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In a study of Darlington, Verhulst, De Winter, Ormel, Passchier, and. Hunfeld ... direction of longitudinal connections changes between the initial and final point.

INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 46(3) 243-270, 2013

PARENTING STRESS AND DIMENSIONS OF PARENTING BEHAVIOR: CROSS-SECTIONAL AND LONGITUDINAL LINKS WITH ADOLESCENTS’ SOMATIZATION

SOFIE ROUSSEAU, PHDC University of Leuven, Belgium HANS GRIETENS, PROF. DR. University of Groningen, The Netherlands JOHAN VANDERFAEILLIE, PROF. DR. University of Brussels, Belgium KAREL HOPPENBROUWERS, PROF. DR. University of Leuven, Belgium JAN ROELF WIERSEMA, PROF. DR. University of Ghent, Belgium KARLA VAN LEEUWEN, PROF. DR. University of Leuven, Belgium

ABSTRACT

Objective: This study explored direct and indirect associations between adolescents’ somatization, parenting stress, and three parenting dimensions (warmth, psychological control, and harsh punishment). First, the associations were explored cross-sectionally. Second, significant cross-sectional links were further examined longitudinally in order to decide upon temporality. Method: A total of 1499 adolescents and one of their parents (mostly the mother) agreed to participate. Questionnaires were administered when the child was respectively 12-13 (T1), 13-14 (T2), and 14-15 (T3) years old. Adolescents reported on their somatization, parents on their parenting 243 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.46.3.b http://baywood.com

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behavior and parenting stress. Results: Cross-sectionally, indirect links were found between all parenting dimensions and adolescents’ somatization, through parenting stress. Longitudinal examination revealed two key aspects. First, parenting stress significantly predicted somatization. Higher T1 parenting stress was predictive for higher T2 and T3 somatization. When controlled for T1 parenting stress, higher T2 parenting stress (or in other words increased parenting stress at T2) was predictive for lower T3 somatization. Second, parenting stress was found to significantly predict parenting behaviors. Higher T1 parenting stress was predictive for higher T2 and T3 harsh punishment but increased parenting stress at T2 was predictive for lower harsh punishment one year later. Higher T1 parenting stress significantly predicted higher T2 psychological control. Conclusions: Clinicians should be aware that parenting stress may be a risk factor for the development of somatization in early adolescence. However, in later adolescence, increased parenting stress might be protective. (Int’l. J. Psychiatry in Medicine 2013;46:243-270)

Key Words: adolescents’ somatization, parenting stress, parenting warmth/support, parenting harsh punishment, parenting psychological control, indirect associations, longitudinal study

INTRODUCTION About 15 to 25% of all adolescents report recurrent or continuous physical complaints, such as dizziness, headaches, or fatigue [1-3]. The majority of these complaints can be classified as physical functional complaints (PFC), or complaints for which no straightforward medical cause is found. The tendency to experience and report multiple PFC is named somatization [4]. The impact of somatization is substantial, both for the child (e.g., physical discomfort, restricted school attendance) and the child’s family (e.g., family stress) [5, 6]. Insight in the aetiology of somatisation is needed in order to provide efficient prevention and intervention. Earlier studies revealed that in the development and progression of PFC/somatization, psychological and/or social factors play a major role. However, knowledge on specific contributing features and processes is still in short supply [7]. One of the domains that remain understudied is that of family factors, in particular parenting aspects [8]. Parenting Aspects Parenting includes both behavioral and emotional aspects [9]. With regard to parenting behavior, researchers agree on a classification along two dimensions, namely warmth/support (parenting behaviors related to warmth, acceptance and understanding) and control (parenting behaviors undertaken to influence the child’s behaviors) [10-12]. The control dimension can be further divided into behavioral control (the child’s behavior is controlled directly, e.g., through

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punishment) and psychological control (the child’s behavior is controlled indirectly, through control of the child’s emotions and cognitions, e.g., guilt induction) [13, 14]. Parenting behavior dimensions can be further combined into parenting styles. The most frequently studied parenting styles are indulgent (low control, high warmth), authoritarian (high control, low warmth), authoritative (high control, high warmth) and uninvolved (low control, low warmth) [10, 11]. With regard to the emotional aspects of parenting, a frequently studied topic is parenting stress. Parenting stress is generally conceived as negative stress, occurring when a parent appraises parenting load higher than the ability to cope with it. Higher parenting stress is related to higher parenting stress-appraisal (i.e., the tendency to appraise parenting situations as stressful), and to the use of less adaptive coping mechanisms [15, 16]. Empirical Research on the Link between Parenting Aspects and Somatization Research on parenting styles has shown that higher parental over-protection is significantly related to higher PFC [17, 18]. Research on parenting behavior dimensions found that higher warmth is connected to lower amounts of PFC [19-21]. Studies on the link between other parenting behavior dimensions and PFC are scarce. Feldman et al. [19] assessed 2491 Puerto Rican families with children aged between 5 and 13 years, living in the Bronx, New York, and did not find a significant relation between parents’ self-reported coercive discipline (a specific type of negative behavioral control), and childrens’ physical health problems. Other studies showed that neglect and abuse were associated with increased amounts of PFC [22-24]. The few studies that have been conducted on emotional aspects of parenting found significant relations between parenting stress and adolescents’ PFC. Eccleston, Crombez, Scotford, Clinch, and Connell [25] revealed a positive relationship between parenting stress and chronicity of pain in adolescents (11-17 years). Cohen, Vowles, and Eccleston [26] found that parents of the most disabled chronic pain patients (10-18 years old) suffered from significantly higher amounts of parenting stress. Janssens et al. [18] revealed that T1 parenting stress significantly predicted T2 somatization in adolescents (10 to 12 years old). In a study of Darlington, Verhulst, De Winter, Ormel, Passchier, and Hunfeld [27], T1 parenting stress (when adolescents were 10-12 years old) significantly predicted the presence of T2 chronic pain in adolescents (when adolescents were 12-15 years old). Gaps in Empirical Research on the Link between Parenting Aspects and Somatization, and Hypotheses Despite the above listed research, several gaps remain regarding our understanding of the link between parenting aspects and somatization. A first gap is

