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Journal of Pediatric Psychology logoLink to Journal of Pediatric Psychology
. 2016 Jun 11;42(1):114–124. doi: 10.1093/jpepsy/jsw043

Parents' Romantic Attachment Predicts Family Ritual Meaning and Family Cohesion Among Parents and Their Children With Cancer

Susana Santos 1,✉, Carla Crespo 2, M Cristina Canavarro 1, Anne E Kazak 3,4
Editor: Guest Editors: Cynthia A. Gerhardt, Cynthia A. Berg, Deborah J. Wiebe and Grayson N. Holmbeck
PMCID: PMC6440258  PMID: 28173184

Abstract

Objective Family functioning is associated with adaptation in pediatric illness. This study examines the role of parents’ relationships (specifically romantic attachment) as a predictor of family ritual meaning and family cohesion for parents and their children with cancer. Methods The dyads, 58 partnered Portuguese parents and their children in treatment, reported on family ritual meaning and family cohesion at Time 1 (T1) and after 6 months (T2). Parents also completed the questionnaire assessing romantic attachment at T1. Results Parents’ avoidant attachment, but not anxious attachment, predicted lower family ritual meaning and family cohesion after 6 months. T2 family ritual meaning mediated the relationship between T1 avoidant attachment and T2 family cohesion. Conclusions Parents’ avoidant attachment may have a negative effect on family functioning in parents and children. Clinical intervention to address avoidant attachment or/and to promote family ritual meaning may help strengthen family ties.

Keywords: family cohesion, family rituals, parents, pediatric cancer, romantic attachment

Pediatric cancer is a potentially traumatic experience for patients and their parents. During cancer treatment, both children and parents are exposed to multiple possibly traumatic events (e.g., the child’s pain, death of other patients) that can trigger posttraumatic stress symptoms (Kazak, Boeving, Alderfer, Hwang, & Reilly, 2005) and have a negative impact on psychological adjustment (Klassen, Anthony, Khan, Sung, & Klaassen, 2011; Klassen et al., 2007). Although most children and parents report improving adjustment over time (Price, Kassam-Adams, Alderfer, Christofferson, & Kazak, 2016), a subset experiences persistent traumatic stress responses that may potentially have negative effects as they grow into adolescence and young adulthood (Rourke, Hobbie, Schwartz, & Kazak, 2007).

Family functioning is a key issue for understanding adaptation (Alderfer & Kazak, 2006). Family rituals such as celebrations, traditions, and patterned family interactions are an important part of family life (e.g., Wolin & Bennett, 1984). Family ritual meaning, the degree to which these events have shared significance for family members (Fiese, 1992), provides a sense of group belonging and identity (Fiese et al., 2002), and is associated with psychological well-being and adjustment for parents and their children, in general and specifically in pediatric health conditions (Crespo et al., 2013; Fiese et al., 2002, for reviews). Empirical studies of families with children suffering from asthma demonstrated that mothers’ family ritual meaning was associated with less anxiety in the child (Markson & Fiese, 2000), and that children’s family ritual meaning was linked to enhanced quality of life and fewer emotional and behavioral problems via high levels of family cohesion and low levels of conflict (Santos, Crespo, Silva, & Canavarro, 2012). Within the pediatric oncology literature, fewer family activities such as shared meals and bedtimes were associated with more depressive symptoms for parents (Manne, Lesanics, Meyers, & Wollner, 1995). When parents and children reported higher levels of family ritual meaning, they also reported more family cohesion and hope, which in turn were linked to better quality of life in family members (Santos, Crespo, Canavarro, & Kazak, 2015). These studies support the claim that family cohesion, the perception of the degree of commitment, help, and support that family members provide to each other (Moos & Moos, 1986), is one of the pathways by which family ritual is associated with adaptation (Fiese, 2006). In fact, family cohesion has been consistently associated with parents’ and children’s adjustment (e.g., Maurice-Stam, Oort, Last, & Grootenhuis, 2008; Varni, Katz, Colegrove, & Dolgin, 1996). Although there is a growing body of research attesting to the benefits of family ritual meaning and family cohesion for families of children with cancer, little is known about the predictors of these benefits or whether they are the same for parents and children.

