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Measuring family communication in pediatric nursing: Psychometric properties of the Parent-Child Communication Scale – Child Report (PCCS-CR)

Open AccessPublished:November 16, 2021DOI:https://doi.org/10.1016/j.pedn.2021.10.022

      Highlights

      • Enhancing parent-child communication is an important outcome in pediatric nursing.
      • Few well-documented parent-child communication measures exists.
      • The Parent-Child Communication Scale (PCCS) is one such measure.
      • We confirmed the factor structure of the PCCS.
      • And established convergent validity against a measure of parent-child relationship.

      Abstract

      Purpose

      Communication quality is an essential indicator of family functioning and represents an important outcome after pediatric nursing interventions. However, few well-documented child-report questionnaires for family communication exist. We aimed to document the psychometric properties of a previously developed child-rated family communication scale for use in pediatric nursing.

      Design and methods

      We examined the Parent-Child Communication Scale – Child Report (PCCS-CR) in terms of factor structure, convergent validity against the Experiences in Close Relationships-Relationship Structures scale (ECR-RS), and known-groups validity between a sample of siblings of children with pediatric health conditions and controls. The sample comprised 101 siblings of children with a pediatric health condition and 44 controls (M age = 11.5 years, SD = 2.2).

      Results

      We confirmed a two-factor structure of the PCCS-CR. One factor is communication from the child to the parent, labelled child communication (e.g., “I discuss problems with my parents”) and the other is communication from the parent to the child, labelled parent communication (e.g., “My parent is a good listener”). Convergent validity of the PCCS-CR was demonstrated through correlations with ECR-RS (r = −0.73 to −0.22, p ≤ .05). Further, construct validity through differences between families with and without a child with a pediatric health condition was demonstrated (g = 0.36–0.83, p ≤ .052).

      Conclusion

      The PCCS-CR appears to be a psychometrically sound measure of parent-child communication from the child's point of view.

      Practical implications

      The PCCS-CR can be administered in pediatric nursing care and can be used to target and measure the outcomes of interventions aimed at enhancing family functioning.

