• Childhood epilepsy;
  • Psychopathology;
  • Parent;
  • child relationship quality;
  • Parental characteristics;
  • Family relationships;
  • Mediator


  1. Top of page
  2. Abstract

Summary: Purpose: To examine the contribution of epilepsy-related factors, proximal (parent–child relationship quality), distal (parental characteristics), and contextual (quality of other family relationships) family factors to psychopathology (both broad-band and narrow-band syndromes) in children with epilepsy and normal intelligence.

Methods: Parents of 91 children (mean, 8.5 years) participated by filling out questionnaires about family factors and child psychopathology. Regression analyses were used to analyze the unique and combined predictive power of family factors in relation to psychopathology.

Results: In contrast to epilepsy-related factors, family factors, especially those related to the quality of the parent–child relationship, appeared to be strong predictors of psychopathology. The results supported the mediational model: Distal and contextual factors affect child psychopathology by affecting proximal factors.

Conclusions: In treating children with epilepsy, clinicians should be aware of the importance of the parent–child relationship quality. Strengthening the relationship quality may prevent or reduce psychopathology.

The literature provides ample evidence that psychopathology is more common in children with epilepsy than in children from the general population (1,2). A recently conducted meta-analysis confirmed that children with epilepsy have higher levels of psychopathology than do children from the general population (3).

The factors that have been found to contribute to psychopathology in children with epilepsy are multiple (4,5). They consist of neurologic factors (e.g., age at onset, epilepsy duration, epilepsy severity, seizure type, and seizure control) (6,7), medication factors such as side effects (8), and psychosocial factors (e.g., perceived stigma, attitude toward illness, and family factors) (9–13). While reviewing the behavioral and cognitive correlates of epilepsy in 1984, Hermann and Whitman (5) pleaded at that time for a more serious examination of family factors as determinants of psychopathology in children with epilepsy. Since then, the examination of distinct family factors as contributors to child psychopathology has gradually been incorporated in childhood epilepsy research.

Family-factor constructs represent different aspects of family functioning, but to date, an appropriate model to differentiate between family factors has frequently been lacking in childhood epilepsy research. It is essential, though, to categorize family factors into distinct types, because each type of factor is considered to play a different role in relation to child outcome (14–16). Following social interactional and ecologic perspectives, family factors can be ordered, according to the level of proximity to the child's everyday life, into proximal family factors (the quality of the parent–child relationship and parenting), distal family factors (parental characteristics), and contextual family factors (the quality of other family relationships) (14,17–19).

Although it can be deduced from childhood epilepsy literature that distinct family factors are associated with psychopathology in children with epilepsy (20), the simultaneous examination of distinct family factors seldom occurred. Little is known about the unique and the combined predictive power of each of these family factors as contributors to child psychopathology. The examination of the interrelationships among distinct family factors themselves and the pathways between these distinct family factors and child psychopathology may add new information, which may be helpful for children with epilepsy and their families.

With the current study, we aim to examine the contribution of epilepsy-related factors and distinct family factors—ordered into proximal, distal, and contextual factors—to psychopathology in children with epilepsy. Even though it is possible to make clear conceptual distinctions between family factors, it also is clear that factors representing family functioning do not function separately from each other within families, but are interrelated constructs that in joint interaction exert their influence on the child's everyday life (21). As a consequence, it may be that spurious associations arise between distinct family factors and child psychopathology. Therefore with this study, we aimed to examine the independent contributions of proximal, distal, and contextual family factors to child psychopathology and to examine whether certain types of family factors predominate in predicting child psychopathology (18). Both family risk factors and protective factors were selected, because it is considered that child outcome is affected by the equilibrium between family stressors and protective (buffering) factors. That is, according to the cumulative risk model, the chance that psychopathology develops in children increases when family risk factors outweigh protective family factors (15,16,22).

Although childhood chronic illness literature has emphasized the importance of applying a noncategoric approach to examining the effects of chronic conditions on child development (that is, generic features of chronic conditions such as functional status, the limitation of activities, or the burden of daily care on the family) (23,24), disease-specific parameters also have been consistently depicted in conceptual models that explain child adjustment in chronic conditions (19,25). Among these disease parameters are condition severity, which has been found to be a contributor to child adjustment (26) and condition duration, which received less attention in childhood chronic illness research (25).

In childhood epilepsy, disease parameters could be described as pathogenetic contributors of psychopathology, that is, central nervous system (CNS)-related or epilepsy-related factors (27). When epilepsy-related factors were examined with parenting factors, it was found that parenting factors predicted internalizing and externalizing behavior problems better than the effects of epilepsy-related factors (12,13). However, significant relations also have been found between seizure severity and child psychopathology (28), including internalizing, externalizing, attention, and thought problems (7,29). Hoare and Mann (30) found an association between longer epilepsy duration and child psychopathology, including depression and anxiety (31).

Proximal family factors comprise the quality of the parent–child relationship and parenting (18,32). Parent–child relationship quality is defined as a constellation of parental attitudes that has been built up in the long history between parent and child, in which the parent's behaviors are expressed (18,32). Good quality in terms of the parent–child relationship has generally been associated with lower levels of child psychopathology in samples of both healthy children and children with epilepsy (9,13,33–35).

In contrast, low parent-child relationship quality, such as parental rejection, has been found to exert negative effects on child development and is thus considered to be a risk factor for the development of child psychopathology (36–38). One study that measured expressed emotion (EE) in mothers of children with epilepsy showed that high maternal criticism, an indicator of a low parent–child relationship quality, was related to higher levels of child psychiatric disturbances and antisocial behavior (33).

Distal family factors are dispositional parental characteristics that are assumed to influence the child indirectly, by disrupting the quality of parenting (18). Maternal depression is a distal family factor that is of current interest in child developmental and family research, and also in childhood epilepsy literature. Child developmental literature consistently showed both direct associations between maternal depression and child psychopathology (39,40) and indirect associations between maternal depression and child psychopathology by disrupting the quality of parenting (18,41). Childhood epilepsy literature showed that ∼30% of the mothers of children with epilepsy are at increased risk for depression and showed associations between maternal depression and higher levels of child psychopathology (33,42,43).

Counter to the risk-factor depression, we selected another dispositional characteristic that protects against psychopathology, parental competence in parenting. Although this characteristic has scarcely been researched in relation to child psychopathology in the epilepsy literature (9), in the child developmental literature, it has frequently been linked to adequate parenting (44,45), which in turn is related to lower levels of child psychopathology (46,47).

Contextual family factors are often understood as indicative of psychopathology in individual family members, reflecting overall family dysfunction (48). In light of childhood chronic conditions, family adaptation is commonly seen as a key factor for healthy child adjustment (49,50). Childhood chronic conditions are considered to affect the whole family, requiring new modes of organization and structure for the family (51). The family failure to adapt adequately to the demands of childhood chronic illness could, therefore, be considered a risk factor for development of psychopathology. Studies with samples of both healthy children and children with a chronic illness, including children with epilepsy, showed a relation between problems with family adaptation and the development or maintenance of child psychopathology (9,52–54).

Marital satisfaction also has frequently been linked to child psychopathology. Unsatisfactory marital relationships have been shown to function as a risk factor for the development of child psychopathology by interfering with parent–child relationship quality (55–57). In contrast, good marital relationship quality is positively associated with adaptive child outcome (58). To date, marital relationship quality has been scarcely researched in samples of children with epilepsy. One study, carried out by Austin, Risinger, and Beckett (59), found that marital strain was correlated with higher levels of child behavior problems. Another earlier study (60) found that a disrupted parental marriage contributed to internalizing and externalizing behavior problems in children with epilepsy.