Attachment is an important concept that has not been extensively studied in families of children with cancer. Attachment theory posits that in times of real or perceived threat endangering a person’s survival, the attachment behavioral system is activated (Bowlby, 1982). However, people differ systematically in the way they regulate distress and cope with threats and stressors (Mikulincer & Shaver, 2007). When a child is diagnosed with cancer, parents may seek security and protection from their partners as attachment figures (Hazan & Shaver, 1987) and use the romantic relationship as a safe haven in times of heightened stress (Burwell, Brucker, & Shields, 2006). However, in these situations, maladaptive patterns associated with insecure attachment (avoidant or anxious attachment) can also occur (Nicholls, Hulbert-Williams, & Bramwell, 2014). On the one hand, avoidantly attached individuals might adopt deactivating strategies, such as denial of attachment needs, because they distrust their partners’ goodwill and strive to maintain emotional distance and independence. On the other hand, anxiously attached individuals might adopt “hyperactivating” attachment strategies, such as insistent attempts to attain proximity and merge with the other person, because they worry that a partner will not be available and responsive in times of need (Mikulincer & Shaver, 2007). Considering the systemic model of attachment, insecure attachment can reduce the quality of couple relationships (Mikulincer, Florian, Cowan, & Cowan, 2002). These difficulties at the couple level can have ripple effects on other family systems and interfere with overall well-being. A systematic review of families with children suffering from cancer showed considerable variability in couple relationships: Whereas many parents consider their partners as their primary source of support and report that closeness can increase over time, this was not true for other couples (Long & Marsland, 2011). In addition, empirical studies have shown a link between marital satisfaction and family functioning (Crespo, Davide, Costa, & Fletcher, 2008; Pedro, Ribeiro, & Shelton, 2015). Given that parents’ romantic attachment affects the couple relationship, it is plausible to suggest that attachment may impact overall family and child functioning (Mikulincer & Shaver, 2007) and shape the ways in which families establish and maintain ritual interactions and family cohesion. This may be particularly relevant in the context of serious illness because the attachment behavioral system is more likely to be activated.

Empirical studies have provided support for the link between attachment security and family functioning, namely, family rituals and family cohesion. Leon and Jacobvitz (2003) concluded that adult attachment measured prior to the first child's birth with the Adult Attachment Interview (a semi-structured interview in which adults are asked to describe childhood relationships with their parents) was an important predictor of family ritual meaning seven years later in the newly formed family. A recent cross-sectional study focusing on preschool children’s food consumption found that adult attachment insecurity was associated with less frequent and planned family mealtimes and less communication during these occasions (Bost, Wiley, Fiese, Hammons, & McBride, 2014). With regard to romantic attachment, three cross-sectional studies with married couples showed that higher scores on avoidant attachment were associated with lower levels of family ritual meaning (Crespo et al., 2008) and lower levels of family cohesion (Mikulincer & Florian, 1999; Pedro et al., 2015) for both wives and husbands. Family ritual meaning reinforces family ties and cohesion (Fiese et al., 2002; Santos et al., 2012), so avoidantly attached individuals may feel less comfortable and be less willing to invest and become involved in these events (Crespo et al., 2008). Although anxious attachment to the romantic partner could be expected to interfere negatively with family functioning because people who score high on anxious attachment can, sometimes, have difficulties with interpersonal skills (Mikulincer & Shaver, 2007), empirical findings have been heterogeneous: two studies did not find a relationship between anxious attachment and family ritual meaning (Crespo et al., 2008) or family cohesion (Pedro et al., 2015); and one study found a positive association between anxious attachment and family cohesion (Mikulincer & Florian, 1999).

So far, no study has examined the links between parents’ romantic attachment and family ritual meaning and family cohesion in individuals in a pediatric health context. In families dealing with pediatric cancer, the parents experience a common threat, and treatment demands might lead to decreased contact with other attachment figures, making the romantic partner a more central person. Previous studies have found that in the context of a threat or stress, when people could benefit more from support, people high in avoidant and anxious attachment not only reported less available support but were also less satisfied with the support they received (Mikulincer & Shaver, 2007). Moreover, the influence of romantic attachment on family ritual meaning and family cohesion has generally been addressed via parents’ reports. We do not know whether children’s own perceptions of family ritual meaning and family cohesion are equally influenced.