      Keywords

      Family communication is a fundamental part of the parent-child relationship. Parent-child communication starts in infancy, when children communicate to their parents through crying and their parents respond (more or less accurately) to their needs (
      • Acebo C.
      • Thoman E.B.
      Role of infant crying in the early mother-infant dialogue.
      ). This communication marks the beginning of an attachment process during which children and their parents reciprocally influence each other to create a parent-child relationship of great importance for later mental health and well-being (
      • McCarty C.A.
      • McMahon R.J.
      Mediators of the relation between maternal depressive symptoms and child internalizing and disruptive behavior disorders.
      ). Family communication represents an important outcome of several pediatric nursing interventions. This is because children's communication about their emotions and experiences, and parents' responses to this communication, are related to how children cope with difficulties (
      • Schrodt P.
      • Witt P.L.
      • Messersmith A.S.
      A Meta-analytical review of family communication patterns and their associations with information processing, behavioral, and psychosocial outcomes.
      ). Specifically, parental acceptance and encouragement in parent-child communication are associated with more use of social support and problem-solving coping strategies in children, whereas lack of these quality indicators in parent-child communication is associated with more mental health difficulties (
      • Chiariello M.A.
      • Orvaschel H.
      Patterns of parent-child communication: Relationship to depression.
      ;
      • Gentzler A.L.
      • Contreras-Grau J.M.
      • Kerns K.A.
      • Weimer B.L.
      Parent–child emotional communication and Children’s coping in middle childhood.
      ). Further, lower quality parent-child communication is related to adolescent alcohol and tobacco use, risky sexual behavior, and suicide attempts (
      • Ackard D.M.
      • Neumark-Sztainer D.
      • Story M.
      • Perry C.
      Parent-child connectedness and behavioral and emotional health among adolescents.
      ;
      • Riesch S.K.
      • Anderson L.S.
      • Krueger H.A.
      Parent–child communication processes: Preventing children’s health-risk behavior.
      ;
      • Ryan S.M.
      • Jorm A.F.
      • Lubman D.I.
      Parenting factors associated with reduced adolescent alcohol use: A systematic review of longitudinal studies.
      ).
      In the current study, we focus particularly on parent-child communication in families of children with pediatric health conditions, using siblings as informants. A pediatric health condition is defined herein as congenital enduring conditions impairing functioning, with no known cure for the core features (
      • Vermaes I.P.R.
      • van Susante A.M.J.
      • van Bakel H.J.A.
      Psychological functioning of siblings in families of children with chronic health conditions: A Meta-analysis.
      ). In general, family functioning, including parent-child communication, in families of children with pediatric health conditions has been found to affect the well-being and mental health of all family members, including parents and siblings of the child with a pediatric health condition (
      • Fossen C.A.V.
      • Wexler R.
      • Purtell K.M.
      • Slesnick N.
      • Taylor C.A.
      • Pratt K.J.
      Family functioning assessment and child psychosocial symptoms in family medicine.
      ;
      • Haukeland Y.B.
      • Czajkowski N.O.
      • Fjermestad K.W.
      • Silverman W.K.
      • Mossige S.
      • Vatne T.M.
      Evaluation of “SIBS”, an intervention for siblings and parents of children with chronic disorders.
      ;
      • Lee A.
      • Knafl G.
      • Knafl K.
      • Riper M.V.
      Parent-reported contribution of family variables to the quality of life in children with down syndrome: Report from an international study.
      ;
      • Liu P.-P.
      • Yin P.
      • Zhu Y.-H.
      • Zhang S.
      • Sheng G.-M.
      The correlation of family resilience with sleep quality and depression of parents of children with epilepsy.
      ).
      • Murphy L.K.
      • Murray C.B.
      • Compas B.E.
      Topical review: Integrating findings on direct observation of family communication in studies comparing pediatric chronic illness and typically developing samples.
      recently reviewed studies of communication in families of children with a pediatric health condition. They found that the communication was characterized by lower warmth and more hostility and withdrawal compared with families of children without a pediatric health condition. The factors outlined by
      • Murphy L.K.
      • Murray C.B.
      • Compas B.E.
      Topical review: Integrating findings on direct observation of family communication in studies comparing pediatric chronic illness and typically developing samples.
      can be considered quality indicators of parent-child communication. Factors like hostility, negative affectivity, withdrawal, criticism, and inconsistency characterized poor quality parent-child communication, whereas other factors such as warmth, engagement, acceptance, structure, and openness characterized high quality parent-child communication (
      • Murphy L.K.
      • Murray C.B.
      • Compas B.E.
      Topical review: Integrating findings on direct observation of family communication in studies comparing pediatric chronic illness and typically developing samples.
      ,
      • Murphy L.K.
      • Preacher K.J.
      • Rights J.D.
      • Rodriguez E.M.
      • Bemis H.
      • Desjardins L.
      • Compas B.E.
      Maternal communication in childhood Cancer: Factor analysis and relation to maternal distress.
      ). Thus, parent-child communication is of uttermost importance within families of children with pediatric health conditions.
      Of particular importance for siblings, open and emotionally supportive communication between parents and siblings of children with a pediatric health condition has been found to be important for siblings mental health and well-being (
      • Haukeland Y.B.
      • Czajkowski N.O.
      • Fjermestad K.W.
      • Silverman W.K.
      • Mossige S.
      • Vatne T.M.
      Evaluation of “SIBS”, an intervention for siblings and parents of children with chronic disorders.
      ;
      • Mitchell A.E.
      • Morawska A.
      • Vickers-Jones R.
      • Bruce K.
      A systematic review of parenting interventions to support siblings of children with a chronic health condition.
      ;
      • Murphy L.K.
      • Murray C.B.
      • Compas B.E.
      Topical review: Integrating findings on direct observation of family communication in studies comparing pediatric chronic illness and typically developing samples.
      ). Siblings of children with pediatric health conditions are at higher risk of psychosocial difficulties like depression, anxiety, and behavioral problems than other children (
      • Schamong A.S.
      • Liebermann-Jordanidis H.
      • Brockmeier K.
      • Sticker E.
      • Kalbe E.