The relation between family factors and psychopathology in children with epilepsy has been examined mainly on the level of Internalizing (e.g., Anxiety/Depression and Withdrawal) and Externalizing (e.g., Aggression and Delinquency) broad-band behavior problems, measured with the Child Behavior Checklist (61,62). The relation between the syndrome scales (Anxiety/Depression, Withdrawal, Somatic complaints, Delinquency, Aggression, Social problems, Attention problems, and Thought problems) and family factors has been less frequently assessed in children with epilepsy (20). To overcome this gap and, in particular, to study thought problems and attention problems that were considered relatively specific to epilepsy (3), the current study includes all the syndrome scales.

In sum, we aimed to examine simultaneously the relation between epilepsy-related factors, distinct family factors, and distinct types of psychopathology in children with epilepsy by examining the independent contribution of each cluster of epilepsy and family factors to child psychopathology. More specifically, concerning the relation between distinct family factors and child psychopathology, two mechanisms may play a role. First, it may be that each family factor has an independent effect on child psychopathology. Although we expect that each of these factors would be related to child psychopathology, we expect that the proximal factors would exert the greatest influence on child psychopathology (16). Second, it may be that family factors are interdependent in their influence on child psychopathology. On basis of the social interactional and ecologic model, it is subsequently assumed that the effects of distal (parental depression and parental competence) and contextual factors (problems with family adaptation and marital satisfaction) are mediated by proximal family factors. In other words, the distal and contextual family factors are expected to affect the parent–child relationship (proximal factors), which, in turn, would affect child psychopathology.


  1. Top of page
  2. Abstract


Parents of children referred for epilepsy to the outpatient clinic of the tertiary epilepsy center Kempenhaeghe (The Netherlands) filled out questionnaires concerning child psychopathology, epilepsy-related aspects, and family factors, that is, parent–child relationship quality, parental characteristics, and family relationships. The study was approved by the scientific review committee of the Kempenhaeghe Institute, and informed, written consent was obtained from every participating parent. The criteria for inclusion of children in the study were (a) an IQ >70 points, (b) aged between 4 and 18 years, and (c) no psychiatric illnesses, such as autism or obsessive–compulsive disorders. An exception to this criterion was the presence of Attention Deficit and Hyperactivity Disorder (ADHD), which is very common for children with epilepsy (1,63). In addition, child psychopathology according to conceptualizations of the Child Behavior Checklist was not defined as psychiatric illness.

In total, 91 children met the inclusion criteria. The number of potential family inclusions was 135. About 33% of the families did not participate in the study because of not fulfilling inclusion criteria (i.e., low IQ/severe mental retardation: five children); refusal to participate, and nondelivered questionnaires. No information about nonparticipating families was available, unfortunately. Boys were slightly overrepresented, 58% (n = 53). The children had a mean age of 8 years, 5 months (SD, 2.42). Most children (86.8%) were younger than 12 years. Mean child IQ was 90 points (SD, 13.18). The majority of the children (60.4%) were in primary school, and 20.9% received special educational services.

Epilepsy-related factors (i.e., seizure type, epilepsy syndrome, frequency of seizures, the presence of mono/polytherapy, epilepsy onset) were specified based on an inspection of the children's medical files. The definition of the type of epilepsy was based on the International League Against Epilepsy criteria (64). The majority of children in the sample had complex partial seizures (44%) and absences (39.6%). The commonest form was generalized idiopathic epilepsy (40.7%), followed by localization-related idiopathic epilepsy (29.7%) and localization-related symptomatic epilepsy (27.5%). Mean epilepsy onset was at 4 years and 1 month (SD, 2.12). Children experienced seizures on a daily (22%), weekly (25.3%), monthly (26.4%), or yearly basis (24.2%). This is a normal representation of the epilepsy center Kempenhaeghe. Because Kempenhaeghe is a tertiary epilepsy center, a slight bias may exist regarding the more severe epilepsies. Moreover, most referred children were in the first phase of diagnosis before the onset of therapy or during the initial phase of treatment, and consequently, the seizures are not very well controlled yet in a large group of children. A number of children had no antiepileptic drug (AED) prescription (19%), the majority of children received monotherapy (59%), a minority had more than one AED prescribed (8%), and for 14% of the children, no medication use information was available.

Eighty-one mothers and 10 fathers completed the questionnaires. Mothers (mean age, 38.8 years; SD, 5.1) had mainly completed lower secondary vocational education (23.1%), secondary education (18.7%), or senior secondary vocational education (27.5%). Seventy-one percent of the mothers had a paid job for several hours a week, and 24% did not work and ran the housekeeping (1% unemployed, and for 4% no information was available). Educational training for fathers (mean age, 42.0 years; SD, 6.4 years) was mainly lower secondary vocational education (27.5%), senior secondary vocational education (20%), or higher professional education (20%). Ninety-two percent of the fathers had a paid job. Parents were overrepresented concerning the lower and senior secondary educational levels and underrepresented concerning the higher educational levels, whereas the percentage of mothers and fathers with paid jobs was relatively high when compared with the general population (65). Most families were intact families with two biologic parents (92%), which is considerably higher than the percentage of two-parent families (∼75%) in the general population (66). One child lived in a stepfamily, two children lived in single-parent families with coparenting, and one child lived in a single-parent family without coparenting. All children were of Dutch origin. Only 12% of the children were single children, 48% had a brother or sister, and 34% of the children had two or more siblings (for 5.5%, no information was available).


Child psychopathology

Psychopathology was measured with the Child Behavior Checklist (CBCL), which is well known for its reliability and validity (61,62). The CBCL assesses psychopathology on both broad-band and narrow-band syndrome levels. Broad-band psychopathology includes Internalizing behavior problems (e.g., depression) and Externalizing behavior problems (e.g., aggression). Narrow-band syndrome scales consist of Somatic complaints, Withdrawal, Anxiety/Depression, Aggressive behavior, Delinquent behavior, Social problems, Attention problems, and Thought problems. At the item level, parents indicate whether descriptions of behavior are (0) not at all true, (1) somewhat true, or (2) very true for their child.

The CBCL uses cutoff scores that indicate whether a child has psychopathology in the borderline or in the clinical range. Normally, raw scores of the CBCL are used in statistical analysis for both males and females in the age ranges younger than 12 years and older than 12 years. Such a division in boys and girls in age ranges younger than 12 years and older than 12 years would divide the current sample into relatively small subsamples. Therefore with the present study, CBCL T-scores were used, which are scores that correct for age and gender. Regarding broad-band behavior problems, children scoring T ≥60 are in the borderline range (scores 60–62), and children scoring T ≥63 are in the clinical range. For the syndrome scales, children scoring T ≥67 are in the borderline range, and children scoring T ≥70 are in the clinical range. Mean normative CBCL scores are T = 50.

For the broad-band scales, excellent alphas were found for Internalizing problems (α= 0.87) and Externalizing problems (α= 0.93). The narrow-band Internalizing syndrome scales also had satisfactory reliability, with α= 0.74 for both Withdrawal and Somatic complaints and α= 0.84 for Anxiety/Depression. Alphas for the narrow-band Externalizing syndrome scales were 0.71 (Delinquent behavior) and 0.93 (Aggression). Attention problems (α= 0.78) had a relatively high alpha, whereas Thought problems (α= 0.64) and Social problems (α= 0.58) had rather low alphas. Social problems were not included in the analyses because of unsatisfactory reliability.