The present study aims to extend previous findings by examining the longitudinal links between parents’ romantic attachment and family functioning in a specific condition of threat, distress, and uncertainty. More specifically, the present study examined whether avoidant and anxious attachments were linked to family ritual meaning and family cohesion for both parents and their children during treatment for pediatric cancer. We expected that higher levels of parents’ avoidant attachment at Time 1 (T1) would predict lower levels of family ritual meaning and family cohesion for both family members at Time 2 (T2). Given the inconclusive findings regarding the links between anxious attachment and whole-family variables, we tested these associations but made no predictions with regard to them. Additionally, based on previous studies showing that family ritual meaning promotes family cohesion, we proposed a mediation hypothesis: T1 avoidant or anxious attachment would predict T2 family ritual meaning, which in turn would be associated with T2 family cohesion for both family members.

Method

Participants and Procedures

This study was approved by the ethics committees of three Portuguese public hospitals: the Portuguese Institute of Oncology (IPO-Porto) and São João Hospital, both in Porto, and the Pediatric Department—Centro Hospitalar e Universitário de Coimbra in Coimbra. Between June 2012 and December 2013, all participants who met the inclusion criteria were invited to participate using a consecutive sampling approach. The inclusion criteria consisted of a diagnosis of pediatric cancer at least 3 months earlier; receiving treatment for a primary diagnosis or relapsed cancer; treatment duration expected for ≥9 months; aged 8–19 years; and parents in a relationship for at least 1 year before the study. Exclusion criteria for the child were comorbidity with other chronic illnesses (e.g., diabetes), major developmental disorders (e.g., Down syndrome), change in marital status (separation or divorce or ending of the relationship), and significant clinical change between the two time points (e.g., palliative care).

After a pediatric oncologist identified the eligible families, a research assistant asked family members to participate in a project to understand factors associated with well-being for families of children with cancer. Written informed consent was obtained from all parents and from children aged ≥13 years; assent was obtained from younger children. The parents and children were asked to individually complete paper-and-pencil versions of self-report measures in a separate room in either the inpatient or outpatient setting in the presence of a research assistant who ensured that the children and parents were unaware of each other’s responses. Of the eligible parent–child dyads approached to participate, all (N = 65) provided data at T1. At T2, 6 months after the first data collection procedure, all eligible participants (N = 58) were contacted to complete the follow-up assessment protocol. Seven dyads were excluded from the sample owing to the patient’s death (n = 6) or clinical change (n = 1) between T1 and T2.

In all, 58 Portuguese children with cancer and one of their parents1 (87.93% female) were enrolled in this study. At T1, the parents ranged in age from 31 to 56 years (M = 41.93; SD = 5.81), and the children ranged in age from 8 to 19 years (M = 12.88; SD = 3.40). The children were in treatment across the study’s two time points; at T1, an average of 11.21 months (SD = 17.65) had passed since the primary diagnosis. Sociodemographic and clinical characteristics of the sample are provided in Table I.

Table I.

Sociodemographic and Clinical Characteristics of the Sample at T1 (N= 58 dyads)

Parents’ and children’s characteristics n %
Parents
 Sex
  Male 7 12.07
  Female 51 87.93
 Marital status
  Married§ 52 89.66
  In a relationship 6 10.34
 Socioeconomic status
  Low 27 46.60
  Medium-high 31 53.40
Children
 Age-group
  Children (8–12 years) 24 41.38
  Adolescents (13–19 years) 34 58.62
 Sex
  Male 29 50.00
  Female 29 50.00
 Relapse status
  Nonrelapse 54 93.10
  Relapse 4 6.90
 Malignancy
  Leukemias 35 60.34
  Lymphomas 10 17.24
  Langerhans cell histiocytosis 1 1.72
  Solid tumor (noncentral nervous system) 9 15.52
  Central nervous system tumor 3 5.17
 Intensity of treatment
  Level 1: least intensive 1 1.72
  Level 2: moderately intensive 17 29.31
  Level 3: very intensive 31 53.45
  Level 4: most intensive 9 15.52
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Note. T1 = Time 1. §The majority (n = 50; 86.21%) were in a first marriage.

Measures2

Avoidant and Anxious Attachment

Parents’ romantic attachment was measured with the Portuguese version of the Experiences in Close Relationships–Relationship Structures Questionnaire (Fraley, Heffernan, Vicary, & Brumbaugh, 2011). Parents answered nine items related to their romantic relationship, six items assessing attachment avoidance (e.g., “It helps to turn to this person in times of need,” “I don’t feel comfortable opening up to this person”), and three items evaluating attachment anxiety (e.g., “I’m afraid this person may abandon me,” “I worry that this person won’t care about me as much as I care about him or her”) on a 7-point Likert scale. Four items were reversed, and mean ratings were calculated; higher scores denoted greater avoidant and anxious attachment. The original study showed a two-factor structure and Cronbach’s alphas of .81 for attachment avoidance and .83 for attachment anxiety (Fraley et al., 2011). Test–retest reliability for romantic attachment was approximately .65 over 30 days (Fraley, 2016). For this sample, internal consistency was .68 for avoidant attachment and .92 for anxious attachment.

