Parent mental health, optimism, intolerance of uncertainty, and perceived child symptom severity as predictors of parents future-oriented thinking

Lucy Harvey

Submitted for the Degree of

Doctor of Psychology

(Clinical Psychology)

School of Psychology

Faculty of Health and Medical Sciences

University of Surrey

Guildford, Surrey

United Kingdom

September 2016

Abstract

Objectives: Central to models of social recovery is the process of finding meaning in life whilst mental health symptoms remain. Critical to this is having hope and optimism for the future. To date, there has been little exploration of the application of recovery models to young people and their families. Research suggests parents of children with a mental health problem display uncertainty and pessimism about their childs future. The current study assessed factors related to parents ability to think about the future and whether they conceptualised positive or negative events in their childs future. This has potential importance in informing recovery-oriented practice for young people and their families.

Method: Participants were recruited through parenting websites and social media. 95 parents/carers of young people aged 3-18 completed online measures of perceived child symptom severity, parents internalising problems, optimism and intolerance of uncertainty. Perceived child symptom severity ranged from non-clinical to clinical levels of severity. Participants listed experiences they anticipated for their childs future and rated the likelihood of their child encountering a number of positive and negative life events.

Results: Parents who perceived their childs symptoms as more severe and those with higher intolerance of uncertainty and lower trait optimism rated future negative events as more likely, and future positive events as less likely. Parents of older children rated future negative events as more likely. Perceived child problem severity mediated the relationship between intolerance of uncertainty/optimism and negative/positive future thinking.

Conclusions: Findings have implications for the application of recovery models to young people and families. To facilitate the recovery dimension of hope and optimism for the future, psychoeducation may enhance parents optimism and reduce uncertainty, helping parents better understand their childs difficulties and their potential impact on the present and future.

Key Practitioner Message

Parents optimism and intolerance of uncertainty should be incorporated and explored in assessment and formulation.

Intervention should aim to enhance parents optimism and reduce uncertainty.

Psychoeducation may inform parents expectations of treatment and short- and long-term outcomes.

Acknowledgements

I would like to start by thanking my clinical supervisors. Each of my placement supervisors taught me something different about what it means to be a clinical psychologist and about what type of clinical psychologist I want to be. Their knowledge and passion for their work and clients inspired me throughout training. Thank you all for imparting some of your wisdom and knowledge onto me, for supporting me and for bearing with me through all of the placement paperwork. In particular, I would like to thank Dr Jane Willis. I am excited to be starting my journey as a newly qualified clinical psychologist with such a knowledgeable, hard-working and yet refreshingly human supervisor!

For inspiring me to want to be a clinical psychologist in the first place, I would like to thank Dr Beth Watkins and Dr Rachel Bryant-Waugh. I also have Professor Bryan Lask to thank for my enthusiasm for research, which has remarkably survived through the weekends and late nights of stats and re-drafting.

I would like to say a huge thank you to my research supervisor, Dr Laura Simonds, and co-supervisor Mary John. Your support, advice and expertise has been invaluable. It has been a pleasure to work with you both over the last three years.

Last but certainly not least, I am extremely lucky to have such amazing and supportive family and friends. I want to thank those closest to me for their endless support, for putting up with me and for keeping me human: Andy, Mum, Dad and Sophie, the Isle of Wight lot and the Chamberlains. To Frankie, Kristy and the Lol girls; Steph, Amy and Dani: Thank you for bearing with me, for moaning, laughing, and drinking with me. I am hugely grateful.

Contents

MRP Empirical Paper: Parent mental health, optimism, intolerance of uncertainty, and perceived child symptom severity as predictors of parents future-oriented thinking5MRP Proposal: The role of parent and young person factors in predicting parents conceptions of their childs future99Literature Review: Parents perceptions of their childs mental health problem: What can they tell us about recovery in young people?116Clinical Experience162Assessments165

MRP Empirical Paper Parent mental health, optimism, intolerance of uncertainty, and perceived child symptom severity as predictors of parents future-oriented thinking

Abstract

Objectives: Central to models of social recovery is the process of finding meaning in life whilst mental health symptoms remain. Critical to this is having hope and optimism for the future. To date, there has been little exploration of the application of recovery models to young people and their families. Research suggests parents of children with a mental health problem display uncertainty and pessimism about their childs future. The current study assessed factors related to parents ability to think about the future and whether they conceptualised positive or negative events in their childs future. This has potential importance in informing recovery-oriented practice for young people and their families.

Method: Participants were recruited through parenting websites and social media. 95 parents/carers of young people aged 3-18 completed online measures of perceived child symptom severity, parents internalising problems, optimism and intolerance of uncertainty. Perceived child symptom severity ranged from non-clinical to clinical levels of severity. Participants listed experiences they anticipated for their childs future and rated the likelihood of their child encountering a number of positive and negative life events.

Results: Parents who perceived their childs symptoms as more severe and those with higher intolerance of uncertainty and lower trait optimism rated future negative events as more likely, and future positive events as less likely. Parents of older children rated future negative events as more likely. Perceived child problem severity mediated the relationship between intolerance of uncertainty/optimism and negative/positive future thinking.

Conclusions: Findings have implications for the application of recovery models to young people and families. To facilitate the recovery dimension of hope and optimism for the future, psychoeducation may enhance parents optimism and reduce uncertainty, helping parents better understand their childs difficulties and their potential impact on the present and future.

