Adolescents of parents with cancer:  A mediation-moderation analysis of the relationship between parental stress and psychological reactions in adolescents

Adolescents of parents with cancer: A mediation-moderation analysis of the relationship between parental stress and psychological reactions in adolescents | 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 Adolescents of parents with cancer: A mediation-moderation analysis of the relationship between parental stress and psychological reactions in adolescents Friedrich Balck, Anja Zimmermann, Stephanie Drössler This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7789985/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Objective: We examine the relationship between parental cancer burden and adolescent psychopathology. Several reviews of stress and negative and positive changes in adolescents are available. We review a model by Compas and Grant describing this relationship and ask about the influence of individual and family resources. Methods: Sixty-one parents with cancer and their children were interviewed 6-9 months after cancer diagnosis. For the ill parents, the Karnofsky index, distress, and psychological distress were measured. In the adolescents, distress, internalization and externalization, threat of the disease, and as moderators: Self-efficacy, Optimism, Coherence, and Family Adaptability and Cohesion were recorded. Moderation, mediation, and moderated mediation models were tested using Hayes Process Programs. Results: 55.2% of adolescents perceive their parents' illness as threatening. This assessment varies with age, intrusion, and social competence. There is no direct relationship between parental stress and adolescents' psychological responses. The adolescent's threat perception mediates the relationship. Optimism, self-efficacy and coherence, and family resources have no moderating influence. Only optimism and self-efficacy moderate the threat perception-adolescent psychological response relationship, i.e., moderated mediation is present here. Conclusions: Adolescents' threat perception, optimism, and self-efficacy are significant in the model. This can be used to plan interventions to improve resilience in adolescents. Cancer adolescents mediation-moderation analysis psychological stress perceived threat Figures Figure 1 Figure 2 Figure 3 1. Introduction Cancer is a stressful life event not only for patients but also for their family members. Some work with adolescents attempts to clarify how they are affected psychologically, behaviorally, and in quality of life (Visser et al., 2004 , 2005 ; Möller et al., 2014 ; Faccio et al., 2018 ; Hauken et al., 2017 ; Morris et al., 2019 ; Graungaard et al., 2019 ). One review (Walczak et al., 2017 ) reported both positive (8 studies) and negative psychological and behavioral changes (29 studies) in adolescents. However, the heterogeneity of results and study designs does not allow for robust conclusions (Faccio et al., 2018 ). The mixed picture may result from the influence of age, gender, adolescent coping behaviors, and family functioning. (Morris et al., 2019 ; Faccio et al., 2018 ). Most studies do not make explicit theoretical assumptions, as noted by (Romer et al., 2002 ), "Most quantitative studies do not refer to any theoretical context. This means that most authors relied on the implicit constructs of the questionnaires without explaining them" (p. 25 f.). Theory-based hypotheses about stress in children whose parents have cancer often refer to the transactional model. Lazarus & Folkman ( 1984 ) assume that the efficacy of a potential stressor, in this case, a parent's cancer, depends primarily on the child's appraisal processes, e.g., the threat of the disease (Compas et al., 1994 ; 1996; Grant et al., 2006 ) and not through the objective disease characteristics. The research group led by Compas and Grant presented a general conceptual model (Fig. 1 ) describing the relationship between stressors and psychopathological disorders in childhood and adolescence (Grant et al., 2003 ). Within the framework of this model, moderators can be understood as diathesis or protective factors since they represent existing characteristics (i.e., conditions already present before the stressful situation) that increase or reduce the probability of psychopathological harm caused by the stressor. Potential moderator variables include age, gender, social and family support, and person-specific attribution and coping styles (Grant et al., 2003 ; Grant et al., 2006 ). Our study aims to test this model with adolescent relatives. We operationalized the Grant et al. model in the following way (Fig. 2 ). The cancer of a parent is understood as a constant stressor in the sense of the definition proposed by Grant et al. ( 2003 ) for children and adolescents as "environmental events or chronic conditions that objectively threaten the physical and/or psychological health or well-being of individuals of a particular age in a particular society" (p. 449). Thus, the emphasis is on an event or condition external to the person that creates "objective stress" (Rudolph and Hammen, 1999 ). In addition to the functional impairment and the general stress due to the patient's illness, we consider the patient's psychological state to be a variable stressor, as it is an essential stress parameter, especially for family caregivers. Cognitive appraisal processes, such as the young person's perceived threat to the situation, are arranged as mediators between the stressor and possible stress reactions (Grant et al., 2006 ). In our model, moderator variables are the individual and family resources that can contribute to resilience, as well as the age and gender of the young people. 2. Aim of the study Using the theoretical model of Grant et al. ( 2003 ), we examine the direct relationships between stressors experienced by parents who have cancer (physical well-being, general stress, psychological well-being) and the psychological and psychosocial effects on adolescents. The outcome variables are adolescents' psychological distress, internalization, and externalization. In addition, we ask whether this direct relationship is mediated by the adolescent's perceived threat to the situation. We also ask whether individual resources of the adolescent, such as optimism and self-efficacy, or family resources (cohesion and adaptability) moderate the relationship. Alternatively, we check whether there is "moderated mediation" (Baron and Kenny, 1986 ), i.e., whether individual resources additionally influence the mediation due to the threat. 3. Design The study is cross-sectional with an interview of the affected parent and the affected adolescent by questionnaire six to nine months after diagnosis. 4. Inclusion and exclusion criteria - Patients with a tumor disease and at least one young person between 12 and 18 years in the household. - Patients with diagnosed cancer whose diagnoses date back six to nine months (criterion for avoiding "initial shock"). - Patients whose disease is in an early stage (as defined by the TNM criteria: T1-T3; N0-N2; M0). The following patients are not included in the study: - Patients with tumors in the head region (due to influence on stressor "psychological state of the sick parent") - Young people with physical and/or mental disabilities - Adolescents with a psychiatric diagnosis are diagnosed shortly before the onset of the first severe symptoms of the parent's tumor disease. 5. Implementation The patients come from the University Cancer Center (UCC), the Mamma Center, and the Clinic for Urology of the University Hospital Dresden and selected focal practices in Dresden. The screening and informed consent were also performed here. After the parents and the adolescent gave their consent, they were contacted and sent a questionnaire in a return envelope. Funding Declaration The study was funded by Deutsche Krebshilfe e.V. (funding number: 107517). Ethics Declaration The ethics committee of the Medical Faculty Dresden approved the study in accordance with the declaration of Helsinki. The informed consent to participate in the study was submitted in writing by the parents or legal guardians for children under the age of 16. 6. Methods 6.1 Measuring instruments Recording the burden on parents / independent variables The doctor recorded the illness-related physical condition of the sick parent using the Karnofsky Index. The ill parent also assessed his general stress on a stress thermometer with a scale: 0 = "lowest conceivable stress" to 10 = "highest conceivable stress." In addition, he assesses whether he has had problems on 34 yes/no questions (NCCN, 2008). These questions map the following aspects: practical (5 items), family (2), emotional (5), physical problems (20), or spiritual concerns (2). The total sum represents the total problem load. Psychological distress was also assessed with the Global Measure of Psychological Distress (GSI) of the Brief Symptom Inventory (BSI, Derogatis, 1977; German version: Franke, 2000). The reliability of the GSI is > .80 (Ulbrich, 2003). Psychological and psychosocial reactions of the adolescent The Impact of Event Scale (IES, Horowitz et al., 1979) measures the individual's handling of critical life events (Ferring and Filipp, 1994) with 16 questions. The anchoring is to the illness of the mother/father. The response scales ("not at all" = 0 to "often" = 5) are six-point. Eight items each belong to the "intrusion" and "avoidance" scales. Avoidance means extensive repression of the unpleasant contents of the experience. The internal consistency (Cronbach's alpha) for intrusion is between .83 and 87, for avoidance between .67 and .76. The sum of all items captures the total stress of the adolescent (alpha = 0.86 - 0.91). In this study, alpha = 0.85. Norms are not available; the results of Huizinga et al. (2005) serve as comparative data. There, children with a higher value than 26 were described as clinically conspicuously burdened. Youth Self-Report (YSR/11-18) questionnaire for adolescents (German: Döpfner, et al., 1994, 1998): This version belongs to the family of procedures around the Child Behaviour Checklist 4-18 (Achenbach, 1991). The questionnaire records social competencies and clinically relevant behavioral problems of the children/adolescents in the last six months. The questions have three gradations: not applicable, somewhat or sometimes applicable, and precisely or frequently applicable. With 119 items on eight factor-analytically determined syndrome scales, problematic behavior and individual symptoms, as well as socially desirable behavior, are asked: (1) social withdrawal, (2) physical complaints, (3) anxiety/depressiveness, (7) dissocial behavior and (8) aggressive behavior. The above YSR scales are combined into the secondary scales Internalisation and Externalisation. The German normalization is based on a representative sample of approx. 