Exploring Relationships Between Optimism,Perceived Health Vulnerability,and Parental Attachment Among Adolescent and Young Adult Survivors of Pediatric Cancer

Abstract

Purpose: This exploratory study assessed adolescent and young adult (AYA) and parent perceptions of optimism, health vulnerability, and parental attachment (trust, alienation, and communication), and interrelations among these variables, in families with a history of pediatric cancer. Patients and Methods: Forty-one AYAs (20 males, 21 females, mean (M)_age=16.66 years, standard deviation (SD)_age=2.99) who were at least 6 months post-cancer treatment (M_time=6.43 years, SD=5.14; M_{age at diagnosis}=8.64 years, SD=5.51) and their parents (76% female) completed questionnaires. Results: Paired sample t-tests indicated AYAs felt less attached to their parents than parents perceived their child to be. AYAs perceived greater alienation and poorer communication than parents reported. AYA-reported health vulnerability was marginally higher than parents' ratings. Parent-AYA dyads rated optimism and trust similarly. Using hierarchical regressions, parents' perceptions of AYA trust significantly contributed to AYA-reported trust beyond the influence of optimism. Similarly, parents' perceptions of how alienated their children felt were significantly related to AYA-reported alienation ratings beyond the influence of optimism. Conclusion: Survivors and parents differed in their perceptions of alienation and communication but rated optimism and trust similarly. Optimism and parent-reported trust and alienation may significantly contribute to AYA attachment. Implications for clinical intervention are discussed.

With overall survival rates at approximately 80% among children and adolescents diagnosed with cancer,^1,2 1 in 640 young adults aged 20–39 in the United States is a survivor of pediatric cancer.² Though most survivors experience positive psychological adjustment³ and good quality of life (QOL),⁴ some, including adolescents and young adults (AYAs), are at risk for negative psychosocial outcomes.⁵ These heightened risks make it imperative that specific factors salient to successful development, such as parent–AYA attachment, be further explored as means of influencing positive adjustment.

Secure parental attachment (i.e., a healthy parent–child bond) is strongly related to positive adjustment and identity development.⁶ Parental attachment predicts psychosocial well-being well into adulthood⁷ and plays an important role in socio-emotional development.⁸ While secure parental attachments promote socialization, school performance,⁹ and adaptive responses to traumatic events,^10,11 insecure attachment is associated with poorer health outcomes and increased pain⁸ and anxiety and depressive symptomatology.¹² All of these can be problematic among AYAs surviving cancer.

Experiencing a chronic illness in childhood has been associated with unique parental attachments, including increased need for dependence on parents.¹³ Despite this atypical phenomenon, few studies have examined parental attachment among AYAs surviving pediatric cancer. One study examining perceptions of parent–child relationships (a similar construct to attachment) in long-term pediatric cancer survivors found positive relationship perceptions were associated with better QOL, including favorable psychological, spiritual, and social outcomes.¹⁴ Although this study offered foundational information regarding survivors' perceptions of parent–child relationships, no published studies have examined parental attachment within parent–AYA dyads.

Parent–AYA attachment literature among chronically ill populations is limited. One study examining adolescents with type 1 diabetes found similar attachment perceptions between mothers and adolescents but not with fathers.¹³ An additional study found that parent–AYA attachment was rated more stressful by AYAs with cystic fibrosis as compared to parent reports.¹⁵ These studies suggest that attachment perceptions held by parents and AYAs may be significantly different, especially in the context of chronic illness, and could result in long-term communication, trust, and alienation problems.

It is also important to identify and explore factors related to attachment as a basis for intervention among families with poor attachment. One potential associated factor is optimism, a personality trait characterized by globally positive expectations.¹⁶ Studies of AYAs with cancer found that increased optimism was associated with lower distress, more adaptive coping, and better health-related QOL.^17,18 Furthermore, attachment style and optimistic/pessimistic expectancies are activated by perceived threats, such as cancer diagnosis. Although associations between attachment style and optimism have been identified among adults,¹⁹ this relationship remains unexamined among families surviving pediatric cancer. Such relationships may be pertinent in understanding adaptive outcomes that allow survivors to achieve appropriate developmental milestones. Perceived health vulnerability, defined here as the subjective risk perception for developing health complications secondary to cancer or cancer treatment,²⁰ may also be related to attachment. Previous studies of AYAs diagnosed with cancer have found that cancer patients may feel more vulnerable than those experiencing other illnesses.²¹ Parental attitudes that involve viewing a child as medically vulnerable and needing increased protection contribute to the “vulnerable child syndrome,”^20,22 characterized by increased shielding behaviors, including parental overprotection.²³ Because perceived health vulnerability influences child–parent relationships, it is likely that these perceptions are also related to attachment, which may then influence independent living skill attainment as survivors age.

