ABSTRACT
Aim
This study aimed to investigate how a child’s quality of life influences the connection between a mother’s and child’s levels of illness anxiety.
Materials and Methods
Online data was collected from 302 mother-child pairs with children aged 10-15. The scale for the Assessment of Illness Behavior was applied to assess the mothers’ level of illness anxiety. The Pediatric Quality of Life Inventory was applied to assess children’s quality of life, and the Childhood Illness Attitude scale was applied to assess children’s level of illness anxiety. To determine participant eligibility based on study criteria, mothers completed a sociodemographic questionnaire. The study employed Process Macro to analyze the mediating effect.
Results
The analysis revealed a significant association between maternal and child illness anxiety, with the child’s quality of life serving as a partially significant mediating factor in this relationship.
Conclusion
Considering the study findings, it can be stated that the child’s quality of life is an important determinant in the relationship between maternal and child illness anxiety. Therefore, the results highlight the importance for professionals working on the treatment of illness anxiety in children to also focus on the quality-of-life variable during intervention.
INTRODUCTION
Health anxiety is defined as a condition characterized by the catastrophic misinterpretation of bodily sensations, coupled with an associated fear or worry about having, or potentially developing, a serious illness. This condition often leads to reassurance-seeking behaviors, such as frequent consultations with physicians or extensive online health-related searches1, 2.
Over the past few years, health anxiety was assumed to be a condition exclusive to adulthood; however, recent research has shown that children may also experience health anxiety3, 4. Given that maternal mental health is a significant predictor of children’s psychological well-being5, it is crucial to examine the relationship between maternal health anxiety and health anxiety symptoms in children.
Models explaining health anxiety and those discussing its etiology suggest that maternal health anxiety may contribute to the development of health anxiety in children6, 7. For instance, the cognitive-behavioral theory of health anxiety emphasizes that environmental learning plays a significant role in the development of health anxiety6. According to ecological systems theory, the family is considered the primary environmental system influencing a child’s behavior and development8. Supporting the perspectives of these theories, research on anxiety suggests that having anxious parents may contribute to higher levels of anxiety in children9. Similarly, there is a growing body of evidence indicating a relationship between maternal and child health anxiety10, 11. While the international literature highlights a diverse range of studies focusing on the relationship between maternal and child illness anxiety, research examining this relationship within the context of Turkish culture remains limited.
Mental health problems are also known to be associated with quality of life12. Quality of life is defined as a multidimensional concept that encompasses physical, emotional, and psychological well-being, as well as overall life satisfaction13. A review of studies focusing on the relationship between quality of life and illness anxiety indicates that as individuals’ illness anxiety increases, their quality-of-life decreases; however, it is also noteworthy that research in this area remains limited14, 15.
It has been observed that the mother’s anxiety level is also related to the children’s quality of life16, 17. The mother’s increased anxiety level may lead to behavioral consequences that reduce quality of life. In the context of illness anxiety, behaviors such as frequent hospital visits and repeated internet searches can reduce quality of life. When evaluated from the perspective of the cognitive-behavioral theory discussed above, the child may learn by observing these behaviors in their mother. As a result of this learning, the child’s quality of life may be affected.
The literature includes studies that separately examine the effect of parental anxiety on child anxiety18, the impact of parental illness anxiety on child illness anxiety11, and the relationship between parental anxiety and the child’s quality of life16, all reporting significant findings regarding these variables. However, there is a lack of research investigating the relationships among these variables through mediation hypotheses, specifically focusing on the mediating role of the child’s quality of life in the effect of parental anxiety on child anxiety.
Designed to address the gaps identified in literature, this study aims to examine the mediating effect of child quality of life in the relationship between maternal and child illness anxiety. Accordingly, it is anticipated that this research will make significant contributions to both national and international literature. Moreover, as the first national study conducted following the adaptation of the Childhood Illness Attitude scale (CIAS) into Turkish, it is expected to provide important contributions to the national literature. Within this context, the primary hypothesis of the study has been formulated as: The child’s quality of life has a significant mediating effect in the relationship between maternal and child illness anxiety.
MATERIALS AND METHODS
Case Selection and Description
The study sample consisted of a total of 302 child participants, including 155 girls and 147 boys, aged between 10 and 15 years, along with their mother. Participants were recruited through social media platforms using a convenience sampling method. Inclusion criteria required that the child be between 10 and 15 years of age and that both the child and the mother provided informed consent to participate in the study. When determining the exclusion criteria for the study, anxiety was considered as a spectrum; therefore, it was assumed that any diagnoses of anxiety or related disorders in participants could affect the results. Consequently, based on self-reports, the absence of an ongoing psychiatric diagnosis and treatment in both the mother and the child was established as an exclusion criterion.