1800 children and adolescents. It is available for the competence and syndrome scales according to age and gender. Mediator variable: Threat of the disease The adolescents rated the threat of the parent's illness on a five-point scale from "not threatening/somewhat threatening/threatening/very threatening/does not apply." This procedure is chosen analogously to Huizinga et al. (2005). Moderator variables: Individual resources are operationalized as "self-efficacy expectancy", "optimistic attitude towards life" ("optimism/confidence"), "sense of coherence". Family resources are measured as cohesion and adaptability. The scale for measuring general self-efficacy expectancy (Schwarzer & Jerusalem, 1999; Schwarzer, 1993) is used. The questionnaire comprises ten items with a four-point scale (1 = does not apply - 4 = applies exactly). Reliabilities (Cronbach's α) of a student sample (N > 3000) ranged between α = 0.75 and α = 0.90. The reliability in our study is α = 0.89. Optimism is measured using a scale from the Bern questionnaire on the well-being of young people (Grob et al., 1991). The questionnaire (39 items) consists of six scales: positive attitude to life/optimism, awareness of problems, physical complaints and reactions, self-worth, depressive mood, and enjoyment of life. Analogous to other studies (Bettge & Ravens-Sieverer, 2003), only the Positive Life Attitude/Optimism scale is used. This contains eight items with the six levels 1 = wrong - 6 = is right. Reliabilities for the scale range from 0.65 to 0.73 (Grob et al., 1991). In our study Cronbach's α = 0.85. The sense of coherence is measured with the Children's Sense of Coherence Scale (C-SOC, Margalit, 1994; Silmilä, 2015, German: Kern, R., Rasky, E., Noack, R., 1995) with 16 items. Three items are added as distractors in the questionnaire. The measure consist of a Likert-type scale ranging from 1-4 points: 1 = never, 2 = some time, 3 = often, 4 = always. The 16 questions were summed up to form the scale "Coherence." The highest possible score is 64, and the lowest is 16. The scale includes all three original dimensions: comprehensibility (Co), manageability (Ma), and meaningfulness (Me). Family resources are assessed with the Family Adaptability and Cohesion Evaluation Scale - FACES III (Olson et al., 1987; German version: Hank et al., 1990) with 20 questions. The scales' cohesion and adaptability are formed. Cohesion measures the emotional bond between the family members and the extent of the autonomy of the persons in the family system. Adaptability measures the dependence of the family system on situational tasks and developmental conditions. The data on internal consistency and retest reliability is sufficient to be very good (Hank et al., 1990). Sociodemographic and medical data Sociodemographic variables of the adolescents and the patients, as well as medical parameters such as diagnosis, TNM stage, Karnofsky index, time of diagnosis, and characteristics of the previous form of treatment, are collected utilizing a questionnaire for patients and doctors. 6.2 Estimated sample The expected effect size can only be estimated based on relevant literature (Cohen, 1988). The correlations reported by Heiney et al. (1997) and Hoke (2001) between the psychological well-being of ill mothers and the anxiety or depressiveness of the children range between r = .28 and .31, while Compas et al. (1994) found no correlation. When calculating a multiple linear regression with an effect size of 0.30 at an alpha of 0.05 and a power of 0.80 with two predictors (stress, Karnofsky index), the sample size should be n = 36 (Bortz & Döring, 2003). 6.3 Description of the samples of young people and parents Sixty-one adolescents from 49 families with sick parents took part in the study. The young people were, on average, 14.28 years old (SD = 2.41). The youngest participants were 11 and the oldest 18 years old. Thirty-six of the respondents were girls (59%). These were no older than the 25 boys (MM = 14.75; SD = 2.27 vs. MJ = 13.60; SD = 2.48; F = 3.50; p = .07). The mean age of the ill parent was 45.7 years (SD = 5.37). Three persons had a lower secondary school leaving certificate, 23 had the Secondary school diploma, 14 had the UAS diploma, and 20 had High school graduation. In 49 families surveyed, the mother had cancer (80.3 %), and in 12 families, the father. Most parents lived in a partnership; 76.7% were married. Sixteen of the parents interviewed (34.8 %) were in employment, of which only two worked full time; 18 parents (39.1 %) were on sick leave, 6 (13.0 %) were receiving a disability pension, and the remaining 6 (13 .0 %) parents did not give any information about their professional status. The diagnosis had been made 15.95 months before the survey (range 1 - 84; parents' self-report). Even those parents who had received the diagnosis some time ago were suffering from the tumor disease or a relapse. The most common disease was breast cancer (52.5 % of the total sample, Tab. 1). 32 of the 49 women (65.3 %) had breast cancer. The over-representation of mothers with breast cancer has been observed in many studies (Krattenmacher et al., 2012) and must be taken into account when interpreting the results. The other cancers are listed in Table 1. The designation of the tumor localisations is based on the classification of the Robert Koch Institute (2012). 16.7% of patients needed care. Care was provided by an outpatient care service or within a clinic. 93.3% of patients were at home at the time of the survey. Table 1: Disease characteristics of the sick parent N % Sick parents mothers 49 80,3 father 12 19,7 Need for care yes 10 16,7 no 50 83,3 previous tumor disease yes 6 12,2 no 43 87,8 Type of disease (tumor localisation) oral cavity and pharynx 3 4,9 Stomach 3 4,9 Intestine 2 3,3 Lung 3 4,9 Malignant melanoma of the skin 2 3,3 Mammary gland of woman 32 52,2 Cervix 2 3,3 Ovaries 2 3,3 Morbus Hodgkin 2 3,3 Non-Hodgkin 4 6,6 Nervous system 2 3,3 Leukaemia 3 4,9 Treatments Chemotherapy yes 43 86,0 Surgery yes 40 80,0 Radiotherapy yes 30 60,0 6.4 Statistical evaluation Multiple linear regressions (SPSS 27) were calculated to test the correlations. In addition, the paths in the models by Hayes (2018) were tested and confirmed with the Sobel test (Chi-Q = 0.360; p = 0.55). The test of Breusch and Pagan (1979) tested the variance homogeneity (heteroskedasticity) of the residuals. In the case of heteroskedasticity of the residuals, we used the robust standard error type HC3 (Davidson & McKinnon, 1993) for the significance tests and confidence intervals. We tested the total, direct and indirect effects in the tested models (mediators, moderators) with the Process program by Hayes version 3.5 for SPSS (Baltes-Götz, 2020). To test the mediation hypothesis (H0: αβ = 0), the bootstrap method with 10000 bootstrap samples was used. Model 1 tested the moderator effects of the bilinear interaction model. Models 4 and 14 tested simple mediation and moderated mediation. Effect sizes were also determined with these programs. The bootstrap method was used as a significance test. 7. Results 7. 1 Functional limitation and the psychological state of the affected parent The functional limitation of the ill parent measured with the Karnofski index is 86.43 (SD = 17.26; n = 28). One-third of the patients experience severe distress. For each of the five sub-aspects (physical, practical, family, emotional and religious problems), more than 40% of the patients are severely distressed. On the distress thermometer (1 to 10), parents score a mean of 5.98 (SD = 2.15). 44% of the parents feel strongly burdened. The parent's mental state is shown on the nine BSI scales and the BSI total score (GSI). In addition to somatization (28.6%), anxiety (23.2%) and phobic fear (16.9%) stand out as highly conspicuous. In total, 57.6% of the GSI respondents have mild to severe psychological problems. The GSI mean is 0.74 (SD = 0.42), which corresponds to a sum-value of 39 (norm values Franke, 2000) and deviates significantly from the mean of the norm sample (p = 0.001). 7.2 Psychological and psychosocial reactions of the young people concerned The scores on the YSR scales: physical complaints, anxiety/depression, aggressive behavior, dissocial behavior, social withdrawal, and the two scales: Internalisation and Externalisation, are shown in Tab. 2. 8.3 % of the young people complain about physical complaints. 23.3 % are conspicuous in internalization. The specific psychological distress of the adolescents was measured by the IES total score in the coding and scaling according to Huizinga (2005), with the threshold values defined there (19: clinically elevated). According to this, 9 (14.8%) are mildly burdened, 29 (47.5%) moderately burdened and 23 (37.7%) severely burdened (M = 21.66; SD = 13.43). Mean stress is significantly higher in girls than in boys (M= 26.08 (SD= 12.73); 15.56 (12.23); p(t) = 0.002). The mean intrusion is 10.34 (SD = 7.42) and avoidance is 11.42 (SD = 8.17). Girls show more intrusion than boys (M= 13.44 (SD= 7.06); 5.88 (5.46); p(t) = 0.001). There is no gender difference in avoidance. Table 2: The mental state of the parent with the illness (BSI) and frequencies, percentages, means (M) and standard deviation (SD) of the adolescents on the YSR scales inconspicuous slightly conspicuous strongly conspicuous n BSI-scales: parent N % N % N % somatisation 18 36,7 17 34,7 14 28,6 49 obsessive-compulsive 37 72,5 9 17,6 5 9,8 51 social insecurity 46 76,7 13 21,7 1 1,7 60 depression 36 61,0 17 28,8 6 9,8 59 anxiousness 32 57,1 11 19,6 13 23,2 56 aggressiveness 28 47,5 22 37,3 9 15,3 59 phobic anxiety 42 71,2 7 11,9 10 16,9 59 paranoid thinking 49 83,1 7 11,9 3 5,1 59 psychoticism 39 66,1 17 28,8 3 5,1 59 GSI 25 42,4 24 40,7 10 16,9 59 YSR: adolescents M SD social withdrawal 53 88,3 5 8,3 2 3,3 3,27 2,46 physical complaints 51 85,0 4 6,7 5 8,3 3,42 2,73 anxious depressive 52 86,7 5 8,3 3 5,0 7,05 4,84 dissocial behavior 59 98,3 1 1,7 - 2,82 1,85 aggressive behavior 58 96,7 2 3,3 - 7,38 4,88 internalisation 34 56,7 12 20,0 14 23,3 13,10 8,15 externalisation 51 85,0 4 6,7 5 8,3 10,20 6,09 7.3 Threat How threatening do young people experience the illness of their parents? This question is answered on a scale from not threatening (1) to very threatening (4). The mean value is 2.69 (SD= 1.06). 55.2% of the adolescents perceive the illness of a parent as threatening (25.9%) or very threatening (29.3%). The threat assessment of girls and boys does not differ (MM = 2.91; DS = 0.95; MJ = 2.40; SD = 1.16: p(t) = 0.07). Age (beta = 0.41), intrusion (beta = 0.32) and social skills (beta = -0.22) (F = 8.50; p = 0.001; R2 = 0.33) covary with the adolescent's threat, but not avoidance. 7.4 Moderator variables: Self-efficacy, optimism, and sense of coherence The mean values and standard deviations of self-efficacy are (2,68/0,54; range: 1-4), optimism (4,45/ 0,66; 1-6), and sense of coherence (2,39/ 0,28; 1-4). The strong optimism is striking. 