Given the lack of dyadic data on AYA–parent attachment, this exploratory study aimed to assess differences and similarities in AYA and parent perceptions of parental attachment (including trust, alienation, and communication), optimism, and perceived health vulnerability among AYA survivors of pediatric cancer. The second objective was to explore relations between perceptions of health vulnerability, optimism, and attachment, which may be utilized as a foundation for future theoretically derived intervention studies addressing attachment outcomes in this population.

Methods

Participants and procedure

AYA-aged survivors and their parents were recruited for study participation through a pediatric hematology/oncology outpatient clinic. Identification of AYAs aged 12 to 22 years was made by clinic staff via patient record review. This age range was chosen due to the developmental period of interest. Participant eligibility included: (1) completion of cancer treatment(s) ≥6 months before participation, (2) no history of premorbid neurological impairment, (3) one parent willing to participate, and (4) English-language proficiency. Eligible AYAs and parents were sent questionnaires, consent/assent forms, and a debriefing script via mail, as delineated in the Institutional Review Board approved research protocol. Parents completed the demographic questionnaire and additional questionnaires measuring optimism, perceptions of their child's health vulnerability, and perceptions of their child's attachment to them. AYAs completed similar questionnaires. Upon completion, study materials were returned via postage-paid envelope; no compensation was offered for study participation.

Instrumentation

Demographic information

Parents completed a demographic questionnaire about their child and their child's illness history.

Optimism

AYAs and parents completed the Life Orientation Test – Revised,²⁴ a self-report measure of optimism. Participants rated statements ranging from 0 (strongly disagree) to 4 (strongly agree). Six items were analyzed as a global optimism construct (factor loadings: 0.58–0.79).²⁴ Adequate convergent and discriminant validity have been reported. Cronbach's alpha has been reported at 0.78, with test–retest reliabilities of 0.68–0.79.²⁴ Internal reliability coefficients were 0.75 for AYAs and 0.78 for parents in this study.

Perceived child health vulnerability

The Vulnerable Child Scale²⁵ measures risk perceptions associated with developing health problems and complications. This instrument consists of 16 four-point items ranging from 1 (definitely true) to 4 (definitely false). AYAs reported perceptions of their health vulnerabilities; parents reported perceptions of their child's vulnerability. Cronbach's alpha has been reported to be 0.75, with a test–retest reliability of 0.95.²⁵ Internal reliability coefficients were 0.84 for AYAs and 0.87 for parents in this study.

Parent attachment

AYA and parent perceptions of parent–AYA attachment were examined using the Inventory of Parent and Peer Attachment (IPPA).²⁶ This measure yields three subscales: communication, trust, and alienation. AYAs and parents rated 28 items ranging from 1 (never true) to 5 (always true). Cronbach's alpha coefficients have been reported from 0.86–0.91.²⁵ Factor loading for items ranged from 0.45–0.74.²⁶ Internal reliabilities for this study were 0.95 and 0.87 for overall attachment, 0.91 and 0.72 for communication, 0.71 and 0.83 for trust, and 0.81 and 0.58 for alienation, for AYAs and parents respectively.

Statistical approach

Optimism, health vulnerability, and parental attachment were the primary variables under investigation. Demographics were assessed as secondary variables. Correlations and paired sample t-tests were utilized to complete the parent–AYA dyadic comparisons. Hierarchical regression analyses were used to explore relationships between parent and AYA perceptions of health vulnerability and optimism on AYA attachment to parents, including specific aspects of attachment (i.e., trust, communication, and alienation). All analyses were conducted using SPSS version 18.0.

Results

Participant characteristics

Of 120 eligible patients, 41 AYAs (20 males, 21 females; mean (M)_{age at participation}=16.66 years, standard deviation (SD)=2.99) and their parents (10 males, 31 females) returned questionnaire packets (35% response rate). There were no significant demographic or treatment-related differences among participants and non-participants. AYAs were previously diagnosed with cancer (M_{age at diagnosis}=8.64 years, SD=5.51, age range at diagnosis: 1 month–17.0 years) and were off active treatment (M_time=6.43 years, SD=5.14, range: 6 months–18.5 years). Diagnoses included leukemias (36%), lymphomas (15%), solid tumors/sarcomas (44%), and central nervous system tumors (5%). Thirty-five percent received chemotherapy only, while 65% received chemotherapy plus additional treatment modalities (i.e., irradiation, surgery, transplant). Demographic information is presented in Table 1.