Epilepsy-related factors

Epilepsy duration

The estimation of epilepsy duration also was based on an inspection of the child's medical files. Mean epilepsy duration was 4 years, 6 months (SD, 2.71).

Epilepsy severity

Similar to the approach of Austin et al. (67), epilepsy severity—a composite variable—was computed by assigning scores from 0 to 3, based on seizure type, seizure frequency, and the presence of mono/polytherapy. Seizure type was scored 3 in case of generalized tonic–clonic seizures, 2 in case of partial seizures, and 1 in case of absences. A score of 3 was given if the child had weekly or daily seizures, 2 if seizures happened monthly, and 1 if the child had seizures once a year. Absence of a medication regimen was scored 1, the presence of monotherapy was scored 2, and in case of polytherapy, a score of 3 was assigned. Scores for seizure type, seizure frequency, and the presence of mono- or polytherapy were then summed. Children scoring between 1 and 5 were considered to have low epilepsy severity, and children with scores ≥6 were considered to have high epilepsy severity. Mean epilepsy severity score was 5.60 (SD, 1.55). Forty-five percent of the children had low epilepsy severity, and 55% had high epilepsy severity.

Proximal Family Factors


Rejection refers to the degree to which the child does not fulfill parental expectations regarding physical, intellectual, and emotional characteristics and was measured with the rejection scale of the Nijmegen Parental Stress Index (PSI) (68,69). The scale consists of 12 items (e.g., “It is not always easy to accept my child the way he/she is”). Parents rated the items on a 6-point Likert scale, ranging from “completely disagree” (1) to “completely agree” (6). Alpha was 0.81. The higher the score, the higher the level of rejection the parent felt toward the child.

Positive parent–child relationship quality

Positive parent–child relationship quality, a composite measure existing of the subscales parental authority and the resolution of conflict between parent and child, and parental acceptance, was measured with the Parent–Child Interaction Questionnaire Revised (PACIQ-R) (70), which includes 21 items (e.g., “I take my time to listen to my child”) to be rated on a 5-point Likert scale ranging from “does not apply to me at all” (1) to “applies to me exactly” (5), and from “never” (1) to “always” (5). Alpha was 0.75. The higher the score, the more positively the parent felt about the quality of the parent–child relationship.

Distal family factors

Parental competence

Parental competence was measured with the competence scale of the Nijmegen PSI (68,69), that is, the degree to which the parent feels confident about dealing with the child. The initial scale consists of 15 items (e.g., “I can take decisions without help”). For the current study, a shortened version, consisting of five items, was used. Parents rated each item on a 6-point Likert scale, ranging from “completely disagree” (1) to “completely agree” (6). Alpha was 0.71. A higher score reflects more confidence.

Parental depression

Parental feelings of depression were measured with the Self-Rating Depression Scale (SDS) (71). This instrument has 20 items (e.g., “Life is worthless for me”). Parents had to rate items on a 4-point Likert scale, ranging from “seldom or never” (1) to “almost always or always” (4). Alpha was 0.82.

Contextual family factors

Family adaptation problems

The Dutch Version of the Family Adaptability and Cohesion Evaluation Scales (FACES) (72,73) was used to assess family adaptation. This scale refers to the degree to which the family system adapts the power structure, role definitions, and relationship rules to changing internal and external circumstances. It includes 13 items (e.g., “In our family, it is unclear which rules are the standard, because they always change”). Although the definition of the scale is positively formulated, the scale is negative: a higher score reflects more problems with family adaptation. Parents had to rate items on a 4-point Likert scale, ranging from “never true” (1) to “always true” (4). Alpha was 0.70.

Marital satisfaction

The satisfaction scale of the Interactional Problem Solving Questionnaire (IPOV) (74) was used to measure the degree of marital satisfaction (e.g., “How satisfied are you about the love and affection that you receive from your partner?”). A higher score reflects more marital satisfaction. A 5-point Likert scale was used, ranging from “unhappy” (1) to “happy” (5). Alpha was 0.84.

Statistical analysis

To replace missing data, we carried out expectation–maximization analysis (75,76). In this procedure, maximal likelihood estimates are computed, which subsequently “treat the missing data as random variables to be removed from the likelihood function as if they were never sampled” (75, p. 148). In our sample, missing data were due to parents (a) simply forgetting to fill out items (items that were not related to any other particular items), or (b) not filling out a part of the questionnaire because the specific part was accidentally not included among the set of questionnaires (n = 21 for positive relationship quality, and n = 11 for adaptation problems). As a consequence, we were able to specify that our missing data were missing completely at random, which is required to conduct missing-data analysis (75).

We examined the severity of the different types of psychopathology by comparing children with epilepsy with children from the normative population (CBCL norms). Differences between children with epilepsy and children from the normative population were calculated with t tests. Subsequently, Pearson correlations were used to explore associations among epilepsy-related factors; proximal, distal, and contextual family factors; and child psychopathology. Next, hierarchic regression analyses were conducted to examine the predictability of child psychopathology from epilepsy-related factors, and the proximal, distal, and contextual family predictors. Two types of hierarchic regression analyses were performed. First, direct effects of epilepsy-related factors and family predictors were examined by entering each type of predictor on the first step of the regression. Putting in a cluster of factors first has the advantage that it shows the independent contribution of the factor to the dependent variable (i.e., psychopathology), compared with the other clusters of factors. Then the remaining significant predictors were entered on the last step of the regression, thereby controlling for the other significant predictors. Entering each cluster of predictors on the last step allows determination of which factor has the most influential effect on child psychopathology. Thus this approach allows the relative influence of each predictor on child psychopathology to be examined (18,77).

Second, we tested the mediational model that proposes that contextual and distal family factors generate their effects on child psychopathology through proximal family factors. To perform a test of mediation, the three following criteria must be met. First, distal and contextual family predictors have to be associated with proximal family mediators. Second, distal and contextual family factors have to be related to child psychopathology outcome; and third, proximal family factors have to be related to child psychopathology (78). Evidence for mediation is achieved if the relation between distal and contextual family factors and psychopathology is reduced when the effects of proximal family factors are controlled for. However, before concluding that proximal family factors mediate the effects of distal and contextual family factors on child psychopathology, mediation effects should be examined at the level of the beta coefficients themselves (78). Therefore a series of Sobel tests was conducted to test whether proximal family factors mediated, to a significant extent, the influence of distal and contextual family factors on the different types of psychopathology (79,80). Holmbeck (81) wrote an excellent article in which he explained the necessity of conducting Sobel tests when examining mediating effects, because failure to do so often leads to conclusions that are false positive or false negative. Sobel tests were computed with a SPSS macro developed by Preacher and Hayes (82), because SPSS does not provide the possibility of testing indirect effects with the Sobel test. This macro can be downloaded from the following website: (82).


  1. Top of page
  2. Abstract

Psychopathology in children with epilepsy

The children in the current study scored far above the normative T-score of 50 (SD, 10) on all syndromes: compared with children in the normative population, these children with epilepsy had significantly higher levels of psychopathology (Table 1). The percentage of children scoring above the clinical cutoff was especially high on Internalizing behavior problems (57%) and Attention problems (48%).

Table 1. Means, standard deviations and percentages of children scoring within the borderline range and above the clinical cutoff of the CBCL
PsychopathologyChildren with epilepsyComparison with normative populationCutoff
MSDt ValueaBorderlineClinical
  1. ap < 0.001.

