Factors in Parenting Stress in Young Patients With Breast Cancer and Implications for Children’s Emotional Development

This cross-sectional study examines the clinical factors in parenting stress in mothers with breast cancer and the association of maternal depression and parenting stress with their children's emotional development.


Introduction
According to the 2019 National Cancer Registration, breast cancer is the most common cancer among females in South Korea. 1 Furthermore, data from the National Cancer Institute have shown that over 30% of patients with breast cancer younger than 54 years have children younger than 18 years. 2In East Asia, the proportion of middle-aged patients with breast cancer is higher than that in the US. 3 Consequently, a substantial number of these patients are expected to be the primary caregivers of their children while managing their disease.For mothers with breast cancer, parenting can be challenging, especially during hospitalization or chemotherapy, which can place considerable psychological distress on these patients.Additionally, the children are required to adjust to their mother's disease and related absence and may also experience anxiety and worries about losing their mother. 4,5Therefore, children may be vulnerable to disrupted emotional development.
7][8][9] Wellisch et al 6 reported that daughters of mothers with breast cancer had psychological symptoms that were comparable with those of daughters with mothers without a history of the disease, whereas Armsden and Lewis 7 found that children of patients with breast cancer scored higher on behavioral adjustment and lower on self-esteem compared with a control group.In contrast, Howes and colleagues 8 reported no substantial differences in emotional or behavioral problems between children of mothers with vs without breast cancer.Brown et al 9 found similar results, although they highlighted the benefits of emotional support to children's psychological adjustment.8][9][10] To date, few studies have investigated the emotional problems of children of patients with breast cancer using relevant psychological and clinical scales.Moreover, research into the association of children's emotional problems and depression with parenting stress of mothers with breast cancer is scarce.Therefore, we aimed to investigate the clinical factors in parenting stress in mothers with breast cancer and the association of maternal depression and parenting stress with their children's emotional development.Specifically, we examined breast cancer characteristics, treatment, and depression.

Study Design and Participants
This cross-sectional survey included females with stage 0 to 3 breast cancer who visited the breast surgery outpatient clinic at Asan Medical Center in Seoul, South Korea, between June 2020 and April 2021.All participants were aged 20 to 45 years at the time of diagnosis and were currently within 10 years from diagnosis.Patients were excluded from the study if they had (1) recurrent breast cancer; (2) a history of taking psychiatric medications prior to cancer diagnosis, including antipsychotics, antidepressants, and mood stabilizers; (3) an intellectual disability; (4) children with intellectual disabilities, autism spectrum disorders, epilepsy, genetic diseases, or congenital deformities; or (5) All participants completed questionnaires that identified their demographic and clinical characteristics as well as assessed their depression.Females with children younger than 12 years also completed rating scales that evaluated their own parenting stress and their children's emotional and behavioral problems, sleeping habits, and temperament.

Clinical Rating Scales
The Center for Epidemiologic Studies Depression-Revised (CESD-R) scale assesses depressive symptoms. 11We validated and used the Korean version of the CESD-R scale (score range: 0-60, with the highest score indicating depression). 12We considered a cutoff score of 16 or higher as depression.
The Korean Parenting Stress Index Short Form (K-PSI-SF) consists of 36 questions, with a 5-point Likert scale grading 3 domains: parental distress, parent-child dysfunctional interaction, and difficult child. 13Scores range from 36 to 180, with higher scores indicating greater parenting stress.
The Child Behavior Checklist (CBCL) assesses the emotional and behavioral problems of children and adolescents. 14,15A profile of psychological problems can be described using 8 subscales across 3 dimensions of the CBCL: internalizing, externalizing, and total behavioral problems.For these 3 dimensions, the cutoff T scores are lower than 60 for the normal range, 60 to 63 for the borderline range, and 64 or higher for the clinical range.For the 8 subscales, the cutoff T scores are lower than 65 for the normal range, 65 to 69 for the borderline range, and 70 or higher for the clinical range.A higher CBCL score indicates greater severity of psychosocial problems.
The Junior Temperament and Character Inventory (JTCI) is based on Cloninger's classification of personality. 16It measures 4 different temperament types (novelty seeking, harm avoidance, reward dependence, and persistence) and 3 dimensions of character (self-directedness, cooperativeness, and self-transcendence). 17 The Children's Sleep Habits Questionnaire (CSHQ) screens for major medical and behavioral sleep disorders in children. 18