Table 1.

Demographic and Treatment Characteristics

	AYA (n=41)	Parent (n=41)
Variable	n (%)	n (%)
Gender
Male	19 (46%)	10 (24%)
Female	22 (54%)	31 (76%)
Race/Ethnicity ¹
Caucasian/White	37 (92%)	37 (92%)
African American	3 (8%)	3 (8%)
Education Level Obtained ¹
Some middle school	11 (27%)	–
Some high school	14 (35%)	2 (5%)
High school	–	9 (22%)
Some college	14 (35%)	11 (28%)
Associate's degree	1 (3%)	3 (7%)
Bachelor's degree	–	11 (28%)
Master's degree	–	4 (10%)
In School Status¹
Yes	38 (95%)	–
No	2 (5%)	–
Living Arrangement ¹
With both parents	29 (72%)	–
With mother only	4 (10%)	–
With father only	1 (3%)	–
With roommate	4 (10%)	–
Alone/other	2 (5%)	–
Diagnostic Categories ¹
Leukemias	15 (37%)	–
Lymphomas	6 (15%)	–
CNS tumor (medulloblastoma)	2 (5%)	–
Sarcomas/solid tumors	17 (43%)	–
Osteosarcoma	2 (5%)	–
Ewing sarcoma	3 (8%)	–
Rhabdomyosarcoma	3 (8%)	–
Neuroblastoma	4 (10%)	–
Wilms tumor	5 (12%)	–
Treatment Modality ¹
Chemotherapy only	14 (36%)	–
Combination treatments²	26 (64%)	–
Number of Treatments Received ³
One modality^a	14 (39%)	–
Two modalities^b	14 (39%)	–
Three modalities^c	4 (11%)	–
Four modalities^d	4 (11%)	–
Had a relapse diagnosis	1 (3%)	–

One participant did not respond to item; ²received chemotherapy and at least one other treatment; ³this item unavailable for five participants; ^areceived chemotherapy only; ^breceived chemotherapy and either radiation or surgery; ^creceived surgery, chemotherapy, and radiation; ^dreceived chemotherapy, surgery, radiation, and bone marrow transplant.

AYA, adolescent and young adult; CNS, central nervous system.

Correlational results

Within participant results

Among AYAs, positive associations were identified between optimism and age (r=0.32, p<0.05), education (r=0.32, p<0.05), and cancer diagnosis (η=0.46, p<0.05); those with lymphoma reported greater optimism. AYA age, education, and diagnosis were unrelated to parent–AYA attachment and health vulnerability. Furthermore, attachment, optimism, and vulnerability were not related to any other demographic factors, including gender, time since diagnosis, living arrangement, or number of treatment modalities completed. Given that no demographic factors were related to parent–AYA attachment, none was included in further analyses.

AYAs reported a positive relationship between optimism and parental trust (r=0.34, p<0.05), communication with parents (r=0.33, p<0.05), and overall attachment (r=0.37, p<0.05). There was an inverse relationship between optimism and health vulnerability (r=−0.48, p<0.01) and alienation from parents (r=−0.38, p<0.05). Similarly parents reported inverse relationships between optimism and perceived vulnerabilities for their child (r=−0.60, p<0.001) and perceptions of their child feeling alienated from them (r=−0.42, p<0.01).

Between participant results

Correlations also revealed concordance between parental and AYA perceptions (Table 2). A positive relationship existed between parent and AYA perceptions of vulnerability (r=0.60, p<0.001), trust (r=0.64, p<0.001), and alienation (r=0.54, p<0.001). AYA trust ratings were inversely related to alienation from parents (r=−0.59, p<0.001) and positively related to overall attachment (r=0.58, p<0.001). AYA ratings of feeling alienated from parents were inversely related to parents' trust perceptions (r=−0.45, p<0.01) and AYA overall attachment ratings (r=−0.51, p<0.001). AYA communication ratings with parents were positively related to parents' trust perceptions (r=0.47, p<0.01) and overall attachment (r=0.46, p<0.001) and inversely related to perceptions of alienation (r=−0.47, p<0.001). Interestingly, parents' perceptions of communication were not related to AYA-reported optimism, vulnerability, trust, communication, alienation, or overall parental attachment.