7.5 Relationship between parental stressors and adolescents' reactions Do the general stress and psychological state of the parent with the illness influence the psychological and psychosocial reactions (psychological state and behavior) of the young person? Medical characteristics of the parent with the disease and characteristics of the adolescent Medical characteristics such as a tumor, lymph node, metastasis classification, Karnofsky index, and previous tumor disease do not correlate with adolescent characteristics. Parental stressors and psychological reactions of the adolescent According to the model of Grant et al. (2003), the relationship between the stress of the ill parent (stress thermometer) and the psychopathology of the adolescents is mediated by the perceived threat of the illness and moderated by personal and family resources (Figure 2). The total, direct and indirect effect is given according to the process program in Table 3 Model 1. There is no direct effect (γ') of the general stress of the parent on the adolescent's IES. Significant effects are shown from the parent's general stress on the adolescent's threat perception (path a) and the threat perception of the adolescent's IES (path b). The estimated indirect effect of general stress on IES (X - M - Y) is αβ = -0.899 (Sd = 0.417). This effect is significant because the confidence interval does not include the value zero (BootLLCI: -1.619 and BootULCI: -0. 2719). The null hypothesis is thus rejected. A mediation of the "threat perception," as named in the model of Grant et al. (2003) as a psychological process, thus exists. The adolescent's characteristics are supposed to have a moderating effect. It was tested whether this applies to self-efficacy, an optimistic attitude toward life, a sense of coherence, and family resources (cohesion/adaptability). None of these characteristics have a moderating influence on the above relationship, as the interaction terms in the regression equations do not become significant. Age and gender also have no moderating effect on the correlation: general burden of the ill parent and IES of the adolescent. A second model with GSI (BSI) of the ill parent as the X variable, the adolescent's IES as the Y variable, and perceived threat (adolescent) as the mediator showed no significance for this mediator. The indirect effect was αβ = -0.014 (Sd: 0.038) with a confidence interval of -0.058 to 0.095, thus including the expected null value. The direct effect GSI (parent) on IES (adolescent) was -0.081 (Sd = 0.064) with t = -1.262; p = 0.212 not significant (Table 3 Model 2). In model 3, the Karnofsky Index as a marker of the ill parent - threat - stress load of the adolescent is also not a mediator. The direct effect is not significant. The indirect effect is also insignificant: the zero value is included in the confidence interval (-0.147 to 0.186) (Tab. 3: Model 3). The same models were tested with the outcome variables internalizing and externalizing. In both models, all indirect and direct paths are not significant. Table 3: Three models with the effect sizes, T-test or F-test and the confidence intervals Models effect se T / F p confidence interval lower -- upper limits 1 stress total .124 .885 0.14 .889 direct 1.02 .805 1.27 .209 indirect -.899 .415 -1.619 -.2719 R 2 .1932 149.93 F: 6.491 .003 2 GSI total -.067 .064 -1.05 .150 direct -.081 .064 -1.26 .106 indirect -.014 .038 -.058 .095 R 2 .433 .187 F:151.080 .001 3 Karnofsky total -.031 .158 -0.19 .847 direct -.063 .175 -0.36 .722 indirect .033 .080 -.147 .186 R 2 .012 1.180 F: 0.1916 .665 Models: 1: X = total stress (Load thermometer)/ Y = IES/ M = threat 2: X = BSI (GSI)/ Y = IES/ M = threat 3: X = Karnofsky Index/ Y = IES/ M = threat Based on the indirect mediation: stress/parent - threat/adolescent --- stress/adolescent (IES), Process Model 14 was used to test whether there is moderated mediation on the pathway threat - stress/adolescent (Figure 3). It is assumed that the path β is moderated by the young person's self-efficacy, optimism, or coherence, in the sense that the influence of the threat on the stress/adolescent is weakened. The effect is tested with the index of moderated mediation. It is significant for self-efficacy and optimism, respectively, as the zero values are outside the confidence intervals. Effect sizes are given for self-efficacy's 16th, 50th, and 84th percentiles. For low (2.20) and medium self-efficacy (2.74), there is a significant indirect effect, i.e., the influence of the threat on the adolescent's stress is significantly weakened (Figure 3). The Johnson-Neyman region indicates the significant range of the moderators. This ranges from the lowest to the value of 3.09 for self-efficacy and from the lowest to the value of 4.93 for optimism. The threat is also attenuated at low and medium optimism values. Coherence has no moderating influence in the mediation model. 8. Discussion This study examines the central question of how the burden of a parent who has cancer affects the adolescent in the family. To this end, 61 adolescents and their parents with cancer were interviewed. The variables studied were grouped according to the model of Grant et al. ( 2003 ). This assumes a direct effect of the parent's stress on the adolescent's well-being. This direct effect is mediated by the individual characteristics of the adolescent. In addition, individual and family resources may have a buffering effect on this relationship. As stressors of the ill parent, the physical and psychological condition and the general stress were surveyed. The adolescent threat assessment was chosen as an individual characteristic. The adolescent's stress was recorded with the IES. 55.2% of the adolescents experienced the illness of a parent as threatening. Girls and boys do not differ in this assessment. The experience of threat is stronger the older the adolescents and the lower their social skills. Adolescents report physical discomfort and strong internalizing, while their externalizing does not differ when compared with normative data. This confirms findings by Birenbaum et al. ( 1999 ) for internalizing and Birenbaum et al. ( 1999 ) and Visser et al. ( 2005 ) for externalizing in adolescents. In a study by Thastum et al. ( 2009 ) of 168 adolescents, however, no differences from the norm were found. 37.7% of adolescents felt a high level of distress. This level of strain affected significantly more adolescents than 29% in Huizinga et al. ( 2010 ) but less than 41% in Edwards et al. (2008). Overall distress and intrusion were stronger among girls than boys. A review of 23 papers by Osborn (2006) reported this result also. The improvement in academic performance in over 40% of adolescents could be interpreted to mean, "I don't want to cause additional worry for parents." This motive to lighten the burden on the family is also reflected in the increased assumption of domestic responsibilities. The heavy burden on adolescents is accompanied by a lower self-efficacy expectation and a lower number of friends. This combination of characteristics could increase their vulnerability to depressive moods. We were unable to confirm the direct effect of parental stressors on the adolescent postulated in Grant's model through path analyses. This is true for the parental stress characteristics: physical and psychological condition and general stress. As a model, a mediator model with the mediator "threat perception by the adolescent" is shown. Such an approach is also suggested by a model derived from the Family Ecology Framework (FEF) (Landi et al., 2021 ). The FEF assumes that parental illness indirectly affects adolescent and family functioning through individual-level and family-level mediators. In addition, these mediating pathways may be influenced by buffering mechanisms (e.g., psychological resources) (Pedersen & Revenson, 2005 ). Conclusions In the present study, path analyses confirmed mediating characteristics at the individual level but not at the family level (adaptability, cohesion). Buffering the threat assessment is the optimism and self-efficacy of the adolescent. Based on these two characteristics, a therapeutic intervention approach for the affected adolescents can be derived. This should be accompanied by child-friendly information about the parent's disorder, especially the diagnosis, planned treatments, and testing (Ellis et al., 2016 ). To improve self-efficacy, adolescents can be talked to about how best they can assist their parents through the cancer experience (Chowns, 2013 ). Limitations Our study is one of the few in which the adolescents themselves were interviewed. Critically, however, our results may be limited by the lack of a control group. Jeppesen et al. ( 2013 ), for example, showed that the problems studied in adolescents with a sick parent were also found in a control group. Declarations ● Abbreviations: Not applicable ● Ethics approval and consent to participate: The ethics committee of the Medical Faculty Dresden (Hospital Carl Gustav Carus - TU-Dresden; 48032008) approved the study in accordance with the declaration of Helsinki. The informed consent to participate in the study was submitted in writing by the parents or legal guardians for children under the age of 16. ● Consent for publication: Not applicable ● Availability of data and materials: The data in this study are available from the corresponding author upon request. ● Competing Interests: there are no conflicts of interest ● Funding: The study was funded by Deutsche Krebshilfe e.V. (funding number: 107517). ● Authors' contributions: F. B.: study design, methods, evaluation, writing the manuscript; A. Z.: control of data collection, basic evaluation; S. 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Krattenmacher, T., Kühne, F., Führer, D., Beierlein, V., Brähler, E., Resch, F., Klitzing, von, K., Flechtner, H.-H., Bergelt, C., Romer, G., & Möller, B. (2013). Coping skills and mental health status in adolescents when a parent has cancer: A multicenter and multi-perspective study. Journal of Psychosomatic Research 74, 252-259. doi:10.1016/j.jpsychores.2012.10.003 Landi, G., Pakenham, K.I., Benassi, M., Giovagnoli, S., Tossani, E., Grandi, S. (2021). A Model of the Effects of Parental Illness on Youth Adjustment and Family Functioning: The Moderating Effects of Psychological Flexibility on Youth Caregiving and Stress. International Journal of Environmental Research and Public Health 18, 1–16. doi:10.3390/ijerph18094902 Lazarus, R. & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer Margalit, M. (1994). How I Feel. Children's orientation scale. Unpublished paper. 