A total of 452 individuals initially participated in the study. However, 30 children were excluded for not meeting age criteria, and 20 mothers and 12 children were excluded due to receiving ongoing psychiatric treatment. Additionally, 78 children, whose mothers had consented to participate, declined to take part in the study, and 10 mothers could not be reached due to incorrect contact information. Therefore, the final sample consisted of 302 mothers and 302 children.
Sociodemographic Form
This form was developed by the researcher to collect information about participant characteristics and was administered to the mothers. It includes questions regarding the child’s date of birth, gender, number of siblings, grade level, academic performance, and the presence of any ongoing psychiatric diagnoses under treatment. The form also collects information about the mothers’ income level, educational background, and any psychiatric diagnoses they may have under treatment.
The Scale for the Assessment of Illness Behavior
This 25-item scale, originally developed by Rief et al.19and adapted into Turkish by Güleç20, was used to assess mothers’ illness-related behavioral tendencies associated with health anxiety. The scale for the Assessment of Illness Behavior (SAIB) is designed to evaluate behavioral manifestations of illness concern, such as excessive health monitoring, preoccupation with bodily symptoms, and frequent medical consultations, rather than health anxiety as a cognitive or affective construct19. In line with cognitive behavioral models of health anxiety, such illness related behaviors are considered observable expressions of underlying health anxiety and may play a role in the intergenerational transmission of illness related fears through modeling processes21. Accordingly, in the present study, SAIB scores were conceptualized as indicators of the behavioral component of maternal health anxiety.
The SAIB is a 4-point Likert-type scale, with responses ranging from 0= Completely true, to 3= Completely untrue. Higher scores indicate lower levels of illness behavior, whereas lower scores reflect higher levels of illness behavior. The internal consistency coefficient of the Turkish version was reported as .81,20 and in the current study, Cronbach’s alpha was also 0.81.
The Pediatric Quality of Life Inventory
The Pediatric Quality of Life Inventory (PedsQL), developed by Varni et al.22 was used to assess the quality of life of child participants. The scale includes self-report forms tailored to different age groups. In this study, the Turkish-adapted versions of the forms for ages 8-12 and 13-18 were used23, 24. The 23-item scale uses a 5-point Likert scale (0= Never to 4= Almost always) and is scored by converting responses to a 0-100 scale (0=100, 1=75, 2=50, 3=25, 4=0). The total score is calculated by dividing the sum of the item scores by the number of items. Higher scores indicate a better perceived quality of life. The internal consistency coefficient for the Turkish version was 0.86 for children aged 8-12 and 0.82 for those aged 13-15. In the present study, Cronbach’s alpha was found to be 0.86.
The Childhood Illness Attitude Scale
The CIAS, developed by Wright and Asmundson4 and adapted into Turkish by Aktan et al.25 was used to assess health anxiety levels in children. The Turkish version of the scale consists of 28 items, 2 of which are excluded from scoring and serve only to gather additional information. The remaining 26 items are rated on a 3-point Likert scale (1= Never to 3= Often). Higher scores indicate higher levels of health anxiety in children. The scale does not have a specific cut-off score. The internal consistency coefficient for the Turkish version was reported as 0.8625, while in this study, it was found to be 0.87.
Data Collection Procedure
Initially, a research proposal was prepared and submitted to the Ethics Committee of Işık University. After receiving ethical approval (decision no: 2022/04, date: 11.04.2022), data collection commenced. The data were collected online using Google Forms to administer the scales. Participants and their parents were provided with information about the study’s purpose, and informed consent was obtained. In the first phase, the mothers were asked to complete the Sociodemographic Information Form and the SAIB. In the second phase, child participants were asked to complete the PedsQL and the CIAS. To prevent common method bias during the response process, the scales were completed at different times for the mother and child. Children were assured that their responses would not be shared with their parents.