Key Practitioner Message

Parents optimism and intolerance of uncertainty should be incorporated and explored in assessment and formulation.

Intervention should aim to enhance parents optimism and reduce uncertainty.

Psychoeducation may inform parents expectations of treatment and short- and long-term outcomes.

Introduction

In the last two decades, mental health service policy in the UK and other developed nations has increasingly emphasised the importance of recovery-focused care. The earliest conceptualisations of mental health recovery (otherwise termed personal or social recovery) on which current policy is based, involved developing meaning and purpose in life despite the presence of continuing mental health symptoms (Anthony, 1993; Deegan, 1988). This conceptualisation of recovery has been contrasted with the more traditional notion of complete recovery, referring to the elimination of psychiatric symptoms and a return to normal functioning (Warner, 2004). Based on an extensive review of the mental health recovery literature, Leamy, Bird, Le Boutillier, Williams and Slade (2011) proposed that social recovery encompasses five processes or dimensions: connectedness; hope and optimism about the future; identity; meaning in life and empowerment (collectively known as CHIME). They described the dimension of connectedness as seeking support from others and being involved in the community. Hope and optimism for the future included having a belief in the possibility of recovery and positive thinking, with value placed on success. Identity referred to overcoming stigma and developing or rebuilding a positive sense of self. Meaning included both making sense of ones experiences of mental ill health as well as finding meaningful social roles and goals. Finally, empowerment referred to focusing on individual strengths and taking control of ones life.

The concept of recovery in mental health is thought to have arisen from the survivor movement in the 1980s and 1990s (Stickley & Wright, 2011). This movement was concerned with advocacy of people who use mental health services and their increased choice in treatment decision-making (Chamberlin, 1995). This resulted in early ideas of recovery, centering on acceptance of the social impact of mental ill health and development of a new sense of ones meaning and purpose (Anthony, 1993; Deegan, 1988). These ideas have since been adopted and applied to mental health service policy in the United Kingdom (Daley, Newton, Slade, Murray, & Banerjee, 2013; Shepherd, Boardman, & Burns, 2010). Despite recovery being a policy imperative in mental health services across the lifespan, to date there has been little critical examination of the extent to which the recovery model might be translated and applied in services for young people and their families (Friesen, 2007; Simonds, Pons, Stone, Warren, & John, 2013; Ward, 2014). In the first empirical study on this topic in the UK, Simonds et al. (2013) found that mothers of young people treated in child and adolescent mental health services (CAMHS) had difficulty envisaging a central aspect of mental health recovery: that a meaningful life is possible with symptoms and that symptom eradication is not the only goal of intervention. This finding is important because mental health services for children and adolescents work closely with parents and carers, given they are considered to be the most knowledgeable advocates in a young persons care (Penzo & Harvey, 2008). Furthermore, parents understandings of mental health problems and their potential impact are likely to shape young peoples own understanding (Simonds et al., 2013). As such, Simonds et al. (2013) and Ward (2014) argued that the social recovery model, given that it had been developed principally from the accounts of adult service users, could not be applied simply and uncritically to services for young people. Furthermore, it should be considered not only in relation to young people alone but also their family members, due to the social nature of recovery. Parents and carers opinions are therefore considered integral in the development of mental health services for young people (Ward, 2014). Understanding parent conceptions of their childs mental health and recovery will be critical to developing recovery-oriented services for young people and to engage families in them.

A review of parents perceptions of their childs mental health problems (Harvey, 2015) indicated that parental conceptions were consistent with some aspects of existing models of recovery, such as the importance of connectedness, achieved through parental involvement in treatment (Fraser & Warr, 2009; Riley, Stromberg, & Clark, 2009; Wahlin & Deane, 2012). However, the review concluded that parents demonstrate much pessimism with regards to their childs future (Ahuja & Williams, 2010; Cotton et al., 2013; Corcoran et al., 2007; Karp & Tanarugsachock, 2000; Mohr & Regan-Kubinski., 2001; Oldershaw, Richards, Simic, & Schmidt, 2008), with parents expressing grief at the prospect of long term or ongoing symptoms, (Corcoran et al., 2007) and the potentially resulting stigma (Corcoran et al., 2007; Mohr & Regan-Kubinski, 2001; Ward, 2014). This is supported by Penzo and Harvey (2008) who attempted to explain parents conceptions of mental health problems within the Kubler-Ross grief model (1969). They suggested that following a crisis, which they described as either a psychiatric emergency for the child or failure of the child to meet a developmental milestone as expected, parents enter into a cycle of grief. They described parents moving from denial, then anger, to bargaining, followed by a period of depression and finally acceptance. They proposed that, if a further crisis arose, parents re-entered this cycle (Penzo & Harvey, 2008), suggesting that acceptance was temporary and therefore not representative of the social recovery notion of acceptance that symptoms may remain. Furthermore, research focusing on parents conceptions of their adult sons and daughters mental health difficulties found that parents were concerned about the future independence of their child (Johansson, Anderzen-Carlsson, hlin, Andershed, & Skndal, 2012; Wane, Larkin, Earl-Gray, & Smith, 2009).