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that concerning parenting behavior, previous studies have focused on parenting styles (i.e., over-protection). Although the assessment of parenting styles has its merits, also the predictive value of separate parenting behavior dimensions has to be considered. This is relevant for clinical practice, because it informs practitioners which aspects of parenting may be the target of interventions. In addition, the studies that did include parenting behavior dimensions have focused on warmth, leaving out other dimensions like psychological and behavioral control. However, based on research concerning internalizing problems in general, a connection between other parenting behavior dimensions and somatization can be expected. Bolger and Patterson [28] found a link between higher parenting maltreatment (among which extreme forms of parenting behavioral control, like harsh punishment) and increased internalizing symptoms in 9-13 years old. Further, also the connection between higher parenting psychological control and higher internalizing symptoms is well documented [13]. A second gap in previous research is that studies on the connection between parenting behavior dimensions and somatization have focused on cross-sectional links. Cross-sectional research definitely has its merits. Primary, analyses of cross-sectional data can guide hypotheses in longitudinal studies. Moreover, it is also useful to explore cross-sectional associations simultaneous with longitudinal ones. After all, it is possible that the time-interval between longitudinal measurement points is too large to identify longitudinal connections, or that the direction of longitudinal connections changes between the initial and final point of analyses [29]. In both cases, longitudinal relations will not be identified, and cross-sectional analyses can give an indication to include in further research smaller time-intervals. Further, it is possible that longitudinal relations do not exist. In that case, the results from cross-sectional analyses can inform clinicians about events which are likely to co-occur. Although the above shows that crosssectional research has its merits, it might over- or under-estimate longitudinal parameters [30]. Therefore, in order to obtain a full understanding of connections, cross-sectional research has to be supplemented with longitudinal analyses. However, associations between parenting behavior dimensions and somatization have not yet been investigated using a longitudinal design. Based on studies assessing the longitudinal connection between parenting behavior dimensions and adolescents’ internalizing problems in general, bidirectionality can be assumed. Previous research identified that higher T1 “negative parenting behavior” (less parenting warmth and higher harsh behavioral control and psychological control) predicted higher T2 internalizing problem behavior [13, 28]. However, also adolescents’ higher T1 internalizing problem behavior has been found to predict higher T2 “negative parenting behavior” [31, 32]. Related to the second gap is the fact that longitudinal research on parenting stress and somatization has focused on unidirectional connections, namely on the prediction of somatization by parenting stress [33, 34]. However, research

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on comparable outcome variables teaches us that a bidirectional relation can be assumed. In a meta-analyses of 29 studies, Pai and colleagues [35] found that adolescents’ T1 medical condition significantly predicted higher T2 parenting stress. A third gap is that research has examined direct links between parenting aspects and somatization, thereby disregarding possible indirect connections. The existence of indirect connections can be hypothesized, based on the assumption of a reciprocal link between parenting aspects. On the one hand, studies have revealed that higher T1 parenting stress leads to higher T2 “negative parenting behavior,” explained by the fact that stressed parents are more likely to adopt reactive adult-centered behaviors instead of active child-centered behaviors [15, 36, 37]. On the other hand, higher T1 “negative parenting behavior” predicts higher T2 “parenting stress”; for example, because parents who use “negative parenting behavior” may want to handle their children differently but lack knowledge of alternatives, a condition which induces stress [38]. The existence of a reciprocal link between parenting behavior and parenting stress makes it assumable that in addition to direct links between parenting aspects and somatization, also indirect ones (through other parenting aspects) exist. Current Study The current study addressed the above mentioned gaps concerning the connection between parenting aspects (warmth, harsh punishment, psychological control, and parenting stress) and somatization. More specific, the overall goal was to assess the following direct and indirect links: • the direct link between three parenting behavior dimensions (warmth, harsh punishment, psychological control) and adolescents’ somatization; • the direct link between parenting stress and adolescents’ somatization; • the indirect link between three parenting behavior dimensions (warmth, harsh punishment, psychological control) and adolescents’ somatization, through parenting stress; and • the indirect link between parenting stress and adolescents’ somatization, through three parenting behavior dimensions (warmth, harsh punishment, psychological control). In order to obtain the most complete view, both cross-sectional and longitudinal connections were contemplated. Following the guidelines of Maxwell and Cole [30, 39], first cross-sectional direct and indirect relations were considered. Based on the outcome of the cross-sectional analyses, hypotheses were made on longitudinal relationships, which were tested in longitudinal analyses. The guidelines of Maxwell and Cole [30, 39] were used to formulate longitudinal hypotheses. The scholars state that when significant direct cross-sectional connections are present, the longitudinal link can be forward (the parenting