      Psychosocial well-being and quality of life in siblings of children with congenital heart disease: A systematic review.
      ;
      • Shivers C.M.
      • Jackson J.B.
      • McGregor C.M.
      Functioning among typically developing siblings of individuals with autism Spectrum disorder: A Meta-analysis.
      ;
      • Vermaes I.P.R.
      • van Susante A.M.J.
      • van Bakel H.J.A.
      Psychological functioning of siblings in families of children with chronic health conditions: A Meta-analysis.
      ). As a consequence of their brother's or sister's pediatric health condition, siblings have to deal with many emotionally challenging experiences (
      • Haukeland Y.B.
      • Fjermestad K.W.
      • Mossige S.
      • Vatne T.M.
      Emotional experiences among siblings of children with rare disorders.
      ). Difficulties in expressing emotions and poorer parent-child communication have been found to predict mental health difficulties among siblings (
      • Long K.A.
      • Lobato D.
      • Kao B.
      • Plante W.
      • Grullón E.
      • Cheas L.
      • Seifer R.
      Perceptions of emotion expression and sibling–parent emotion communication in Latino and non-Latino white siblings of children with intellectual disabilities.
      ). On the opposite side, emotionally supportive communication with parents have been found to be protective of sibling mental health difficulties (
      • Haukeland Y.B.
      • Czajkowski N.O.
      • Fjermestad K.W.
      • Silverman W.K.
      • Mossige S.
      • Vatne T.M.
      Evaluation of “SIBS”, an intervention for siblings and parents of children with chronic disorders.
      ;
      • Incledon E.
      • Williams L.
      • Hazell T.
      • Heard T.R.
      • Flowers A.
      • Hiscock H.
      A review of factors associated with mental health in siblings of children with chronic illness.
      ). Moreover, emotionally supportive mother-sibling communication has been found to be related to sibling strengths such as prosocial behavior (
      • Orm S.
      • Haukeland Y.
      • Vatne T.
      • Silverman W.K.
      • Fjermestad K.
      Prosocial behavior is a relative strength in siblings of children with physical disabilities or autism Spectrum disorder.
      ).
      Because of the enduring and often incurable nature of many pediatric health conditions, pediatric nurses often need to focus on family dynamics and processes in their interventions. In order to assess family processes and measure relevant outcomes, psychometrically sound measures of family communication are needed. In fact, a meta-analysis of effective components in parent-training programs found that components targeting parent-child interactions and parent skills in emotional communication were associated with larger intervention effects (
      • Wyatt Kaminski J.
      • Valle L.A.
      • Filene J.H.
      • Boyle C.L.
      A Meta-analytic review of components associated with parent training program effectiveness.
      ). Further, recent studies targeting parent-sibling communication in families of children with pediatric health conditions have found improvements in both sibling and parental mental health (
      • Fjermestad K.W.
      • Pat P.
      • Dearozet S.
      • Vatne T.
      • Hafting M.
      • Jegannathan B.
      Manual-based group intervention for siblings and parents of children with neurodevelopmental disorders in Cambodia.
      ;
      • Haukeland Y.B.
      • Czajkowski N.O.
      • Fjermestad K.W.
      • Silverman W.K.
      • Mossige S.
      • Vatne T.M.
      Evaluation of “SIBS”, an intervention for siblings and parents of children with chronic disorders.
      ). This underscores the importance of including parent-child communication training in pediatric nursing interventions for families.
      Family communication can be measured by observation, and some observational measures of parent-child communication have been validated (e.g.,
      • Murphy L.K.
      • Preacher K.J.
      • Rights J.D.
      • Rodriguez E.M.
      • Bemis H.
      • Desjardins L.
      • Compas B.E.
      Maternal communication in childhood Cancer: Factor analysis and relation to maternal distress.
      ). However, observational measures are time- and labor consuming, making them impractical for clinical practice and intervention research. Thus, self-report measures represent an important supplement. In terms of self-report, both parents and children can rate their perception of family communication quality. Generally, in the field of pediatric nursing, parent-report dominates over child-report (
      • Harrison T.M.
      Family-centered pediatric nursing care: State of the science.
      ). Furthermore, the overlap between parents and children in reports about psychosocial factors tend to be moderate at best (
      • De Los Reyes A.
      • Kazdin A.E.
      Informant discrepancies in the assessment of childhood psychopathology: A critical review, theoretical framework, and recommendations for further study.
      ). From a patient advocacy perspective, listening to children's own voices is important in pediatric nursing. Therefore, questionnaires that measure family communication from the child's perspective may be particularly relevant for the field.
      Many different measures of family processes have been developed for use in pediatric clinical settings and research (
      • Alderfer M.A.
      • Fiese B.H.
      • Gold J.I.
      • Cutuli J.J.
      • Holmbeck G.N.
      • Goldbeck L.
      • Patterson J.
      Evidence-based assessment in pediatric psychology: Family measures.
      ;
      • Zapf H.
      • Boettcher J.
      • Orm S.
      • Wiegand-Grefe S.
      • Haukeland Y.B.
      • Fjermestad K.
      A systematic review of parent-child and adolescent communication measures: Instruments and psychometric properties.
      ). However, some limitations exist in regard to communication measures. First, many measures are measuring domain general family processes instead of specific processes such as family communication (
      • Alderfer M.A.
      • Fiese B.H.
      • Gold J.I.
      • Cutuli J.J.
      • Holmbeck G.N.
      • Goldbeck L.
      • Patterson J.
      Evidence-based assessment in pediatric psychology: Family measures.
      ;
      • Murphy L.K.
      • Murray C.B.
      • Compas B.E.
      Topical review: Integrating findings on direct observation of family communication in studies comparing pediatric chronic illness and typically developing samples.
      ). Second, insufficient attention has been paid to the psychometric properties of these measures (
      • Alderfer M.A.
      • Fiese B.H.
      • Gold J.I.
      • Cutuli J.J.
      • Holmbeck G.N.
      • Goldbeck L.
      • Patterson J.
      Evidence-based assessment in pediatric psychology: Family measures.
      ;
      • Zapf H.
      • Boettcher J.
      • Orm S.
      • Wiegand-Grefe S.
      • Haukeland Y.B.
      • Fjermestad K.
      A systematic review of parent-child and adolescent communication measures: Instruments and psychometric properties.
      ), and the use of non-validated scales is common (e.g.,
      • Paclikova K.
      • Dankulincova Veselska Z.
