Abstract
Background:
Parkinson’s disease (PD) is one of the most common chronic, progressive neurodegenerative diseases, with well-developed research focusing on the caregiver-spouse showing low well-being along with predeath grief and feelings of loss among caregivers. However, offspring of a parent diagnosed with PD may also suffer predeath grief and loss even if they are not their parent‘s main caregiver. Yet, this research is not well developed.
Objective:
The objective of the current study was to examine offspring’s coming to terms with their parent’s PD and the well-being of the offspring, within the conceptual framework of attachment theory.
Methods:
Seventy-one Israeli adult children of parents with PD participated in the study and completed self-report questionnaires assessing their resolution of their parent‘s PD, attachment, well-being, and the severity of the PD symptoms.
Results:
Results showed that attachment anxiety negatively associated with higher resolution of the parent’s disease, beyond the effect of the PD symptoms’ severity. In addition, resolution of the parent’s disease was positively associated with the offspring‘s well-being.
Conclusion:
Resolution of a parent’s PD is highly challenging for offspring with attachment anxiety. Therefore, targeting these individuals within the offspring of parents diagnosed with PD may assist them with coping during this challenging period. This may be especially impactful, as research shows that those offspring who resolve their parent’s PD also have higher well-being.
INTRODUCTION
Parkinson’s disease (PD) is one of the most common chronic, progressive neurodegenerative diseases [1]. In industrialized countries, the estimated prevalence of PD is 0.3% in the general population, 1.0% in people older than 60, and 3.0% in people older than 80 [2]. PD’s motor symptoms are tremor, rigidity, slowness of movement (i.e., bradykinesia), impairment of the power of voluntary movement (i.e., akinesia), and postural instability [3]. It also has nonmotor symptoms (e.g., apathy, tiredness, depression, and anxiety), with up to 80% of people with PD showing cognitive impairment and developing dementia as the disease progresses [1], which further harm their well-being and that cause predeath grief and feelings of loss among their caregivers [4–6]. Most of the research to date regarding these feelings focuses on partners of persons with PD as caregivers. However, offspring also may suffer predeath grief and loss regarding their parents diagnosed with PD even if they are not their main caregivers. Yet, this research is not well developed, and broadening this research is essential for understanding offspring‘s coping strategies and their outcome. Hence, the aim of the current study is to examine these offspring’s resolution of their parent’s diagnosis with PD and the well-being of the offspring, within the conceptual framework of attachment theory.
Attachment
Attachment theory is the most influential framework for understanding close relationships, emotion regulation, and coping strategies [7, 8]. In Bowlby’s [9] terms, the attachment system functions as an inner resource during distress, leading people to maintain or restore proximity (actual or symbolic) to the attachment figure, who functions as a “safe haven” in times of need, providing support, comfort, and relief.
Proximity maintenance with significant others may alleviate distress and facilitate the development of positive beliefs about the self and about the other, shape a more optimistic outlook about life [8], and allow people to form an internalized “secure attachment,” leading them to use their effective emotion regulation strategies (e.g., reappraisal), turn to others to seek support, and use support effectively [10]. However, when significant others are unavailable or nonresponsive in times of need, proximity maintenance may elicit distress and encourage the formation of insecure attachment [10]. Two dimensions of such insecurity are avoidance (e.g., distrust of others and preferring self-reliance) and anxiety (e.g., worry that others will not be available when needed; anxiously looking for attention, love, and support).
Attachment-avoidant individuals tend to feel discomfort with emotional closeness and use a deactivating strategy of emotion regulation [11, 12]. When faced with potential or actual threatening events (e.g., separation or loss), they may practice denial; suppress their emotions and focus their attention on other issues; or withdraw and try to cope on their own, keeping out any feelings or thoughts that might threaten their highly developed sense of competence and independence [13, 14], seeking to prevent unwanted attachment needs [15]. These deactivating strategies may be adaptive in the short term, yet over time they may have a negative influence on well-being and contribute to emotional distress (e.g., [8, 16]).
Individuals with an anxious attachment style tend to be self-centered, worry about their own attachment needs, feel extremely distressed when other people need their assistance, and use a hyperactivating strategy of emotion regulation [8, 12]. This includes exaggeration of threats and hypervigilance to negative cues, emotions, and thoughts when confronted with challenging situations [8, 11] and may lead to the development of psychopathological symptoms such as depression and anxiety disorders (e.g., [17]).