Statistical Analysis
The Univariable and multivariable logistic regression analyses were performed to examine the correlates of depression among patients with breast cancer, and a CESD-R scale score of 16 or higher was used as the dependent variable.Variables with P < .10 in the univariable analysis were entered into the multivariable analysis using backward elimination.In addition, univariable and multivariable linear regression analyses using stepwise selection were performed with the K-PSI-SF score as the dependent variable to investigate factors associated with level of parenting stress in patients with children.The proportion of participants who scored in the borderline and clinical ranges on the CBCL was calculated.Given the associations between disease duration and depression and between depression and parenting stress, we analyzed the CESD-R scale and K-PSI-SF scores according to disease duration.Thus, disease duration was categorized into 6 categories: less than 1, 1 to 2, 2 to 3, 3 to 4, 4 to 5, and more than 5 years.
A 2-sided P < .05 was considered statistically significant.All statistical analyses were performed using SAS, version 9.4 (SAS Institute), and R, version 3.6.1 (R Project for Statistical Computing).

Results
Of   3).Chemotherapy had no significant role in the association between GnRH treatment and depression (eTable in Supplement 1; P for interaction = .77).subscale scores of the CSHQ were also directly correlated with the K-PSI-SF score.Similarly, the total CESD-R scale score was correlated with the K-PSI-SF score (β = 0.56; 95% CI, 0.45-0.66).Other cancer-related factors were not associated with the K-PSI-SF score.

As shown in
Disease duration was associated with the CESD-R scale score (Figure , A).Despite the decreasing score pattern similar to that of the CESD-R scale score, the K-PSI-SF score was not associated with CESD-R scale score throughout the disease duration (Figure , B).
Children of patients with breast cancer did not score higher than the normal score ranges for internalizing, externalizing, and total behavioral problem (T scores: <64 [92nd percentile] and <60