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Scales for the assessment of teacher and pupil characteristics. Documentation of the psychometric procedures within the framework of the scientific monitoring of the pilot project Selbstwirksame Schulen. Institute of Psychology, Free University of Berlin, Berlin Similä, W. (2015). The children's orientation scale in health-promoting schools; Theoretical background, potential for action research, and validation of the salutogenic instrument The Children's Orientation scale (C-SOC). Master's thesis in health science. NTNU-Trondheim Thastum, M., Watson, M., Kienbacher, C., et al. (2009). Prevalence and predictors of emotional and behavioural functioning of children where a parent has cancer: a multinational study. Cancer, 115: 4030-4039å Ulbrich, C. (2003). BSI. In H. Berth & F. Balck, (Eds.), Psychological tests for medical professionals. Berlin: Springer Visser, A., Huizinga, G.A., van der Graaf, W.T., Hoekstra, H.J., & Hoekstra-Weebers, J.E. (2004). The impact of parental cancer on children and the family: a review of the literature. Cancer Treatment Reviews, 30, 683-694 Visser, A., Huizinga, G.A., Hoekstra, H.J., van der Graaf, W.T., Klip, E. C., Pras, E. , & Hoekstra-Weebers, J.E. (2005). Emotional and behavioural functioning of children of a parent diagnosed with cancer: a cross-informant perspective. Psycho-Oncology, 14, 746-758 Walczak, A., McDonald, F., Patterson, P., Dobinson, K., & Allison, K. (2017). How does parental cancer affect adolescent and young adult offspring? A systematic review of recent literature. Int J Nurs Stud 1-65. doi:10.1016/j.ijnurstu.2017.08.017 Additional Declarations No competing interests reported. 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09:58:30","extension":"html","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":147798,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7789985/v1/a5c8fdb8adc0873112400b3a.html"},{"id":96978203,"identity":"260e6b6b-d1c3-482a-b6a7-2c1f0288643a","added_by":"auto","created_at":"2025-11-28 08:52:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25648,"visible":true,"origin":"","legend":"\u003cp\u003eGeneral conceptual model of the role of stressors in the etiology of childhood and adolescent psychopathology. (Grant et al., 2003, p. 452)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7789985/v1/8fd7f3d85b609ea4e1fd0da2.png"},{"id":96978204,"identity":"9c9f3b90-4efc-4702-bc14-a1482b9a9ad0","added_by":"auto","created_at":"2025-11-28 08:52:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32702,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual model of the burden of adolescents of parents with cancer\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7789985/v1/62c29a06028464e9b86f399b.png"},{"id":96978205,"identity":"948ca543-f176-41e3-9815-4ec78a99576e","added_by":"auto","created_at":"2025-11-28 08:52:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":68363,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7789985/v1/a9a878accd485f4e36062cc3.png"},{"id":97248670,"identity":"2a06e03f-1525-4354-af49-f61f8572b395","added_by":"auto","created_at":"2025-12-02 13:05:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":894613,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7789985/v1/a6b61264-c67b-4312-b9d8-ae92c9377de0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adolescents of parents with cancer: A mediation-moderation analysis of the relationship between parental stress and psychological reactions in adolescents","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eCancer is a stressful life event not only for patients but also for their family members. Some work with adolescents attempts to clarify how they are affected psychologically, behaviorally, and in quality of life (Visser et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2004\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; M\u0026ouml;ller et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Faccio et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Hauken et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Morris et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Graungaard et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). One review (Walczak et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) reported both positive (8 studies) and negative psychological and behavioral changes (29 studies) in adolescents. However, the heterogeneity of results and study designs does not allow for robust conclusions (Faccio et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The mixed picture may result from the influence of age, gender, adolescent coping behaviors, and family functioning. (Morris et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Faccio et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMost studies do not make explicit theoretical assumptions, as noted by (Romer et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2002\u003c/span\u003e), \"Most quantitative studies do not refer to any theoretical context. This means that most authors relied on the implicit constructs of the questionnaires without explaining them\" (p. 25 f.). Theory-based hypotheses about stress in children whose parents have cancer often refer to the transactional model. Lazarus \u0026amp; Folkman (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e1984\u003c/span\u003e) assume that the efficacy of a potential stressor, in this case, a parent's cancer, depends primarily on the child's appraisal processes, e.g., the threat of the disease (Compas et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1994\u003c/span\u003e; 1996; Grant et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) and not through the objective disease characteristics.\u003c/p\u003e\u003cp\u003eThe research group led by Compas and Grant presented a general conceptual model (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) describing the relationship between stressors and psychopathological disorders in childhood and adolescence (Grant et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2003\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eWithin the framework of this model, moderators can be understood as diathesis or protective factors since they represent existing characteristics (i.e., conditions already present before the stressful situation) that increase or reduce the probability of psychopathological harm caused by the stressor. Potential moderator variables include age, gender, social and family support, and person-specific attribution and coping styles (Grant et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Grant et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Our study aims to test this model with adolescent relatives. We operationalized the Grant et al. model in the following way (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe cancer of a parent is understood as a constant stressor in the sense of the definition proposed by Grant et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) for children and adolescents as \"environmental events or chronic conditions that objectively threaten the physical and/or psychological health or well-being of individuals of a particular age in a particular society\" (p. 449). Thus, the emphasis is on an event or condition external to the person that creates \"objective stress\" (Rudolph and Hammen, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). In addition to the functional impairment and the general stress due to the patient's illness, we consider the patient's psychological state to be a variable stressor, as it is an essential stress parameter, especially for family caregivers.\u003c/p\u003e\u003cp\u003eCognitive appraisal processes, such as the young person's perceived threat to the situation, are arranged as mediators between the stressor and possible stress reactions (Grant et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn our model, moderator variables are the individual and family resources that can contribute to resilience, as well as the age and gender of the young people.\u003c/p\u003e"},{"header":"2. Aim of the study","content":"\u003cp\u003eUsing the theoretical model of Grant et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2003\u003c/span\u003e), we examine the direct relationships between stressors experienced by parents who have cancer (physical well-being, general stress, psychological well-being) and the psychological and psychosocial effects on adolescents. The outcome variables are adolescents' psychological distress, internalization, and externalization.\u003c/p\u003e\u003cp\u003eIn addition, we ask whether this direct relationship is mediated by the adolescent's perceived threat to the situation. We also ask whether individual resources of the adolescent, such as optimism and self-efficacy, or family resources (cohesion and adaptability) moderate the relationship. Alternatively, we check whether there is \"moderated mediation\" (Baron and Kenny, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e1986\u003c/span\u003e), i.e., whether individual resources additionally influence the mediation due to the threat.\u003c/p\u003e"},{"header":"3. Design","content":"\u003cp\u003eThe study is cross-sectional with an interview of the affected parent and the affected adolescent by questionnaire six to nine months after diagnosis.\u003c/p\u003e"},{"header":"4. Inclusion and exclusion criteria","content":"\u003cp\u003e- Patients with a tumor disease and at least one young person between 12 and 18 years in the household.\u003c/p\u003e\n\u003cp\u003e- Patients with diagnosed cancer whose diagnoses date back six to nine months (criterion for avoiding \"initial shock\").\u003c/p\u003e\n\u003cp\u003e- Patients whose disease is in an early stage (as defined by the TNM criteria: T1-T3; N0-N2; M0).\u003c/p\u003e\n\u003cp\u003eThe following patients are not included in the study:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;- Patients with tumors in the head region (due to influence on stressor \"psychological state of the sick parent\")\u003c/p\u003e\n\u003cp\u003e- Young people with physical and/or mental disabilities\u003c/p\u003e\n\u003cp\u003e- Adolescents with a psychiatric diagnosis are diagnosed shortly before the onset of the first severe symptoms of the parent's tumor disease.\u003c/p\u003e"},{"header":"5. Implementation ","content":"\u003cp\u003eThe patients come from the University Cancer Center (UCC), the Mamma Center, and the Clinic for Urology of the University Hospital Dresden and selected focal practices in Dresden. The screening and informed consent were also performed here. After the parents and the adolescent gave their consent, they were contacted and sent a questionnaire in a return envelope.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding Declaration\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by Deutsche Krebshilfe e.V. (funding number: 107517).