Family Ritual Meaning

The children’s and parents’ perceptions of family ritual meaning were assessed with the Portuguese version of the Family Ritual Questionnaire (Fiese & Kline, 1993). Parents and children answered 15 forced-choice items covering family ritual meaning in three settings: dinnertime, weekends, and annual celebrations. Example items were “In some families, dinnertime is just for getting food/In other families, dinnertime is more than just a meal; it has special meaning”; “In some families, there are strong feelings at birthdays and other celebrations/In other families, annual celebrations are more casual; people aren’t emotionally involved.” The participants first chose the description that best represented their family and then decided whether that description was really true or sort of true. The four possible answers were scored using a 4-point Likert scale. A total score was computed by taking the average of the item scores, and higher scores indicated perceptions of stronger family ritual meaning. The internal consistency in the current sample ranged from .79 to .85 across respondents and time points (Table II).

Table II.

Means, Standard Deviations, Actual Range, Cronbach’s Alphas, and Intercorrelations Among Study Variables for Parents and Children

Variables Parents
 Children
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Parents
1. T1 avoidant attachment −
2. T1 anxious attachment .28* −
3. T1 family ritual meaning −.49** (−.47**) −.13 (.00) −
4. T2 family ritual meaning −.58** (−.54**) −.28* (−.15) .71** −
5. T1 family cohesion −.53** (−.51**) −.19 (−.05) .62** .58** −
6. T2 family cohesion −.69** (−.69**) −.12 (.10) .45** .58** .68** −
7. T1 age −.08 (−.11) .09 (.12) −.02 .11 .08 .10 −
8. T1 sex (male/female) .14 (.14) .01 (−.04) .01 −.05 −.20 −.14 −.03 −
9. T1 SES (low/medium-high) .01 (−.13) .07 (−.14) .05 −.02 .09 .12 −.23 −.13 −
Children
10. T1 family ritual meaning −.07 (−.02) −.17 (−.16) .39** .36** .27* .11 −.13 .06 −.02 −
11. T2 family ritual meaning −.34** (−.31*) −.17 (−.08) .55** .62** .46** .36** −.14 −.04 −.01 .73** −
12. T1 family cohesion −.28* (−.25∼) −.13 (−.06) .52** .41** .53** .31** −.08 .23 .02 .54** .54** −
13. T2 family cohesion −.46** (−.42**) −.22 (−.11) .56** .58** .56** .51** −.08 .01 .15 .37** .52** .63** −
14. T1 age −.20 (−.23) .08 (.14) .08 .17 .13 .19 .51** −.05 −.24 −.29* −.16 .05 .11 −
15. T1 sex (male/female) .07 (.10) −.07 (−.10) −.08 .01 .08 .04 .26* −.05 .04 .14 −.00 .22 −.04 .16 −
16. T1 time since primary diagnosis .23 (.19) .20 (.14) −.19 −.24 −.27* −.34** −.12 −.07 .09 −.10 −.11 −.20 −.36** .13 −.18
Cronbach’s alphas .68 .92 .85 .82 .89 .82 − − − .79 .83 .80 .83 − −
Means 2.27 1.97 3.33 3.35 5.00 4.95 41.93 − − 3.35 3.26 5.18 5.13 12.88 −
Standard deviations 0.99 1.40 0.56 0.49 0.84 0.73 5.81 − − 0.47 0.52 0.62 0.70 3.40 −
Actual range 1.00− 5.33 1.00− 7.00 1.53− 4.00 1.93− 4.00 1.89− 6.00 2.44− 6.00 31− 56 − − 2.40– 4.00 2.00– 4.00 3.22– 6.00 2.00− 6.00 8− 19 3– 108
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Note. T1 = Time 1. T2 = Time 2. Pearson and Spearman correlations. Values inside parentheses are partial correlation coefficients, controlling for avoidant or anxious attachment.

**p < .01; *p ≤ .05; ∼p < .06.

Family Cohesion

The children’s and parents’ perceptions of family cohesion were measured with the nine-item Family Cohesion subscale from the Portuguese version of the Family Environment Scale (Moos & Moos, 1986). The scale assessed the degree of family cohesion (e.g., “Family members help and support one another”). The participants responded using a 6-point Likert scale. Mean ratings were calculated, with higher scores indicating greater levels of family cohesion. The internal consistency in the current sample ranged from .80 to .89 across respondents and time points (Table II).