      • Filakovska Bobakova D.
      • Palfiova M.
      • Madarasova Geckova A.
      What role do family composition and functioning play in emotional and behavioural problems among adolescent boys and girls?.
      ;
      • Su S.
      • Li X.
      • Lin D.
      • Xu X.
      • Zhu M.
      Psychological adjustment among left-behind children in rural China: The role of parental migration and parent–child communication.
      ;
      • Xin M.
      • Chen P.
      • Liang Q.
      • Yu C.
      • Zhen S.
      • Zhang W.
      Cybervictimization and adolescent internet addiction: A moderated mediation model.
      ). However, a few child-report measures of family communication have been developed. Two widely used measures are the 26-item Revised Family Communication Pattern (RFCP;
      • Ritchie L.D.
      • Fitzpatrick M.A.
      Family communication patterns: Measuring intrapersonal perceptions of interpersonal relationships.
      ) and the 20-item Parent-Adolescent Communication Scale (PACS;
      • Barnes H.L.
      • Olson D.H.
      Parent-adolescent communication scale.
      ). The RFCP and PACS have demonstrated adequate reliability (
      • Houck C.D.
      • Rodrigue J.R.
      • Lobato D.
      Parent–adolescent communication and psychological symptoms among adolescents with chronically ill parents.
      ;
      • Jackson S.
      • Bijstra J.
      • Oostra L.
      • Bosma H.
      Adolescents’ perceptions of communication with parents relative to specific aspects of relationships with parents and personal development.
      ;
      • Keim M.C.
      • Lehmann V.
      • Shultz E.L.
      • Winning A.M.
      • Rausch J.R.
      • Barrera M.
      • Gerhardt C.A.
      Parent–child communication and adjustment among children with advanced and non-advanced Cancer in the first year following diagnosis or relapse.
      ;
      • Ritchie L.D.
      • Fitzpatrick M.A.
      Family communication patterns: Measuring intrapersonal perceptions of interpersonal relationships.
      ;
      • Sillars A.
      • Holman A.J.
      • Richards A.
      • Jacobs K.A.
      • Koerner A.
      • Reynolds-Dyk A.
      Conversation and conformity orientations as predictors of observed conflict tactics in parent-adolescent discussions.
      ), and have been used with children as young as 12 and 10 years of age, respectively (
      • Jackson S.
      • Bijstra J.
      • Oostra L.
      • Bosma H.
      Adolescents’ perceptions of communication with parents relative to specific aspects of relationships with parents and personal development.
      ;
      • Keim M.C.
      • Lehmann V.
      • Shultz E.L.
      • Winning A.M.
      • Rausch J.R.
      • Barrera M.
      • Gerhardt C.A.
      Parent–child communication and adjustment among children with advanced and non-advanced Cancer in the first year following diagnosis or relapse.
      ;
      • Ritchie L.D.
      • Fitzpatrick M.A.
      Family communication patterns: Measuring intrapersonal perceptions of interpersonal relationships.
      ).
      In the current report, we focus on an adapted version of the PACS, the Parent-Child Communication Scale – Child Report (PCCS-CR;
      • Conduct Problems Prevention Research Group
      Parent-child communication, child report.
      ). The PCCS-CR is widely used in recent observational and interventional studies (e.g.,
      • Fjermestad K.W.
      • Pat P.
      • Dearozet S.
      • Vatne T.
      • Hafting M.
      • Jegannathan B.
      Manual-based group intervention for siblings and parents of children with neurodevelopmental disorders in Cambodia.
      ;
      • Fjermestad K.W.
      • Silverman W.K.
      • Vatne T.M.
      Group intervention for siblings and parents of children with chronic disorders (SIBS-RCT): Study protocol for a randomized controlled trial.
      ;
      • Haukeland Y.B.
      • Czajkowski N.O.
      • Fjermestad K.W.
      • Silverman W.K.
      • Mossige S.
      • Vatne T.M.
      Evaluation of “SIBS”, an intervention for siblings and parents of children with chronic disorders.
      ;
      • Orm S.
      • Haukeland Y.
      • Vatne T.
      • Silverman W.K.
      • Fjermestad K.
      Prosocial behavior is a relative strength in siblings of children with physical disabilities or autism Spectrum disorder.
      ;
      • Reedtz C.
      • van Doesum K.
      • Signorini G.
      • Lauritzen C.
      • van Amelsvoort T.
      • van Santvoort F.
      • de Girolamo G.
      Promotion of wellbeing for children of parents with mental illness: A model protocol for research and intervention.
      ;
      • Schulte M.T.
      • Armistead L.
      • Marelich W.D.
      • Payne D.L.
      • Goodrum N.M.
      • Murphy D.A.
      Maternal parenting stress and child perception of family functioning among families affected by HIV.
      ). The potential advantage of this scale is that it was developed to be used with children younger than 10 years of age. Further, the number of items was reduced from 20 to 8, making the scale easier to administer in pediatric nursing care. However, to our knowledge, only unpublished analyses of the PCCS-CR psychometric properties exist (
      • McCarty C.M.
      • Doyle S.R.
      Parent-Child Communication (Child) (Technical Report).
      ).
      • McCarty C.M.
      • Doyle S.R.
      Parent-Child Communication (Child) (Technical Report).
      suggested, based on unpublished exploratory factor analysis, that the PCCS-CR comprises two subscales; (1) child communication, i.e., communication of feelings and problems from the child to their parent (three items), and (2) parent communication, i.e., children's perception of their parents' efforts to maintain open communication with them (five items). However, given that the factor analysis has not been published in peer-reviewed journals, information about the extraction method, criteria, and factor loadings is unknown and, to our knowledge, no later study has confirmed the validity of the PCCS-CR.
      The purpose of our study was to investigate the construct and convergent validity of the PCCS-CR in a sample of siblings of children with a pediatric health condition through three steps. First, we use confirmatory factor analysis (CFA) to test the proposed two-factor solution of the PCCS-CR. Second, we investigate the overlap between PCCS-CR and a measure of the child's perception of quality of the relationship with their parent. We chose this comparator because communication quality is conceptualized as a related, but distinct, phenomena to overall relationship quality in attachment theory (e.g.,
      • Ehrlich K.B.
      • Cassidy J.
      • Dykas M.J.
      Reporter discrepancies among parents, adolescents, and peers: Adolescent attachment and informant depressive symptoms as explanatory factors.
      ;
      • McCarty C.A.
      • McMahon R.J.
      Mediators of the relation between maternal depressive symptoms and child internalizing and disruptive behavior disorders.
      ). Third, we investigate the known-groups validity (
      • Davidson M.
      Known-groups validity.
      ) of the PCCS-CR's ability to differentiate between siblings of children with pediatric health conditions and controls.