The current study is therefore concerned with examining factors that might influence how parents conceptualise their childs future. The concept of future oriented-thinking itself has been explored extensively in the literature. A number of different aspects of future-oriented thinking have been outlined, including the ability to think about the future, extension of thinking into the future, orientation towards future goals and the valence of future events (De Volder & Lens, 1982; Lewin, 1948; Nurmi, 1991; Trommsdorff, 1983; Trommsdorff, Burger, & Fuchsle, 1982). The development of hope for the future is a central component of mental health recovery models (Leamy et al., 2011). The current study focused on future-thinking in terms of both ability to conceptualise the future and the valence of future-thinking (i.e. the perceived likelihood of positive or negative events occurring in the future).

Importantly, the review by Harvey (2015) concluded that hope and optimism about the future and about future quality of life, central components in recovery models (Leamy et al., 2011; Resnick, Fontana, Lehman, & Rosenheck, 2005), are potentially influenced by a number of factors. One of these factors is the perceived severity of the childs symptoms (Harvey, 2015). Research has suggested that parents think more negatively about the future when their childs mental health symptoms are perceived to be more severe (Ma, Lai, & Pun, 2002; Riley et al., 2009), as they perceive their childs quality of life might be permanently diminished by their mental health difficulties (Corcoran et al., 2007) and their childs dreams for the future might not be fulfilled (Karp & Tanarugsachock, 2000). However, to date, research has not explored further the relationship between parents perceptions of the severity of their childs symptoms and the valence of their future-thinking. Given that parents conceptions of their childs future have been found to shape young peoples thoughts about their own future (Zhu, Tse, Cheung, & Oserman, 2014), understanding the factors that influence parents conceptions of the future is important.

An additional factor highlighted in the literature as potentially influencing parents future-oriented thinking is child age. In their qualitative study which recruited fathers of young people with a mental health problem, Fraser and Warr (2009) suggested participants expressed more hope about the future if the child was younger when receiving treatment, whilst there was more uncertainty around the future independence of older children (Fraser & Warr, 2009). Additionally, in their study of young people diagnosed with Major Depressive Disorder and their mothers, Kiss et al. (2007) found that reports of symptom severity increased with their childs age. Taken together, these findings suggest that perceived symptom severity might mediate the relationship between child age and the valence of parents future-thinking such that older children are perceived to experience more severe problems which, in turn, is related to less positive future-thinking.

In addition to young person factors such as age and perceived symptom severity, parent factors are also important to consider in understanding differences in future-thinking, both in terms of ability to think about the future and the valence of future-thinking. Previous research has suggested that internalising problems, such as anxiety and depression, impede individuals ability to think about their own future (OConnor, Connery, & Cheyne, 2000; MacLeod & Byrne, 1996). In addition, Kiss et al. (2007) found that parents with higher self-reported levels of depression conceptualised their childs problem as more severe. Although negative thoughts about the future are a key feature in depression (Beck, 1979), the relevance of parents internalising problems and the valence of their future-thinking in relation to their childs future has not been explored in the literature to date. However, previous research has linked depression and hopelessness with envisaging fewer positive events in the future (MacLeod, Pankhania, & Mitchell, 1997; MacLeod, Rose, & Williams, 1993). Taken together with the suggestion that perceived problem severity may impact on parents future-oriented thinking (Corcoran et al., 2007; Karp & Tanarugsachock, 2000; Ma et al., 2002; Riley et al., 2009), these studies indicate that perceived child symptom severity might mediate the relationship between parents internalising problems and their future-thinking. Parents internalising problems should, therefore, be considered when understanding differences in parents future-thinking.

Studies of children with a physical illness, such as cancer (e.g. Fotiadou, Barlow, Powell, & Langton, 2008) further support the idea that parents with higher levels of internalising problems perceive their childs problem as more severe. Additionally, in the same study, Fotiadou et al. (2008) found that parents with higher trait optimism perceived their childs cancer symptoms as less severe. Optimism has been explored in detail in the literature with regards to future-thinking (e.g. DArgembeau & Van der Linden, 2004). Optimism about the future is a key feature of adult models of social recovery (Leamy et al., 2011) but has received little exploration within the mental health literature in relation to parents thinking about their childs future. A review of future-thinking literature highlighted the link between adolescents optimism and perceived positive achievements in the future (Nurmi, 1991), with lower levels of optimism associated with less hope for the future. Optimism has also been suggested to be related to the ability to generate thoughts about the future in more detail (DArgembeau & Van der Linden, 2004). To date, this has not been explored in terms of how parents think about their childs future. Therefore, parental optimism is a factor to consider in relation to parents perceptions of the severity of their childs symptoms and is also likely to be important in terms of both parents ability to think about the future and the valence of their future-thinking.

The literature further suggests that the ability of parents to tolerate uncertainty might play a role in explaining individual differences in the conceptualisation of their childs future. Intolerance of uncertainty refers to the need for security or control of outcomes or situations (Dugas, Freeston, & Ladouceur, 1997). Someone who is high in intolerance of uncertainty will, when faced with an uncertain situation, tend to exaggerate risk and the likelihood of negative outcomes. Because of this they may be less able to think flexibly or consider alternatives to the negative outcome. The fathers in Fraser and Warrs (2009) study reported feelings of uncertainty about the future for their child with a mental health problem. Although uncertainty itself may not be problematic, how the parent manages the uncertainty might impact on how they understand and manage their childs mental health problem. For example, a parent who is higher in intolerance of uncertainty may be more likely to worry about their child, which in turn could impact on their own and their childs wellbeing. In support of this, Sanchez, Kendall and Comer (2016) found that parents with higher intolerance of uncertainty were more likely to make negative inferences about events in their childs life and that this in turn affected how their child thought about these events. In addition, individuals who are less able to tolerate uncertainty have been found to display some rigidity in their thinking (Dugas et al., 1997) and therefore may have a limited ability to conceptualise the future. This suggests that intolerance of uncertainty might be related to how parents conceptualise their childs problem, as well as both their ability to think about the future for their child and the valence of their future-thinking.