Discussion
In this cross-sectional study, we found that parenting stress was associated with depression, and various child-related factors played a role in this association, such as age, temperament, emotional problems, and sleeping patterns.We did not observe an association between the characteristics of breast cancer itself and parenting stress.Having children, a high school educational level, and GnRH treatment were associated with an increased risk of depression among patients with breast cancer.
Conversely, older maternal age and a longer disease duration were correlated with a lower risk of depression.Additionally, we found that maternal breast cancer diagnosis and treatment did not have an association with the emotional development of children.Among cancer-related factors, disease duration and GnRH treatment were associated with maternal depression.0][21] In line with previous research, [22][23][24] we found that younger age, having a child, and a lower educational level were all independently correlated with depression.In addition, a short disease duration and GnRH treatment were associated with depression, both of which have previously been reported as risk factors for depression in patients with breast cancer. 25,26 found that GnRH treatment was associated with the risk of depression, whereas chemotherapy had no association.Although adverse psychological outcomes have been previously reported, 27 the present study highlighted the importance of assessing mental status in those undergoing GnRH treatment, regardless of previous chemotherapy.Brunt and colleagues 28 reported the substantial role of additional ovarian suppression treatment, which was associated with worsened depression and anxiety induced by chemotherapy.However, we found that GnRH treatment alone increased the risk of depression in patients who had not undergone chemotherapy.
In general, patients are educated and prepared for chemotherapy prior to treatment, particularly regarding its potential toxic effects; however, such preparation is not common for endocrine therapy. 29This difference may contribute to distress in patients undergoing endocrine therapy.
We found that maternal depression and parenting stress were correlated.1][32] Given the high prevalence of depression among patients with breast cancer, 33 active surveillance of depression and timely intervention are recommended to reduce psychological distress.In addition, early intervention for mental health issues may be required for children if their mothers with breast cancer are at greater risk of depression.
Results of the present study also revealed that maternal parenting stress was correlated with maternal primary caregiver status and child behavioral problems, sleeping problems, and temperament but was not associated with cancer-related factors.In contrast to previous studies suggesting that maternal parenting stress was highest for mothers with preschool-aged children, 34 we found that patients with children 6 years or older reported higher parenting stress.This finding may be attributed to participants' limited ability (given their diagnosis and/or treatment) to help their children adjust to school activities.Mothers who were the sole caregiver had significantly higher parenting stress than those who shared caregiving with other family members.Although the presence of additional caregivers was associated with reduced parenting stress, it was also associated with increased risk of depression, which may be attributed to the mother's relationship association of mother's breast cancer with their children's emotional development was assessed by comparison with reference values.Comparisons between patients with and patients without children were conducted using χ 2 or Fisher exact tests for categorical variables and unpaired, 2-tailed t tests or Wilcoxon rank-sum tests for continuous variables.Analysis of variance and Kruskal-Wallis tests were used to compare CESD-R scale and K-PSI-SF scores according to disease duration.JAMA Network Open | Oncology Factors in Parenting Stress in Young Patients With Breast Cancer and Children's Emotional Development JAMA Network Open.2023;6(11):e2344835. doi:10.1001/jamanetworkopen.2023.44835(Reprinted) November 28, 2023 3/13 Downloaded from jamanetwork.comby guest on 12/17/2023

Figure . 16
Figure.Center for Epidemiologic Studies Depression-Revised (CESD-R) Scale and Korean Parenting Stress Index Short Form (K-PSI-SF) Scores According to Disease Duration Factors in Parenting Stress in Young Patients With Breast Cancer and Children's Emotional Development JAMA Network Open.2023;6(11):e2344835. doi:10.1001/jamanetworkopen.2023.44835(Reprinted) November 28, 2023 2/13 Downloaded from jamanetwork.comby guest on 12/17/2023 children who were not biologically related or older than 12 years.Written informed consent was obtained from all participants.The Asan Medical Center Institutional Review Board approved this cross-sectional study.We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Table 2
shows the risk factors for depression among patients with breast cancer.Univariable

Table 4
Factors in Parenting Stress in Young Patients With Breast Cancer and Children's Emotional Development , parenting stress was significantly higher in mothers with children 6 years or older (β = 3.09; 95% CI, 0.19-5.99)than in those with younger children (1.5 to <6 years) as well as in mothers who were the sole primary caregiver rather than in those who shared the role with other JAMA Network Open | Oncology JAMA Network Open.2023;6(11):e2344835. doi:10.1001/jamanetworkopen.2023.44835(Reprinted) November 28, 2023 4/13 Downloaded from jamanetwork.comby guest on 12/17/2023

Table 1 .
Baseline Characteristics of Patients With Breast Cancer According to Presence of Children

Table 2 .
Risk Factors for Depression Among Patients With Breast Cancer Factors in Parenting Stress in Young Patients With Breast Cancer and Children's Emotional Development [84th percentile]) subscales of the CBCL (eFigure in Supplement 1).However, more children of patients with breast cancer scored higher on the anxious/depressed (T score: Ն70 [98th percentile]) and thought problems (T score: Ն65 [93rd percentile]) subscales than expected based on the CBCL normal ranges.

Table 3 .
Risk Factors for Depression Among Mothers With Breast Cancer

Table 4 .
Multivariable Linear Regression Analysis of the Korean Parenting Stress Index Short Form (K-PSI-SF) Scores