Broad-band syndromes
 Internalizing problems63.5510.4612.09 7%57%
 Externalizing problems58.5512.14 6.53 9%37%
Narrow-band syndromes
 Withdrawal63.09 9.5912.66 9%27%
 Somatic complaints62.2310.3210.9917%18%
 Aggressive behavior61.0211.03 9.27 6%20%
 Delinquent behavior57.33 8.44 8.05 4%13%
 Thought problems65.0810.1813.74 6%38%
 Attention problems70.1810.8217.3015%48%

Parental depression

The mean score on parental depression was 42.03 (SD, 9.15). Twelve percent of the parents scored above the cutoff of 50 for mild depression, and 6% scored above the cutoff of 60 for moderate depression. None of the parents scored above the cutoff of 70 for severe depression (71).

Associations among epilepsy, proximal, distal, and contextual family factors, and child psychopathology

Epilepsy-related factors were not related to either distinct family factors or child psychopathology (Table 2). Significant associations were found between almost all family factors and Internalizing and Externalizing behavior problems. Parental rejection was correlated with higher levels of Internalizing and Externalizing problems, whereas a positive parent–child relationship was associated with lower levels of Internalizing and Externalizing behavior problems. Parental confidence in parenting was related to Externalizing behavior problems only. Parental depression was connected with both higher levels of Internalizing and Externalizing behavior problems. Problems with family adaptation were related to higher levels of Internalizing and Externalizing behavior problems. Finally, marital satisfaction was related to lower levels of Externalizing behavior problems.

Table 2. Means, standard deviations, and correlations among psychopathology (broad-band syndromes), epilepsy, proximal, distal, and contextual family factors
  1. ap < 0.001.

  2. bp < 0.05.

  3. cp < 0.01.

 1. Internalizing problems63.5510.46- 
 2. Externalizing problems58.5512.140.54a- 
Epilepsy-related factors
 3. Duration4.602.710.060.05- 
 4. Severity5.611.50− 
Proximal factors
 5. Rejection2.540.900.41a0.59a0.160.15 
 6. Positive quality4.160.32−0.35a−0.64a−0.08−0.07−0.60a- 
Distal factors
 7. Parental competence4.770.76−0.05−0.23b0.15−0.02−0.42a0.41a- 
 8. Depression1.680.350.33c0.32c0.060.110.47a−0.41a−0.43a- 
Contextual factors
 9. Adaptation problems1.540.240.24b0.28c0.01−0.040.43a−0.30c−0.37a0.40a-
 10. Marital satisfaction4.230.82−0.14−0.31c−0.01−0.12−0.47a0.30c0.24b−0.48a−0.43a

Family factors appeared to be interrelated. Especially strong association was found between two proximal factors: parental rejection and parent–child relationship quality. The magnitude of associations among other family factors varied from 0.24 to 0.48, indicating that, although related, each of these factors offers unique information about the family.

Table 3 presents the association between the CBCL syndrome scales and epilepsy and family factors. Again, epilepsy-related factors were not associated with any particular type of psychopathology. With the exception of Somatic problems that were only marginally linked to family factors, the pattern of the correlations between the syndrome scales and family factors was largely similar to the correlations obtained with the broad-band scales.

Table 3. Correlations between psychopathology (narrow-band syndromes) and epilepsy, proximal, distal, and contextual family factors
VariableWithdrawalDepressionSomatic problemsAggressionDelinquencyThought problemsAttention problems
  1. ap < 0.001.

  2. bp < 0.01.

  3. cp < 0.05.

Epilepsy-related factors
Proximal factors
 Positive quality−0.36a−0.35a−0.12−0.61a−0.54a−0.35a−0.33b
Distal factors
 Parental competence−0.06−0.060.01−0.18−0.07−0.13−0.22c
Contextual factors
 Adaptation problems0.28b0.26c0.130.29b0.160.28b0.28b
 Marital satisfaction−0.21c−0.06−0.09−0.31b−0.27c−0.03−0.15

Predicting psychopathology in children with epilepsy: direct effects

Direct effects of epilepsy-related factors and family factors were investigated by entering each group of factors in the first step of the regression. Subsequently, the remaining significant predictors were entered in the last step of the regression. The results of these regression analyses are presented in Table 4. When entered first, epilepsy factors were nonsignificant contributors of both broad-band and narrow-band syndromes. The factor most closely related to the child's everyday life, proximal family factors, accounted for most variance in all types of problem behavior. The only exception was Somatic complaints, for which none of the family factors appeared to be a significant predictor. Distal factors were significant predictors of broad-band syndromes (Internalizing and Externalizing problems). These factors also accounted for a significant percentage of the variance in Withdrawal, Aggressive and Delinquent behavior, and Thought and Attention problems. Finally, contextual factors significantly predicted Externalizing problems and five narrow-band syndromes: Withdrawal, Anxiety/Depression, Aggressive behavior, Thought problems, and Attention problems.

Table 4. Predicting psychopathology from epilepsy, proximal, distal, and contextual family factors
Predictors/PsychopathologyEpilepsy-related factorsProximal factorsDistal factorsContextual factors
  1. R2, Change in the first and in the last step.

  2. ap < 0.001.

  3. bp < 0.01.

  4. cp < 0.05.

Broad-band syndromes
Narrow-band syndromes
 Somatic complaints0.02-0.02-0.06-0.02-
 Aggressive behavior0.00-0.45a0.31a0.11b0.000.12 b0.00
 Delinquent behavior0.01-0.31a0.19a0.09c0.000.08c0.01
 Thought problems0.04-0.23a0.13a0.07c0.000.09c0.01
 Attention problems0.01-0.23a0.11a0.12b0.010.08c0.00

At the level of individual predictors (Table 5), of the proximal factors, rejection and positive quality were both significant predictors in almost all regression analyses. Predictive power of distal factors was, however, mostly due to the parental depression. Beta coefficients for competence did not reach significance in any of the analyses. Two indicators of contextual factors were about equal regarding their predictive power, although marital satisfaction appeared to be a stronger predictor of the externalizing types of problems (broad-band syndromes Externalizing problems, Aggressive behavior, and Delinquent behavior), whereas adaptation problems were a stronger predictor of other types of problems.

Table 5. Predicting psychopathology from epilepsy, proximal, distal, and contextual family factors (beta coefficients in the first and in the last step)
Predictors/PsychopathologyEpilepsy-related factorsProximal factorsDistal factorsContextual factors
Duration FirstSeverity FirstRejectionPositive qualityCompetence FirstDepressionAdaptation problemsMarital Satisfaction
  1. ap < 0.05.

  2. bp < 0.01.

  3. cp < 0.001.

Broad-band syndromes
Narrow-band syndromes
 Somatic complaints−0.05−0.120.07-0.08-0.120.27a0.22a0.11-−0.05-
 Aggressive behavior0.040.000.33b0.32b−0.42c−0.42c−0.040.31b0.000.19-−0.22a−0.03
 Delinquent behavior0.090.000.20--0.42c−0.49c0.070.32b0.050.05-−0.25a−0.10
 Thought problems0.16−0.150.41c0.42c−0.11-−0.030.25b0.020.33b0.100.11-
 Attention problems0.03−0.080.44c0.39c−0.07-−−0.03-

In the next step of the analyses, only the contributors that had significant effects in the first step were entered in the last step (Tables 4 and 5). Given the nonsignificant contribution of each type of family factors to Somatic complaints, this narrow-band syndrome was excluded from the subsequent analyses. The same results were obtained for all types of problems. Proximal family factors remained significant contributors, even after the distal and contextual factors were controlled for. The significant effects of distal and contextual factors, however, disappeared after the other factors were controlled for.

