2011. Vol.2, No.7, 681-686
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.27104
Family Functioning and Adolescents’ Psychological Well-Being
in Families with a TBI Parent
Dan Florin Stanescu1, Georg Romer2
1Department of Communication and Public Relations, National School of Political Studies and Public
Administration, Bucharest, Romania;
2Universität Sklinikum Hambrug-Eppendorf, Hamburg, Germany.
Received July 7th, 2011; revised August 12th, 2011; accepted September 21st, 2011.
This study aimed at examining the interrelation between family functioning and children’s mental health in
families with a brain injured parent. The first goal of this study was to investigate the predictive power of fam-
ily functioning for children’s psychological well-being. Second, differential sub-dimensions of family function-
ing were examined in respect of their predictive power for children’s psychological adaptation. Third, coping
strategies on the family system level were differentiated in terms of their predictive power both for family func-
tioning and for children’s psychosocial adjustment. 58 families were included in the current study. The follow-
ing instruments were used: Youth Self Report, Family Crisis Oriented Personal Scales, and Family Assessment
Device. Family dysfunction as a whole positively correlates with psychological symptoms of adolescents; four
sub-dimensions of family functioning predicted children’s problems, namely affective responsiveness, affective
involvement, roles, and communication. This research is all the more informative as the studies on the subject
are nearly inexistent, and since it focuses on a category of utmost value—children.
Keywords: Mental Health, Somatically Ill Parents, Acute TBI, Protective Factors, Children
It has long been known that somatic illness in a parent is a
risk factor for subsequent psychiatric disorders in children (Rutter,
1966). Although many professionals recognize the potential
psycho-traumatic effect of parental illnesses for children (Lezak,
1986; Lewandowski, 1992), some of the best information
comes from those working on a daily basis with these kinds of
cases, i.e. those being directly involved in care process (De-
Boskey & Morin, n.d.; Johnson, 2000). Due to their clinical
experience, one can now have a broad image about the changes
forced onto families and their members by parental illnesses.
Thus, on the one hand, Armistead, Klein & Forehand (1997)
suggested parental depression, withdrawal, inter-parental con-
flict, and parental divorce as factors mediating children’s mal-
adjustment by disrupting the parenting function. Other authors
(Compas, Worsham, Epping-Jordan et al., 1994; Compas,
Worsham, Ey et al., 1996) found that subjective perceptions of
a parental illness predicted internalizing problems or distress in
the child better than did objective severity of the parental dis-
ease, and also that adolescent girls whose mothers had cancer
reported more symptoms of anxiety or depression than girls
whose fathers were ill, or boys with an ill parent of either gen-
On the other hand, it can be generally assumed that the qual-
ity of the parent-child relationship and other intra-familial at-
tachments are important links in the mechanisms that explain
how exposure to parental illness and severe stress in families
may or may not lead to psychological problems in children
(Romer et al., 2002). Since any parent-child dyad is embedded
into, and interrelated with, all other dyadic, triadic and polyadic
relationships within the family system, the construct of family
relational functioning (Epstein, Bishop, & Levine, 1978) ap-
pears to be a central issue for explaining adaptive as well as
maladaptive patterns in families. If a family develops adaptive
coping strategies, these may serve as a model for the individual
child’s psychological adaptation. This model’s stated assump-
tion is that the primary function of the family unit is to pro-
vide a setting for the development and maintenance of family
members on the biological, social, and psychological levels
(Epstein, Bishop, and Baldwin 1984, 1978). Hence, family is-
sues are grouped into three areas—the basic task area, the de-
velopmental task area, and the hazardous task area.