      Method

      Participants

      Two groups were included in the current study; (1) siblings of children with a pediatric health condition (n = 101), and (2) controls (n = 44) without a sibling with a pediatric health condition. The total sample thus comprised 145 children between 8 and 16 years of age (M = 11.5, SD = 2.2; 50.3% males; 49.7% females). The majority of mothers (82.3%) and fathers (66.9%) had university education. There were no significant group differences in age, gender, or mothers' educational level. However, fathers of controls (88.6%) had significantly higher educational level than fathers of siblings (60.2%) (ꭓ2 (1) = 11.60, p = .001).
      Among the siblings of children with a pediatric health condition, the majority were siblings of children with rare genetic disorders affecting physical and/or cognitive development (52.5%; i.e., Smith-Magenis Syndrome; DiGeorge syndrome; Prader-Willis syndrome; Fragile X syndrome; Angelman syndrome; Becker/Duchenne muscular dystrophies, Friedreich's ataxia, spinal muscular atrophy), while the remaining sample were family members of children with either autism spectrum disorder (25.3%), congenital heart disease (12.1%), Down syndrome (7.1%), or cerebral palsy (3.0%).

      Procedure

      Siblings of children with pediatric health conditions were recruited to participate in an intervention for siblings and parents of children with pediatric health conditions targeting parent-child communication, called the SIBS intervention (
      • Vatne T.M.
      • Haukeland Y.B.
      • Mossige S.
      • Fjermestad K.W.
      The development of a joint parent-child intervention for siblings of children with chronic disorders.
      ). The siblings were recruited through two national resource centers for rare disorders and neurodevelopmental disorders and four user associations (autism spectrum disorder; congenital heart disease; Down syndrome; cerebral palsy). Typically developing siblings between the age of 8 and 16 years were invited. The invitation contained information letters for siblings and parents, respectively. In total, 199 siblings were invited to participate, of which 107 (54%) accepted but only 101 (51%) returned baseline data. Among the families who provided a reason for declining (17%), the most common was that the sibling did not want to participate (44%) or that participation was not possible due to family logistics (31%). For siblings of children with pediatric health conditions, the baseline pre-intervention assessments of parent-child communication and parent-child relationship were analyzed in the current study. The controls were recruited through public elementary schools in the same country as siblings of children with pediatric health conditions. The study was approved by the Regional Committee for Medical and Health Research Ethics prior to data collection and written informed consent were collected from all participating families, informing them that participation was voluntary, would not affect their service access, and that they had the right to withdraw from the study at any time. No financial incentives were provided.