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variable predicts somatization), backward (somatization predicts the parenting variable), or a combination of forward and backward. With regard to indirect cross-sectional connections, two longitudinal hypotheses can be made. A first possibility is the existence of mediation, which can be forward (parenting behavior predicts parenting stress, which predicts somatization; or parenting stress predicts parenting behavior which predicts somatization), backward (somatization predicts parenting stress, which predicts parenting behavior; or somatization predicts parenting behavior which predicts parenting stress), or a combination of forward and backward. Further, mediation can be full (when in addition to the mediation effect, no direct effects are found) or partial (when in addition to the mediation effect, a forward and/or backward direct effect is found). A second possibility is that no mediation exists, but that the indirect parenting variable predicts both the other parenting variable and somatization, or that another (not included in the study) variable is at stake which predicts both parenting variables and somatization. Based on the above mentioned research, all links investigated in this study (direct, indirect, forward, and backward) may be expected to be significant. In addition, also the large theoretical framework on somatization in youth can be addressed to sustain the hypotheses [40-42]. In this theoretical frameworks, adolescents’ cognitive and emotional functioning have been proposed to play a key role in the development of somatization. More specifically, negative affect [43, 44] and features regarding appraisal/coping/emotion regulation [34, 45] seem to be important. Since cognitive and emotional functioning may be influenced by parenting features, it can be assumed to (partly) explain the link between parenting and somatization. One could, for example, hypothesize that certain parenting practices (e.g., harsh behavioral control, psychological control, parenting stress, and low amounts of warmth) are unpleasant for adolescents and thereby induce negative affect. In addition, these parenting practices might also show a link with adolescents’ worse appraisal/coping/emotion regulation. For example, adolescents with parents showing high parenting stress, might be likely to observe (some of) their parents less adaptive stress-appraisal and coping mechanisms. As a result, the adolescents might be more likely to use this less adaptive style in their approach of all kinds of potential stressors. Another example is that parents who show high levels of parenting warmth (e.g., making more time to speak with their children and to teach their children), are also more likely to teach their children efficient coping skills [46-48]. Contrary, parents who show high psychological control or harsh punishment are more likely to teach their children less adapted coping skills, like aggressive coping [48, 49]. Other theories can be applied to support the hypotheses of somatization influencing parenting aspects [6]. Living with a child who somatizes may induce parental anxiety, role stress, depressive symptoms, and social restrain [6], all of which have been included in theories concerning predictors of less adaptive parenting features [36].

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METHODS Participants Parents and adolescents participated in the JOnG!-study, a longitudinal research program on development, parenting, behavior, and health in three cohorts of Flemish children [50]. The present study reports on data from the first (2009; T1), second (2010; T2) and third (2011; T3) data wave of the adolescents’ cohort. Out of 9861 informed families, 1445 parents (14.7%) and 1443 (14.6%) adolescents sent back a questionnaire at T1. For T2 this was respectively 936 (64.8% of T1 respondents) and 889 (61.6% of T1 respondents), for T3, 796 (55.1% of T1 respondents) and 772 (53.50% of T1 respondents). All families that sent back at least one questionnaire were included in this research. In total, the sample contained 1499 families. Five hundred eighty families (38.7%) sent back all six questionnaires; 83 (5.5%) five questionnaires; 364 (24.3%) four; 64 (4.3%) three; 382 (25.5%) two; and 26 (1.7%) one. The socioeconomic profile of the responders-group matched that of the target population (Flemish families with a child born in 1996) [51]. The parent questionnaire was filled out by the mother, in respectively 92.1% (T1), 90.6% (T2) and 94.6% (T3) of the families. The children’s mean age was 12.77 years at T1 (SD .31), 13.99 at T2 (SD .30) and 15.49 at T3 (SD .33). Since no information is available on nonresponding families, non-responder bias could not be quantified. Families that sent back all six questionnaires differed significantly from those who did not, on various demographic characteristics, except for mothers’ paid work (Table 1). Possible implications of this inequality are taken into account by the use of a multiple imputation method in replacing missing values. Measures Somatization was assessed by means of the Somatic Complaint List (SCL), filled out by the adolescent [52]. The SCL contained 11 types of physical complaints (e.g., dizziness, tiredness). For every complaint, the adolescent indicated how often he/she suffered from it during the last 4 weeks, using a 5-point Likert scale ranging from 1 (almost never) to 5 (quite often). A somatization-score was obtained by averaging all item scores. SCL Cronbach’s alpha were .82 at T1, .84 at T2, and .85 at T3. Parenting behavior as reported by the parents, by means of the scales “warmth/support” (13 items; e.g., I ask my child about hobbies and interests) and “harsh punishment” (4 items; e.g., I give my child a shaking when we have a fight) of the Parental Behavior Scale (PBS) [53]. In addition, the Dutch translation of the Psychological Control Scale (PCS) was completed (8 items; e.g., I try to change the thoughts and feelings my child has about certain subjects) [13, 54]. All items were filled out on a 5-point Likert scale ranging from “never” (1) to “always” (5). Cronbach’s alphas were respectively .84, .73, .73 for T1; .86, .76, .74 for T2; and .87, .71, .76 for T3.

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Table 1. Comparison of Demographic Characteristics of Families with Complete and Incomplete Data Families who returned all 6 questionnaires (n = 580) Valid %

Families who did not return all 6 questionnaires (n = 919) Valid %

Gender child (n = 1496) Male

41.2

48.0

Origin (n = 1436)II Belgian WHO A WHO B-D

92.2 4.2 3.6

88.3 4.3 7.4

Mothers’ occupation (n = 1412) Paid work

84.4

81.9

Fathers’ occupation (n = 1272) Paid work

96.4

92.7

Mothers’ education (n = 1407) Bachelor/master High school

66.1 26.5

51.1 33.6

Fathers’ education (n = 1252) Bachelor/master High school

51.2 37.1

43.7 39.8

Family structure (n = 1418) Two-parent Newly-formed Single-parent

83.7 6.8 9.4

74.5 10.9 14.7

Family income (n = 1165) < 1500 1500–3000 > 3000

3.2 37.2 59.7

7.9 44.2 47.8

DemographicsI

c2 6.7c

9.0c

1.4

7.7b

36.6a

9.0c

17.2a

21.3a

ap < .001; bp < .01; cp < .05; Ibased on time 1 (2009) parent-questionnaires; IIbased on country of birth and nationality of the parents; WHO = World Health Organi-

zation [71].