The current study was therefore concerned with exploring the factors that predict parents future-thinking, including both their ability to think about the future for their child and the valence of their future-thinking. The study aimed to assess both components of parents future-thinking and to establish whether parent factors, such as internalising problems, optimism and intolerance of uncertainty, and child factors, such as age and perceived symptom severity, predict variability in parents future-thinking. The findings might inform the understanding of differences in parents conceptions of the future for their child. This, in turn, might inform recovery-oriented practice with young people and families and their potential engagement with mental health recovery.

Hypotheses

In this study, hypotheses were tested based on two ways of assessing future-thinking: ability to think about the future (i.e. projecting forward to anticipate events that might happen) and the valence of future-thinking (i.e. projecting forward to estimate the likelihood that specific positive or negative events might happen in the future).

It was hypothesised that parent perceived rating of their childs symptom severity would be positively correlated with negative future-thinking (i.e. would estimate a high likelihood of negative future events) and negatively correlated with positive future-thinking (i.e. would estimate a low likelihood of positive future events).

In line with Fraser and Warrs (2009) findings, child age was expected to be negatively correlated with positive future-thinking.

Parents internalising problems were hypothesised to be negatively correlated with their ability to conceptualise their childs future, in line with research suggesting anxiety and depression impede the ability to think about the future (OConnor et al., 2000; MacLeod & Byrne, 1996). Additionally, it was hypothesised that parent internalising problems would be related to the valence of future-thinking (MacLeod et al., 1997; Macleod et al., 1993), such that internalising problems would be positively correlated with parents ratings of the likelihood of occurrence of negative future events and negatively correlated with the likelihood of positive future events.

Parental optimism was proposed to be positively correlated with their ability to think about the future (DArgembeau & Van der Linden, 2004). Optimism was also proposed to be positively correlated with future-thinking for positive events and negatively correlated with future-thinking for negative events. This hypothesis is in line with the literature around optimism and future-oriented thinking (Nurmi, 1991), which is yet to be explored in relation to parents thoughts about their childs future.

Parents intolerance of uncertainty was proposed to be negatively correlated with their ability to think about their childs future, as intolerance of uncertainty might reflect rigidity in parents thinking and an inability to think beyond negative consequences (Dugas et al., 1997). Intolerance of uncertainty was therefore also hypothesised to be associated with valence of future-thinking in that it would be positively correlated with parents ratings of the likelihood of negative future events and negatively correlated with the likelihood of positive future events.

It was hypothesised that perceived child symptom severity and child age would predict variance in the valence of parents future-thinking. Parents optimism, intolerance of uncertainty and internalising problems were also hypothesised to predict variance both in terms of parents ability to think about the future and the valence of their future-thinking.

The evidence reviewed above suggests that child age (Fraser & Warr, 2009), parent internalising problems (OConnor et al., 2000; MacLeod & Byrne, 1996), optimism (Fotiadou et al., 2008; Nurmi, 1991) and intolerance of uncertainty (Sanchez et al., 2016) all relate to both perceived child symptom severity and future-thinking. Perceived symptom severity may also have an impact on the valence of parents future-thinking (Ma et al., 2002; Riley et al., 2009). Therefore, perceived symptom severity was tested as a mediator of the relationship between child age, parent internalising problems, optimism, intolerance of uncertainty, and the valence of parents future-thinking. It was hypothesised that the relationship between parent and child factors (child age, parents intolerance of uncertainty, parents internalising problems and parents optimism), and the valence of parents future-thinking, would be mediated by the perceived severity of the childs symptoms.

Method

Design

The study employed a cross-sectional survey design in order to understand how parents conceptualised their childs future. Future-thinking was operationalised in two ways: ability to think about the future (i.e. projecting forward to anticipate events that might happen) and valence of future-thinking (i.e. projecting forward to estimate the likelihood that specific positive or negative events might happen in the future). Predictors of future-thinking included child symptom severity as perceived by the parents, child age, parent internalising problems, optimism and intolerance of uncertainty. The survey used for the study was developed in Qualtrics survey software (Qualtrics, 2015) and could be accessed remotely and completed electronically.

Participants

Participants were parents or carers of young people, recruited from online parent forums and via parenting pages on social networking platforms. To ensure recruitment of participants with children perceived to have varying severity of mental health symptoms, advertising on mental health pages on social networking sites was also employed.

Participants were deemed eligible for the study if they were over the age of 18 and a parent or carer of a young person between the ages of 3 and 18 years. This was thought to represent the ages of childhood, without including infancy, and was additionally thought to be a representative age range for generic and specialist Child and Adolescent Mental Health Service (CAMHS) populations, for which the study aimed to derive potential service delivery implications. For the current study, participants were not recruited from formal treatment services due to the multiple barriers to families accessing CAMHS treatment described in much of the child and adolescent literature (Harvey, 2015). These barriers may have proved problematic in the recruitment of participants and in addressing the hypotheses for the current study. Additionally, recruitment of a non-clinical sample allowed for findings to be applied to a population of young people and their families more broadly, and not only to those families where the child had an identified mental health problem.