Intensity of Treatment

Intensity of treatment was measured by the Portuguese version of the Intensity of Treatment Rating Scale 3.0 (Kazak et al., 2012). Using data from medical records, a pediatric oncologist, blind to the patient’s identity, classified each child’s treatment into one of four levels of intensity, from levels 1 (least intensive treatment) to 4 (most intensive treatment), based on the diagnosis, phase of illness (new diagnosis or relapse), stage/risk level for the patient, and treatment modalities (Table I). Inter-rater reliability was k = .97 (Santos, Crespo, Canavarro, & Pinto, 2014).

Clinical and Socio-Demographic Characteristics

Additional clinical and sociodemographic characteristics (e.g., time since primary diagnosis, age) were collected from the parents. Socioeconomic status (SES) was measured according to an accepted classification system for the Portuguese context (Simões, 1994). Using data from both parents’ jobs (for nonactive workers, we used the last job) and educational level, the research assistant classified SES into one of the three levels, from level 1 (low) to level 3 (high), based on a standardized chart. Mean scores of SES were calculated between the two parents’ SES. For analysis purposes, SES was dichotomized into two levels: low and medium-high (Table I).

Data Analysis

The statistical analyses were conducted with the Statistical Package for the Social Sciences (SPSS, v. 21; IBM SPSS Inc., Chicago, IL). To test for significant changes across the two assessment points in family ritual meaning and family cohesion, we conducted two repeated-measures multivariate analyses of variance (RM-MANOVAs). Descriptive statistics and correlations were computed for all variables. Given that participants might endorse both the avoidant and anxious attachment characteristics (Bartholomew & Horowitz, 1991), we conducted partial correlations between parents’ avoidant attachment and the study variables, controlling for parents’ anxious attachment and vice versa. Then, we ran four hierarchical multiple regression analyses. These analyses examined longitudinal associations between T1 parents’ avoidant and anxious attachment and T2 parents’/children’s family ritual meaning or family cohesion, after controlling for T1 parents’/children’s family ritual meaning or family cohesion and covariate effects (variables significantly correlated with one of the dependent variables). The INDIRECT macro for SPSS provided by Preacher & Hayes (2004) was used to test our mediation hypothesis with four models. T1 parents’ avoidant or anxious attachment was the independent variable, T2 parents’/children’s family ritual meaning was the mediator, T2 parents’/children’s family cohesion was the outcome, and T1 parents’ avoidant or anxious attachment and T1 time since primary diagnosis were included as the covariates. The significance of the indirect effects was tested using bootstrapping, a nonparametric procedure that constructs a confidence interval for the indirect effects by computing the effects in 5,000 subsamples constructed with replacements. The indirect effects were considered significant when zero did not fall within the 95% confidence interval (95% CI). The alpha level was set at p < .05. Effect sizes for the correlational and hierarchical multiple regression analyses are reported (small: r ≥ .10, f2 ≥ .02; medium: r ≥ .30, f2 ≥ .15; large: r ≥ .50, f2 ≥ .35; Cohen, 1992).

Results

Preliminary Analyses

On average, the participants scored low in avoidant and anxious attachment and high in family ritual meaning and family cohesion (Table II presents means, standard deviations, actual range, and Cronbach’s alphas of the study variables). RM-MANOVAs revealed no significant multivariate effect of time on parents’ and children’s family ritual meaning, Wilk’s λ = .94; F(2,56) = 1.73, p = .19, and family cohesion, Wilk’s λ = .99; F(2,56) = 0.34, p = .71.

Small to large correlations were found among the main study variables at each time point (Table II). T1 parents’ avoidant and anxious attachment were significantly and positively correlated. T1 parents’ avoidant attachment was significantly and negatively correlated with T2 parents’/children’s family ritual meaning/family cohesion, after controlling for parents’ anxious attachment. T1 parents’ anxious attachment was negatively correlated with T2 parents’ family ritual meaning. However, after controlling for parents’ avoidant attachment, this association was no longer significant.