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics Declaration\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe ethics committee of the Medical Faculty Dresden approved the study in accordance with the declaration of Helsinki. The informed consent to participate in the study was submitted in writing by the parents or legal guardians for children under the age of 16.\u003c/p\u003e"},{"header":"6. Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e6.1\u003c/em\u003e\u003c/strong\u003e \u003cstrong\u003e\u003cem\u003eMeasuring instruments\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRecording the burden on parents / independent variables\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe doctor recorded the illness-related physical condition of the sick parent using the Karnofsky Index. The ill parent also assessed his general stress on a stress thermometer with a scale: 0 = \u0026quot;lowest conceivable stress\u0026quot; to 10 = \u0026quot;highest conceivable stress.\u0026quot; In addition, he assesses whether he has had problems on 34 yes/no questions (NCCN, 2008). These questions map the following aspects: practical (5 items), family (2), emotional (5), physical problems (20), or spiritual concerns (2). The total sum represents the total problem load. Psychological distress was also assessed with the Global Measure of Psychological Distress (GSI) of the Brief Symptom Inventory (BSI, Derogatis, 1977; German version: Franke, 2000). The reliability of the GSI is \u0026gt; .80 (Ulbrich, 2003).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePsychological and psychosocial reactions of the adolescent\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Impact of Event Scale (IES, Horowitz et al., 1979) measures the individual\u0026apos;s handling of critical life events (Ferring and Filipp, 1994) with 16 questions. The anchoring is to the illness of the mother/father. The response scales (\u0026quot;not at all\u0026quot; = 0 to \u0026quot;often\u0026quot; = 5) are six-point. Eight items each belong to the \u0026quot;intrusion\u0026quot; and \u0026quot;avoidance\u0026quot; scales. Avoidance means extensive repression of the unpleasant contents of the experience. The internal consistency (Cronbach\u0026apos;s alpha) for intrusion is between .83 and 87, for avoidance between .67 and .76. The sum of all items captures the total stress of the adolescent (alpha = 0.86 - 0.91). In this study, alpha = 0.85. Norms are not available; the results of Huizinga et al. (2005) serve as comparative data. There, children with a higher value than 26 were described as clinically conspicuously burdened.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYouth Self-Report (YSR/11-18) questionnaire for adolescents (German: D\u0026ouml;pfner, et al., 1994, 1998): This version belongs to the family of procedures around the Child Behaviour Checklist 4-18 (Achenbach, 1991). The questionnaire records social competencies and clinically relevant behavioral problems of the children/adolescents in the last six months. The questions have three gradations: not applicable, somewhat or sometimes applicable, and precisely or frequently applicable. With 119 items on eight factor-analytically determined syndrome scales, problematic behavior and individual symptoms, as well as socially desirable behavior, are asked: (1) social withdrawal, (2) physical complaints, (3) anxiety/depressiveness, (7) dissocial behavior and (8) aggressive behavior. The above YSR scales are combined into the secondary scales Internalisation and Externalisation. The German normalization is based on a representative sample of approx. 1800 children and adolescents. It is available for the competence and syndrome scales according to age and gender.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMediator variable: Threat of the disease\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe adolescents rated the threat of the parent\u0026apos;s illness on a five-point scale from \u0026quot;not threatening/somewhat threatening/threatening/very threatening/does not apply.\u0026quot; This procedure is chosen analogously to Huizinga et al. (2005).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eModerator variables:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIndividual resources are operationalized as \u0026quot;self-efficacy expectancy\u0026quot;, \u0026quot;optimistic attitude towards life\u0026quot; (\u0026quot;optimism/confidence\u0026quot;), \u0026quot;sense of coherence\u0026quot;. Family resources are measured as cohesion and adaptability.\u003c/p\u003e\n\u003cp\u003eThe scale for measuring general self-efficacy expectancy (Schwarzer \u0026amp; Jerusalem, 1999; Schwarzer, 1993) is used. The questionnaire comprises ten items with a four-point scale (1 = does not apply - 4 = applies exactly). Reliabilities (Cronbach\u0026apos;s \u0026alpha;) of a student sample (N \u0026gt; 3000) ranged between \u0026alpha; = 0.75 and \u0026alpha; = 0.90. The reliability in our study is \u0026alpha; = 0.89.\u003c/p\u003e\n\u003cp\u003eOptimism is measured using a scale from the Bern questionnaire on the well-being of young people (Grob et al., 1991). The questionnaire (39 items) consists of six scales: positive attitude to life/optimism, awareness of problems, physical complaints and reactions, self-worth, depressive mood, and enjoyment of life. Analogous to other studies (Bettge \u0026amp; Ravens-Sieverer, 2003), only the Positive Life Attitude/Optimism scale is used. This contains eight items with the six levels 1 = wrong - 6 = is right. Reliabilities for the scale range from 0.65 to 0.73 (Grob et al., 1991). In our study Cronbach\u0026apos;s \u0026alpha; = 0.85.\u003c/p\u003e\n\u003cp\u003eThe sense of coherence is measured with the Children\u0026apos;s Sense of Coherence Scale (C-SOC, Margalit, 1994; Silmil\u0026auml;, 2015, German: Kern, R., Rasky, E., Noack, R., 1995) with 16 items. Three items are added as distractors in the questionnaire. The measure consist of a Likert-type scale ranging from 1-4 points: 1 = never, 2 = some time, 3 = often, 4 = always. The 16 questions were summed up to form the scale \u0026quot;Coherence.\u0026quot; The highest possible score is 64, and the lowest is 16. The scale includes all three original dimensions: comprehensibility (Co), manageability (Ma), and meaningfulness (Me).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFamily resources are assessed with the Family Adaptability and Cohesion Evaluation Scale - FACES III (Olson et al., 1987; German version: Hank et al., 1990) with 20 questions. The scales\u0026apos; cohesion and adaptability are formed. Cohesion measures the emotional bond between the family members and the extent of the autonomy of the persons in the family system. Adaptability measures the dependence of the family system on situational tasks and developmental conditions. The data on internal consistency and retest reliability is sufficient to be very good (Hank et al., 1990).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSociodemographic and medical data\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSociodemographic variables of the adolescents and the patients, as well as medical parameters such as diagnosis, TNM stage, Karnofsky index, time of diagnosis, and characteristics of the previous form of treatment, are collected utilizing a questionnaire for patients and doctors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e6.2 Estimated sample\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe expected effect size can only be estimated based on relevant literature (Cohen, 1988). The correlations reported by Heiney et al. (1997) and Hoke (2001) between the psychological well-being of ill mothers and the anxiety or depressiveness of the children range between r = .28 and .31, while Compas et al. (1994) found no correlation. When calculating a multiple linear regression with an effect size of 0.30 at an alpha of 0.05 and a power of 0.80 with two predictors (stress, Karnofsky index), the sample size should be n = 36 (Bortz \u0026amp; D\u0026ouml;ring, 2003).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e6.3 Description of the samples of young people and parents\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSixty-one adolescents from 49 families with sick parents took part in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe young people were, on average, 14.28 years old (SD = 2.41). The youngest participants were 11 and the oldest 18 years old. Thirty-six of the respondents were girls (59%). These were no older than the 25 boys (MM = 14.75; SD = 2.27 vs. MJ = 13.60; SD = 2.48; F = 3.50; p = .07).\u003c/p\u003e\n\u003cp\u003eThe mean age of the ill parent was 45.7 years (SD = 5.37). Three persons had a lower secondary school leaving certificate, 23 had the Secondary school diploma, 14 had the UAS diploma, and 20 had High school graduation.\u003c/p\u003e\n\u003cp\u003eIn 49 families surveyed, the mother had cancer (80.3 %), and in 12 families, the father. Most parents lived in a partnership; 76.7% were married. Sixteen of the parents interviewed (34.8 %) were in employment, of which only two worked full time; 18 parents (39.1 %) were on sick leave, 6 (13.0 %) were receiving a disability pension, and the remaining 6 (13 .0 %) parents did not give any information about their professional status.\u003c/p\u003e\n\u003cp\u003eThe diagnosis had been made 15.95 months before the survey (range 1 - 84; parents\u0026apos; self-report). Even those parents who had received the diagnosis some time ago were suffering from the tumor disease or a relapse. The most common disease was breast cancer (52.5 % of the total sample, Tab. 1). 32 of the 49 women (65.3 %) had breast cancer. The over-representation of mothers with breast cancer has been observed in many studies (Krattenmacher et al., 2012) and must be taken into account when interpreting the results. The other cancers are listed in Table 1. The designation of the tumor localisations is based on the classification of the Robert Koch Institute (2012).\u003c/p\u003e\n\u003cp\u003e16.7% of patients needed care. Care was provided by an outpatient care service or within a clinic. 93.3% of patients were at home at the time of the survey.