To preserve independence of observations, the information for participants specified that only one parent/carer per family should complete the survey (Appendix B). Parents with more than one child were asked to complete the study only for their oldest child, as it was thought that parents future-thinking about younger offspring could be shaped by the achievements of their older children (Himelstein, Graham, & Weiner, 1991). Participants had to be registered with, or accessing, one or more of the online platforms from which recruitment took place, such as a parents forum or a social networking site. Parents perceptions of their childs symptom severity was measured on a continuous scale to capture a range of presentations from non-clinical to potentially higher, clinical levels of severity. Although recruitment via parenting websites and social media might represent some bias in relation to socioeconomic status, gender or cultural background in the sample, this method was deemed the most viable strategy to recruit a sufficient sample to the study.

A priori sample size calculations based on correlation analyses between parent and child factors and parents future-thinking variables, with a medium effect size of .30 at 80% power (alpha .05, 2-tailed), suggested a sample size of N=90 was required (Clark-Carter, 1997). Multiple regression analyses to establish the extent to which parent and child factors predict parents future-thinking, with five predictors, for a medium effect size of R2=.13 at 80% power (alpha = .05), suggested a sample size of N=80-100 (Clark-Carter, 1997). Finally, to establish whether child symptom severity mediated the relationship between parent and child factors and the valence of parents future-thinking, a sample size estimate was derived using Fritz and MacKinnons (2007; p14) table of empirically based sample sizes for mediation analyses. This table suggested that, for a moderately robust mediation analysis, between N=90 to N=196 participants were needed for 80% power with a medium effect size (.26-.39). Fewer participants were suggested to be needed for more robust methods in mediation analysis (such as bootstrapping) and significantly more participants were suggested to be required for less robust methods, such as the Baron and Kenny method (Fritz & MacKinnon, 2007). As at least a moderately robust method was planned to be used for the mediation analysis in the current study, a minimum sample of N=90 participants was required for the study.

Measures

Parents future-thinking. This was assessed in two ways: a) parents ability to conceptualise the future (i.e. projecting forward to anticipate events that might happen) and b) the valence of their future-thinking (i.e. projecting forward to estimate the likelihood that specific positive or negative events might happen in the future).

In order to measure parents ability to conceptualise their childs future, participants were asked to list the future experiences they conceive for their child, without cues or prompts. They were asked to list as many of these as possible until they could not think of any more (Appendix C). The total number of words used and the total number of items listed provided two indices of parents ability to conceptualise their childs future, with more words used or items listed representing greater ability to conceptualise the future. A similar method was used previously by Trommsdorff et al. (1982) to assess adolescents ability to conceptualise their own future and by Malmberg, Ehrman and Lithen (2005) to assess both parents and young peoples future-thinking.

To assess the valence of parents future-thinking, they completed a future life events questionnaire. The questionnaire used in the current study included both positive (e.g. Having a happy long term relationship) and negative future events (e.g. Becoming homeless) and was adapted from similar life events scales (Holmes & Rahe, 1967; Kanner, Coyne, Schaefer, & Lazarus, 1981), including those designed for research related to the perceived future impact of smoking (McKenna, Warburton, & Winwood, 1993) and for non-clinical populations (Lench, Quas, & Edelstein, 2006). Following Trommsdorff et al.s (1982) method, participants were asked to rate the likelihood that each item on the inventory would be realised by their child, on a scale of 0 (impossible) to 100 (certain) (Appendix D). Higher scores on individual items indicated parents perception that these events would be more likely to happen for their child.

Intolerance of uncertainty: Intolerance of Uncertainty Scale (IUS; Buhr & Dugas, 2002). The IUS is a 27-item self-report questionnaire assessing the degree to which individuals believe that uncertainty has negative implications (Sexton & Dugas, 2009; Appendix E). Each item is scored on a scale of 1 (Not at all characteristic of me) to 5 (Entirely characteristic of me), with a maximum total score of 135. Higher total scores indicate greater levels of intolerance of uncertainty. The IUS has been widely used, including with non-clinical parent participants (Buhr & Dugas, 2002; De Bruin, Rassin, & Muris, 2007). It has previously demonstrated good internal consistency (=.94) and testretest reliability (r=.74) and convergent and divergent validity when assessed with symptom measures of worry, depression, and anxiety (Buhr & Dugas, 2002). For the current study, the scale yielded a Cronbachs alpha of =.95.

Parents internalising problems: Depression, Anxiety and Stress Scale Short form (DASS-21; Lovibond & Lovibond, 1995). The DASS-21 is a 21-item self-report questionnaire measuring depression, anxiety and stress on three 7-item scales (Appendix F). The extent to which respondents have experienced each state over the past week is rated on four-point scales, ranging from zero (Did not apply to me at all) to three (Applied to me very much). Higher scores indicate higher levels of anxiety, depression and stress. Cronbachs alphas for the scales have previously been reported as .95 .93 and .97 respectively (Henry & Crawford, 2005). Due to the likely multicollinearity between the anxiety, depression and stress subscales in the regression analyses, an aggregate total score representing parents internalising problems was used. This method has been used in previous research with parents (e.g. Pennell, Whittingham, Boyd, Sanders, & Colditz, 2012). Cronbachs alpha for the aggregate score in the current study was =.92.