Attachment relationships are typically shaped by the end of infancy, tend to be relatively stable over time [9], and play a significant role in a person’s life “from the cradle to the grave” [10, p. 129]. Thus, attachment relationships may be challenged by changes that occur during one’s lifespan [9], such as the serious illness of a parent that may enhance feelings of loss as the illness progresses and becomes more severe, provoking anticipatory grief [18].
Feelings of loss are painful and yet an inevitable part of life. Bowlby (1980) noticed that when adults lose or are separated from a significant other (parent, intimate partner, etc.), they show similar behavior to that of an infant’s reaction to separation from a parent. At first, the person seeks proximity with the significant other. As attachment needs are not fulfilled, emotional distress increases, and the person enters a mourning process, experiencing conflicting representations regarding the self, the significant other, and their relationships, influenced by the representations that existed prior to the loss and new representations that reflect the current reality.
In the case of successful resolution of a loss, these conflicting representations come to reflect the reality of the loss and become integrated within a single set of relatively nonconflicting representations. In the case of unsuccessful resolution, the individual is preoccupied with thoughts of the person they lost, is overwhelmed with negative emotions (e.g., depression, anxiety, etc.), or continues to exhibit detached behavior, while the conflicting representations continue to exist [9]. Attachment theory would suggest that, in the case of a parent’s diagnosis with a severe disease, where the offspring is experiencing the loss of the parent he or she had [18], the representations of the self, the parent, and their relationship that existed before the diagnosis need to be adjusted to and integrated with the representations of the “new” parent post-diagnosis.
The current study
The purpose of the current research is to examine the association between offspring’s resolution of a diagnosis of a parent with PD, attachment, and well-being of the offspring.
Research on the offspring of persons diagnosed with PD has not been fully developed. However, there has been relatively substantial research focusing on spouses of persons diagnosed with PD who report on changes in their well-being relative to their caregiving burden [19–21]. Further, research has shown that the severity of the PD and the presence of nonmotor symptoms (e.g., cognitive decline, delusions) predict spouses’ anticipatory and prolonged grief, as well as depression and a high caregiver burden [22, 23]. Lawson and colleagues [5] investigated the adjustment of partners of persons with PD and found their grief focused on how the disease was taking the spouse they had known from them—some referred to the spouse as already gone. The partner also felt helpless and overwhelmed being left to cope with great distress without the support of the partner (i.e., “safe haven”) they had prior to the diagnosis.
The current study suggests that attachment to a significant other (partner, parent, sibling, etc.) is an inner resource for better adjustment and coping [7, 8]; thus offspring‘s attachment to the parent would be associated with the offspring’s resolution of the parent’s diagnosis with PD. Individuals with insecure anxiety attachment would be anxiously overwhelmed by the diagnosis and their hypervigilance to negative cues would exaggerate threats and symptoms of the disease [8, 11], which eventually might bring about diminished well-being (e.g., [17]). For avoidant individuals, however, the findings will be less consistent, due to the avoidant individuals‘ subconscious tendency to keep emotions and cognitions separate [24]. Thus, insecure avoidant attachment would cause offspring to be more detached from the parent and therefore from their disease, keeping away feelings and thoughts that might threaten their own sense of competence [13, 14] and preventing unwanted attachment needs [15, 25]. Suppressing the reality of their parents‘ disease and the parents‘ new needs might be adaptive for the offspring for the first stages of their parent‘s disease. Yet, as the disease advanced and symptoms worsened, avoidant individuals would experience difficulties in further suppressing and effectively coping with the reality of their parent‘s disease and coming to terms with it, which might contribute to higher emotional distress and diminished well-being [8, 16].
Research hypotheses
H1: Attachment anxiety will be negatively associated with offspring’s resolution of their parent’s diagnosis with PD. The association between attachment avoidance to offspring’s resolution of their parent’s diagnosis with PD will not be significant.
H2: Offspring’s resolution of their parent’s diagnosis with PD will be positively associated with the offspring’s well-being.
I also explored whether the severity of the disease moderated the associations between the offspring’s resolution of their parent’s diagnosis and attachment anxiety.
Finally, I examined the prediction of the offspring’s well-being by their resolution of their parent’s diagnosis with PD and the offspring’s attachment insecurity.