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Three subscales of the Nijmegen Questionnaire regarding Child-rearing Situations (NQCS) were completed by the parents to assess parenting stress: experiencing problems (7 items; e.g., If someone else spends a day with . . . , they will notice how difficult the parenting of . . . is); ability to cope (8 items; e.g., Of course there is sometimes tension between myself and . . . but in general, I can handle the parenting of . . .); and child is a burden (7 items; e.g., . . . causes problems in parenting) [55]. A total of 22 items were filled out on a 5-point Likert-scale (ranging from “this is definitely not the case” to “this is definitely true”). Cronbach’s alphas were respectively .78, .86, .87 for T1; .75, .81, .87 for T2; and .77, .82, .88 for T3. Since the research hypotheses of the current study involve general parenting stress, a combined parenting stress score was used (parenting stress was entered in the model as a latent variable, operationalized by the three NQCS-subscale scores, cfr. infra). Procedure The study protocol was approved by the Medical Ethics Committees of the universities of Leuven and Ghent. Participants were recruited in using a conditional random sampling plan. In a first phase (2008), eight Flemish regions were chosen based on socioeconomic, urbanizational, and provincial diversity [56]. In a second phase (2009), all families living in one of these regions, with a child born in 1996, were by post informed about the study and invited to participate. Adolescents and one of their parents who agreed to be involved completed an informed consent form and subsequently filled out separately a first questionnaire. Those parents and adolescents who consented to participate in 2009 (T1), received follow up questionnaires in 2010 (T2) and 2011 (T3). Data Analyses In order to investigate cross-sectional direct and indirect connections, nine models were assessed: three models (each including parenting stress, somatization, and one of the three parenting behavior dimensions) were assessed three times (using data from three different time moments: when adolescents were respectively 12-13, 13-14, and 14-15 years old) (Figure 1). In each model, direct effects between all included variables were estimated. In addition, the Sobel test was used to calculate the indirect link between parenting behavior and somatization through parenting stress, and the indirect link between parenting stress and somatization through parenting behavior. Further, based on the results of cross-sectional analyses, hypotheses were made regarding longitudinal connections, using the above discussed guidelines of Maxwell and Cole [30, 39]. Finally, longitudinal hypotheses were tested by means of longitudinal model analyses. All models were assessed through structural equation modeling (SEM), using the statistical package LISREL 8.8 [57]. Structural equation models exist of a measurement model (indicating if the latent variables are operationalized in a

Figure 1. Cross-sectional models (assessed three times, using data from different data-waves).

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reliable way by their indicators) and a structural model (indicating the relationships between the latent variables). With regard to the measurement models used in the cross-sectional analyses, the latent variable “parenting stress” was operationalized by three indicators (three NQCS-subscales), imposing a unit variance identification (ULI constraint) to the indicator “ability to cope.” Since somatization and parenting behavior were operationalized by only one indicator, factor loadings were fixed to 1, and error variances to 0. Variances of the latent variables were freed and allowed to correlate. For measurement models to be considered appropriate, the correlation between indicators cannot be excessively high, the model should have good fit, indicators must have relatively high standardized loadings, and the variance of the indicators explained by the models has to be high [58]. With regard to the measurement models used in the longitudinal analyses, first T1 measurement models were checked on stability across the data waves. For the measurement model to be stable, Milfont and Fischer [59] state that when one is not interested in comparing means over time, it is sufficient to test configural invariance (a model in which the factor structure is constrained to be the same across groups has good fit) and metric invariance (a model in which both the factor structure and factor loadings are constrained to be the same across groups, does not have worse fit than the configural model). Second, the full measurement model was tested, in which the measurement models of the three waves were included, and error covariances between the same variables at the three time moments were freed. SEM parameters were estimated using the maximum likelihood method. Overall model fit was assessed by means of the likelihood-ratio test (c2), Root Mean Square Estimation of Association (RMSEA), and the Bentler comparative fit index (CFI) [60, 61]. A good model fit was indicated by a non-significant c2, a RMSEA lower than 0.06 (> 0.1 suggests poor fit) or a CFI larger than 0.95. To test the significance of overall fit-improvement between two models, the Chi-square difference statistic (Dc2) and the difference in Comparative Fit Index (DCFI) were used. Indifference was indicated by a non-significant c2 difference or a CFI difference lower than 0.01 [60]. Data Preparation All variables were multinormally distributed (skewness < |2| and kurtosis < 7) [62]. Percentages of missing values varied between 4.5% and 49.1%. Little’s missing completely at random (MCAR) test suggested that the data were not MCAR (c2(72053) = 78646.96, p < 0.001), so multiple imputation on subscalelevel was used to replace missing values [63, 64]. The imputation model contained all items included in the analysis, plus the socioeconomic auxiliary variables family income, parental education, and gender since they have a well-known link with PFC [7]. A total of 20 complete datasets were constructed, using the statistical package PASWstatistics20. Given a missing value rate up to 50%, the efficiency of an estimate based on 20 imputations is approximately 98 to 100% [63].

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RESULTS Descriptives Table 2 presents descriptive information on the study variables. The first criterion for appropriate measurement models was met, namely that the correlation between indicators must not be excessively high (> .85; for this study, all indicator correlations are below .86) [58]. Cross-Sectional Analyses For the nine cross-sectional SEM-models, results are presented in Table 3. Before adding the structural paths, always the measurement model was tested (and if necessary improved). A discussion of the measurement models is provided in Appendix 1. In what follows, structural parts are discussed. Table 3 shows that, at all three time moments, there were significant direct effects between higher parenting stress and higher somatization. Direct relations between parenting dimension and somatization were not significant. Further, significant indirect relations were seen between all parenting dimensions and somatization, through parenting stress. Lower parenting warmth was related to higher somatization through higher parenting stress; higher harsh punishment to higher somatization, through higher parenting stress; higher psychological control to higher somatization, through higher parenting stress. However, not all the total effects of parenting dimensions on somatization were significant (for warmth not at T2 and T3; for harsh punishment not at T2; and for psychological control not at T3). Indirect relationships between parenting stress and somatization through parenting dimensions were not significant. However, all total effects of higher parenting stress on higher adolescent somatization were significant. Longitudinal Analyses Based on the outcome of the cross-sectional analyses, hypotheses were made on longitudinal connections, following the guidelines of Maxwell and Cole [30, 39]. The significant direct relationship between parenting stress and somatization was assessed on being longitudinally forward, backward, or both. The indirect relationship between parenting dimensions and somatization through parenting stress, was assessed on full or partial mediation (forward, backward or both), or on the prediction of both parenting dimensions and somatization by parenting stress. All hypotheses were addressed by means of three models (cfr Figure 2, assessed separate for each of the three parenting dimensions), using SEManalyses. Before adding structural paths, the models’ measurement parts were tested and if necessary improved (Table 4). A discussion of the measurement models is provided in Appendix 1. In what follows, structural parts are discussed.

