors during and after Treatment: A Scoping Review. \u003cem\u003eNursing Reports\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(3), Article 3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/nursrep14030161\u003c/span\u003e\u003cspan address=\"10.3390/nursrep14030161\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRachmad, Y. E. (2022). \u003cem\u003ePsychological Adaptation Theory\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosenblat, J. D., \u0026amp; Li, M. (2021). Is ketamine a litmus test for capacity in assisted dying with depression? \u003cem\u003ePsycho-Oncology\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith, V. A., Lindquist, J., Miller, K. E., Shepherd-Banigan, M., Olsen, M., Campbell-Kotler, M., Henius, J., Kabat, M., \u0026amp; Van Houtven, C. H. (2019). Comprehensive family caregiver support and caregiver well-being: Preliminary evidence from a pre-post-survey study with a non-equivalent control group. \u003cem\u003eFrontiers in Public Health\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e, 122.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpaggiari, S., Calignano, G., Montanaro, M., Zaffani, S., Cecinati, V., Maffeis, C., \u0026amp; Di Riso, D. (2024). Examining Coping Strategies and Their Relation with Anxiety: Implications for Children Diagnosed with Cancer or Type 1 Diabetes and Their Caregivers. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(1), 77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan, R., Koh, S., Wong, M. E., Rui, M., \u0026amp; Shorey, S. (2020). Caregiver stress, coping strategies, and support needs of mothers caring for their children who are undergoing active cancer treatments. \u003cem\u003eClinical Nursing Research\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(7), 460\u0026ndash;468.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeo, I., Ng, S., Bundoc, F. G., Malhotra, C., Ozdemir, S., Steel, J. L., Finkelstein, E. A., \u0026amp; COMPASS Group. (2023). A prospective study of psychological distress among patients with advanced cancer and their caregivers. \u003cem\u003eCancer Medicine\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(8), 9956\u0026ndash;9965.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThompson, B., Tickle,Anna,and, \u0026amp; Dillon, G. (2021). Discovery awareness for staff supporting individuals with intellectual disabilities and challenging behaviour: Is it helpful and does it increase self-efficacy? \u003cem\u003eInternational Journal of Developmental Disabilities\u003c/em\u003e, \u003cem\u003e67\u003c/em\u003e(1), 44\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/20473869.2019.1599605\u003c/span\u003e\u003cspan address=\"10.1080/20473869.2019.1599605\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomson, M. D., Genderson, M. W., \u0026amp; Siminoff, L. A. (2022). Understanding cancer caregiver burden over time: Dyadic assessments of family cohesion, conflict and communication. \u003cem\u003ePatient Education and Counseling\u003c/em\u003e, \u003cem\u003e105\u003c/em\u003e(6), 1545\u0026ndash;1551.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Hout, E., Contreras, M., Mioshi, E., \u0026amp; Kishita, N. (2024). The role of experiential avoidance and cognitive fusion in the development of anxiety symptoms among family carers of people with dementia. \u003cem\u003eJournal of Behavioral and Cognitive Therapy\u003c/em\u003e, \u003cem\u003e34\u003c/em\u003e(1), 100482.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, C., Zhao, B., \u0026amp; Fang, P. (2024). Evaluation of the Effect of Social Care Collaboration on the Psychological State of the Parents of Children with Leukemia. \u003cem\u003eSAGE Open\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(3), 21582440241279568. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/21582440241279568\u003c/span\u003e\u003cspan address=\"10.1177/21582440241279568\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, Y., Yan, J., Chen, J., Wang, C., Lin, Y., Wu, Y., \u0026amp; Hu, R. (2021). Comparison of the anxiety, depression and their relationship to quality of life among adult acute leukemia patients and their family caregivers: A cross-sectional study in China. \u003cem\u003eQuality of Life Research\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e, 1891\u0026ndash;1901.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeigold, I. K., Weigold, A., Dykema, S. A., Drakeford, N. M., \u0026amp; Ethridge, E. T. (2024). Personal Growth Initiative: Relation to Coping Styles, Strategies, and Self-Efficacy. \u003cem\u003eJournal of Happiness Studies\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(6), 80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10902-024-00782-3\u003c/span\u003e\u003cspan address=\"10.1007/s10902-024-00782-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong, C. L., Choi, K. C., Lau, M. N., Lam, K. L., \u0026amp; So, W. K. W. (2020). Caregiving burden and sleep quality amongst family caregivers of Chinese male patients with advanced cancer: A cross-sectional study. \u003cem\u003eEuropean Journal of Oncology Nursing\u003c/em\u003e, \u003cem\u003e46\u003c/em\u003e, 101774.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiao, S. (2008). \u003cem\u003eClinical research design\u003c/em\u003e. Peking University Medical Publishing House.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXie, Y. (1998). Reliability and validity of the simplified coping style questionnaire. \u003cem\u003eChinese Journal of Clinical Psychology\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu, Q., Ma, J., Zhang, Y., \u0026amp; Gan, J. (2024). Family resilience and social support as mediators of caregiver burden and capacity in stroke caregivers: A cross-sectional study. \u003cem\u003eFrontiers in Psychology\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyg.2024.1435867\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2024.1435867\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang, W., Gao, Y. J., Ye, M. M., \u0026amp; Zhou, L. S. (2024). Post-stroke family resilience is correlated with family functioning among stroke survivors: The mediating role of patient\u0026rsquo;s coping and self-efficacy. \u003cem\u003eNursing Open\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(7), e2230. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/nop2.2230\u003c/span\u003e\u003cspan address=\"10.1002/nop2.2230\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang, W. C., Ji, Y., Li, X., Guo, H. N., \u0026amp; Zhu, Z. H. (2014). Reliability and validity of the Chinese version of the Cognitive Fusion Questionnaire. \u003cem\u003eChinese Mental Health Journal\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimet, G. D., Powell, S. S., Farley, G. K., Werkman, S., \u0026amp; Berkoff, K. A. (1990). Psychometric characteristics of the multidimensional scale of perceived social support. \u003cem\u003eJournal of Personality Assessment\u003c/em\u003e, \u003cem\u003e55\u003c/em\u003e(3\u0026ndash;4), 610\u0026ndash;617.\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":"[email protected]","identity":"journal-of-clinical-psychology-in-medical-settings","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jocs","sideBox":"Learn more about [Journal of Clinical Psychology in Medical Settings](http://link.springer.com/journal/10880)","snPcode":"10880","submissionUrl":"https://submission.springernature.com/new-submission/10880/3","title":"Journal of Clinical Psychology in Medical Settings","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Psychological adaptation, caregivers, hematological malignancies, family intimacy, social support, cognitive fusion, cognitive coping, structural equation modelling","lastPublishedDoi":"10.21203/rs.3.rs-9371422/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9371422/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCaregivers of children with hematological malignancies frequently face intense emotional and psychological challenges that impair their mental health, well-being, and caregiving ability. Understanding the interaction of factors influencing psychological adaptation is essential for designing targeted interventions. However, limited research has explored these dynamics in the contexts of pediatric cancer. The aim of this study is to investigate psychological adaptation in caregivers of children with hematological malignancies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional design was used with 214 primary caregiversrecruited from pediatric hematological oncology wards. Standardized scales measured psychological adaptation, family intimacy, social support, cognitive fusion and cognitive coping. Structural equation modeling (SEM) used to analyze the direct and indirect pathways among the variables.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFamily intimacy and social support were positively associated with psychological adaptation. Family intimacy was a significant negative predictor of cognitive fusion (β = \u0026minus;\u0026thinsp;0.167, p\u0026thinsp;=\u0026thinsp;0.029), which was inversely associated with psychological adaptation (β = \u0026minus;\u0026thinsp;0.239, p\u0026thinsp;=\u0026thinsp;0.001). Social support positively predicted the use of positive coping strategies (β\u0026thinsp;=\u0026thinsp;0.283, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), which in turn enhanced adaptation (β\u0026thinsp;=\u0026thinsp;0.387, p\u0026thinsp;=\u0026thinsp;0.001). Notably, indirect effects were observed for social support via positive coping (β\u0026thinsp;=\u0026thinsp;0.112, p\u0026thinsp;=\u0026thinsp;0.001), and family intimacy via cognitive fusion (β\u0026thinsp;=\u0026thinsp;0.035, p\u0026thinsp;=\u0026thinsp;0.057).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFamily intimacy and social support promote psychological adaptation primarily through their impact on cognitive fusion and cognitive coping. Positive coping plays a key mediating role which underscoring the importance of interventions that enhance psychological adaptation and caregiving ability of caregivers.\u003c/p\u003e","manuscriptTitle":"A Structural Equation Model of Psychological Adaptation in Caregivers of Children with Hematological Malignancies: The Role of Family Intimacy, Social Support, Cognitive Fusion and Coping","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-08 16:18:07","doi":"10.21203/rs.3.rs-9371422/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-28T15:22:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"193799945541661108689059453267432070094","date":"2026-04-27T11:21:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79430790486365732195246069202487230863","date":"2026-04-23T17:48:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-23T17:46:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-20T05:03:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-16T07:14:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Clinical Psychology in Medical Settings","date":"2026-04-09T17:22:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-clinical-psychology-in-medical-settings","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jocs","sideBox":"Learn more about [Journal of Clinical Psychology in Medical Settings](http://link.springer.com/journal/10880)","snPcode":"10880","submissionUrl":"https://submission.springernature.com/new-submission/10880/3","title":"Journal of Clinical Psychology in Medical Settings","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8384be5e-8528-449e-8779-d4b72a5d7ffe","owner":[],"postedDate":"May 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T16:18:08+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-08 16:18:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9371422","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9371422","identity":"rs-9371422","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}