Table 2.

Intercorrelations Among AYA- and Parent-Reported Psychosocial Variables

Variable	Parent Optimism	Parent Vulnerability	Parent Trust	Parent Alienation	Parent Communication	Parent Overall Attachment
AYA Optimism	0.15	−0.23	0.05	−0.03	−0.11	−0.01
AYA Vulnerability	−0.29	0.60^***	0.10	−0.01	0.29	0.17
AYA Trust	0.22	−0.11	0.64^***	−0.59^***	0.21	0.58^***
AYA Alienation	−0.18	0.22	−0.45^**	0.54^***	−0.29	−0.51^***
AYA Communication	0.17	−0.05	0.47^**	−0.47^**	0.23	0.46^**
AYA Overall Attachment	0.21	−0.12	0.55^***	−0.56^***	0.25	0.55^***

Note: AYAs, n=41; Parents, n=41; ^*p<0.05; ^**p<0.01; ^***p<0.001.

AYA, adolescent and young adult.

AYA–parent dyadic comparisons

Paired sample t-tests were utilized to assess differences in AYA and parent optimism, perceived health vulnerability, and three aspects of parent–AYA attachment: trust, alienation, and communication. Results indicated significant parent–AYA differences on alienation and communication subscales (Table 3). Specifically, AYAs felt more alienated from their parents than their parents perceived them to be (t(40)=2.53, p=0.02). AYAs also rated communication with parents as being poorer than reported by parents (t(40)=3.00, p=0.005). AYA ratings of perceived health vulnerability were marginally higher than ratings provided by parents (t(40)=−1.93, p=0.06). Overall, AYAs felt significantly less attached to their parents than was perceived by parents (t(40)=2.56, p=0.01). There were no significant differences in parent–AYA ratings of optimism or perceptions of trust.

Table 3.

Paired Sample t-tests Comparing Parent–AYA Dyad Perceptions

Comparison	M	SD	t	df	p
AYA Optimism	15.51	4.35	1.70	40	0.10
Parent Optimism	16.98	4.06
AYA PHV	29.71	8.06	−1.93	40	0.06
Parent PHV	27.56	7.91
AYA Trust	41.63	5.94	.64	40	0.53
Parent Trust	42.10	4.82
AYA Alienation	14.61	5.26	−2.53	40	0.02
Parent Alienation	12.85	3.34
AYA Communication	32.98	7.98	3.00	40	0.005
Parent Communication	36.78	4.18
AYA Attachment	96.00	17.96	2.56	40	0.01
Parent Attachment	102.02	10.30

Note: n=41 dyads.

AYA, adolescent and young adult; df, degrees of freedom; M, mean; PHV, perceived health vulnerability; SD, standard deviation.

Attachment to parents

Next, relations between parent and AYA perceptions of health vulnerability, optimism, and parent-reported attachment on AYA attachment to parents were explored. Simultaneous regression analysis was initially conducted assessing AYA and parent optimism and AYA and parent perceptions of the AYAs' health vulnerability on AYAs' reported attachment to parents. A power analysis indicated that with 41 dyads, 5 independent variables, a standard power of 0.80, and an alpha of 0.05, the effect size for this analysis was 0.37. Regression results indicated that the model significantly predicted AYA attachment to parents (R²=0.45, F(5, 35)=5.65, p=0.001) with AYA and parent optimism, AYA and parent perceived vulnerability, and parent ratings of their child's overall attachment together accounting for 45% of the variability in AYA-reported attachment. Independently, there was a significant main effect of parents' perceptions of attachment (B=1.00, p<0.001, 95% CI: 0.51–1.48) and AYA-reported optimism (B=1.45, p=0.02, 95% CI: 0.24–1.67) on AYA-reported attachment to parents. Parent reports of their child's perceived attachment toward them accounted for 27% of the unique variance in AYA-reported attachment (sr²=0.27, p<0.001), while AYA-reported optimism accounted for 10% (sr²=0.10, p=0.02). There were no main effects of parent-reported optimism (B=0.14, p=ns) or AYA (B=−0.23, p=ns) or parent perceived health vulnerability (B=0.25, p=ns) on AYA-reported attachment to parents.