The McMasters Model of Family Functioning conceives of
the basic task area (providing food, money, transportation, and
shelter) as the most fundamental of the three areas. The devel-
opmental task area includes family issues related to the stages
of the family developmental sequence. At the individual level,
these issues include crises in infancy, childhood, or adolescence;
at the family level, these could be issues such as the beginning
of marriage or the first pregnancy. The hazardous tasks area
encompasses the ways in which families handle crises resulting
from e.g. accidents, illness, or loss of income or of job. It sug-
gests that families who are unable to handle these task areas are
most likely to develop clinically sig nif ica nt prob lem s.
Starting from these assumptions, high family relational func-
tioning may be considered a protective factor for children ex-
posed to acute severe physical illness in a parent, and low fam-
ily relational functioning is likely to predict children’s malad-
justment respectively. However, there are few empirical data
supporting this assumption (Romer et al., 2002). Therefore,
knowledge is needed about family characteristics that predict
their children’s higher or lower risk for psychological mal-
adaptation to parental illness.
This study aimed at examining the interrelation between fam-
ily functioning, family coping strategies and children’s mental
health in families with a severe acute brain injured parent. Fam-
ily coping strategies represent a combination of the meaning
families attribute to events and how they utilize resources as
they attempt to manage stressor events (McCubbin, Larsen, &
Olson, 1982). Consequently, in a first step, the predictive power
of family functioning for children’s psychological well-being
was investigated. More specifically, it was hypothesized that
higher family functioning is associated with fewer psychologi-
cal symptoms in children exposed to parental illness. Second,
differential sub-dimensions of family functioning were exam-
ined in their predictive power for children’s psychological ad-
aptation. Third, coping strategies on the family system level
(family coping) were analyzed in their predictive power both
for family functioning and children’s psychosocial adjustment.
A total of 58 families with a traumatic brain injury parent
were recruited. According to the Brain Injury Association of
Washington, traumatic brain injury is an insult to the brain,
which is not of degenerative or congenital nature, and which is
caused by an external physical force that may produce a dimin-
ished or altered state of consciousness that results in an im-
pairment of cognitive abilities or physical functioning (Uomoto
& Uomoto, n.d.). It can also result in the disturbance of behav-
ioural or emotional functioning.
General inclusion criteria for the study were: 1) for the fam-
ily: stabile domicile in Bucharest, having a children between 4 -
18 years old, legally constituted family, both parents alive
(typical family constellation); 2) for the ill parent: brain injury
severity between 3 and 12 on Glasgow scale (severe 3 - 7, me-
dium 8 - 12), hospitalisation in a neurosurgery clinic, approxi-
mately one week before living the hospital, after vital risk stage
is overtaken and amelioration evolution begins, without so-
matic or mental illnesses prior to current affection; 3) for the
spouse/healthy parent: consent signature, minimum 4 years of
school education, speaking, reading and writing Romanian
language, without somatic or mental illnesses prior to current
affection of spouse; 4) for children: somatically healthy and
without any treatment for psychiatric disorders prior to current
traumatic event, between 4 - 18 years old, living with both par-
ents, no IQ deficiency, and, 5) for self reporting children:
minimum 4 years of school education, speaking, reading and
writing Romanian language. General exclusion criteria were: 1)
for the family: single parent, divorced, concubinage; 2) for
children: knowledge of IQ deficit.
For the current study, data were used from n = 46 families
(Table 1), in which the healthy parent and one child between 11
and 17 years had completed all questionnaires. The mothers’
age ranged from 33 to 58 years (n = 20; M = 40.95; SD = 6.93),
the fathers’ age ranged from 33 to 52 years (n = 26; M = 44.42;
SD = 4.75). Among the children and adolescents between 11
and 18 years were 18 boys (39%) and 28 girls (61%). They had
a mean age of M = 14.69 years (SD = 2.02).
In 28 cases the study child was the oldest kid (61%), in 14
cases it was the middle (30%), and in 4 cases a youngest sibling
(9%). The ill parents’ prognoses were assessed by the doctors
as follows: 26 cases were assessed as “probably curable”, 15
cases as “static” and 5 cases as “chronically progressive”.