      Measures

      The PCCS-CR was used to measure parent-child communication (
      • Conduct Problems Prevention Research Group
      Parent-child communication, child report.
      ). The PCCS-CR comprises ten items rated on a Likert-scale from almost never (1) to almost always (5). Previous studies have suggested two factors; (1) child communication comprising three items and (2) parent-communication comprising five items. The PCCS-CR has been found to have adequate inter-item reliability (α = 0.71–0.81) (
      • McCarty C.M.
      • Doyle S.R.
      Parent-Child Communication (Child) (Technical Report).
      ). Children completed the PCCS-CR separately for their mothers and fathers.
      The Experiences in Close Relationships-Relationship Structures scale (ECR-RS;
      • Fraley R.C.
      • Heffernan M.E.
      • Vicary A.M.
      • Brumbaugh C.C.
      The experiences in close relationships-relationship structures questionnaire: A method for assessing attachment orientations across relationships.
      ) was used to assess child-reported relationship quality with their mother and father. The ECR-RS comprises nine items rated on a Likert-scale from strongly disagree (1) to strongly agree (7). Psychometric investigations have suggested that the ECR-RS is reliable (α ≥ 0.81) and valid (
      • Donbaek D.F.
      • Elklit A.
      A validation of the experiences in close relationships-relationship structures scale (ECR-RS) in adolescents.
      ;
      • Fraley R.C.
      • Heffernan M.E.
      • Vicary A.M.
      • Brumbaugh C.C.
      The experiences in close relationships-relationship structures questionnaire: A method for assessing attachment orientations across relationships.
      ). The ECR-RS comprises two subscales measuring the attachment dimensions avoidance (six items) and anxiety (three items) in close relationships. Higher scores indicate more avoidance and anxiety, respectively. In the current study the ERC-RS showed good inter-item reliability (α = 0.74–0.81).

      Statistical analyses

      We conducted CFA using JASP (JASP
      • JASP Team
      JASP (Version 0.13.1).
      ). We used the Diagonally Weighted Least Squared (DWLS) estimator (
      • Li C.-H.
      Confirmatory factor analysis with ordinal data: Comparing robust maximum likelihood and diagonally weighted least squares.
      ). We used the following indicators of good fit: non-significant chi-square test of model fit, Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI) ≥ 0.95, Root Mean Square Error Approximation (RMSEA) < 0.06, and Standardized Root Mean Square Residual (SRMS) < 0.10. Missing data were imputed using the fully conditional specification method (MCMC) in SPSS version 27.
      We used SPSS version 27 to conduct independent samples t-tests (two-tailed) to analyze group differences between siblings of children with pediatric health conditions and controls and calculated Hedges g as the effect size measure. Hedges g of 0.20, 0.50, 0.80, were interpreted as respectively a small, medium, and large effect size (
      • Cohen J.
      Statistical power analysis for the behavioral sciences.
      ). We reconducted analyses using analysis of covariance (ANCOVA) to control for fathers' educational level. We used Pearson's r to investigate the degree of overlap between the PCCS-CR and the ECR-RS.

      Results

      Factor structure of the PCCS-CR

      The two-factor solution of the PCCS-CR comprising a child communication subscale of three items and a parent communication subscale of five items showed good model fit for both report about mother and report about father (see Table 1; Table 2; Table 3).
      Table 1Fit indices from CFA of PCCS-CR report about mother and about father.
      χ2pRMSEAp-closeCFITLISRMR
      Model
       Report about mother21.0250.3350.0270.7030.9950.9930.067
       Report about father17.8780.5310.0000.9551.0001.0020.051
      Table 2Factor loadings on PCCS-CR about mother.
      95% Confidence Interval (CI)
      FactorItemFactor loadingLowerUpper
      Child communicationDo you discuss problems with your mother?0.7560.6140.898
      Do you think you can tell your mother how you really feel about some things?1.0100.8391.181
      Can you let your mother know what's bothering you?0.8790.7161.041
      Parent communicationIs your mother a good listener?0.5260.4250.627
      Can your mother tell how you are feeling without asking you?0.6720.5410.803
      Does your mother try to understand what you think?0.5620.4350.689
      Does your mother insult you when she is angry with you?−0.243−0.335−0.151
      Can you have your say even when your mother disagrees with you?0.6310.4850.777
      Items are obtained from

      The Fast Track Project. (n.d.). Parent-child communication (child). Retrieved June 11, 2021, from https://fasttrackproject.org/techrept/p/pcc/parentchldcommchld.pdf

      : https://fasttrackproject.org/techrept/p/pcc/parentchldcommchld.pdf.
      Table 3Factor loadings on PCCS-CR about father.
      95% Confidence Interval (CI)
      FactorItemFactor loadingLowerUpper
      Child communicationDo you discuss problems with your father?0.9640.8501.077
      Do you think you can tell your father how you really feel about some things?0.9810.8651.097
      Can you let your father know what's bothering you?0.7850.6830.886
      Parent communicationIs your father a good listener?0.5110.4300.591
      Can your father tell how you are feeling without asking you?0.8560.7450.967
      Does your father try to understand what you think?0.6540.5550.752
      Does your father insult you when she is angry with you?−0.170−0.230−0.110
      Can you have your say even when your father disagrees with you?0.5930.4960.690
      Items are obtained from

      The Fast Track Project. (n.d.). Parent-child communication (child). Retrieved June 11, 2021, from https://fasttrackproject.org/techrept/p/pcc/parentchldcommchld.pdf

      : https://fasttrackproject.org/techrept/p/pcc/parentchldcommchld.pdf.