MATERIALS AND METHODS
Participants
Participants in this study were 71 Israeli adult children of parents with PD. The average age of participants was about 40 years old (SD = 10.63) and 81.7% were female. The number of siblings in the participants’ families ranged from 0 to 6, with 32.8% of participants being the youngest child, 28.4% the middle child, and 38.8% the oldest child. About 20% of participants were from the same family. Over half of participants were married (58.6%), and most had a graduate/professional degree (88.6%). An average or above average income (average monthly income in Israel is approximately $2500) [26] was reported by 84.3% of participants.
Parents with PD were 71.51 years old on average (SD = 8.75), and 55% were male, 91.4% were married, 60% had a graduate/professional degree, and most lived close to the participant (73%). The number of years since their diagnosis was 8.91 on average (SD = 6.28), and their disease at the time of the study was at varying degrees of severity (M = 4.34, SD = 1.27) (see Table 1).
Demographic Data for Offspring and Parents (N = 71)
Procedure
Data were collected in a manner consistent with ethical standards for the treatment of human subjects, with an ethics committee approval (ID. 10/2019-1).
Offspring of parents diagnosed with PD, with the inclusion criteria of having both parents alive and a minimum of one year since the PD diagnosis, were invited through social media to participate in an online survey presented as “Well-being of adult children of a parent diagnosed with Parkinson’s Disease.” After signing a digital informed consent form, participants began the survey and were asked to complete the online questionnaire, which included a demographic questionnaire, the adapted version of Reaction to Diagnosis Questionnaire (RDQ), the Hoehn and Yahr Scale to assess the level of the parent’s disability and progress of symptoms, the Experiences in Close Relationships-Relationship Structures (ECR-RS), and WHO-5 Well-Being Index. Participants were informed that their anonymity would be preserved throughout the study and that they had the right to discontinue participation at any time. There were 18 additional participants who initially signed consent forms, but they filled out less than 20 items on the questionnaires and therefore were dropped from the study (there not being enough data from them to compare their characteristics with those who completed the questionnaires). There was no financial incentive for participating, but I offered to share the results of the study with the participants.
Instruments
Demographic questionnaire
Information about offspring participants was collected: Age, gender, education level, income level, marital status, number of siblings, and order of birth. Participants also reported on the age, gender, marital status, and education level of the diagnosed parent; the number of years since the parent’s diagnosis; and whether the participant lived nearby the parent.
Reaction to Diagnosis Questionnaire (RDQ) [27]
The RDQ is a 42-item self-report scale originally developed to assess parents’ resolution of their child’s diagnosis. Thirteen items represent resolution (e.g., “I believe that my family and I can cope with my child’s difficulties and help him/her”) and 29 items represent lack of resolution (e.g., “I believe that that my child’s diagnosis is incorrect”). Forty-one items on the scale were adapted to assess resolution of a parent’s PD diagnosis by their offspring (e.g., “I believe that my family and I can cope with my parent’s difficulties and help him/her” or “I believe that my parent’s diagnosis is incorrect”), and one irrelevant item was deleted (”My child is in an educational setting that is appropriate to his needs and abilities”). Participants were asked to address the statements using a 5-point Likert scale ranging from 1 (”strongly disagree”) to 5 (”strongly agree”). Items that represented lack of resolution were reversed and the average of all items was calculated, with higher scores reflecting higher resolution of parents’ PD. Internal consistency in the current research was 0.84.
The Hoehn and Yahr Scale [28]
The Hoehn and Yahr Scale is a well-validated measure of the progress of PD symptoms and the level of disability [29]. As originally published in 1967 in the journal Neurology by Melvin Yahr and Margaret Hoehn, it included stages 1 to 5. Since then, stage 0 has been added and stages 1.5 and 2.5 have been proposed and are widely used. The stages are: Stage 0 –No signs of disease; Stage 1 –Symptoms on one side only (unilateral); Stage 1.5 –Symptoms unilateral and also involving the neck and spine; Stage 2 –Symptoms on both sides but no impairment of balance; Stage 2.5 –Mild symptoms on both sides, with recovery when the “pull” test is given (the doctor stands behind the person and asks them to maintain their balance when pulled backwards); Stage 3 –Balance impairment, mild to moderate disease, physically independent; Stage 4 –Severe disability, but still able to walk or stand unassisted; and Stage 5 –Needing a wheelchair or bedridden unless assisted. In the current research, the participant was asked to rate their parent’s symptoms and abilities according to the parent’s treating physician’s most recent report.