Statistical Analysis
IBM SPSS 25 statistical software was used to conduct the data analyses. Initially, skewness and kurtosis values were examined to assess whether the data followed a normal distribution. Subsequently, reliability analyses were performed to determine the Cronbach’s alpha coefficients of the scales, and frequency analyses were conducted to examine the sociodemographic characteristics of the sample. Pearson correlation analysis was employed to investigate the relationships between variables. To test the study’s main hypothesis regarding the mediating effect of child quality of life in the relationship between maternal and child illness anxiety, the direct effects of parental anxiety on child anxiety, parental anxiety on child quality of life, and child quality of life on child anxiety were first analyzed. Thereafter, the mediating role of child quality of life in this relationship was examined using the PROCESS Macro version 4.3 for SPSS.
RESULTS
The variables’ normal distributions, as well as their means and standard deviations, are displayed in Table 1.
In the next step, the correlations between the variables were examined, and the results are summarized in Table 2. The findings revealed a weak but significant negative correlation between scores on the SAIB and the CIAS (r=-.270, p<0.001). Additionally, a moderate negative correlation was found between CIAS scores and the PedsQL scores (r=0-.445 p<0.001). Finally, the relationship between maternal health anxiety (SAIB scores) and children’s quality of life (PedsQL scores) was not significant (r=0.111, p=0.053). According to Baron and Kenny26, for mediation analysis to be conducted, all variables must be statistically significant with each other. However, according to Hayes, while this is important, it is not a requirement for conducting mediation analysis27.
To investigate the mediating role of children’s quality of life in the relationship between maternal and child health anxiety, the PROCESS Macro was applied. In the present study, the mediating effect was tested using Hayes’ Model 427 with 5,000 bootstrap resamples and a 95% confidence interval. The results of the mediation analysis are presented in Table 3, and the hypothesized model is illustrated in Figure 1.
As shown in Table 3, path a, representing the relationship between the SAIB scores and the PedsQL scores, was not statistically significant. Looking at the path b values in Table 3, PedsQL scores significantly and negatively predict CIAS scores. Examining the effect of SAIB scores on CIAS scores (path c), it is observed that SAIB scores significantly and negatively predict CIAS scores. Considering the results for SAIB scores, it was found that maternal health anxiety positively predicts children’s health anxiety. When the mediating variable (PedsQL) was included in the model, the direct effect of maternal health anxiety on children’s health anxiety (path c’) was found to be significantly negative, with SAIB scores significantly negatively predicting CIAS scores. In conclusion, based on the SAIB scores, it was determined that maternal health anxiety significantly and positively predicts children’s health anxiety severity.
As shown in Table 3, the analysis results indicate that the child’s quality of life mediates the relationship between maternal and child health anxiety. The effect between the dependent and independent variables, initially -0.2228, decreased to -0.1842 when the mediating variable was included in the model, but it remained significant. It was concluded that the child’s quality of life plays a partial mediating role. The proportion of the mediating effect in the total effect was found to be 15%.
DISCUSSION
This study aimed to examine the mediating role of children’s quality of life in the relationship between maternal and child health anxiety. Although existing literature explores and validates the relationship between maternal-child health anxiety11, 28, and the connection between quality of life and health anxiety levels14, 15, there is a lack of studies specifically addressing the variables of maternal health anxiety, child health anxiety, and child quality of life simultaneously. Additionally, since the CIAS scale, which assesses health anxiety in children, has only recently been introduced to the Turkish literature, there are no studies examining these relationships. Therefore, it is considered important to examine the relationships between the mentioned variables in order to enhance children’s psychological functionality and contribute to both national and international literature.
The first finding indicated that maternal health anxiety significantly and positively predicts children’s health anxiety. This result is consistent with the literature suggesting that maternal psychopathology is a risk factor for the development of psychopathology in children5, 9, as well as studies that have identified a relationship between maternal and child health anxiety11, 28. A recent review by Rask et al.10 suggested that the relationship between maternal and child health anxiety can be explained through both social learning and genetic perspectives. Based on these findings, it is recommended that specialists working with children who have health anxiety examine the role of maternal health anxiety in these symptoms and its impact on the treatment process.
In another step of the study, the direct effect of maternal illness anxiety on children’s quality of life was examined. Although this effect did not reach statistical significance (p=0.0529), some sources consider this level to be marginally significant29. A review of the literature indicates that studies specifically investigating this relationship are limited, with most focusing instead on the effects of general parental anxiety on children’s quality of life. Reporting findings similar to our study, Thorgaard et al.30 compared children whose mothers had a diagnosis of rheumatoid arthritis with children of healthy mothers and found no significant differences in quality of life between the experimental and control groups. The same study also reported that children of mothers with high illness anxiety exhibited more symptomatic complaints and attended more hospital visits. However, a study focusing on children with cerebral palsy and their parents demonstrated that maternal anxiety levels had a significantly negative effect on children’s quality of life17. Considering these inconsistencies and the limited number of studies in literature, it is evident that future research on parental health anxiety and its impact on children is of considerable importance.