934 933 932 929 927 927 882

793 792 788 788 787 788 763

T2 8 Warmth 9 Harsh punishment 10 Psychological Control 11 Coping capacityI 12 Parenting problemsI 13 Child is a burdenI 14 Somatization

T3 15 Warmth 16 Harsh punishment 17 Psychological Control 18 Coping capacityI 19 Parenting problemsI 20 Child is a burdenI 21 Somatization 3.98 1.08 1.72 4.60 1.75 1.56 1.85

4.03 1.11 1.70 4.56 1.79 1.60 1.60

4.10 1.18 1.67 4.51 1.85 1.68 1.68

M

0.55 0.23 0.42 0.47 0.56 0.66 0.62

0.53 0.29 0.41 0.49 0.57 0.67 0.54

0.49 0.33 0.41 0.52 0.59 0.71 0.54

SD

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

.67a –.17a –.30a .23b –.24a –.18c –.04 .71a –.17a –.33a .22a –.25a –.17a –.06c –.12a .54a .15a –.27a .25a .20a .08c –.16a .60a .15a –.17a .20a .15a .05 –.13a –.24a .25a .55a –.26a .29a .23a .08c –.29a .29a .60a –.27a .32a .24a .09b –.34a .27a .21a –.21a –.26a .59a –.54a –.56a –.15a .18c –.19a –.31a .61a –.56a –.57a –.12a .25a –.27a –.40a –.22a .26a .33a –.56a .58a .53a .14a –.22a .22b .36a –.58a .66a .56a .15a –.28a .29a .45a –.81a –.16b .20a .26a –.60a .57a .63a .15a –.15a .19a .31a –.64a .60a .68a .12a –.21a .24a .38a –.82a .77a .00 .02 .05 –.14a .11b .10b .45a –.02 –.02 .01 –.06 .09c .07c .56a –.02 .06 .06 –.10b .14a .12b

.69a –.21a –.29a .23a –.21a –.17a –.05 –.19a .57a .20a –.23a .22a .20a .07c –.20a –.30a .26a .58a –.33a .35a .30a .11a –.35a .28a .21a –.23a –.29a .69a –.63a –.65a –.17a .23a –.24a –.40a –.25a .25a .35a –.65a .69a .64a .14a –.28a .25a .44a –.79a –.18a .22a .28a –.68a .64a .71a .15a –.21a .21a .37a –.82a .77a –.07c .02 .08b –.16c .15b .15a .53a –.03 .01 .08c –.14a .15a .14a

–.22a –.31a .32a .29a –.33a –.38a –.29a .32a .42a –.84a –.21a .28a .33a –.85a .80a –.09a .06c .11a –.20a .21a .19a

1

21

ap < .001; bp < .01; cp < .05; T1 = time 1 (2009); T2 = time 2 (2010); T3 = time 3 (2011). Note: I = in the SEM analyses, the three NQCS subscales “coping capacity,” “parenting problems,” and “child is a burden,” are used as three indicators of the same latent factor “parenting stress.”

1429 1428 1429 1431 1428 1427 1427

T1 1 Warmth 2 Harsh punishment 3 Psychological Control 4 Coping capacityI 5 Parenting problemsI 6 Child is a burdenI 7 Somatization

n

Table 2. Pearson Correlations between Study Variables

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2.20 (2) 6.57 (2) 17.45 (2)

1.56 (1) 3.23 (1) 9.53 (1)

Harsh punishment T1 T2 T3

Psychological control T1 T2 T3 0.02 0.03 0.07

0.01 0.03 0.07

0.02 0.07 0.07

1 1 1

1 1 1

1 1 1

RMSEA CFI

PS -> som

b (SE)

PB -> som

PS -> som

Direct effects

0.14 (0.03)a –0.32 (0.02)a 0.04 (0.04) –0.22 (0.03)a 0.11 (0.05)c –0.38 (0.04)a 0.02 (0.05) –0.18 (0.08)a –0.07 (0.05) –0.19 (0.06)b –0.02 (0.07) –0.20 (0.07)a

0.10 (0.05)c –0.51 (0.04)a –0.02 (0.05) –0.23 (0.03)a 0.01 (0.07) –0.18 (0.04)a –0.08 (0.08) –0.21 (0.05)a 0.16 (0.09)c –0.18 (0.04)a 0.06 (0.10) –0.18 (0.06)b

0.09 (0.03)a –0.23 (0.03)a –0.03 (0.03) –0.22 (0.03)a 0.00 (0.05) –0.19 (0.05)a 0.01 (0.03) –0.18 (0.06)b –0.02 (0.04) –0.19 (0.06)b 0.03 (0.04) –0.18 (0.06)b

b (SE)

PB -> som

Total effects

5.25 (0.02)a 3.16 (0.03)a 2.71 (0.03)a

5.98 (0.02)a 3.45 (0.02)a 2.63 (0.04)b

–5.73 (0.01)a –2.30 (0.02)c –2.81 (0.02)b

Sobel z (SE)

–1.01 (0.02) –0.44 (0.02) 0.24 (0.03)

0.44 (0.02) 0.95 (0.03) –0.55 (0.06)

–0.83 (0.01) –0.31 (0.01) –0.63 (0.01)

PB -> PS -> som PS -> PB -> som

Indirect effects

ap < .001; bp < .01; cp < .05; higher parenting stress scores signify lower self-reported parenting stress; T1 = Measurement Time 1 (2009); T2 = Measurement Time 2 (2010); T3 = Measurement Time 3 (2011); som = somatization.