      Correlations between PCCS-CR and ERC-RS

      There was significant overlap between the PCCS-CR and the ERC-RS (r = −0.22–0.73, p < .05; see Table 4), meaning that better parent-child communication is associated with less avoidance and anxiety in the parent-child relationship. There were small to large correlations between the PCCS-CR subscales and between report about mother and report about father on the PCCS-CR (r = 0.24–0.74, p < .05; see Table 4), meaning that children reporting higher quality mother-child communication also reports higher quality father-child communication and vice versa.
      Table 4Correlations between PCCS-CR and ERC-RS.
      1.2.3.4.5.6.7.8.
      1. PCCS-CR child communication (mother)
      2.. PCCS-CR parent communication (mother)0.37**
      3. PCCS-CR child communication (father)0.74**0.24**
      4. PCCS-CR parent communication (father)0.64**0.41**0.64**
      5. ERC-RS avoidance mother−0.61**−0.48**−0.50**−0.48**
      6. ERC-RS anxiety mother−0.22*−0.34**−0.19*−0.22**−0.25**
      7. ERC-RS avoidance father−0.63**−0.39**−0.73**−0.59**0.67**−0.29**
      8. ERC-RS anxiety father−0.23*−0.42**−0.24**−0.27**−0.24**0.78**−0.35**
      p ≤ .05, ⁎⁎p ≤ .01.

      Group differences in PCCS-CR

      Siblings of children with pediatric health conditions scored their parent-child communication significantly lower than controls on all scales except of the parent-communication subscale for mothers (p = .052; see Table 5). Differences in child communication were large (g = 0.75–83) whereas differences in parent communication were small to medium (g = 0.36–52). When including fathers' educational level as covariate, there was significant group differences in child communication with mother (F (1,138) = 13.285, p < .001) and with father (F (1,137) = 12.068, p = .001). Fathers' educational level was a significant covariate in all four comparisons (p ≤ .020), associated with better parent-child communication, and there was no longer a significant group effect for parent communication with mothers nor fathers. This suggests that group differences in fathers' educational level could explain the observed differences in parent communication.
      Table 5Comparison of siblings and controls on the subscales of the PCCS-CR.
      SiblingsControlsGroup difference
      SumSDSumSDp-valueHedges g
      Report about mother
       Child communication10.792.9613.092.20< 0.0010.83
       Parent communication20.263.2121.362.800.0520.36
      Report about father
       Child communication10.183.1212.362.22<0.0010.75
       Parent communication18.843.5720.602.870.0050.52