Test of the mediational model

In the next series of analyses, we tested the hypothesis that distal and contextual factors exert their effects on child psychopathology by affecting the proximal factors. In other words, the proximal factors are expected to mediate the relation between distal/contextual factors and psychopathology. Epilepsy-related factors were not entered in these analyses, because these variables did not meet the criteria formulated by Baron and Kenny (78): epilepsy duration and severity were not correlated with proximal family factors, were not correlated with child psychopathology, and were not related to the other predictors.

For each test of mediation, only those predictors were entered that had proved to be significant in the first step of the regression analyses for testing direct effects (see Table 5). Table 5 also shows which type of proximal family factor was a significant predictor of child psychopathology. This particular type (i.e., rejection or positive relationship quality) was entered in each of the analyses for testing mediation. On the level of the distal family factors, only depression was a significant contributor, and therefore whether the effects of parental competence were mediated by proximal family factors was not tested. In the case of Internalizing problems, only effects of depression could be tested for, as both indicators of contextual factors appeared to be nonsignificant predictors. In each analysis, proximal factors were entered in the first step, followed by distal and contextual factors. Table 6 shows the beta coefficients of individual predictors after controlling for the proximal factors and shows the results of the Sobel tests.

Table 6. Parent–child relationship quality as a mediator of the relationship between distal and contextual factors and child psychopathology: Sobel tests
PsychopathologyDistal factorsContextual factors
Depression βSobel testAdaptation problems βSobel testMarital satisfaction βSobel test
z95% CIz95% CIz95% CI
  1. aMediated through parental rejection.

  2. bMediated through positive parent–child relationship quality.

  3. *p < 0.05.

  4. **p < 0.01.

  5. ***p < 0.001.

Broad-band syndromes
 Externalizing−0.023.69***4.29–14.01a- -−0.03−3.66***−6.01—1.82a
Narrow-band syndromes 3.46***3.70–13.35b −2.69**−4.71–0.74b
 Aggressive behavior0.013.61***3.67–12.36a-- −0.03−3.61***−5.39–1.60a
 3.12**1.80–7.86b −2.65**-4.08–0.61b
 Delinquent behavior0.092.87**1.42–7.54---−0.12−2.53**−2.78–0.35
 Thought problems0.053.13**2.30–9.980.102.92**2.50–12.70---
 Attention problems0.142.99**2.05–9.890.092.97**2.82–13.80---

The results were consistent across all types of problems: after controlling for the proximal factors, the effects of previously significant predictors, within the distal and contextual groups of factors, were reduced to nonsignificance. Although this reduction to nonsignificance indicates evidence for indirect effects, the significance of indirect effects was formally confirmed with the Sobel tests. The 95% confidence intervals for the size of the indirect effects also were reported (82). The effects of parental depression were mainly mediated by parental rejection (on the internalizing types of psychopathology, thought and attention problems), whereas positive relationship quality also mediated the effects of parental depression on externalizing problems and aggression. In addition, positive relationship quality mediated the effects of depression on delinquent behavior problems. Family adaptation problems were mediated by parental rejection for their influence on withdrawal, anxiety/depression, thought problems, and attention problems. The effects of marital satisfaction were mediated both by rejection and positive relationship quality on externalizing behavior problems and aggression, whereas positive relationship quality only mediated the effects of marital satisfaction on delinquent behavior problems.


  1. Top of page
  2. Abstract

The goal of this study was to explore the relative influence of epilepsy-related factors and distinct family factors on child psychopathology. Based on the social interaction and ecologic model, we hypothesized that the most proximal interactions between parent and child (parent–child relationship quality) would exert the greatest influence on child psychopathology. In addition, it was hypothesized that proximal family factors would mediate the effects of distal and contextual family factors on child psychopathology.

First, however, the severity of child psychopathology in our sample was compared with the norm group. The comparison showed that children with epilepsy had significantly higher levels of psychopathology. This holds particularly for the presence of Internalizing problems, Externalizing problems, and Attention problems, thereby confirming findings from the existing childhood epilepsy literature that indicated that children with epilepsy are at higher risk for the development of psychopathology (1,2,83).

Considering the relative influences of epilepsy-related factors and distinct family factors on both broad-band and narrow-band behavior problems, it appears that epilepsy-related factors were nonsignificant contributors, irrespective of the type of psychopathology, whereas each type of family factor significantly influenced almost each type of child psychopathology (an exception appeared for Somatic complaints, distal factors as predictors of Anxiety/Depression, and contextual factors as predictors of Internalizing behavior problems). However, when each type of family factor that appeared to be significant in the first step of the regression analyses was entered in the last step (i.e., when the other significant family factors were controlled for), only proximal family factors exerted influence on child psychopathology, whereas former significant effects of distal and contextual factors disappeared. These findings support the social interaction and ecologic model in that the effects of the most proximal family factors on child psychopathology are stronger than the effects of the more distal and contextual family factors (15–17). Internalizing behavior problems (including Depression and Withdrawal) and Thought and Attention problems were solely predicted by three family risk factors: rejection, depression, and family adaptation problems. In contrast, a better equilibrium appears to exist between stressors and compensatory factors in case of Externalizing behavior problems (at least as many protective factors as risk factors are found).

Besides that the parent–child relationship quality was revealed to be the most important contributor to child psychopathology, even when the other family factors were controlled for, the results also confirm our hypothesis that proximal family factors would mediate the effects of distal and contextual family factors. First, parental depression and marital satisfaction influence Externalizing behavior problems and Aggression through parent–child relationship quality (both rejection and positive parent–child relationship quality). Second, the effects of parental depression and marital satisfaction on Delinquency are mediated by the positive parent–child relationship quality. Third, parental depression and problems of family adaptation (except for Internalizing behavior problems) exert their influence on Internalizing behavior problems, Anxiety/Depression, Withdrawal, and Thought and Attention problems through parental rejection. Especially in the latter case, the adverse effects of distal and contextual family risk factors seem to spill over into poor parent–child relationship quality, which in turn, negatively affects child psychopathology.

It should be pointed out that, because of the cross-sectional nature of this study, we are not able to draw any conclusions regarding causality. Although we assume that family factors contribute to the development of psychopathology in children with epilepsy, it is just as possible that problems within the family are reactions to already existing pathology and thus emerge as contributors to the maintenance of psychopathology. Besides, it may also be true that child psychopathology contributes to higher levels of maternal depression, family adaptation problems, or marital conflict, which in turn, contribute to the maintenance of child psychopathology. Such pathways may be addressed in future research that examines pediatric epilepsy from a child-developmental psychopathology perspective (84).

Regardless of the direction of the effects, the results clearly show that family factors are more strongly related to psychopathology in children with epilepsy than are epilepsy-related factors. This may indicate that it is especially the presence of a chronic condition (i.e., generic factors) that places demands on the family, rather than the effects of specific disease parameters (e.g., severity and duration). It may be that the burden of epilepsy interacts with family processes and that these factors form together a complex web of contributors to child psychopathology (19,51). Therefore it may be of importance for future childhood epilepsy research to use generic effects of epilepsy (for instance, the degree to which epilepsy affects the child's functional status, visibility and stability of the condition, the need for extra medical care, and the impairments of daily activities) (19,85). In addition, it might be important to study parental beliefs and child beliefs about the child's illness and treatment (10,11,13).

From meta-analytic results, it was recently deduced that family factors were less strongly involved in Thought and Attention problems, as these were found to be relatively specific to epilepsy (3). This study showed, however, that distinct family factors also are strongly involved with Thought and Attention problems. Therefore the contribution of family factors to Thought and Attention problems may be attributed to reactions of the family to already existing pathogenetic causes of psychopathology.