Experiences in Close Relationships-Relationship Structures (ECR-RS) [30]
The ECR-RS is a nine-item self-report questionnaire designed to assess attachment orientation to four attachment figures—mother, father, romantic partner (current or former), and best friend—on two sub-scales: avoidance (”I don’t feel comfortable opening up to this person”) and anxiety (”I’m afraid that this person may abandon me”). Participants rated each of the items on a 7-point Likert scale from 1 (”strongly disagree”) to 7 (”strongly agree”). The average of attachment avoidance is calculated for items 1 to 6 (with items 1 to 4 reverse scored). The average of attachment anxiety is calculated for items 7 to 9. In the current research, attachment to mother and attachment to father were used. In the current research, internal consistencies were 0.86–0.87 for anxiety and 0.85–0.89 for avoidance. Based on mother and father scores, scores for attachment to parent with PD and to healthy parent (i.e., parent without PD) were created.
WHO-5 Well-Being Index
The WHO-5 is a self-report questionnaire (based on the WHO-10 Well-Being Index) [31, 32], covering five items related to positive mood (good spirits, relaxation), vitality (being active and waking up fresh and rested), and general interests (being interested in things). Each item is rated on a 6-point Likert scale from 0 (not present) to 5 (constantly present). Scores are summed, and then the scores are transformed to a 0–100 scale by multiplying by 4, with higher scores meaning better well-being. The Hebrew version of the WHO-5 has shown solid reliability (e.g., [33]). Internal consistency in the current research was 0.85.
Data analysis
Data were analyzed with SPSS ver. 25. Demographic data for the offspring and the parents were analyzed with frequencies and percentages and means and standard deviations. Internal consistencies were calculated with Cronbach α. Variable distributions were examined with the skewness values and their standard errors. As level of education, income, and severity of the disease were ordinal variables, Spearman correlations were calculated for them. RDQ (Reaction to Diagnosis Questionnaire), well-being, anxiety and avoidance in attachment were found to be normally distributed (Gaussian distribution- skewness=–0.28 to 0.47, SE = 0.28 to 0.31), and thus Pearson correlations were calculated for them.
A multiple regression was calculated to examine the moderating effect of the severity of the parent’s disease in the relationship between attachment anxiety and offspring’s resolution of diagnosis. Independent and moderator variables were standardized, and their interaction was entered last into the equation. Education level (child‘s and parent‘s) was controlled for. Another multiple regression was calculated to assess the contribution of the demographic variables and attachment insecurity to well-being. Due to the exploratory nature of the study and the relatively small sample, only variables that were found significant in the bivariate analyses were included. Thus, among the demographic variables, only the offspring’s income level was included, and was dichotomized as: 0 = below average and average level, 1 = above average level. As anxiety in attachment was highly interrelated between the sick parent and the healthy parent (r = 0.89 p < 0.001), anxiety in the relationship with the sick parent was used.
RESULTS
Spearman correlations between the RDQ score and the child’s education level and parent’s education level were positive and significant, revealing that a higher education level was related with a greater acceptance of the parent’s disease. Further, the RDQ score was negatively related with the level of severity of the disease, so that higher severity was related with a lower acceptance of the parent’s disease (see Table 2).
Spearman Correlations Between Total RDQ Score and Demographic Variables (N = 71)
A series of t-tests showed that the RDQ score was unrelated with child’s gender (p = 0.17), child’s marital status (p = 0.97), sick parent’s gender (p = 0.33), or sick parent’s marital status (p = 0.33). RDQ was unrelated to the geographical proximity of the child to the parent (p = 0.87) as well. Pearson correlations between the RDQ score and the child’ age or parent’s age were nonsignificant (p = 0.43 and p = 0.49, respectively), as were the correlations with number of siblings (p = 0.340) and the number of years since the diagnosis (p = 0.19).
H1: To examine the first hypothesis of the association between attachment insecurity (anxiety∖avoidance) and offspring’s resolution of their parent’s diagnosis with PD (RDQ score), a series of Pearson correlation tests were conducted. Results revealed significant negative correlations between attachment anxiety, with both the sick parent and the healthy parent, and RDQ score (r = –0.30, p < 0.01; r = –0.40, p < 0.001, respectively). Lower attachment anxiety associates with a greater acceptance of the parent’s disease. As hypothesized, there were no significant correlations between attachment avoidance and offspring’s resolution of their parent’s diagnosis with PD (see Table 3).