      Discussion

      Few studies have investigated the psychometric properties of family communication scales rated from the child's perspective. We found that the PCCS-CR, a child-report scale of family communication, had a solid two-factor structure, converged with a family relations measure, and discriminated between children who were siblings of children with pediatric health conditions and controls. Thus, the PCCS-CR can be considered a convenient and valid scale for pediatric nursing care providers to examine parent-child communication from the child's point of view.
      The two-factor solution for the PCCS-CR suggests that children perceive their communication of feelings and problems towards their parents as separate from parents' efforts to maintain open communication. However, the two subscales were moderately to strongly correlated, suggesting that children who perceive that their parents make an effort to maintain open communication are more likely to tell their parents about their feelings and problems or vice versa. Further, there were small to large correlations between children's report about mothers and about fathers. This suggests that children perceive their communication with their mothers and fathers as similar. If a child feels comfortable communicating his/her feelings and problems to their mother, chances are high they also feel comfortable communicating about their feelings and problems with their father. This could suggest that open and supportive communication with a parent forms the child's internal working models (
      • Pietromonaco P.R.
      • Barrett L.F.
      The internal working models concept: What do we really know about the self in relation to others?.
      ) and make them more comfortable communicating their feelings and problems in general.
      Children's report of their communication with their parents overlapped substantially with how they reported the relationship quality with their parents, suggesting that the PCCS-CR is valid and that parent-child communication is an important part of the parent-child relationship (
      • Ackard D.M.
      • Neumark-Sztainer D.
      • Story M.
      • Perry C.
      Parent-child connectedness and behavioral and emotional health among adolescents.
      ;
      • Gentzler A.L.
      • Contreras-Grau J.M.
      • Kerns K.A.
      • Weimer B.L.
      Parent–child emotional communication and Children’s coping in middle childhood.
      ). Better parent-child communication related to less avoidance and anxiety in the parent-child relationship. This finding can be interpreted in light of
      • Murphy L.K.
      • Murray C.B.
      • Compas B.E.
      Topical review: Integrating findings on direct observation of family communication in studies comparing pediatric chronic illness and typically developing samples.
      framework of family communication which distinguish between positive and negative family communication. Positive family communication is characterized by warmth and structure with positive statements and cohesion. Negative communication is on the opposite side characterized by hostile-intrusive and withdrawn communication, including negative statements, criticism, and disengagement. Negative parent-child communication such as criticism and withdrawnness can probably underpin children's avoidance and anxiety in the parent-child relationship, whereas open and warm communication attenuates anxiety and probably reinforce approach behaviors rather than avoidance.
      Our study also supports the results of previous studies using observational measures who have found poorer family communication in families of children with pediatric health conditions compared with controls (
      • Murphy L.K.
      • Murray C.B.
      • Compas B.E.
      Topical review: Integrating findings on direct observation of family communication in studies comparing pediatric chronic illness and typically developing samples.
      ). This emphasizes the importance of assessing and intervening on family communication in families of children with a pediatric health condition (
      • Fjermestad K.W.
      • Silverman W.K.
      • Vatne T.M.
      Group intervention for siblings and parents of children with chronic disorders (SIBS-RCT): Study protocol for a randomized controlled trial.
      ;
      • Haukeland Y.B.
      • Czajkowski N.O.
      • Fjermestad K.W.
      • Silverman W.K.
      • Mossige S.
      • Vatne T.M.
      Evaluation of “SIBS”, an intervention for siblings and parents of children with chronic disorders.
      ). Opportunities for siblings to discuss their emotional experiences and thoughts regarding their brother or sister with the condition is essential and parents are the most natural interlocutor in this matter (
      • Incledon E.
      • Williams L.
      • Hazell T.
      • Heard T.R.
      • Flowers A.
      • Hiscock H.
      A review of factors associated with mental health in siblings of children with chronic illness.
      ). Strengthening parents' communication skills is important in order to consider siblings' needs, and enhanced sibling well-being can possibly have a positive influence on the child with a disability (
      • Ferraioli S.J.
      • Hansford A.
      • Harris S.L.
      Benefits of including siblings in the treatment of autism spectrum disorders.
      ;
      • Fjermestad K.W.
      • Haukeland Y.B.
      • Mossige S.
      • Vatne T.M.
      Children’s perspectives on the experiences of their siblings with chronic disorders.
      ;
      • Rum Y.
      • Zachor D.A.
      • Dromi E.
      Prosocial behaviors of children with autism spectrum disorder (ASD) during interactions with their typically developing siblings.
      ).
      It is important to note that our results suggested that paternal education could explain group differences in child-reported parent-communication, but not child-communication. This could imply that parents' communication skills are adequate, and that greater focus should be placed on siblings' communication. It could be that siblings of children with a pediatric health condition do not discuss their emotions and problems with their parents because they are afraid of placing a greater burden on their parents, who already have to take care of their brother or sister with the pediatric health condition. Thus, perhaps greater clinical focus should be placed on providing siblings with opportunities to discuss their emotions and problems, for example in sibling support groups or individually with pediatric nurses responsible for family support (
      • Incledon E.
      • Williams L.
      • Hazell T.
      • Heard T.R.
      • Flowers A.
      • Hiscock H.
      A review of factors associated with mental health in siblings of children with chronic illness.
      ).

      Limitations

      Our sample mainly comprised siblings of children with pediatric health conditions, as well as controls. This poses some limits on the conclusions that can be drawn with respect to validity. The PCCS-CR showed good convergent validity and sensitivity to differences in parent-child communication in the current sample. However, it is uncertain if the PCCS-CR is equally valid for use with families of children with, for example, behavioral and emotional problems. It is also uncertain whether the PCCS-CR is equally valid as a measure of the communication between parents and children with a pediatric health condition (i.e., not their sibling). Thus, there is a need for further studies investigating the validity of PCCS-CR used with different populations.

      Clinical implications

      The PCCS-CR discriminated between parent-child communication quality rated by siblings of children with a pediatric health condition versus controls. This suggests that the PCCS-CR might be useful in pediatric nursing care with families of children with a health condition to assess communication in the family. The brevity of the PCCS-CR makes it useful in clinical practice where the PCCS-CR may be used for screening purposes with a low score indicating a need for a more comprehensive assessment, for example using observational measures. The brevity of the scale is also an advantage in interventional research, where parent-child communication is a relevant outcome variable. Given the array of screeners that are already routinely used in pediatric departments, the PCCS-CR may be considered an additional screening tool when there are concerns about poor family functioning or sibling mental health difficulties already exist. However, given that many pediatric health conditions have no cure, so that families need to learn to live with the condition over time, family communication is an important factor that can be easily screened with the PCCS-CR. As a clinical tool, the PCCS-CR can be useful in a range of different fields, including social work with families, child welfare, child and adolescent's mental health services, and pediatric departments. The PCCS-CR comprises both child and parent communication efforts, and both positive and negative aspects of family communication, and can thus be used to tailor family interventions. For example, if a parent-child dyad is scoring particularly low on parent communication, enhancing parental communication skills can be a particular focus in intervention. In contrast, if a parent-child dyad is scoring particularly low on child communication, this could suggest that pediatric nursing care is needed for the sibling to be able to address his or her feelings and problems. Further, assessing parent-child communication from the child's point of view may make pediatric nurses and parents more aware of siblings' experiences. Such processes may enhance parents' meta-awareness of their communication patterns.

      Declaration of Competing Interest

      The authors declare no conflict of interest.

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