Moreover, as many pathways explain psychopathology in children with epilepsy (16,86), it may be that the influence of pathogenetic contributors is easier to detect in other childhood epilepsy populations. For example, it might be that symptomatic epilepsy syndromes, which involve central nervous system (CNS) lesions, are, among other factors, strong contributors to child psychopathology (27). Therefore future research should focus on longitudinal studies with large samples, which would enable us to examine transactional pathways of social ecologic contributors and pathogenetic epilepsy contributors to child psychopathology (19,87).

Some other limitations also should be addressed. First, psychopathology was assessed with the CBCL, a screening instrument that examines the risk at psychopathology. Although it has consistently been demonstrated that the empirically based CBCL scales converge with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnostic categories (88,89) use of the CBCL in clinical samples should be considered with some caution. For instance, Perrin et al. (85) stated that the interpretation of Somatic complaints in clinical populations should be done cautiously, because it is difficult to discriminate between symptoms that may reflect psychopathology and symptoms that reflect the effects of chronic conditions or reflect side effects of medical treatment itself. Besides, Perrin et al. also stated that Somatic complaints could be reflections of psychopathology but nevertheless are interpreted as consequences of a chronic condition. Moreover, it has been suggested that certain behavioral items on the CBCL checklist reflect seizure features rather than behavior problems (90). However, if parents of children with epilepsy were asked to exclude behaviors that they considered to be seizure specific, parents still rated their children higher on levels of psychopathology than did parents of children from the general population (6).

Second, psychopathology and distinct family factors were measured by means of parental questionnaires only. Therefore the findings of the present study should be ascribed to parent's reflections on their own behaviors, beliefs, and attitudes as well as to reflections on their children's behaviors and should be interpreted with caution. In particular, solely using parental report of child psychopathology may lead to shared method variance. That is, parental depression may distort parental ratings of child psychopathology, leading to artificial stronger relations. For instance, maternal reports of internalizing behavior problems, but not externalizing behavior problems, were significantly biased by maternal psychopathology (91). With regard to the current study, shared method variance should then be ascribed to the more internalizing types of child psychopathology rather than to the more externalizing and unambiguous types of psychopathology such as attention problems and thought problems. It also has been demonstrated that, contrary to former research, depressed mothers are accurate reporters of their children's behaviors (92,93), indicating that parental depression does not distort parental ratings of their children's behavior.

In addition, although inconsistent findings exist about the convergence between parental reports of parenting and other informants of parenting (e.g., 94,95), it has been found that mothers are not inclined to rate their parenting behaviors more positively (95). Because parental subjective experiences are of importance for child behavior and development, it can then be considered that, in particular, in the context of parenting, parents seem to be optimal informants of rating family factors and child behavior. Therefore we concur with the optimal informant strategy (96) that assumes that the person most engaged in a particular context is also the person in best position to rate the constructs belonging to that context. This strategy, however, may eliminate additional, unique information of other informants (e.g., child report). Therefore multisource (by means of multimethod) reporting of psychopathology and social ecologic factors may elucidate how parental, child, and environmental influences affect psychopathology in children with epilepsy, which, as a consequence, should be more consistently applied in future research (96).

Third, as children with idiopathic epilepsy syndromes constituted the majority of children in this study, the research findings may not be representative for the whole population of children with epilepsy. Seizure-condition severity is generally assumed to contribute to adjustment in childhood epilepsy, but one of the contributors to condition severity—epileptic syndrome severity—is seldom included in research. Dunn et al. (97) recently pleaded for the inclusion of epilepsy-syndrome severity in the measurement of condition severity, and they developed a syndrome-severity rating. Therefore future childhood epilepsy research should examine whether certain samples of children (children with symptomatic epilepsy) are at higher risk for psychopathology and whether the pathways that explain psychopathology are different for these particular groups of children.

This study showed that when epilepsy-related factors and distinct family factors are examined within a social interaction and ecologic framework, it is the most proximal family factors that exert the greatest influence on psychopathology in children with epilepsy. In particular, parental rejection appeared to be a risk factor that contributes to Internalizing behavior problems, Withdrawal, Depression, Thought, and Attention problems. Moreover, with respect to the same types of psychopathology, rejection appeared to be a mediator of two other family risk factors: depression and problems with family adaptation. Thus clinicians should be aware of the detrimental effects of negative parent–child relationship quality on child psychopathology and the risk factors that are associated with parent–child relationship quality. In contrast, positive parent–child relationship quality may compensate for adverse effects of family risk factors in case of Externalizing behavior problems. Therefore in treating children with epilepsy, attention should be paid to the quality of the parent–child relationship and to the use of strategies that ameliorate and strengthen it.