3.77 (2) 17.78 (2) 19.03 (2)

Warmth T1 T2 T3

c2 (df)

Fit

Table 3. Cross-Sectional Analyses: SEM-Models

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Figure 2. Structural part full longitudinal model. T1 = Measurement Time 1 (2009); T2 = Measurement Time 2 (2010); T3 = Measurement Time 3 (2011).

For the three longitudinal SEM-models, statistics are provided in Table 5. Higher T1 parenting stress significantly predicted higher T2 and T3 somatization. When controlled for T1 parenting stress, higher T2 parenting stress significantly predicted lower T3 somatization. In addition, higher T1 parenting stress significantly predicted higher T2 and T3 harsh punishment and higher T3 psychological control. When controlled for T1 parenting stress, higher T2 parenting stress significantly predicted lower T3 harsh punishment. DISCUSSION Insight in the aetiology of adolescents’ somatization is needed in order to tailor efficient treatment. This study addressed three gaps in knowledge on the association between aspects of parenting and adolescents’ somatization. First, previous research on the link between parenting behavior and somatization have focused on parenting styles (over-protection), omitting the study of separate parenting behavior dimensions like warmth, harsh punishment, and psychological control. Second, especially cross-sectional or unidirectional longitudinal studies have been performed. Third, past studies have focused on direct associations, leaving out the study of indirect relations. The present research addressed those gaps by investigating both direct and indirect links between three parenting behavior dimensions (warmth, psychological control, and harsh punishment),

1.00 1.00 0.99 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

0.05 0.06 0.07 0.03 0.05 0.03 0.02 0.05 0.05 0.02 0.05 0.05 0.02 0.05 0.05

< .05 < .05 < .05 < .05 < .05 < .05 < .05 < .05 < .05 < .05 < .05 < .05 < .05 < .05 < .05

21.55 (4) 22.80 (4) 36.80 (4) 8.77 (2) 19.64 (2) 23.97 (2) 11.17 (4) 25.31 (4) 26.45 (4) 5.45 (4) 14.31 (4) 14.43 (4) 6.13 (6) 13.17 (6) 13.50 (6)

metric T1–T2 invariance T1–T3 model T2–T3

Harsh punishment configural T1–T2 invariance T1–T3 model T2–T3

metric T1–T2 invariance T1–T3 model T2–T3

Psychological control configural T1–T2 invariance T1–T3 model T2–T3

metric T1–T2 invariance T1–T3 model T2–T3

(Ddf)

0.68 (2) 1.13 (2) 0.93 (2)

2.40 (2) 5.66 (2) 2.48 (2)

2.05 (2) 5.74 (2) 2.29 (2)

Dc2

> .05 > .05 > .05

> .05 > .05 > .05

> .05 > .05 > .05

p

Fixed-freed

Note: T1 = Measurement Time 1 (2009); T2 = Measurement Time 2 (2010); T3 = Measurement Time 3 (2011).

1.00 1.00 0.99

CFI

0.04 0.05 0.06

RMSEA

< .05 < .05 < .05

p

23.59 (2) 28.54 (2) 39.09 (2)

(df)

Fixed

Warmth configural T1–T2 invariance T1–T3 model T2–T3

c2

Table 4. Longitudinal Analyses: Measurement Models

.00 .00 .00

.00 .00 .00

.00 .00 .00

D CFI

Accept Accept Accept

Accept Accept Accept

Accept Accept Accept

Accept Accept Accept

Accept Accept Accept

Accept Accept Accept

Decision

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259

parenting stress, and adolescents’ somatization. Following the guidelines of Maxwell and Cole [30, 39], both cross-sectional and longitudinal analyses were performed using data from three waves, including children from respectively 12-13, 13-14, and 14-15 years old. Cross-sectional analyses showed for each time moment a significant direct association between parenting stress and somatization, and a significant indirect association between all parenting dimensions and somatization, through parenting stress. Higher amounts of harsh punishment and psychological control, and lower amounts of warmth, were significantly related to higher somatization, through higher parenting stress. No direct relations were seen between parenting dimensions and somatization. Total associations with adolescents’ somatization were not significant for T2 parenting warmth and harsh punishment and T3 parenting warmth and psychological control, indicating that for these parenting dimensions, the significant indirect relations with somatization (through parenting stress) are cancelled out by other indirect links (through other variables) with opposite signs [65]. One might, for example, hypothesize that in later stages of adolescence, when the adolescent enters in various relationships with other persons than the parent, negative parenting behavior is compensated for [29]. Longitudinal analyses revealed that the significant cross-sectional indirect associations between parenting dimensions and somatization through parenting stress, were not due to mediation. Two other key findings were demonstrated. First, parenting stress significantly predicted adolescents’ somatization. Higher T1 parenting stress (when adolescents were 12-13 years old), predicted augmented T2 and T3 somatization (when adolescents were respectively 13-14 and 14-15 years old). However, when controling for T1 parenting stress, higher T2 parenting stress predicted lower T3 somatization. In other words, while high levels of early parenting stress in early adolescence (when adolescents are 12-13 years old) predict higher levels of adolescents’ somatization 1 year later, augmented levels of later parenting stress in later adolescence (when adolescents are 13-14 years old) are related to lower levels of adolescents’ somatization 1 year later. A first explanation for this finding could be the existence of age related moderators or, in other words, the existence of critical periods in which parenting stress is related to higher somatization. A potential moderator is the number of risky situations children are exposed to (e.g., be offered drugs), which generally increases during adolescence (e.g., due to augmented responsibility, like going out unsupervised). Parenting stress might be adaptive when children face multiple dangerous situations, for example because it stimulates parents to explore different coping mechanisms [33]. Although the developmental appropriateness of parenting aspects has been considered by some researchers, we are not aware of studies that included longitudinal data of both parenting and child developmental aspects to specifically study this issue [66, 67]. Although the current study cannot give information on the relative importance of behavior of parents compared to significant others (e.g., peers), the longitudinal findings do reflect that parents