Family Functioning—Family Assessment Device (FAD) by
Epstein, Baldwin and Bishop (1983) is a questionnaire for
evaluation of family functioning as a whole. The FAD, which is
Table 1.
Mean age and distribution of gender of the sample.
Parents Children (11 - 18 years)
MothersFathers Girls Boys
n 20 26 28 18
Mean age40.95 44.42 14.85 14.44
SD 6.93 4.75 1.91 2.20
based on the widely known McMasters Model of Family Func-
tioning (Epstein, Bishop, & Levine, 1978), contains a total of
60 items. Higher scores on the FAD indicate a greater degree of
family dysfunction. Besides a general functioning scale com-
prising 12 items, six sub-dimensions of family functioning are
differentiated. The dimension “Problem Solving” (PS, 6 items)
measures a family’s capacity to solve problems. “Communica-
tion” (CM, 9 items) assesses the degree to which verbal com-
munication among family members is clear in content and di-
rection, where “clear in direction” means that the person spoken
to is the person for whom the message is intended. The dimen-
sion “Roles” (RL, 11 items) measures repetitive patterns of
behaviour by which individuals fulfil their parts in the man-
agement of family life. The degree to which tasks are clearly
assigned to individuals is also considered. “Affective Respon-
siveness” (AR, 6 items) refers to family members’ ability to
respond with the appropriate emotion to each other. “Affective
Involvement” (AI, 7 items) assesses the level of interest and
value that family members have in each others’ activities. “Be-
haviour control” (BC, 9 items) encompasses the methods used
in a family for expressing and maintaining rules. Differential
profiles of family dysfunction based on these sub-dimensions
may inform goal-directed family interventions. The FAD items
can be answered on a 4-point Likert scale from 1 = “strongly
agree” to 4 = “strongly disagree”. Participants aged 11 years
and older are asked to rate the extent to which they think gen-
eral statements on how families may function match their own
family. For each scale, answers for unhealthy coded items are
reversed. Adequate test-retest reliabilities have also been re-
ported (Epstein, Baldwin, & Bishop, 1983). Discriminant valid-
ity of the FAD has been satisfactorily established by its ability
to discriminate families with a psychiatric patient from those
without (Epstein et al., 1983). The FAD can be completed by
children and adolescents of 11 years and older. The reliability
and validity of the FAD have repeatedly been proved to be
good (Epstein et al., 1983). The reliability for each scale varies
between .72 and .92 (Chronbach’s alpha), with general func-
tioning having the strongest internal consistency (Epstein et al.,
1983). The discriminative validity of the test is also strong as
the results correlated well with clinicians’ ratings of healthy
and unhealthy families (68% - 89%) (Epstein et al., 1983).
Family coping—to assess the style of coping on the family
system level, parents were asked to answer the Family Crisis
Oriented Personal Scales (F-COPES; McCubbin, Olson, & Lar-
sen, 1981), a questionnaire consisting of 29 items. Parents are
asked to rate the statements on a 5-point-Likert-scale (1 =
“strongly disagree” to 5= “strongly agree”) regarding the ques-
tion: “When we face problems or difficulties in our family we
respond by…”. The questionnaire consists of five subscales:
acquiring social support (9 items, e.g. “Seeking encouragement
and support from friends”), reframing (8 items, e.g. “Defining
the family problem in a more positive way so that we do not
become too discouraged”), seeking spiritual support (4 items,
e.g. “Attending church services”), mobilizing family to acquire
and accept help, (4 items, e.g. “Seeking assistance from com-
munity agencies and programs designed to help families in our
situation”) and passive appraisal (4 items, e.g “Believing if we
wait long enough, the problem will go away”). Sum scores of
the subscales and a total score represent the degree in which the
family utilizes the specific style of coping.