Hierarchical Multiple Regression Analyses

Four separate hierarchical multiple regression analyses were constructed to examine the combined contribution of T1 variables (time since primary diagnosis, parents’/children’s family ritual meaning/family cohesion, parents’ attachment dimensions) on T2 parents’ and children’s family ritual meaning and family cohesion (Table III). Preliminary analyses of the collinearity statistics in the regression models (tolerance values and variance inflation factor) showed that multicollinearity did not compromise the interpretability of the results.

Table III.

Hierarchical Multiple Regression Analyses for Variables Associated with T2 Parents'/Children' Family Ritual Meaning and T2 Parents'/Children' Family Cohesion

Dependent variable, steps, and predictor variables B SE B 95% CI Β F df R2
T2 parents’ family ritual meaning
 Step 1 3.29 1,56 .06
  T1 time since primary diagnosis −0.00 0.00 [−0.01, 0.00] −.05
 Step 2 29.56 2,55 .52***
  T1 parents’ family ritual meaning 0.49 0.09 [0.31, 0.67] .56***
 Step 3 19.37 4,55 .59***
  T1 parents’ avoidant attachment −0.13 0.05 [−0.23, −0.02] −.26*
  T1 parents’ anxious attachment −0.04 0.03 [−0.11, 0.02] −.12
T2 parents’ family cohesion
 Step 1 7.45 1,56 .12**
  T1 time since primary diagnosis −0.01 0.00 [−0.01, 0.00] −.14
 Step 2 26.91 2,55 .50***
  T1 parents’ family cohesion 0.36 0.09 [0.19, 0.53] .42***
 Step 3 23.91 4,55 .64***
  T1 parents’ avoidant attachment −0.34 0.07 [−0.49, −0.20] −.47***
  T1 parents’ anxious attachment 0.06 0.05 [−0.03, 0.15] .12
T2 children’s family ritual meaning
 Step 1 0.70 1,56 .01
  T1 time since primary diagnosis 0.00 0.00 [−0.01, 0.01] .02
 Step 2 31.89 2,55 .54***
  T1 children’s family ritual meaning 0.80 0.10 [0.61, 0.99] .72***
 Step 3 21.84 4,55 .62***
  T1 parents’ avoidant attachment −0.16 0.05 [−0.26, −0.07] −.31***
  T1 parents’ anxious attachment 0.01 0.03 [−0.05, 0.08] .04
T2 children’s family cohesion
 Step 1 8.24 1,56 .13**
  T1 time since primary diagnosis −0.01 0.00 [−0.02, 0.00] −.19
 Step 2 22.46 2,55 .45***
  T1 children’s family cohesion 0.58 0.11 [0.35, 0.81] .51***
 Step 3 14.20 4,55 .52***
  T1 parents’ avoidant attachment −0.18 0.07 [−0.33, −0.04] −.26*
  T1 parents’ anxious attachment −0.02 0.05 [−0.12, 0.08] −.05
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Note. T1 = Time 1. T2 = Time 2.

***p ≤ . 001; **p ≤ .01; *p < .05.

Parents’ Family Ritual Meaning and Family Cohesion

T1 parents’ avoidant, but not anxious, attachment was statistically significant and responsible for 7.6% of the additional variance of T2 parents’ family ritual meaning (Cohen f2 = .19), after controlling for T1 time since primary diagnosis and T1 parents’ family ritual meaning. For family cohesion, after controlling for T1 time since primary diagnosis and T1 parents’ family cohesion, T1 parents’ avoidant, but not anxious, attachment was statistically significant and explained 14.9% of the additional variance of T2 parents’ family cohesion (Cohen f2 = .41).

Children’s Family Ritual Meaning and Family Cohesion

T1 parents’ avoidant, but not anxious, attachment was statistically significant and was responsible for 8.5% of the additional variance of their family ritual meaning at T2 (Cohen f2 = .22), after accounting for T1 time since primary diagnosis and T1 children’s family ritual meaning. For family cohesion, after accounting for T1 time since primary diagnosis and T1 children’s family cohesion, T1 parents’ avoidant, but not anxious, attachment was statistically significant and responsible for 6.8% of the additional variance of T2 children’s family cohesion (Cohen f2 = .14).

Mediation Analyses

T2 parents’ family ritual meaning (point estimate = −0.10; CI = −0.26, −0.02) mediated the relationship between T1 parents’ avoidant attachment and T2 parents’ family cohesion, after accounting for T1 parents’ anxious attachment and T1 time since primary diagnosis (Figure 1a); the variance explained by the whole model was R2 = .57. T2 children’s family ritual meaning (point estimate = −0.09; CI = −0.20, −0.01) mediated the relationship between T1 parents’ avoidant attachment and T2 children’s family cohesion, after accounting for T1 parents’ anxious attachment and T1 time since primary diagnosis (Figure 1b); the variance explained by the whole model was R2 = .42. Finally, we tested two equivalent models, considering T1 parents’ anxious attachment as the independent variable. No indirect effects were found.