= Parenting DimensionT1 = Parenting DimensionT2 = Parenting DimensionT1 = Parenting StressT1 = Parenting StressT2 = Parenting StressT1 = SomatizationT1 = SomatizationT2 = SomatizationT1

= Parenting DimensionT1 = Parenting DimensionT2 = Parenting DimensionT1 = Parenting StressT1 = Parenting StressT2 = Parenting StressT1

Autoregressive Parenting DimensionT2 Parenting DimensionT3 Parenting DimensionT3 Parenting StressT2 Parenting StressT3 Parenting StressT3 SomatizationT2 SomatizationT3 SomatizationT3

Forward Parenting StressT2 Parenting StressT3 Parenting StressT3 SomatizationT2 SomatizationT3 SomatizationT3

–0.01 (0.02) –0.01 (0.03) 0.01 (0.04) –0.07 (0.03)c 0.16 (0.09)c –0.15 (0.08)c

0.75 (0.03)a 0.46 (0.05)a 0.39 (0.05)a 0.75 (0.03)a 0.51 (0.07)a 0.23 (0.06)a 0.54 (0.03)a 0.51 (0.04)a 0.25 (0.05)a

Model 4: Parenting dimension = Warmth

Table 5. Longitudinal Analyses: Structural Models

0.02 (0.03) –0.01 (0.06) –0.01 (0.05) –0.06 (0.03)c 0.17 (0.09)c –0.15 (0.09)c

0.49 (0.03)a 0.36 (0.04)a 0.19 (0.03)a 0.75 (0.03)a 0.51 (0.06)a 0.22 (0.06)a 0.54 (0.03)a 0.50 (0.04)a 0.25 (0.05)a

Model 5: Parenting dimension = Harsh punishment

–0.03 (0.03) –0.03 (0.07) –0.01 (0.05) –0.07 (0.03)c 0.17 (0.09)c –0.14 (0.09)c

0.52 (0.03)a 0.42 (0.05)a 0.32 (0.04)a 0.75 (0.03)a 0.49 (0.07)a 0.23 (0.06)a 0.54 (0.03)a 0.50 (0.04)a 0.25 (0.05)a

Model 6: Parenting dimension = Psychological control

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= Parenting DimensionT1

= Parenting DimensionT1

= SomatizationT1 = SomatizationT2 = SomatizationT1 = Parenting StressT1 = Parenting StressT2 = Parenting StressT1

0.02 (0.03) 0.00 (0.00) 0.01 (0.03)

0.09 (0.05) –0.49 (0.00) 0.07 (0.05)

0.00 (0.02) 0.04 (0.03) –0.02 (0.02) 0.02 (0.03) 0.03 (0.07) 0.05 (0.14)

0.01 (0.03) 0.00 (0.01) –0.01 (0.06)

–0.02 (0.06) 0.63 (0.01) 0.01 (0.02)

0.00 (0.02) 0.00 (0.03) –0.02 (0.02) –0.04 (0.02)c 0.08 (0.04)c –0.09 (0.03)b

–0.04 (0.03) –0.23 (0.00) –0.02 (0.05)

–0.01 (0.05) –0.98 (0.01) –0.01 (0.03)

0.05 (0.02) 0.01 (0.03) –0.02 (0.02) –0.13 (0.04)b –0.04 (0.07) 0.01 (0.07)

scores signify lower self-reported parenting stress.

Note: All cells represent b(SE) of SEM-analyses, except for the indirect effects, which represent z(SE) of the sobel-test; ap < .001; bp < .01; cp < .05; T1 = Measurement Time 1 (2009); T2 = Measurement Time 2 (2010); T3 = Measurement Time 3 (2011); higher parenting stress

Mediation backward Direct effect: Parenting DimensionT3= SomatizationT1 Indirect effect Total effect: Parenting DimensionT3 = SomatizationT1

Mediation forward Direct effect: SomatizationT3 Indirect effect Total effect: SomatizationT3

Backward Parenting StressT2 Parenting StressT3 Parenting StressT3 Parenting DimensionT2 Parenting DimensionT3 Parenting DimensionT3

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keep on playing a significant role throughout adolescence [29]. Other studies on adolescent development validated this finding [68]. A second possible explanation for the different links between parenting stress and somatization is T2 and T3 non-responders bias (e.g., socioeconomic factors as confounding variables). Although in this study multiple imputation was used to address this issue, it is possible that some bias remained. Further research could address this topic by giving special attention to the inclusion of vulnerable families, which typically drop out in large longitudinal studies like the present one, and by subsequently analyzing the effect of factors like parental education and income on the connection between parenting stress and adolescents’ somatization. A second key finding of the longitudinal analyses was that parenting stress significantly predicted two of the three parenting dimensions. Higher T1 parenting stress predicted augmented T2 and T3 harsh punishment. Analogous to the link between parenting stress and somatization, when controlled for T1 parenting stress, higher T2 parenting stress predicted lower T3 harsh punishment. In other words, the significant indirect cross-sectional relation between harsh punishment and somatization through parenting stress, is due to the fact that parenting stress predicts both harsh punishment and somatization [37]. For warmth, no significant longitudinal relationships with parenting stress were seen. The significant cross-sectional links between warmth and stress were, therefore, probably due to other shared causes, like parental emotional problems or social support [69]. Another possible shared cause is “harsh punishment”. Earlier research revealed that parents who tend to punish harsh are likely to use less warmth [10]. Regarding psychological control, between T1 and T2 study variables, relationships were analogous to those concerning harsh punishment, namely that T1 parenting stress predicted both T2 psychological control and T2 somatization. However, for the link between T2 and T3 study variables, a pattern comparable to that for warmth was distinguished, namely a mere covariation in time between parenting stress and psychological control. The results suggest that clinicians should be aware that parenting stress may be a risk factor for the development of somatization in early adolescence. However, in later adolescence, increased parenting stress might be protective. The fact that parenting stress, rather than parenting behavior, seems to play a role in somatization development, does not mean that parenting behavior is unimportant. After all, it is plausible that parenting behavior has significant direct relationships with several other aspects of adolescent development. An important limitation of this study is the fact that only one parent, predominantly the mother, was included in the sample. Assessment of both parents was not feasible due to limited financial resources. We preferred mothers as informants because they often provide the most accurate information on other variables assessed in the JOnG!-study (e.g., medical and educational ones). However, inclusion of paternal parenting stress and paternal parenting behavior would have been valuable. Related to this is the limitation that only one type of