Dyadic analyses had suggested differences in parent–AYA perceptions of certain aspects of parental attachment. In an effort to determine potential mechanisms for interventions promoting attachment, additional hierarchical regression analyses were utilized to explore whether parent perceptions predict AYA ratings of communication, trust, and alienation. Because AYA-reported optimism contributed a significant amount of variance in overall AYA attachment ratings, it was included as a covariate. For each of the three hierarchical regression analyses conducted, a power analysis revealed that with 41 dyads, 2 independent variables, power of 0.80, and an alpha of 0.05, the effect size for these analyses was 0.25. With respect to AYA perceptions of parent–AYA trust, the model significantly predicted AYA trust ratings (R²=0.51, F(2, 38)=19.61, p<0.001). Parents' perceptions of how trustworthy their children perceived them to be was significantly related to AYA trust ratings beyond the influence on optimism (ΔR²=0.39, ΔF(1, 38)=30.16, B=0.77, p<0.001, 95% CI: 0.48–1.05). Parent perceptions of trust accounted for 39% of the unique variance in AYA trust ratings (sr²=0.39, p<0.001). In terms of AYA perceptions of alienation from parents, the overall model (i.e., parent perceptions of alienation and AYA-reported optimism) significantly predicted AYA alienation ratings (R²=0.40, F(2, 38)=14.14, p<0.001). Parents' perceptions of how alienated their child felt was significantly related to AYA alienation ratings beyond the influence of optimism (ΔR²=0.28, ΔF(1, 38)=18.75, B=0.84, p<0.001, 95% CI: 0.45–1.23). Parent perceptions of alienation accounted for 28% of the unique variance in AYA alienation perceptions (sr²=0.28, p<0.001). When assessing AYA perceptions of communication, the model significantly predicted AYA communication ratings (R²=0.14, F(2, 38)=4.18, p=0.02). However, parents' perceptions of communication within the parent–AYA relationship were not significantly related to AYA communication ratings beyond the influence of optimism (ΔR²=0.07, ΔF(1, 38)=3.30, B=0.51, p=0.08, 95% CI: −0.06–1.08).

Discussion

This is the first reported dyadic comparison of parent–AYA attachment among AYA-aged pediatric cancer survivors, despite previous research describing the significance of attachment in facilitating positive outcomes well into adulthood among typically developing populations.^7,27–29 Armsden and Green²⁶ described the importance of high levels of attachment, or “high security,” which equated to a secure attachment style. Per their report, a “high security” attachment style was indicated by high communication and trust with low alienation on the IPPA, which, in turn, related to greater contentment with oneself and lower distress toward negative life events. Within this study, initial analyses indicated strong relationships between parent–AYA perceptions of attachment. Specifically, AYA perceptions were rated more positively when parents also perceived better attachment. Based on Armsden and Green's²⁶ conceptualization of attachment, this finding may be especially important among AYA cancer survivors who have been forced to cope with challenging life situations at a young age. AYA survivor–parent attachment may also serve as an influential factor allowing AYAs to continue adapting appropriately with developmental and life demands as they age. Unfortunately, AYA survivors felt less attached to, and more alienated or isolated from, their parents than their parents perceived their AYAs to be. If AYA survivors feel detached or estranged from their parents, and this goes unrecognized by these family members, who are often expected to provide a tremendous level of support in AYA populations, survivors may not be developing the skill set required to cope adequately as adults. Similarly, parents also believed that communication with their AYA was better than what the AYAs reported, which can result in decreased security and poorer functioning as adults.²⁶ In contrast, parents and AYA survivors reported similar levels of trust within the parent–AYA relationship. Among typically developing populations, trust promotes respectful relationships that may act as protective factors.²⁶

Given the relationship between perceptions of parent–AYA attachment and QOL, self-esteem, and scholastic performance,^30–33 understanding that the AYA's perception of the parent–AYA relationship may be more negative than parents perceive offers a foundation upon which to build future interventions. Although not yet applied to AYA-aged cancer survivors, previous interventions targeting communication, alienation, and trust within families were successful in achieving better family-based coping and adjustment during stressful situations.³⁴ Therefore, strengthening these aspects of attachment, which have been found to be modifiable, and improving perceptions of the parent–AYA relationship may act as protective factors facilitating adaptive mental health outcomes among survivors while simultaneously developing functional family relationships.