Another finding of the study indicates that children’s quality of life significantly and negatively predicts child illness anxiety. A review of the literature reveals that most studies have focused on adults, consistently reporting a negative association between quality of life and illness anxiety14, 15. Studies involving children have predominantly aimed to assess the quality of life of those with developmental disorders, chronic illnesses, or physical disabilities31-34. While no studies directly examining the relationship between illness anxiety and quality of life in children were identified, research has demonstrated associations between children’s mental health problems and their quality of life35, 36. Considering these findings, the observed negative relationship between quality of life and child illness anxiety highlights the potential importance of incorporating interventions aimed at improving quality of life into the treatment of illness anxiety in children.
Literature reviews reveal that the relationship between children’s quality of life and their mothers’ health anxiety has also been explored30. In one study, when comparing children with healthy mothers to those whose mothers had a diagnosis of rheumatoid arthritis, no significant difference was found in the quality-of-life scores of children whose mothers had severe health anxiety30. On the other hand, in a study showing the opposite result, it was found that the life satisfaction of adolescents with highly stressed parents was affected within a year37. Given that a marginal significance was found between the two variables in this study, along with the contradictory results in the literature, it is believed that further investigation of this relationship in different populations and larger samples would be valuable.
The mediation analysis revealed that the child’s quality of life partially mediates the relationship between maternal and child illness anxiety. As one of the few studies to investigate the indirect role of quality of life in this context, it provides valuable insights for clinicians. The findings suggest that incorporating interventions aimed at enhancing children’s quality of life into treatment modules for illness anxiety could be particularly beneficial. The results reveal that when assessing children’s health anxiety, it is clinically critical to focus not only on the level of symptoms but also on the emotional, social, and physical functioning dimensions of quality of life. In this context, the mediating effect of the child’s quality of life provides concrete clinical guidance for parent-focused interventions: reducing maternal anxiety may not only directly affect the child’s health anxiety but also create an indirect protective effect by improving the child’s daily functioning. Therefore, adding components to intervention programs that aim to regulate parents’ cognitive distortions about illness, reduce the burden of caregiving, and improve the quality of mother-child interaction can contribute significantly at the clinical level to reducing children’s health anxiety by enhancing their quality of life. Consequently, this study may guide professionals by highlighting strategies that help strengthen children throughout the psychotherapy process.
Study Limitations
Despite the strengths of this study, several limitations should be acknowledged. For instance, the mediating effect of children’s quality of life on the relationship between maternal and child illness anxiety accounted for only 15% of the total effect. Consequently, other potential mediators were not examined and should be addressed in future research. A study examining the relationship between maternal and child psychopathologies found that emotion regulation38 mediates this relationship, while another study found that mindful awareness39 mediates this relationship. Future research may consider including these variables. The sample comprised a non-clinical population; however, no formal psychiatric assessments or structured interviews were conducted. Data on psychiatric conditions were obtained solely through self-report, with exclusion criteria based on participants’ responses. Additionally, the lack of information regarding participants’ other physical, neurological, or chronic conditions constitutes a further limitation.
Although mothers and children completed the measures at separate times, the online data collection setting may still entail contextual factors that could influence responses, and this should be considered when interpreting the results.
Although the sample size was adequate for the planned analyses, the use of a convenience sampling method limits the generalizability of the findings. This approach was preferred due to practical constraints in reaching mother-child dyads that met the study’s inclusion and exclusion criteria. Participants recruited through social media may differ from the broader population in ways that could introduce selection bias, and this should be taken into account when interpreting the results. Online recruitment, however, allowed access to participants from diverse geographical regions, which provided some practical advantages despite the inherent limitations of convenience sampling.
Another limitation of the study is that demographic variables such as the child’s age, the mother’s educational level, and socioeconomic status were not included as covariates in the mediation model. These factors may be associated with both health anxiety and quality of life, and their absence should be considered when interpreting the findings.
CONCLUSION
In conclusion, the findings of this study are believed to make a valuable contribution to the literature on health anxiety in children and to future research in this area. It is hoped that studies like this, which can guide experts in both preventive and therapeutic interventions for health anxiety, will increase in the future.