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measurement (self report) was used to operationalize concepts. It could have been useful to complement the data with information on, for example, child-reports of parenting aspects and/or observations. Additional studies should examine the link between dimensions of parenting behavior, parenting stress, and other aspects of adolescent functioning. Moreover, future research should include children with a wider age range, in order to further assess developmental appropriateness of parenting stress. Furthermore, prospective studies should not only focus on average longitudinal connections but also assess diversity in trajectories and factors related to it [70]. Additionally, future studies should explore the process linking parenting stress to somatization. The models explained in the introduction might guide hypotheses. APPENDIX 1: Discussion Measurement Parts SEM Models Cross-Sectional SEM Models Model 1 (included latent variables: Parenting dimension warmth; parenting stress; somatization), assessed at T1, T2, and T3

For T1, the basic warmth measurement model showed acceptable fit (c2(4) = 33.22, p < .05; RMSEA = 0.07; CFI = 0.99). Modification indices suggested to free the error variances between “experience problems” and “ability to cope” and between “warmth” and “child is a burden”. A disturbance correlation reflects the assumption that the corresponding endogenous variables share at least one common omitted cause. Because this assumption was arguable for the two suggested variables (e.g., social support as omitted cause) [72, 73], error variances were freed, which resulted in a model with good model fit at T1, T2, and T3 (Table 3). For all three measurement moments, indicators had high standardized loadings (> .87), and indicators' variance explained by the model was high (child is a burden: > 76%; parenting problems: > 84%; coping capacity: > 94%). Model 2 (included latent variables: Parenting dimension harsh punishment; parenting stress; somatization), assessed at T1, T2, and T3

For T1, the basic harsh punishment measurement model showed acceptable fit (c2(4) = 12.47, p .87), and the indicators’ variance explained by the model was high (child is a burden: > 76%; parenting problems: > 84%; coping capacity: > 94%).

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Model 3 (included latent variables: Parenting dimension psychological control; parenting stress; somatization), assessed at T1, T2, and T3

At T1, the basic psychological control measurement model showed acceptable fit (c2(4) = 44.07, p < .05; RMSEA = 0.08; CFI = 0.99). Based on modification indices, the error variances between “experience problems” and “ability to cope” and between “psychological control” on the one hand and “experience problems” and “ability to cope” on the other hand were freed, which resulted in good model fit at T1, T2, and T3 (Table 3). For all three measurement points, indicators had high standardized loadings (> .88), and the indicators’ variance explained by the model was high (child is a burden: > 76%; parenting problems: > 83%; coping capacity: > 94%). Longitudinal SEM Models Model 4 (included latent variables: Parenting dimension warmth at T1, T2, and T3; parenting stress at T1, T2, and T3; somatization at T1, T2, and T3)

Table 4 shows a good fit for the configural invariance model. Fit indices revealed no significantly worse fit for the metric invariance model. A full measurement model, in which the measurement models of the three waves were included, and error covariances between the same variables at the three time moments were freed, fitted the data well (c2(45) = 193.32, p < .05; RMSEA = 0.05; CFI = 1). The model where in addition to the full measurement model, autoregressive, forward, and backward cross-lagged paths were added (see Figure 2 for the structural part of the model) had reasonable fit (c2(49) = 207.21, p < .05; RMSEA = 0.05; CFI = 1). Model 5 (included latent variables: Parenting dimension harsh punishment at T1, T2, and T3; parenting stress at T1, T2, and T3; somatization at T1, T2, and T3)

Table 4 shows a good fit for the configural invariance model. Fit indices showed no significantly worse fit for the metric invariance model. A full measurement model, in which the measurement models of the three waves were included, and error covariances between the same variables at the three time moments were freed, had good fit (c2(45) = 169.01, p < .05; RMSEA = 0.04; CFI = 1). A model where in addition to the full measurement model, autoregressive, forward, and backward cross-lagged paths were added (the longitudinal nonmediation model: see Figure 2 for the structural part of the model) had reasonable fit (c2(55) = 519.87, p < .05; RMSEA = 0.08; CFI = 0.98).

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Model 6 (included latent variables: Parenting dimension psychological control at T1, T2, and T3; parenting stress at T1, T2, and T3; somatization at T1, T2, and T3)

Table 4 shows a good fit for the configural invariance model. Fit indices showed no significantly worse fit for the metric invariance model. A full measurement model, in which the measurement models of the three waves were included, and error covariances between the same variables at the three time moments were freed, had good fit (c2(45) = 198.37, p < .05; RMSEA = 0.05; CFI = 1). A model where in addition to the full measurement model, autoregressive, forward, and backward cross-lagged paths were added (the longitudinal nonmediation model: see Figure 2 for the structural part of the model) had reasonable fit (c2(55) = 519.87, p < .05; RMSEA = 0.08; CFI = 0.98).

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