Figure 1.

Figure 1.

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(a and b) Models depicting the mediating effects of T2 parents’/children’s family ritual meaning on the links between T1 parents’ avoidant attachment and T2 parents’/children’s family cohesion, controlling for T1 parents’ anxious attachment and T1 time since primary diagnosis. Note. The values inside parentheses represent the independent variable’s direct effect on the dependent variable after controlling for the mediator. ***p < .001; **p < .01; *p < .05.

Discussion

This study provides a novel approach to an important issue in pediatric psychology research—the impact of parents’ romantic attachment on family functioning during children’s cancer treatment. The main finding was that the couple’s avoidant (vs. anxious) attachment was a unique risk factor for lower levels of family ritual meaning and family cohesion. Moreover, parents’ avoidant attachment influenced family cohesion both directly and indirectly via its impact on the meaning of family rituals. This finding is important because attachment style is related to emotional regulation and strategies for managing stress (Bowlby, 1982). In the context of the parents’ shared threat posed by a child’s cancer, romantic attachment style may impact family adjustment.

More avoidant attachment among parents predicted lower levels of family ritual meaning and family cohesion. Prior cross-sectional research found support for these relationships in normative contexts (Crespo et al., 2008; Mikulincer & Florian, 1999; Pedro et al., 2015). Because individuals higher on avoidant attachment may distrust their partners’ goodwill and strive to maintain emotional distance and independence (Bartholomew & Horowitz, 1991; Mikulincer et al., 2002), they might be less inclined to participate in family rituals (Crespo et al., 2008), events that promote affective expression and emotional support (Fiese, 2006). These individuals may be less likely to seek or give support (Simpson, Rholes, & Nelligan, 1992), which may help explain why they perceive family rituals occasions as less meaningful and their families as less cohesive. With regard to anxious attachment, it did not predict parents' family ritual meaning nor family cohesion in accordance with prior studies (Crespo et al., 2008; Pedro et al., 2015). Although the preliminary analysis suggested that anxious attachment could compromise family rituals, an in-depth examination of results demonstrated that avoidant attachment was a unique contributor to both decreased family ritual meaning and family cohesion.

Parents’ romantic attachment influenced not only the parents’ views of the family, but also their children’s. Parents who scored higher in avoidant, but not anxious, attachment had lower levels of family ritual meaning and family cohesion for patients. This is consistent with previous research showing that avoidant, but not anxious, attachment has a negative impact on parenting (e.g., child care perceived as a stressful experience; Rholes, Simpson, & Friedman, 2006) and child outcomes (Edelstein et al., 2004). It is possible that parents who are avoidantly attached may transmit a more casual attitude toward family rituals to their children. In addition, they may be less likely to demonstrate commitment, help, and support to family members. Furthermore, parents, especially mothers, are known to be “kinkeepers” of rituals, that is, the people who organize and take on the most responsibility for family rituals. When parents do not endorse family rituals, the intergenerational transmission of the meaning of these events may be diminished (Fiese, 2006).

Additionally, family ritual meaning was identified as a possible mechanism through which avoidant attachment may influence family relationships; when parents scored higher on avoidant attachment, they and their children reported lower levels of family ritual meaning and, subsequently, lower levels of cohesion. Individuals higher in avoidant attachment may have learned that others are not completely reliable (Hazan & Shaver, 1987); they might prefer not to open up to others (Mikulincer & Shaver, 2012) and might avoid situations that encourage intimacy, physical contact, communication, and reliance (Mikulincer &Shaver, 2007), which seem to be the basis for the formation of cohesive relationships (Mikulincer & Florian, 1999). When parents score higher on avoidant attachment, family rituals can be compromised, which can then impair family relationships, an argument in line with previous research showing that parents’/children’s family ritual meaning strengthens family ties (e.g., Fiese et al., 2002; Imber-Black, 2014).