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: Disease characteristics of the sick parent\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"344\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eSick parents \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003emothers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e80,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003efather\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e19,7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eNeed for care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e16,7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e83,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eprevious tumor disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e12,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e87,8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eType of disease\u003c/p\u003e\n \u003cp\u003e(tumor localisation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eoral cavity and pharynx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e4,9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eStomach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e4,9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eIntestine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eLung\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e4,9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eMalignant melanoma of the skin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eMammary gland of woman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e52,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eCervix\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eOvaries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eMorbus Hodgkin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eNon-Hodgkin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e6,6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eNervous system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eLeukaemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e4,9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eTreatments \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eChemotherapy yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e86,0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eSurgery yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e80,0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eRadiotherapy yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e60,0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e6.4 Statistical evaluation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMultiple linear regressions (SPSS 27) were calculated to test the correlations. In addition, the paths in the models by Hayes (2018) were tested and confirmed with the Sobel test (Chi-Q = 0.360; p = 0.55). The test of Breusch and Pagan (1979) tested the variance homogeneity (heteroskedasticity) of the residuals. In the case of heteroskedasticity of the residuals, we used the robust standard error type HC3 (Davidson \u0026amp; McKinnon, 1993) for the significance tests and confidence intervals. We tested the total, direct and indirect effects in the tested models (mediators, moderators) with the Process program by Hayes version 3.5 for SPSS (Baltes-G\u0026ouml;tz, 2020). To test the mediation hypothesis (H0: \u0026alpha;\u0026beta; = 0), the bootstrap method with 10000 bootstrap samples was used. Model 1 tested the moderator effects of the bilinear interaction model. Models 4 and 14 tested simple mediation and moderated mediation. Effect sizes were also determined with these programs. The bootstrap method was used as a significance test.\u0026nbsp;\u003c/p\u003e"},{"header":"7. Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e7. 1 Functional limitation and the psychological state of the affected parent\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe functional limitation of the ill parent measured with the Karnofski index is 86.43 (SD = 17.26; n = 28).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne-third of the patients experience severe distress. For each of the five sub-aspects (physical, practical, family, emotional and religious problems), more than 40% of the patients are severely distressed. On the distress thermometer (1 to 10), parents score a mean of 5.98 (SD = 2.15). 44% of the parents feel strongly burdened.\u003c/p\u003e\n\u003cp\u003eThe parent\u0026apos;s mental state is shown on the nine BSI scales and the BSI total score (GSI). In addition to somatization (28.6%), anxiety (23.2%) and phobic fear (16.9%) stand out as highly conspicuous. In total, 57.6% of the GSI respondents have mild to severe psychological problems. The GSI mean is 0.74 (SD = 0.42), which corresponds to a sum-value of 39 (norm values Franke, 2000) and deviates significantly from the mean of the norm sample (p = 0.001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e7.2 Psychological and psychosocial reactions of the young people concerned\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe scores on the YSR scales: physical complaints, anxiety/depression, aggressive behavior, dissocial behavior, social withdrawal, and the two scales: \u0026nbsp;Internalisation and Externalisation, are shown in Tab. 2. 8.3 % of the young people complain about physical complaints. 23.3 % are conspicuous in internalization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe specific psychological distress of the adolescents was measured by the IES total score in the coding and scaling according to Huizinga (2005), with the threshold values defined there (\u0026lt;8.6: no/low, 9-19: at risk, \u0026gt;19: clinically elevated). According to this, 9 (14.8%) are mildly burdened, 29 (47.5%) moderately burdened and 23 (37.7%) severely burdened (M = 21.66; SD = 13.43). Mean stress is significantly higher in girls than in boys (M= 26.08 (SD= 12.73); 15.56 (12.23); p(t) = 0.002). The mean intrusion is 10.34 (SD = 7.42) and avoidance is 11.42 (SD = 8.17). Girls show more intrusion than boys (M= 13.44 (SD= 7.06); 5.88 (5.46); p(t) = 0.001). There is no gender difference in avoidance.\u003c/p\u003e\n\u003cp\u003eTable 2: The mental state of the parent with the illness (BSI) and frequencies, percentages, means (M) and standard deviation (SD) of the adolescents on the YSR scales\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003einconspicuous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eslightly conspicuous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003estrongly conspicuous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eBSI-scales: \u0026nbsp; parent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eN \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eN \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eN \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003esomatisation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e18 \u0026nbsp; \u0026nbsp; \u0026nbsp;36,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e17 \u0026nbsp; \u0026nbsp; \u0026nbsp;34,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e14 \u0026nbsp; \u0026nbsp; \u0026nbsp;28,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eobsessive-compulsive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e37 \u0026nbsp; \u0026nbsp; \u0026nbsp;72,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e9 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;17,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e5 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;9,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003esocial insecurity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e46 \u0026nbsp; \u0026nbsp; \u0026nbsp;76,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e13 \u0026nbsp; \u0026nbsp; \u0026nbsp;21,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;1,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003edepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e36 \u0026nbsp; \u0026nbsp; \u0026nbsp;61,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e17 \u0026nbsp; \u0026nbsp; \u0026nbsp;28,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e6 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;9,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eanxiousness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e32 \u0026nbsp; \u0026nbsp; \u0026nbsp;57,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e11 \u0026nbsp; \u0026nbsp; \u0026nbsp;19,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e13 \u0026nbsp; \u0026nbsp; \u0026nbsp;23,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eaggressiveness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e28 \u0026nbsp; \u0026nbsp; \u0026nbsp;47,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e22 \u0026nbsp; \u0026nbsp; \u0026nbsp;37,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e9 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;15,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ephobic anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e42 \u0026nbsp; \u0026nbsp; \u0026nbsp;71,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e7 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;11,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e10 \u0026nbsp; \u0026nbsp; \u0026nbsp;16,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eparanoid thinking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e49 \u0026nbsp; \u0026nbsp; \u0026nbsp;83,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e7 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;11,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;5,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003epsychoticism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e39 \u0026nbsp; \u0026nbsp; \u0026nbsp;66,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e17 \u0026nbsp; \u0026nbsp; \u0026nbsp;28,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;5,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e25 \u0026nbsp; \u0026nbsp; \u0026nbsp;42,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e24 \u0026nbsp; \u0026nbsp; \u0026nbsp;40,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e10 \u0026nbsp; \u0026nbsp; \u0026nbsp;16,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYSR: \u0026nbsp;adolescents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eM \u0026nbsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003esocial withdrawal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e53 \u0026nbsp; 88,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e5 \u0026nbsp; \u0026nbsp; 8,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 \u0026nbsp; \u0026nbsp;3,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3,27 \u0026nbsp; \u0026nbsp; \u0026nbsp;2,46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ephysical complaints\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e51 \u0026nbsp; 85,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4 \u0026nbsp; \u0026nbsp; 6,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e5 \u0026nbsp; \u0026nbsp;8,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3,42 \u0026nbsp; \u0026nbsp; \u0026nbsp;2,73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eanxious depressive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e52 \u0026nbsp; 86,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e5 \u0026nbsp; \u0026nbsp; 8,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3 \u0026nbsp; \u0026nbsp;5,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7,05 \u0026nbsp; \u0026nbsp; \u0026nbsp;4,84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003edissocial behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e59 \u0026nbsp; 98,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; 1,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2,82 \u0026nbsp; \u0026nbsp; \u0026nbsp;1,85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eaggressive behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e58 \u0026nbsp; 96,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 \u0026nbsp; \u0026nbsp; 3,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7,38 \u0026nbsp; \u0026nbsp; \u0026nbsp;4,88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003einternalisation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e34 \u0026nbsp; 56,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e12 \u0026nbsp;20,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e14 \u0026nbsp; 23,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e13,10 \u0026nbsp; \u0026nbsp;8,15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eexternalisation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e51 \u0026nbsp; 85,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4 \u0026nbsp; \u0026nbsp; 6,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;5 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;8,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e10,20 \u0026nbsp; \u0026nbsp;6,09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e7.3 Threat\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHow threatening do young people experience the illness of their parents? This question is answered on a scale from not threatening (1) to very threatening (4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe mean value is 2.69 (SD= 1.06). 