  1. Top of page
  2. Abstract
  • 1
    McDermott S, Mani S, Krishnaswami S. A population-based analysis of specific behavior problems associated with childhood seizures. J Epilepsy 1995;8: 110118.
  • 2
    Rutter M, Graham P, Yule W. A Neuropsychiatric Study in Childhood. London : William Heinemann Medical, 1970.
  • 3
    Rodenburg R, Stams GJ, Meijer AM, et al. Psychopathology in children with epilepsy: a meta-analysis. J Pediatr Psychol 2005;30: 453468.
  • 4
    Hermann B, Whitman S. Psychopathology in epilepsy: the role of psychology in altering paradigms of research, treatment, and prevention. Am Psychol 1992;47: 11341138.
  • 5
    Hermann BP, Whitman S. Behavioral and personality correlates of epilepsy: a review, methodological critique, and conceptual model. Psychol Bull 1984;95: 451497.
  • 6
    Austin JK, Harezlak J, Dunn DW, et al. Behavior problems in children before first recognized seizures. Pediatrics 2001;107: 115122.
  • 7
    McCusker CG, Kennedy PJ, Anderson J, et al. Adjustment in children with intractable epilepsy: importance of seizure duration and family factors. Dev Med Child Neurol 2002;44: 681687.
  • 8
    DuPaul GJ, McGoey KE, Mautone JA. Pediatric pharmacology and psychopharmacology. In: RobertsMC, ed. Handbook of Pediatric Psychology. New York : Guilford Press, 2003: 234250.
  • 9
    Austin JK, Dunn DW, Johnson CS, et al. Behavioral issues involving children and adolescents with epilepsy and the impact of their families: recent research data. Epilepsy Behav 2004;5(suppl 3):3341.
  • 10
    Austin JK, Huberty TJ. Development of the Child Attitude Toward Illness Scale. J Pediatr Psychol 1993;18: 467480.
  • 11
    Austin JK, MacLeod J, Dunn DW, et al. Measuring stigma in children with epilepsy and their parents: instrument development and testing. Epilepsy Behav 2004;5: 472482.
  • 12
    Pianta RC, Lothman DJ. Predicting behavior problems in children with epilepsy: child factors, disease factors, family stress, and child-mother interaction. Child Dev 1994;65: 14151428.
  • 13
    Sbarra DA, Rimm-Kaufman SE, Pianta RC. The behavioral and emotional correlates of epilepsy in adolescence: a 7-year follow-up study. Epilepsy Behav 2002;3: 358367.
  • 14
    Belsky J. The determinants of parenting: a process model. Child Dev 1984;55: 8396.
  • 15
    Belsky J. Etiology of child maltreatment: a developmental ecological analysis. Psychol Bull 1993;114: 413434.
  • 16
    Cicchetti D, Toth SL. Transactional ecological systems in developmental psychopathology. In: LutharSS, BurackJA, CicchettiD et al., eds. Developmental Psychopathology: Perspectives on Adjustment, Risk, and Disorder. New York : Cambridge University Press, 1997: 317349.
  • 17
    Bronfenbrenner U. Ecology of the family as a context for human development: research perspectives. Dev Psychol 1986;22: 723742.
  • 18
    Deković M, Janssens JMAM, Van As NMC. Family predictors of antisocial behavior in adolescence. Fam Proc 2003;42: 223235.
  • 19
    Kazak AE, Rourke MT, Crump TA. Families and other systems in pediatric psychology. In: RobertsMC, ed. Handbook of Pediatric Psychology. New York : Guilford Press, 2003: 159175.
  • 20
    Rodenburg HR, Meijer AM, Deković M, et al. Family factors and psychopathology in children with epilepsy: a literature review. Epilepsy Behav 2005;6: 488503.
  • 21
    Boyce WT, Frank E, Jensen PS, et al. Social context in developmental psychopathology: recommendations for future research from the MacArthur Network on psychopathology and development: the MacArthur Foundation Research Network on Psychopathology and Development. Dev Psychopathol 1998;10: 143164.
  • 22
    Sameroff AJ, Seifer R, Bartko W. Environmental perspectives on adaptation during childhood and adolescence. In: LutharSS, BurackJA, CicchettiDet al., eds. Developmental Psychopathology: Perspectives on Adjustment, Risk, and Disorder. New York : Cambridge University Press, 1997: 507526.
  • 23
    Jessop DJ, Stein RE. Uncertainty and its relation to the psychological and social correlates of chronic illness in children. Soc Sci Med 1985;20: 993999.
  • 24
    Perrin EC, Newacheck P, Pless IB, et al. Issues involved in the definition and classification of chronic health conditions. Pediatrics 1993;91: 787793.
  • 25
    Wallander JL, Thompson RJ Jr, Alriksson Schmidt A. Psychosocial adjustment of children with chronic physical conditions. In: RobertsMC, ed. Handbook of Pediatric Psychology. New York : Guilford Press, 2003: 141158.
  • 26
    Lavigne JV, Faier Routman J. Correlates of psychological adjustment to pediatric physical disorders: a meta-analytic review and comparison with existing models. J Dev Behav Pediatr 1993;14: 117123.
  • 27
    Noeker M, Haverkamp-Krois A, Haverkamp F. Development of mental health dysfunction in childhood epilepsy. Brain Dev 2005;27: 516.
  • 28
    Carlton-Ford S, Miller R, Nealeigh N, et al. The effects of perceived stigma and psychological over-control on the behavioural problems of children with epilepsy. Seizure 1997;6: 383391.
  • 29
    Schoenfeld J, Seidenberg M, Woodard A, et al. Neuropsychological status of children with complex partial seizures. Dev Med Child Neurol 1999;41: 724731.
  • 30
    Hoare P, Mann H. Self-esteem and behavioural adjustment in children with epilepsy and children with diabetes. J Psychosom Res 1994;38: 859869.
  • 31
    Oǧuz A, Kurul S, Dirik E. Relationship of epilepsy-related factors to anxiety and depression scores in epileptic children. J Child Neurol 2002;17: 3740.
  • 32
    Darling N, Steinberg L. Parenting style as context: an integrative model. Psychol Bull 1993;113: 487496.
  • 33
    Hodes M, Garralda ME, Rose G, Schwartz R. Maternal expressed emotion and adjustment in children with epilepsy. J Child Psychol Psychiatry1999;40: 10831093.
  • 34
    Lamborn SD, Mounts NS, Steinberg L, et al. Patterns of competence and adjustment among adolescents from authoritative, authoritarian, indulgent, and neglectful families. Child Dev 1991;62: 10491065.
  • 35
    Owens EB, Shaw DS. Predicting growth curves of externalizing behavior across the preschool years. J Abnorm Child Psychol 2003;31: 575590.
  • 36
    Akse J, Hale WW III, Engels RCME, et al. Personality, perceived parental rejection and problem behavior in adolescence. Soc Psychiatry Psychiatr Epidemiol 2004;39: 980988.
  • 37
    Mann BJ, MacKenzie EP. Pathways among marital functioning, parental behaviors, and child behavior problems in school-age boys. J Clin Child Psychol 1996;25: 183191.
  • 38
    Nicholas KK, Pianta RC. Mother-child interactions and seizure control: relations with behavior problems in children with epilepsy. J Epilepsy 1994;7: 102107.
  • 39
    Brennan PA, Hammen C, Andersen MJ, et al. Chronicity, severity, and timing of maternal depressive symptoms: relationships with child outcomes at age 5. Dev Psychol 2000;36: 759766.
  • 40
    Dawson G, Ashman SB, Panagiotides H, et al. Preschool outcomes of children of depressed mothers: role of maternal behavior, contextual risk, and children's brain activity. Child Dev 2003;74: 11581175.
  • 41
    Burke L. The impact of maternal depression on familial relationships. Int Rev Psychiatry 2003;15: 243255.
  • 42
    Hoare P. Psychiatric disturbance in the families of epileptic children. Dev Med Child Neurol 1984;26: 1419.
  • 43
    Shore CP, Austin JK, Dunn DW. Maternal adaptation to a child's epilepsy. Epilepsy Behav 2004;5: 557568.
  • 44
    Coleman PK, Karraker KH. Self-efficacy and parenting quality: findings and future applications. Dev Rev 1997;18: 4785.
  • 45
    Teti DM, Gelfand DM. Behavioral competence among mothers of infants in the first year: the mediational role of maternal self-efficacy. Child Dev 1991;62: 918929.
  • 46
    Baumrind D. Effective parenting during the early adolescent transition. In: CowanPA, HetheringtonEM, eds. Family Transitions: Advances in Family Research Series. Hillsdale , NJ : Lawrence Erlbaum Associates, 1991: 111163.
  • 47
    Maccoby EE. The role of parents in the socialization of children: an historical overview. Dev Psychol 1992;28: 10061017.