Child psychopathology—children’s and adolescents’ self-
reported psychological symptoms were measured by the Youth
Self Report (YSR; Achenbach, 1991). YSR is designed to be
completed by 11 to 18 year-old children having a mental age of
at least 10 years. Besides enabling youths to describe them-
selves in terms of many specific items, the YSR is designed to
identify syndromes of problems that tend to occur together. The
YSR includes 112 items referring to symptomatic behaviours
and feelings that individuals rate on a 3-point scale as “not
true”, “somewhat or sometimes true”, or “very true or often
true” of themselves. By adding the respective symptom items,
eight syndrome scales can be determined (withdrawn, somatic
complaints, anxious/depressed, social problems, thought prob-
lems, attention problems, delinquent behaviour, and aggressive
behaviour). By adding the respective syndrome scales, two
spectrum scales and a total score can be obtained (internalizing,
externalizing, total problems). In order to define the prevalence
of psychological problems, the so-called borderline cut-off
values were used (T-scores 60) so that individuals with
symptoms in the borderline range were included as defined
cases (Achenbach, 1991).
The present study has been conducted in the context of the
international research project COSIP—Children of Somatically
Ill Parent (QLG-4-CT-2001-02378, 5th Framework Program
QoL) which was funded by the EU and coordinated by the
Universitätsklinikum Hamburg-Eppendorf, Germany. Individu-
als were all patients with acute traumatic brain injury, hospital-
ised at neurosurgery clinic from “Dr. Bagdasar” Emergency
Hospital Bucharest. After agreement to participate, families
were sent questionnaires, information and written consent sheets
to their homes. In families with more than one child between 4
and 18 years, data from one study child per family were se-
lected for statistical analyses. Medical information on the ill
parents’ like diagnoses, prognosis and physical impairment was
obtained from the doctors by the patients’ consent.
Family Functioning and A dolescents’
The data were analysed using Pearson correlations between
YSR total problem score, as dependent variable, and FAD gen-
eral functioning scale and corresponding subscales, as inde-
pendent variables (Table 2). For data archiving and processing,
the statistical package SPSS (Version 17. 0) was used.
Here, due to the fact that the consideration of a wide range of
hypotheses was planned using the YSR total problem as vari-
able, it appears necessary to take into account the Bonferroni
correction. However, in spite of its simplicity (or perhaps be-
cause of it), the Bonferroni correction has attracted some criti-
cism. Its biggest problem is that it is too conservative: by con-
trolling the group-wise error rate, each individual test is held to
an unreasonably high standard. One must be aware about the
fact that, this can cause a substantial loss in the precision of the
research findings (Simon, 2005), and could thus reduce the
power of the study (Perneger, 1998). That is the reason why all
correlations also were determined as effect sizes (d), whose
largeness were estimated using Cohen’s classification. There-
fore, the above results will be presented in the light of both
significance and effect size (Sava, 2004).
A positive correlation was found (r = .301, p < .05) with a
medium size effect (d = 0.6) between family dysfunction as a
whole (example items: 51 “We dont get along well together”;
56 “We confide in each other”) and psychological symptoms of
children and adolescents. Here one must have in mind that, high
scores of the FAD subscales stand for more pathology in family
function. Besides the general functioning scale of the FAD (r
= .301*), the following subscales showed significant correla-
tions at the 0.05 level: communication (example items: 43 “We
are frank with each other”; 22 “It is difficult to talk to each
other about tender feelings”), which means that, the higher the
communication dysfunction the higher were the scores for chil-
dren psychological symptomatology (r = .314*), dysfunction in
clarity and acceptance of the distribution of roles within the
family (example items: 30 “Each of us has particular duties
and responsibilities”; 45 “If people are asked to do something,
they need reminding”) (r = .303*), affective involvement (ex-
ample items: 25 “We are too self-centered”; 5 “If someones in
trouble, the others become too involved”) (r = .331*) and af-
fecttive responsiveness (example items: 49 “We express ten-
derness”; 28 “We do not show our love for each other”) (r
= .319*). For behaviour control dysfunction within the family
(example items: 55 “There are rules about dangerous situa-
tions”; 44 “We dont hold to any rules or standards”), even
though the data point in this direction, the correlation was not
significant (r = .239, p > .05; ns.). The same results were ob-
tained for dysfunction in problem-solving within the family
(example items: 2 “We resolve most everyday problems around
the house”; 60 “We try to think of different ways to solve prob-
lems”) were the correlation does not show a signifycant result (r
= .247, p > .05; ns.) although the effect size was medium (d =
Family Coping Styles and Family Functioning
In order to analyze the relation between family coping styles
Table 2.