Parents and AYAs reported similar levels of optimism. Greater AYA optimism was significantly related to their perceptions of parental attachment, including higher parental trust and communication and lower alienation from parents. Older participants also reported greater optimism. These results, combined with previous reports from chronically ill and healthy populations,^1,27,35 suggest that interventions designed to increase optimism (a modifiable trait) in AYA-aged pediatric cancer survivors could translate to improved QOL, coping, parental attachment, and life satisfaction and that participant age and developmental level should be considered in designing these interventions. Such interventions, which could include positive psychology³⁶ or optimism therapy approachs,³⁷ may be promising mechanisms to promote positive adjustment.

AYAs reported feeling somewhat more vulnerable to negative health outcomes than indicated by parents. This finding warrants further examination of health vulnerability as a target for clinical intervention. Potential differences between the perceived and actual risks for survivors could be addressed via interventions aimed at achieving balance between extremely high- and low-vulnerability perceptions while encouraging healthy lifestyle choices.^38,39 Creating such interventions could be beneficial in empowering families to address concerns, understand risks, and develop skills needed to reduce risks (e.g., medical adherence).

Primary study limitations include a cross-sectional design, small sample size, and low response rate. Although cross-sectional designs enable expedient data collection and a reasonable approach to address study aims, this methodology is limited in its ability to produce predictive results. A longitudinal design would strengthen the ability to examine changes in AYAs' perceptions over time while reducing cohort effects. The relatively small sample size, coupled with parent–AYA dyads self-selecting to participate, raises potential problems with selection bias and generalizability. Additionally, only medium to large effect sizes could be identified, limiting the detection of smaller effects that might be important in understanding attachment.

Although participant age, age at diagnosis, and time since treatment were unrelated to attachment, the fact that our study queried members of two developmental groups (i.e., adolescents and emerging adults)^40,41 and included a range of diagnostic ages and times since treatment can be viewed as study limitations. Secure attachments may be at risk of deterioration when a family's sense of normalcy is disrupted by pediatric cancer.^11,42,43 Research among healthy families indicates that 72% of attachment styles reported in infancy remain consistent into adulthood.⁴³ This suggests that attachment ratings of AYAs would not be expected to vary substantially,^43,44 despite awareness that relationships with peers and parents increasingly intermix in young adulthood.⁴⁵ However, specific cancer diagnosis, treatment, and survivorship factors may result in greater risks to attachment. For example, functional sequelae (e.g., seizures, headaches) are associated with insecure relationships and greater ambivalence toward parental attachment.¹¹ Moreover, age at diagnosis and treatment may be salient to attachment, as children often require greater dependence on their parents/caregivers while completing cancer treatment.¹³ This may be problematic for older adolescents and young adults, who typically seek greater independence and potentially modify communication styles and levels of trust with parents as they age. Collectively, this information indicates that future research may benefit from further exploration of how parental attachment varies as a function of developmental level/age and specific treatment factors, like functional sequelae.

Future studies would also benefit from incorporating more rigorous theory-driven approaches so that a foundation for multilevel modeling aimed at identifying moderating and/or mediating variables can be established. This will then allow the development of targeted interventions promoting parental attachment, which can enhance overall psychosocial adjustment.^8–11 Such studies could be strengthened by querying both parents in regard to their attachment perceptions. This would contribute to future work by taking into consideration that AYAs may not feel equally attached to both mothers and fathers, a finding that would be consistent with previous research^13–15 and allow for interventions addressing gender-specific parent–AYA relationship development. Studies utilizing a sibling control group design would also allow parents to rate perceptions of attachment for cancer survivors as compared to their healthy children to determine whether attachment perceptions vary as a function of cancer history. Alternately, a study design including a matched sample of healthy AYAs would enable similar investigations of how cancer experiences influence attachment and may also lend itself to more rigorous assessment of how AYAs vary as a function of developmental status. Furthermore, although AYA participants were screened for obvious neurological deficits that would exclude them from the study, obtaining additional information regarding cognitive and adaptive functioning and treatment intensity may strengthen future studies by reducing potential confounds. While typically developing AYAs are likely to move toward independence from their parents as they age,³⁷ those with deficits may need to maintain greater dependence, thereby impacting both parent and AYA perceptions of appropriate attachment.

Conclusion

In summary, this study adds to the current literature by increasing insight into perceptions of the parent–AYA relationship among AYA cancer survivors and their parents. Findings suggest that AYAs reported feeling more isolated from their parents and perceived poorer parent–AYA communication when compared to parent report. Optimism was related to these perceptions and suggests that interventions focused on increasing optimism could improve perceptions of attachment while alleviating negative health perceptions.

Footnotes

Disclosure Statement

No competing financial interests exist.

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