  • 48
    Minuchin S, Baker L, Rosman BL, et al. A conceptual model of psychosomatic illness in children: family organization and family therapy. Arch Gen Psychiatry 1975;32: 10311038.
  • 49
    Brown RT. Society of Pediatric Psychology presidential address: toward a social ecology of pediatric psychology. J Pediatr Psychol 2002;27: 191201.
  • 50
    Wallander JL, Varni JW. Effects of pediatric chronic physical disorders on child and family adjustment. J Child Psychol Psychiatry 1998;39: 2946.
  • 51
    Wamboldt MZ, Wamboldt FS. Role of the family in the onset and outcome of childhood disorders: selected research findings. J Am Acad Child Adolesc Psychiatry 2000;39: 12121219.
  • 52
    Dunn DW, Austin JK, Huster GA. Symptoms of depression in adolescents with epilepsy. J Am Acad Child Adolesc Psychiatry 1999;38: 11331138.
  • 53
    Goldberg S, Janus M, Washington J, et al. Prediction of preschool behavioral problems in healthy and pediatric samples. J Dev Behav Pediatr 1997;18: 304313.
  • 54
    Olson SL, Ceballo R, Park C. Early problem behavior among children from low-income, mother-headed families: multiple risk perspective. J Clin Child Adolesc Psychol 2002;31: 419430.
  • 55
    Cowan PA, Cowan CP. Interventions as tests of family systems theories: marital and family relationships in children's development and psychopathology. Dev Psychopathol 2002;14: 731759.
  • 56
    Gordis EB, Margolin G, John RS. Parents' hostility in dyadic marital and triadic family settings and children's behavior problems. J Consult Clin Psychol 2001;69: 727734.
  • 57
    Katz LF, Woodin EM. Hostility, hostile detachment, and conflict engagement in marriages: effects on child and family functioning. Child Dev 2002;73: 636651.
  • 58
    Erel O, Burman B. Interrelatedness of marital relations and parent child relations: a meta-analytic review. Psychol Bull 1995;118: 108132.
  • 59
    Austin JK, Risinger MW, Beckett LA. Correlates of behavior problems in children with epilepsy. Epilepsia 1992;33: 11151122.
  • 60
    Hermann BP, Whitman S, Hughes JR, et al. Multietiological determinants of psychopathology and social competence in children with epilepsy. Epilepsy Res 1988;2: 5160.
  • 61
    Achenbach TM. Manual for the Child Behavior Checklist/14–18 and 1991 Profiles. Burlington , VT : University of Vermont, Department of Psychiatry; 1991.
  • 62
    Verhulst FC, Van Der Ende J, Koot HM. Handleiding voor de CBCL/4–18. (Manual for the Child Behavior Checklist/4–18, Dutch Version.). Rotterdam , The Netherlands : Erasmus University Rotterdam, 1996.
  • 63
    Dunn DW, Austin JK, Harezlak J, et al. ADHD and epilepsy in childhood. Dev Med Child Neurol 2003;45: 5054.
  • 64
    International League Against Epilepsy. Proposal for revised classification of epilepsies and epileptic syndromes. Epilepsia 1989;30: 389399.
  • 65
    Van Der Aart SA, Van Baal MD, Blom F, et al. Jaarboek onderwijs in cijfers 2003–2004 (Yearbook education in statistics). Deventer : Kluwer/Centraal Bureau voor de Statistiek, 2004.
  • 66
    Aalders M. Demografie van gezinnen (Demographics of families). Deventer : Centraal Bureau voor de Statistiek (CBS) (Statistics Netherlands), 2003.
  • 67
    Austin JK, Huster GA, Dunn DW, et al. Adolescents with active or inactive epilepsy or asthma: a comparison of quality of life. Epilepsia 1996;37: 12281238.
  • 68
    Abidin RR. Parenting Stress Index: Manual. Charlottesville : Pediatric Psychology Press, 1990.
  • 69
    Groenendaal JHA, Gerrits LAW, Rispens J. Opvoeding en ontwikkeling in de kinderperiode (Parenting and development in childhood). In: RispensJ, HermannsJMA, MeeusWHJ, eds. Opvoeden in Nederland (Parenting in the Netherlands). Assen , The Netherlands : Van Gorcum, 1996.
  • 70
    Lange A, Evers A, Jansen H, et al. The Parent Child Interaction Questionnaire–Revised. Fam Proc 2002;41: 709722.
  • 71
    Zung WW. A self-rating depression scale. Arch Gen Psychiatry 1965;12: 6370.
  • 72
    Buurmeijer FA, Hermans PC. Gezins Dimensie Schalen (Family Adaptability and Cohesion Evaluation Scales). Lisse : Swets & Zeitlinger, 1988.
  • 73
    Olson DH. Circumplex Model VII: validation studies and FACES III. Fam Proc 1986;25: 337351.
  • 74
    Lange A. De Interactionele Probleem Oplossings Vragenlijst (The Interactional Problem Solving Questionnaire). Deventer : Van Loghum Slaterus, 1983.
  • 75
    Schafer JL, Graham JW. Missing data: our view of the state of the art. Psychol Methods 2002;7: 147177.
  • 76
    Tabachnick BG, Fidell LS. Using Multivariate Statistics. 4th ed. Boston : Allyn & Bacon, 2001.
  • 77
    Jennings KD, Stagg V, Connors RE. Social networks and mothers' interactions with their preschool children. Child Dev 1991;62: 966978.
  • 78
    Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 1986;51: 11731182.
  • 79
    MacKinnon DP, Lockwood CM, Hoffman JM, et al. A comparison of methods to test mediation and other intervening variable effects. Psychol Methods 2002;7: 83104.
  • 80
    Sobel ME. Asymptotic Intervals for Indirect Effects in Structural Equations Models. San Francisco : Jossey-Bass, 1982.
  • 81
    Holmbeck GN. Post hoc probing of significant moderational and mediational effects in studies of pediatric populations. J Pediatr Psychol 2002;27: 8796.
  • 82
    Preacher KJ, Hayes AF. SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behav Res Methods Instrum Comput 2004;36: 717731.
  • 83
    Davies S, Heyman I, Goodman R. A population survey of mental health problems in children with epilepsy. Dev Med Child Neurol 2003;45: 292295.
  • 84
    Spirito A, Brown RT, D'Angelo E, et al. Society of Pediatric Psychology task force report: recommendations for the training of pediatric psychologists. J Pediatr Psychol 2003;28: 8598.
  • 85
    Perrin EC, Stein RE, Drotar D. Cautions in using the Child Behavior Checklist: observations based on research about children with a chronic illness. J Pediatr Psychol 1991;16: 411421.
  • 86
    Davies PT, Cicchetti D. Toward an integration of family systems and developmental psychopathology approaches. Dev Psychopathol 2004;16: 477481.
  • 87
    Sameroff AJ, MacKenzie MJ. Research strategies for capturing transactional models of development: the limits of the possible. Dev Psychopathol 2003;15: 613640.
  • 88
    Achenbach TM, Dumenci L, Rescorla LA. DSM-oriented and empirically based approaches to constructing scales from the same item pools. J Clin Child Adolesc Psychol 2003;32: 328340.
  • 89
    Hudziak JJ, Copeland W, Stanger C, et al. DSM-IV externalizing disorders with the Child Behavior Checklist: a receiver-operating characteristic analysis. J Child Psychol Psychiatry 2004;45: 12991307.
  • 90
    Oostrom KJ, Schouten A, Kruitwagen CL, et al. Epilepsy-related ambiguity in rating the Child Behavior Checklist and the teacher's report form. Epileptic Disord 2001;3: 3945.
  • 91
    Kroes G, Veerman JW, De Bruyn EEJ. Bias in parental reports? Maternal psychopathology and the reporting of problem behavior in clinic-referred children. Eur J Psychol Assess 2003;19: 195203.
  • 92
    Richters JE. Depressed mothers as informants about their children: a critical review of the evidence for distortion. Psychol Bull 1992;112: 485499.
  • 93
    Cicchetti D, Rogosch FA, Toth SL. Maternal depressive disorder and contextual risk: contributions to the development of attachment insecurity and behavior problems in toddlerhood. Dev Psychopathol 1998;10: 283300.
  • 94
    Kochanska G, Kuczynski L. Radke et al. Correspondence between mothers' self-reported and observed child-rearing practices. Child Dev 1989;60: 5663.
  • 95
    Sessa FM, Avenevoli S, Steinberg L, et al. Correspondence among informants on parenting: preschool children, mothers, and observers. J Fam Psychol 2001;15: 5368.
  • 96
    Holmbeck GN, Li ST, Schurman JV, et al. Collecting and managing multisource and multimethod data in studies of pediatric populations. J Pediatr Psychol 2002;27: 518.
  • 97
    Dunn DW, Buelow JM, Austin JK, et al. Development of syndrome severity scores for pediatric epilepsy. Epilepsia 2004;45: 661666.