Adolescentscorrelation between total problem behaviour (YSR) and
various personal and family va ri a bl es, n = 46.
Correlation of YSR total problem
(self-perspective) with… Pearson
correlation Sig. Cohen’s
effect size
Family dysfunction as a whole .301* .042 Medium (0.6)
Family’s dysfunction in clarity and
acceptanc e of roles distribution .303* .041 Medium (0.6)
Family’s dy s function in
behaviour cont rol .239 .110 Small (0.4)
Family’s dy s function in
affective responsive n ess .319* .031 Medium (0.6)
Family’s dy s function in
affective involvem e n t .331* .025 Medium (0.7)
Family’s dy s function in
communication .314* .033 Medium (0.6)
Family’s dy s function in
problem solving .247 .065 Medium (0.5)
and family functioning, each subscale of the F-COPES was
correlated with the FAD and its subscales respectively (Table
Two significant negative correlations were found between
the subscale “reframing” of the F-COPES and the “problem
solving” (r = –.329*), respectively “affective involvement” (r =
–.349*) scales of the FAD in the sense that frequent use of
reframing strategies was associated with low family dysfunc-
tion regarding problem solving and affective involvement
(namely over-involvement). A significant positive correlation
was found in the same way for the coping strategies “passive
appraisal” and “affective responsiveness” (r = .374*), which
means that frequent use of passive appraisal strategies was
associated with high level of family dysfunction regarding af-
fective responsiveness.
The main purpose of this study was to examine the interrela-
tions between differential family functioning, family coping
and adolescents’ mental health in a sample of 46 adolescents
having a parent affected by a severe central nervous system
injury. Differential family relational functioning was measured
by the Family Assessment Device (FAD, Epstein et al. 1983).
Preferred coping strategies in families were detected using the
F-COPES. Children’s psychological functioning was measured
based on self reporting of adolescents. For measuring the
prevalence of problems in children and adolescents, the Youth
Self Report (YSR) was administered as a widely used screening
instrument for individual psychopathology in teenagers.
Regarding the family functioning, the quality of intra-famil-
ial relationships is an important missing link in the mechanisms
involved that explains how exposure to stress in families may
or may not lead to psychological problems in children (Romer
et al., 2002). If a family develops adaptive coping strategies,
these serve as a model for the individual child’s psychological
adaptation. Based on these assumptions, high family function-
ing was considered protective for children exposed to parental
physical illness, whereas family dysfunction may be likely to
predict children’s maladjustment respectively. The new situa-
tion can be considered as one of family crisis which leads to
major disorganizations of routines and to a huge increase of
emotional tensions between the healthy family membe rs. Thus,
the child’s psychosocial development is assumed to be affected
by the secondary effects of a parent’s illness on family life,
such as fears for the future, financial burdens, role changes,
physical strains of caring, or marital distress, as well as on the
parent-child relationship in particular, such as changes in pa-
rental personality traits, parents’ self-esteem, emotional avail-
ability, parenting competencies, as well as separations due to
hospitalisation or anticipated loss (Lewandowski, 1992; Romer
et al., 2002).