Parents trait optimism: Life Orientation Test - Revised (LOT-R; Scheier, Carver, & Bridges, 1994). Parents trait optimism was measured using the Life Orientation Test Revised (Appendix G), a 10-item self-report questionnaire with items rated on a scale from 0 (strongly disagree) to 4 (strongly agree), with three items that are reverse scored. The total score is calculated by adding six of the ten items together. The remaining items are filler questions in the revised version of the scale (Scheier et al., 1994). Scores range from 0-24, with higher scores indicating higher levels of trait optimism. The measure has been widely used in adult populations, including parents of children with health problems (Fotiadou et al., 2008). The measure has previously shown acceptable internal reliability (=.68, Glaesmer et al., 2012) and a testretest correlation of .68 over four months (Scheier et al., 1994). A Cronbachs alpha of =.86 was found in the current study.

Young persons symptom severity: Pediatric Symptom Checklist (PSC; Jellinek et al., 1988). The PSC is a 35-item parent-report measure of young peoples cognitive, emotional and behavioural symptom severity (Appendix H). Items are scored on a scale of zero (Never) to two (Often). A total score of up to 70 is calculated by adding together the score for each of the 35 items, with higher scores indicating greater parent perceived psychological impairment in young people from preschool age to 18 years (Jellinek, Patel, & Froehle, 2002a; Jellinek, Patel, & Froehle, 2002b; Little, Murphy, Jellinek, Bishop, & Arnett, 1994; Pagano et al., 1996). A cut-off score for clinical severity has been suggested to be 24 for pre-school age children and 28 for children from age 6 (Little et al., 1994; Pagano et al., 1996) Internal consistency has been previously found to be good (=0.89; Reijneveld, Vogels, Hoekstra, & Crone, 2006). Cronbachs alpha for the current study was =0.91.

Demographics. Parents and carers were asked to provide demographic details for themselves and their child, including their age, gender and ethnicity and whether they have experienced a mental health problem in the past (Appendix B). They were also asked to detail their highest level of education and their occupation in order to establish participants simplified socioeconomic classification (Office of National Statistics, 2010).

Procedure

The study was delivered using Qualtrics survey software (Qualtrics, 2015). An electronic link to the survey was posted on online parent forums, on Twitter and on mental health social networking pages, with a brief description of the studys aims (Appendix I). Parents and carers following the electronic link were led to the online information sheet (Appendix J), providing full details of the studys aims, eligibility criteria and what was required of participants if they chose to consent to the study. Participants were informed that the estimated completion time for the study was approximately 30 minutes. The survey was piloted beforehand to establish this. Participants were also informed that all their answers would be anonymous.

Parents wishing to participate in the study were asked to provide consent electronically (Appendix K), before beginning the online questionnaires. Once completed, or if participants declined consent, a final page thanked them for accessing the survey and provided links to relevant resources if they wished to seek further support (Appendix L). Data were collected via Qualtrics survey software and downloaded into SPSS Version 22. Data files were stored electronically on password-protected PCs and an encrypted memory stick. All data were analysed quantitatively using SPSS Version 22.

Ethics

Ethical dimensions considered included participant anonymity and confidentiality, participant distress and storage of data. To address the issue of anonymity, participants were not asked for their name and, as the study was conducted over an online platform, it was not possible to identify participants. This method meant that anonymity was considered to be incorporated in the design as participants could not be identified by researchers. In order to address the risk of potential distress to participants, due to the sensitive subject matter addressed by the study, the information sheet advised potential participants that the study would ask them to think about their own and their childs mental health. This meant that those who might have found this distressing could choose not to participate. Furthermore, information was included at the end of the online survey, directing participants who may have experienced distress or wished to seek further help, to sources of support such as mental health charities, or their GP (Appendix L). Protection of the integrity of the data was also considered and in order to address this, data were handled and stored according to governance requirements.

The information sheet for participants included the supervisors contact details, in case participants wanted to raise any other concerns in relation to the research. The study received ethical approval from the Faculty of Arts and Human Sciences Ethics Committee at the University of Surrey (Appendix M).

Data Analysis

Participants were not included in the analysis if they did not complete the survey to the end, as not completing all measures was assumed to represent removal of consent.

Kolmogorov-Smirnov tests and inspection of histograms and skew and kurtosis were used to test the normality of the variables in correlation analyses. Assumptions of normality were checked for the purpose of the regression analyses by assessing the distribution of the residuals. Linear multiple regression analysis was used to determine the degree to which child problem severity, child age, parents optimism, parents intolerance of uncertainty and parents internalising problems predicted variance in parents future-thinking. Hayes PROCESS macro (Hayes, 2012) was used to test the mediation hypothesis.

Results

Participant Characteristics

Of the 346 people who accessed the survey, 103 (29.7%) completed all online measures. Of these 103, 95 (92.2%) met inclusion criteria. Eight completers did not meet inclusion criteria on the basis of their childs age. Therefore, the total final sample in the analysis comprised 95 participants (See Figure 1). Characteristics of the final sample are displayed in Tables 1 and 2.

Table 1

Characteristics of the Sample for Continuous Demographic Variables

Eligible completers

Child Age

N

95

Mean(SD)

11.79(4.09)

Median

12.15

Parent Age

N

94a

Mean(SD)

43.38(7.80)

Median

44.07

a N does not equal total sample N because one participant did not supply a response to the question

Of the 95 eligible completers, 75 (78.9%) were mothers, 19 (20%) were fathers and 1 was a female carer (aunt). Sample age ranged from 35 to 60 years (Mean = 43.48, SD = 7.80). Participants were parents or carers of 46 girls and 49 boys aged from 3 to 18 years (Mean = 11.79, SD = 4.09).