Finally, family ritual meaning and family cohesion remained constant and high over a 6-month period for parents and children. This finding is in contrast to the idea that serious illness may disrupt family rituals and decrease cohesion because families are overwhelmed with the new demands imposed on family members (e.g., Imber-Black, 2014). These discrepant findings may be owing to the time of assessment in this study, given that at T1, an average of 11 months had passed since the primary diagnosis. It is possible that this time frame might be enough for the majority of the families to adapt to the new demands imposed by the condition and reinforce the ritual interactions and the cohesion within the family. Future studies anticipating T1 closer to the diagnosis can further clarify the issue of stability and change of family rituals and family cohesion in pediatric cancer.

This study, while providing novel information on families whose children have cancer, presents some limitations. Although family rituals are universal family events, it cannot be assumed that the current findings from a Portuguese sample are valid for families in other cultures. Because most parents were females, caution is needed when generalizing the findings. We do not know whether the links between attachment, family ritual meaning, and family cohesion are moderated by gender. Given that the parents in this study generally scored low on both dimensions of attachment, it is not known whether the results are generalizable to clinical samples. It is also possible that answering questions about family rituals and family cohesion at T1 prompted families to recognize and preserve the meaning of family rituals and cohesive relationships. This may also help explain the stability of family ritual meaning and family cohesion. In addition, it is possible that medium and small effects remained undetected with this modest sample size (cf. Cohen, 1992). The sample size was adequate to detect large and medium effects in the regression analyses, but not large enough to detect small effects.

Moreover, nearly half of the sample was composed of low SES families. Although a previous study indicated that SES does not seem to compromise the positive contribution of family rituals for adaptation (Santos et al., 2015), future research would benefit from a more heterogeneous distribution of SES levels. In addition, this study focused on romantic attachment. Future studies might expand the assessment of attachment to other relational domains to further understand the role of attachment in adjustment to pediatric cancer. Finally, because attachment styles are considered to be relatively stable throughout the life span (Bowlby, 1982), attachment was only measured once. Additional longitudinal studies are needed to corroborate the direction of causality between avoidant attachment and family ritual meaning and family cohesion.

The longitudinal findings have noteworthy clinical implications. Families in which parents are avoidantly attached may be deprived of the benefits of family rituals, such as group cohesion, support, or emotional expression (Fiese, 2006). For these families, psychological interventions designed to target attachment issues in couples can be useful. Recent findings with couples suggested that individuals significantly decreased in avoidant attachment after undergoing Emotionally Focused Couple Therapy (Burgess Moser et al., 2016). Additionally, our findings suggest that interventions may also focus on family rituals. Given that family rituals are potentially modifiable interactions, it is important to work with families to establish or reestablish rituals that fit their current circumstances (Buchbinder, Longhofer, & McCue, 2009; Roberts, 2003).

Overall, our results contribute to the growing body of studies (e.g., Crespo et al., 2008; Edelstein et al., 2004; Pedro et al., 2015) based on attachment theory that demonstrate the negative effects of avoidant (but not anxious) attachment in relational processes. This finding may be particularly relevant in the challenging context of pediatric cancer because people who scored high on avoidant attachment might tend to seek less support in increasingly anxiety-provoking situations (Simpson et al., 1992); hence, they and their children may be deprived of the benefits of family rituals and family cohesion when dealing with this adverse life event (Santos et al., 2015). Moreover, our findings strengthen the literature that suggests that family rituals can promote family cohesion (e.g., Fiese et al., 2002; Imber-Black, 2014). Specifically in pediatric cancer, given the close relationship between family functioning (e.g., family cohesion, family ritual meaning) and adaptation (e.g., Alderfer & Kazak, 2006; Maurice-Stam et al., 2008; Santos et al., 2015), it is crucial to identify factors that help to explain this relationship.

Funding

This research was supported by a PhD studentship (SFRH/BD/80777/2011) from the Portuguese Foundation for Science and Technology to the first author. Additional support for the preparation of this article was provided from K05CA128805 (Kazak) and the Nemours Center for Healthcare Delivery Science.

Conflicts of interest: None declared.

Acknowledgment

This article is one of the seven independent studies that were completed as part of Susana Santos’ doctoral dissertation at the University of Coimbra.

Footnotes

1 The participants were all biological parents. Of the 58 parents, the majority (n = 51) were in a relationship with their child's other biological parent.

2 All measures were previously validated in past studies following the guidelines for translating and validating assessment instruments in different countries. Once conceptual, item, semantic, and operational equivalences were established, the translation processes were performed, including translation and back-translation (Streiner & Norman, 2008). Finally, empirical studies allowed to assess the measurement equivalence between the Portuguese and the original versions of all the measures.

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