Pearson Correlations Between RDQ Score and Attachment (N = 71)
In order to examine the extent to which the level of severity of the parent’s disease moderates the relationship between offspring’s resolution of their parent’s diagnosis and attachment anxiety, a multiple regression was calculated. Offspring’s resolution of their parent’s diagnosis was the dependent variable; Anxiety in the relationship with the sick parent was used as the independent variable (as anxiety in attachment was highly interrelated between the sick parent and the healthy parent, r = 0.89, p < 0.001), and the severity of the parent’s disease was the moderator variable.
The interaction between the level of severity of the parent’s disease and attachment anxiety to the sick parent was not significant (β= 0.04, p = 0.756), revealing that attachment anxiety to the sick parent did not moderate the relationship between the level of severity of the parent’s disease and offspring’s resolution of their parent’s diagnosis.
H2: Preliminary to the examination of the second hypothesis of the association between the offspring‘s resolution of their parent’s diagnosis with PD and well-being, several tests were conducted. A Spearman correlation between offspring‘s income and well-being was found to be significant (r = 0.36, p = 0.002), revealing that a higher income level was related with higher well-being. A series of t-tests showed that well-being was unrelated with child’s gender (p = 0.15), child’s marital status (p = 0.55), sick parent’s gender (p = 0.71), or sick parent’s marital status (p = 0.077). Well-being was unrelated with the child’s or parent’s level of education (p = 0.26 and p = 0.26, respectively), geographical proximity of the child to the parent (p = 0.24), or level of severity of the disease (p = 0.26). Pearson correlations between well-being and the child’s or parent’s age were nonsignificant (p = 0.29 and p = 0.34, respectively), as were the correlations with number of children in the family (p = 0.17) and length of the disease (p = 0.33).
A Pearson test was then conducted between well-being and RDQ score, revealing a significant positive association (r = 0.42, p < 0.001), as the higher resolution of their parent’s diagnosis the higher the well-being (see Table 4).
Pearson Correlations Between Well-Being and RDQ Score and Attachment (N = 71)
Finally, a regression approach was applied to assess the relative contribution of the demographic variables and the attachment insecurity to well-being. Variables that were found significant in the bivariate analyses were included. Among the demographic variables, the offspring‘s income level was dichotomously used (0 = below average and average level, 1 = above average level). As anxiety in attachment was highly interrelated between the sick parent and the healthy parent (r = 0.89 p < 0.001), anxiety in the relationship with the sick parent was used. Results, as presented in Table 5, reveal that higher resolution of parent’s diagnosis, beyond income level, was related with higher well-being.
Multiple Hierarchical Regression for Well-Being
Adj. R2 = 0.21, F(3, 61) = 6.66, p < 0.001. B, unstandardized coefficient; SE, standard error of B; β, standardized coefficient; RDQ, Reaction to Diagnosis Questionnaire.
DISCUSSION
PD is one of the most common chronic and progressive neurodegenerative diseases [1], with an estimated prevalence of 0.3% in the general population, 1.0% in people older than 60, and 3.0% in people older than 80 [2]. Most of the research dealing with the mental effects of PD focuses on the individual diagnosed with PD and their caregiver-partner, and it shows that the partners of individuals with PD experience distress [19–21] and prolonged grief and helplessness during caregiving for the sick spouse, especially when confronting the nonmotor symptoms of PD, such as cognitive decline and delusions [5, 23]. However, research focusing on the adjustment and coping of offspring of persons with PD is lacking.
The aim of the current study was to examine offspring’s resolution of their parent’s diagnosis with PD and the well-being of the offspring, within the framework of attachment theory. The first part of the first hypothesis that attachment anxiety will be negatively associated with offspring‘s resolution of their parent’s diagnosis with PD was confirmed, as attachment anxiety was negatively correlated with offspring‘s resolution of their parent’s diagnosis. Furthermore, an examination of the moderation role of the severity of PD symptoms between attachment anxiety and offspring‘s resolution of their parent’s diagnosis with PD revealed that the association that was found was not affected by the severity of PD symptoms.
These results are compatible with prior research that showed that individuals with an anxious attachment style may show difficulties in adjustment [7] and tend to use a hyperactivating strategy of emotion regulation [8, 12], which includes exaggeration of threats and hypervigilance to negative cues, emotions, and thoughts when confronted with challenging situations [8, 11], such as having a significant other (parent, partner, etc.) with a severe disease. In the case of coming to terms with the parent‘s PD, offspring with attachment anxiety experience high emotional distress when their attachment needs are not fulfilled, and when conflicting (prior to diagnosis vs. subsequent to diagnosis) representations regarding the self, the sick parent, and their relationship emerged, they tended to be preoccupied with thoughts and feelings of the parent they had before the diagnosis, overwhelmed with negative emotions (anger, blame, etc.) and thoughts (e.g., “why me?”), and had difficulty integrating the representation of the “new” parent post-diagnosis and their new relationship in the context of the disease [9].