Figure 1. Flowchart of participant drop-out. This figure illustrates the recruitment and drop-out of participants to the study, including participants retained in the final sample.

Table 2

Characteristics of the Sample for Categorical Demographic Variables

Eligible completers

Child Gender

Male

N

49

Percentage

51.6%

Female

N

46

Percentage

48.4%

Parent Gender

Male

N

19

Percentage

20.0%

Female

N

76

Percentage

80.0%

Parent Education

Age 16 or below

N

5

Percentage

5.3%

A levels or equivalent

N

21

Percentage

22.1%

Degree/ Diploma

N

37

Percentage

38.9%

Post-graduate

N

32

Percentage

33.7%

Has mental health (MH) history

None

N

66

Percentage

69.5%

Parent

N

25

Percentage

26.3%

Child

N

2

Percentage

2.1%

Parent & child

N

2

Percentage

2.1%

Ethnicity a

White British/ Irish/Other

N

89

Percentage

94.7%

Mixed White/Black African/ Black Other

N

4

Percentage

4.2%

Mixed White/Asian

N

1

Percentage

1.1%

a N does not equal total sample N because one participant did not supply a response to the question

The majority of participants described themselves and their children as White British (See Table 2), were educated to degree or diploma level, and were mostly classified within the Lower Professional/Higher Technical category of occupation (50.5%) (Office of National Statistics, 2010). The majority of participants reported no prior history of mental health problems for themselves or their child. Whilst just over a quarter of parents who completed the study reported a history of mental health problems, very few children were reported to have had a mental health problem. However, Pediatric Symptom Checklist scores ranged from 1-50, therefore capturing a range of presentations from non-clinical to higher, clinical levels of symptom severity.

Development of Future-Thinking Questionnaire Scores

Factor analysis. The suitability of all future thinking items for exploratory factor analysis was assessed in order to establish whether future thinking items should be assessed together or as separate positive and negative future thinking scales. As the item scores were not normally distributed, a Principle Axis Factoring method was used (Costello & Osborne, 2005). Inspection of the correlation matrix revealed the majority of coefficients to be .3 and above (Pallant, 2010) and the Kaiser-Meyer-Olkin (KMO) value was .84, exceeding the recommended value of .6 (Kaiser, 1974). In addition, Bartletts Test of Sphericity (Bartlett, 1954) reached statistical significance. However, the ratio of participants to items was approximately 4:1, which below the ratio recommended for factor analysis (Costello & Osborne, 2005). Principle Axis Factoring for all items revealed the presence of six components with eigenvalues exceeding 1, explaining 32.2%, 11.6%, 7.0%, 6.4%, 5.2% and 4.8% of the variance respectively. An inspection of the scree plot revealed a break after the second component and it was therefore decided two components would be retained for further investigation. The two-component solution explained a total of 43.8% of the variance and demonstrated simple structure (Thurstone, 1947), whereby loadings on each factor where maximised, with minimal cross-loadings. As the factor analysis of all items was limited in terms of its sample size, and initial exploration of all items separated positive and negative items into separate factors, exploratory factor analyses were therefore carried out separately on the positive and negative future events items to investigate whether it was viable to aggregate all positive items (11 items) into one scale and all negative items (12 items) into another, in order to generate total positive and negative future events scores for the purpose of the analysis. Factor matrices for factor analyses of all items, and positive and negative items separately, are presented in Appendix N.

The suitability of the positive future event data for factor analysis was assessed beforehand. Inspection of the correlation matrix revealed the majority of coefficients to be .3 and above (Pallant, 2010) and the Kaiser-Meyer-Olkin (KMO) value was .82, exceeding the recommended value of .6 (Kaiser, 1974). In addition, Bartletts Test of Sphericity (Bartlett, 1954) reached statistical significance. There was a ratio of approximately 8:1 participants to items, which was considered consistent with recommendations for factor analysis (Costello & Osborne, 2005). Inspection of item communalities found only one item below .3 (Having an outstanding personal achievement), suggesting that this item should not be retained (Pallant, 2010). The factor analysis for the positive future events revealed the presence of three components with eigenvalues exceeding 1, explaining 40.3%, 13.9% and 9.4% of the variance respectively. Following examination of the scree plot, one component was retained for further investigation. The one component solution explained 40% of the variance and revealed the presence of a simple structure (Thurstone, 1947), in which all variables loaded strongly on the one component with no cross-loadings. Therefore no interpretable solution beyond a single factor was yielded. =

For the negative future event data, there was a ratio of approximately 7:1 participants to items, which was considered to be acceptable (Costello & Osborne, 2005). Inspection of the correlation matrix revealed the majority of coefficients to be .3 and above (Pallant, 2010) and the Kaiser-Meyer-Olkin (KMO) value was .84, exceeding the recommended value of .6 (Kaiser, 1974). In addition, Bartletts Test of Sphericity (Bartlett, 1954) reached statistical significance. Inspection of item communalities found one item below .3 (Being made redundant), suggesting that this item should not be retained (Pallant, 2010). The factor analysis for the negative future events revealed the presence of two components with eigenvalues exceeding 1, explaining 45.1% and 12.4% of the variance respectively. Following examination of the scree plot, one component was retained for further investigation. The one component solution explained 45% of the variance and revealed the presence of a simple structure (Thurstone, 1947), showing strong loadings on one component and minimizing cross-loadings, again demonstrating no interpretable solution beyond a single factor. =

Internal consistency. Cronbachs alpha was .83 for the positive future events and .88 for the negative future events. This further supported aggregating items to derive total positive and negative event scores.