55.2% of the adolescents perceive the illness of a parent as threatening (25.9%) or very threatening (29.3%). The threat assessment of girls and boys does not differ (MM = 2.91; DS = 0.95; MJ = 2.40; SD = 1.16: p(t) = 0.07). Age (beta = 0.41), intrusion (beta = 0.32) and social skills (beta = -0.22) (F = 8.50; p = 0.001; R2 = 0.33) covary with the adolescent\u0026apos;s threat, but not avoidance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e7.4 Moderator variables: Self-efficacy, optimism, and sense of coherence\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean values and standard deviations of self-efficacy are (2,68/0,54; range: 1-4), optimism (4,45/ 0,66; 1-6), and sense of coherence (2,39/ 0,28; 1-4). The strong optimism is striking.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e7.5 Relationship between parental stressors and adolescents\u0026apos; reactions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDo the general stress and psychological state of the parent with the illness influence the psychological and psychosocial reactions (psychological state and behavior) of the young person?\u003c/p\u003e\n\u003cp\u003eMedical characteristics of the parent with the disease and characteristics of the adolescent\u003c/p\u003e\n\u003cp\u003eMedical characteristics such as a tumor, lymph node, metastasis classification, Karnofsky index, and previous tumor disease do not correlate with adolescent characteristics.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParental stressors and psychological reactions of the adolescent\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the model of Grant et al. (2003), the relationship between the stress of the ill parent (stress thermometer) and the psychopathology of the adolescents is mediated by the perceived threat of the illness and moderated by personal and family resources (Figure 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe total, direct and indirect effect is given according to the process program in Table 3 Model 1. There is no direct effect (\u0026gamma;\u0026apos;) of the general stress of the parent on the adolescent\u0026apos;s IES. Significant effects are shown from the parent\u0026apos;s general stress on the adolescent\u0026apos;s threat perception (path a) and the threat perception of the adolescent\u0026apos;s IES (path b). The estimated indirect effect of general stress on IES (X - M - Y) is \u0026alpha;\u0026beta; = -0.899 (Sd = 0.417). This effect is significant because the confidence interval does not include the value zero (BootLLCI: -1.619 and BootULCI: -0. 2719). The null hypothesis is thus rejected. A mediation of the \u0026quot;threat perception,\u0026quot; as named in the model of Grant et al. (2003) as a psychological process, thus exists.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe adolescent\u0026apos;s characteristics are supposed to have a moderating effect. It was tested whether this applies to self-efficacy, an optimistic attitude toward life, a sense of coherence, and family resources (cohesion/adaptability). None of these characteristics have a moderating influence on the above relationship, as the interaction terms in the regression equations do not become significant. Age and gender also have no moderating effect on the correlation: general burden of the ill parent and IES of the adolescent.\u003c/p\u003e\n\u003cp\u003eA second model with GSI (BSI) of the ill parent as the X variable, the adolescent\u0026apos;s IES as the Y variable, and perceived threat (adolescent) as the mediator showed no significance for this mediator. The indirect effect was \u0026alpha;\u0026beta; = -0.014 (Sd: 0.038) with a confidence interval of -0.058 to 0.095, thus including the expected null value. The direct effect GSI (parent) on IES (adolescent) was -0.081 (Sd = 0.064) with t = -1.262; p = 0.212 not significant (Table 3 Model 2).\u003c/p\u003e\n\u003cp\u003eIn model 3, the Karnofsky Index as a marker of the ill parent - threat - stress load of the adolescent is also not a mediator. The direct effect is not significant. The indirect effect is also insignificant: the zero value is included in the confidence interval (-0.147 to 0.186) (Tab. 3: Model 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe same models were tested with the outcome variables internalizing and externalizing. In both models, all indirect and direct paths are not significant.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 3: Three models with the effect sizes, T-test or F-test and the confidence intervals\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eModels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eeffect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003ese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eT \u0026nbsp; \u0026nbsp;/ F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003econfidence\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003einterval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003elower \u0026nbsp; --\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eupper \u0026nbsp;limits\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1 stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003etotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;.124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e.885\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e.889\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003edirect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e.805\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e.209\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003eindirect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e-.899\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e.415\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;-1.619\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-.2719\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e.1932\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e149.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eF: 6.491\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2 GSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003etotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e-.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e-1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e.150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003edirect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e-.081\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e-1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e.106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003eindirect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e-.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e.038\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;-.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e.095\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;.433\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e.187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eF:151.080\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e3 Karnofsky\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003etotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e-.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e.158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e-0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e.847\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003edirect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e-.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e.175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e-0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e.722\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003eindirect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e.080\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e-.147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e.186\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e1.180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eF: \u0026nbsp;0.1916\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e.665\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eModels: \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1: X = total stress (Load thermometer)/ Y = IES/ M = threat\u003c/p\u003e\n\u003cp\u003e2: X = BSI (GSI)/ Y = IES/ M = threat\u003c/p\u003e\n\u003cp\u003e3: X = Karnofsky Index/ Y = IES/ M = threat \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on the indirect mediation: stress/parent - threat/adolescent --- stress/adolescent (IES), Process Model 14 was used to test whether there is moderated mediation on the pathway threat - stress/adolescent (Figure 3). It is assumed that the path \u0026beta; is moderated by the young person\u0026apos;s self-efficacy, optimism, or coherence, in the sense that the influence of the threat on the stress/adolescent is weakened. The effect is tested with the index of moderated mediation. It is significant for self-efficacy and optimism, respectively, as the zero values are outside the confidence intervals. Effect sizes are given for self-efficacy\u0026apos;s 16th, 50th, and 84th percentiles. For low (2.20) and medium self-efficacy (2.74), there is a significant indirect effect, i.e., the influence of the threat on the adolescent\u0026apos;s stress is significantly weakened (Figure 3). The Johnson-Neyman region indicates the significant range of the moderators. This ranges from the lowest to the value of 3.09 for self-efficacy and from the lowest to the value of 4.93 for optimism. The threat is also attenuated at low and medium optimism values. Coherence has no moderating influence in the mediation model. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"8. Discussion","content":"\u003cp\u003eThis study examines the central question of how the burden of a parent who has cancer affects the adolescent in the family. To this end, 61 adolescents and their parents with cancer were interviewed. The variables studied were grouped according to the model of Grant et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). This assumes a direct effect of the parent's stress on the adolescent's well-being. This direct effect is mediated by the individual characteristics of the adolescent. In addition, individual and family resources may have a buffering effect on this relationship. As stressors of the ill parent, the physical and psychological condition and the general stress were surveyed. The adolescent threat assessment was chosen as an individual characteristic. The adolescent's stress was recorded with the IES.\u003c/p\u003e\u003cp\u003e55.2% of the adolescents experienced the illness of a parent as threatening. Girls and boys do not differ in this assessment. The experience of threat is stronger the older the adolescents and the lower their social skills. Adolescents report physical discomfort and strong internalizing, while their externalizing does not differ when compared with normative data. This confirms findings by Birenbaum et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1999\u003c/span\u003e) for internalizing and Birenbaum et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1999\u003c/span\u003e) and Visser et al. (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) for externalizing in adolescents. In a study by Thastum et al. (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) of 168 adolescents, however, no differences from the norm were found. 37.7% of adolescents felt a high level of distress. This level of strain affected significantly more adolescents than 29% in Huizinga et al. (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) but less than 41% in Edwards et al. (2008). Overall distress and intrusion were stronger among girls than boys. A review of 23 papers by Osborn (2006) reported this result also. The improvement in academic performance in over 40% of adolescents could be interpreted to mean, \"I don't want to cause additional worry for parents.\" This motive to lighten the burden on the family is also reflected in the increased assumption of domestic responsibilities.\u003c/p\u003e\u003cp\u003eThe heavy burden on adolescents is accompanied by a lower self-efficacy expectation and a lower number of friends. This combination of characteristics could increase their vulnerability to depressive moods.\u003c/p\u003e\u003cp\u003eWe were unable to confirm the direct effect of parental stressors on the adolescent postulated in Grant's model through path analyses. This is true for the parental stress characteristics: physical and psychological condition and general stress.\u003c/p\u003e\u003cp\u003eAs a model, a mediator model with the mediator \"threat perception by the adolescent\" is shown. Such an approach is also suggested by a model derived from the Family Ecology Framework (FEF) (Landi et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The FEF assumes that parental illness indirectly affects adolescent and family functioning through individual-level and family-level mediators. In addition, these mediating pathways may be influenced by buffering mechanisms (e.g., psychological resources) (Pedersen \u0026amp; Revenson, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn the present study, path analyses confirmed mediating characteristics at the individual level but not at the family level (adaptability, cohesion). Buffering the threat assessment is the optimism and self-efficacy of the adolescent. Based on these two characteristics, a therapeutic intervention approach for the affected adolescents can be derived. This should be accompanied by child-friendly information about the parent's disorder, especially the diagnosis, planned treatments, and testing (Ellis et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). To improve self-efficacy, adolescents can be talked to about how best they can assist their parents through the cancer experience (Chowns, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eOur study is one of the few in which the adolescents themselves were interviewed. Critically, however, our results may be limited by the lack of a control group. Jeppesen et al. (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), for example, showed that the problems studied in adolescents with a sick parent were also found in a control group.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e● Abbreviations: Not applicable\u003cbr\u003e\u0026nbsp;● Ethics approval and consent to participate: The ethics committee of the Medical Faculty Dresden (Hospital Carl Gustav Carus - TU-Dresden; 48032008) approved the study in accordance with the declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eThe informed consent to participate in the study was submitted in writing by the parents or legal guardians for children under the age of 16.\u003cbr\u003e\u0026nbsp;● Consent for publication: Not applicable\u003cbr\u003e\u0026nbsp;● Availability of data and materials: The data in this study are available from the corresponding author upon request.\u003cbr\u003e\u0026nbsp;● Competing Interests: there are no conflicts of interest\u003cbr\u003e\u0026nbsp;● Funding: The study was funded by Deutsche Krebshilfe e.V. (funding number: 107517).\u0026nbsp;\u003cbr\u003e\u0026nbsp;● Authors' contributions:\u0026nbsp;F. B.: study design, methods, evaluation, writing the manuscript;\u003c/p\u003e\n\u003cp\u003eA. Z.: control of data collection, basic evaluation; \u0026nbsp;S. D.: data collection.\u003cbr\u003e\u0026nbsp;● Acknowledgements: Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAchenbach, T.M. (1991). Manual for the Child Behavior Checklist/2-3 and 1991 Profile, Burlington, V.T.: University of Vermont, Department of Psychiatry.\u003c/li\u003e\n \u003cli\u003eBaltes-G\u0026ouml;tz, B. (2020). Mediator and moderator analysis with SPSS and PROCESS. University of Trier, Centre for Information, Media and Communication Technology. Trier\u003c/li\u003e\n \u003cli\u003eBaron, R., \u0026amp; Kenny, D.A. (1986). The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. 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Balck, (Eds.), Psychological tests for medical professionals. Berlin: Springer\u003c/li\u003e\n \u003cli\u003eVisser, A., Huizinga, G.A., van der Graaf, W.T., Hoekstra, H.J., \u0026amp; Hoekstra-Weebers, J.E. (2004). The impact of parental cancer on children and the family: a review of the literature. Cancer Treatment Reviews, 30, 683-694\u003c/li\u003e\n \u003cli\u003eVisser, A., Huizinga, G.A., Hoekstra, H.J., van der Graaf, W.T., Klip, E. C., Pras, E. , \u0026amp; Hoekstra-Weebers, J.E. (2005). Emotional and behavioural functioning of children of a parent diagnosed with cancer: a cross-informant perspective. Psycho-Oncology, 14, 746-758\u003c/li\u003e\n \u003cli\u003eWalczak, A., McDonald, F., Patterson, P., Dobinson, K., \u0026amp; Allison, K. (2017). How does parental cancer affect adolescent and young adult offspring? A systematic review of recent literature. Int J Nurs Stud 1-65. doi:10.1016/j.ijnurstu.2017.08.017\u003c/li\u003e\n\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":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cancer, adolescents, mediation-moderation analysis, psychological stress, perceived threat","lastPublishedDoi":"10.21203/rs.3.rs-7789985/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7789985/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective: We examine the relationship between parental cancer burden and adolescent psychopathology. Several reviews of stress and negative and positive changes in adolescents are available. We review a model by Compas and Grant describing this relationship and ask about the influence of individual and family resources.\u003c/p\u003e\n\u003cp\u003eMethods: Sixty-one parents with cancer and their children were interviewed 6-9 months after cancer diagnosis. For the ill parents, the Karnofsky index, distress, and psychological distress were measured. In the adolescents, distress, internalization and externalization, threat of the disease, and as moderators: Self-efficacy, Optimism, Coherence, and Family Adaptability and Cohesion were recorded. Moderation, mediation, and moderated mediation models were tested using Hayes Process Programs.\u003c/p\u003e\n\u003cp\u003eResults: 55.2% of adolescents perceive their parents' illness as threatening. This assessment varies with age, intrusion, and social competence.\u003c/p\u003e\n\u003cp\u003eThere is no direct relationship between parental stress and adolescents' psychological responses. The adolescent's threat perception mediates the relationship. Optimism, self-efficacy and coherence, and family resources have no moderating influence. Only optimism and self-efficacy moderate the threat perception-adolescent psychological response relationship, i.e., moderated mediation is present here.\u003c/p\u003e\n\u003cp\u003eConclusions: Adolescents' threat perception, optimism, and self-efficacy are significant in the model. This can be used to plan interventions to improve resilience in adolescents.\u003c/p\u003e","manuscriptTitle":"Adolescents of parents with cancer: A mediation-moderation analysis of the relationship between parental stress and psychological reactions in adolescents","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-28 08:52:18","doi":"10.21203/rs.3.rs-7789985/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"15724974715275921639400308304510226347","date":"2025-11-27T13:47:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-19T12:14:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-24T10:20:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-24T10:09:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-24T09:02:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-10-24T08:58:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ff7d51d9-0280-4e46-9ff0-45e2c0972f20","owner":[],"postedDate":"November 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-28T08:52:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-28 08:52:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7789985","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7789985","identity":"rs-7789985","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}