The second part of the first hypothesis that attachment avoidance will not be significantly associated with offspring‘s resolution of their parent’s diagnosis with PD was also confirmed. This result is consistent with the literature that argues that when individuals with attachment avoidance are faced a threatening event, they suppress their feelings and subconsciously keep away any thoughts that might threaten their highly developed sense of competence and independence [13, 24]. Therefore, when avoidant offspring are facing the diagnosis of a parent with PD, they will be more detached from the parent, the parent’s disease, and the parent‘s needs, preventing unwanted feelings and thoughts [15, 25], which affects their RDI self-report ratings. Yet, although this strategy might be adaptive for the offspring for the first stages of their parent‘s disease, as the disease advances and symptoms worsen, they might have difficulties in further suppressing their parent‘s disease and coming to terms with it [8, 16], as may be expressed in lower levels of RDI self-report ratings.
The second hypothesis that offspring‘s resolution of their parent’s diagnosis with PD will be positively associated with the offspring‘s well-being was fully confirmed.
As previously stated, research on the offspring of persons diagnosed with PD has not been fully developed. However, research has shown that intimate partners of individuals diagnosed with PD reported changes in their well-being (e.g., depression), burden [19–21], and anticipatory grief associated with the loss of the past relationship, the loss of the partner as the disease progressed and deteriorated, and the loss of future hopes and plans [5, 23]. In a successful process of resolution of the prolonged loss, the past, present, and future are integrated into a coherent set of representations that reflect the new reality and therefore lead to better well-being [9]. However, when having difficulty coming to terms with a parent’s disease, the offspring is overwhelmed with negative emotions (e.g., depression), showing low vitality. Nevertheless, it is important to note that lower well-being is not necessarily an outcome of difficulties with the resolution process of the disease but may be a normative stage of the ongoing resolution process. Finally, it is also possible that the well-being that characterized the offspring prior to the diagnosis may serve him or her in successfully resolving their parent’s PD.
Implications
Results indicated that coming to terms with their parent’s PD is highly challenging for offspring with attachment anxiety. Therefore, targeting these individuals within the offspring of parents diagnosed with PD may assist them with coping during this challenging period, especially while symptoms are deteriorating. It might be that interventions focused on emotion regulation could foster their ability to resolve their parent’s PD. This may be especially impactful, as research shows that those offspring who resolve their parent’s PD also have higher well-being.
The lack of significant association between attachment avoidance and resolution of a parent‘s PD emphasizes the need for better assessment of avoidant individuals’ coping strategies, bypassing the defense mechanism they use to cope with stressful experiences.
Limitations and future studies
The current study employed a cross-sectional design using self-report instruments and indirect assessment of the severity of the disease. Hence, it is impossible to disentangle whether offspring‘s well-being is the result of the resolution of their parent’s diagnosis or whether well-being increases the levels of resolution of a parent’s diagnosis. Further, due to the relatively small number of participants and the preponderance of female participants in the current study, any conclusions need further exploration. Finally, the RDQ was developed to assess parents‘ resolution with their child’s disease and was modified by the author for the current study; therefore, it may need further validation.
Future research should also address other aspects of the offspring’s life (e.g., marital satisfaction, intimate relationships, and their own parenting style) and include different methods of assessment (e.g., interviews). Also, this study revealed a positive association between education level and resolution. Future studies could examine whether targeted education and informational support regarding the disease and the parent’s treatment (such as educational programs, websites, support groups, etc.) could also be associated with better resolution. In addition, it could be interesting to associate the well-being and feelings of the patient with those of the offspring. Finally, the current study focused on a sample from a Western society that emphasizes the value of family intimacy and closeness. Therefore, generalization of the results to other cultural contexts might be difficult.
Footnotes
ACKNOWLEDGMENTS
I wish to thank Prof. Nir Giladi, Prof. Anat Mirelman, and Dr. Avner Thaler from the Tel Aviv Sourasky Medical Center (Ichilov) for their collaboration and consultation prior to and during this research. Also, I want to express my gratitude to all the participants in the study.
CONFLICT OF INTEREST
The author has no conflict of interest to report.