Positive future events items and their item-total statistics are displayed in Table 3. Consistent with the assessment of item communalities above, inspection of item-total correlations suggested removal of one item (Having an outstanding personal achievement), due to its item-total correlation being less than .3 (Pallant, 2010). Removal of this item resulted in an increased Cronbachs alpha of .85. This item was therefore removed for the purpose of computing a total positive future events score.

Table 3

Item-Total Correlations and Cronbachs Alpha If Item Deleted for Positive Future Events Items

Item

Item-total correlation

Cronbachs alpha if item deleted

Getting their first job

.51

.82

Getting a promotion at work

.48

.82

Completing education

.45

.82

Being financially stable

.66

.80

Getting married

.46

.82

Having a family of their own

.57

.81

Holding an occupation

.62

.80

Having a happy long-term relationship

.59

.81

Having their first romantic relationship

.54

.81

Moving into their own home

.66

.80

Having an outstanding personal achievement

.16

.85

Negative future events items and their item-total statistics are displayed in Table 4. Consistent with the examination of item communalities above, inspection of item-total correlations for this scale suggested removal of one item (Being made redundant), as its item-total correlations were lower than those of the other items at .32 (Pallant, 2010). The Cronbachs alpha for the scale was slightly increased by the removal of this item to .89. This item was therefore removed for the purpose of computing a total negative future events score.

Table 4

Item-Total Correlations and Cronbachs Alpha If Item Deleted for Negative Future Events Items

Item

Item-total correlation

Cronbachs alpha if item deleted

Developing a chronic health condition

.48

.88

Being a victim of violence

.55

.88

Dropping out of education

.69

.87

Getting a divorce/separation

.44

.88

Getting a sexually transmitted infection

.71

.87

Using illicit drugs

.61

.87

Having an unwanted pregnancy

.70

.87

Becoming homeless

.71

.87

Going to prison

.62

.87

Being made redundant

.32

.89

Being sacked from work

.64

.87

Being in serious debt

.59

.87

Normality Testing

Kolmogorov-Smirnov tests indicated the distribution of all variable scores, except intolerance of uncertainty scores, was significantly different from a normal distribution. Due to the sensitivity of this test in detecting even small deviations from normality, particularly in larger samples (Tabachnick & Fidell, 2007), this test was supplemented with visual inspection of histograms (Appendix O) and interpretation of skew and kurtosis values.

Following inspection of boxplots and 5% trimmed means for outliers that might be influencing the data (Pallant, 2010), one participant was removed from the analysis (N=94).

All variables except child age were found through interpretation of skew and kurtosis statistics not to be normally distributed and so Spearmans Rho correlations were used throughout. Effect sizes for correlation and regression analyses were interpreted with reference to Cohen (1988). Details of descriptive statistics and skew and kurtosis values are displayed in Table 5.

Table 5

Descriptive Statistics and Normality Information for the Sample Included In the Analysis (N=94)

Mean (SD)

Median

Interquartile Range

Skewness Z-scorea

Kurtosis Z-scoreb

Child Age

11.77 (4.11)

12.03

7.18

-.58

-2.53

Negative Future Events

21.05 (16.80)

16.59

20.32

6.55*

7.70*

Positive Future Events

82.24 (13.28)

85.25

15.38

-3.79*

.83

Count of Future Events

9.90 (9.43)

7.50

7.00

10.88*

17.75*

Word Count of Future List

41.37 (38.70)

26.50

28.75

7.33*

5.76*

Paediatric Symptom Checklist (PSC)

15.07 (9.80)

14.00

12.25

4.70*

3.39*

Depression, Anxiety and Stress Scale (DASS-21)

10.64 (8.85)

9.00

11.00

5.15*

3.34*

Optimism: Life Orientation Test Revised (LOTR)

15.11 (4.56)

16.00

6.00

-2.80*

.21

Intolerance of Uncertainty (IUS)

56.24 (19.17)

54.50

26.25

2.69*

.10

aSkewness z-score calculated by skewness divided by standard error of skewness; bKurtosis z-score calculated by kurtosis divided by standard error of kurtosis.

*Denotes z-scores above upper cut-off of 2.58/below lower cut-off of -2.58, suggesting variables are not normally distributed (Field, 2005; p72).

To assess normality for the purpose of checking assumptions for the regression analyses, normality of residuals was assessed (Field, 2013) and were not found to be markedly skewed (Appendix P). Assumptions of sample size, linearity, multicollinearity and homoscedasticity were met for the regression analyses (Pallant, 2010).

Factors Associated with Future-Thinking

Perceived child symptom severity (Table 6). As hypothesised, Pediatric Symptom Checklist (PSC) scores were found to be significantly positively correlated with negative future events scores with a large effect size. PSC scores were significantly negatively correlated with positive future events scores with a moderate to large effect size. There was not found to be an association between PSC scores and other future-thinking variables.

Table 6.

Spearmans Correlations between Perceived Child Symptom Severity and Future-Thinking Variables (N=94)

Correlation coefficient

Sig (2-tailed)

95% CI

Negative future events

.51

p