The re sults show tha t discrepant levels of fa mily functi oning
predicted children’s psychological symptoms. This is supported
by the positive correlation between family dysfunction as a
whole and adolescents psychological symptoms. Furthermore,
the finding that, besides the general functioning subscale, dys-
function in four other sub-dimensions of family functioning
predicted children’s problems, namely affective responsiveness,
affective involvement, communication and roles, deserves more
in-depth interpretation. Affective responsiveness refers to fam-
ily members’ open sharing of feelings, whereas affective in-
volvement reflects interest and value family members attach to
each others’ activities; communication, involving honesty, dif-
ficulty and level of communication between family members;
and roles, which refers to clarity and acceptance of roles distri-
bution, to particular duties and responsibilities. The present
findings suggest that teenage children’s healthy adaptation to
illness-related family stress is facilitated if parents and children
are able to express and share feelings openly while maintaining
appropriate boundaries between individual family members that
help to prevent over-involvement with each other, if they are
able to communicate openly to each other and to share and also
accept specific new roles and responsibilities. Furthermore,
open communication about illness-related concerns and related
feelings should be facilitated in order to prevent a conspiracy of
silence. These findings may well inform focused intervention
concepts in medical family therapy.
These findings are supported by similar results from previ-
ous studies. Thus, Rost (1992) in his review on empirical stud-
ies on children of somatically ill parents summarized some
protective factors, such as open communication between par-
ents and children about the illness as well as flexible boundaries
between the family system and the social environment. Fol-
lowing the same idea, Power (1985), found that well-adjusted
families were those in which family members took care of their
own needs and were involved in activities outside the family.
Furthermore, communication about the disease was open and
information to/about all family members was appropriate. In
the poorly adjusted families, the disease was perceived as an
Table 3.
Intercorrelations of F AD scal e s a n d F-COPES scales, Adolescents, n = 46.
F-COPES FAD Seeking social support Reframing Seeking spiritual suppo rtMobilizing family to acquire and accept help Passive appraisal
Problem sol ving –.096 –.329* –.212 –.045 .106
Communication .122 –.185 –.171 .105 .202
Roles .191 –.200 –.188 .203 .184
Affective responsiveness .142 .096 –.210 .013 .374*
Affective involvement .085 –.349* –.174 .102 .084
Behaviour c ontrol .009 .278 –.169 –.050 .246
General func tioning .090 –.093 –.157 .085 .213
*Correlation is significant at the .05 level (2-tailed).
ongoing source of distress. Lack of communication, informa-
tion and understanding was prominent in these families. Corre-
lation analyses revealed that only two of the FAD subscales did
not correlate with children and adolescents psychological
symptoms, namely behaviour control and problem solving.
Here, one can assume that by the very nature of the traumatic
event and its consequences for family life, all families will have
to make use of their resources and skills in problem solving and
behaviour control to a maximum degree. Therefore, these two
areas of family function are highly activated in terms of pri-
mary coping requ i r e ments.
Differential family coping strategies could not discriminate
families in which adolescents reported symptoms from those
families with asymptomatic offspring. It has to be noted here
again, that F-COPES data were not available from the adoles-
cents’ perspective. Therefore a bias based on a shift of report-
ing perspectives in the data correlated with each other cannot be
excluded. Data suggest that there is no significant path from
families’ coping strategies to children’s psychological outcome.
However, in both parents’ perspective, common use of reframe-
ing as a coping strategy predicted to an impressive degree high
family function. In fathers’ reporting respectively, seeking so-
cial and/or spiritual support was associated with higher rela-
tional functioning in families.
To sum up, these findings are well applicable to inform fo-
cused concepts for systemic interventions in families with an ill
parent, that are not only geared to utilize the family system as a
supporting resource for the ill parent, but also aim at preventing
mental health problems in children of ill parents. Fostering
family rela t ional functioni ng in crisis can be assumed to equally
serve both goals. Our findings suggest that supporting a family
in finding appropriate ways of reframing the stressful situation
may be especia lly effective in stre ngthening family funct ioning
in crisis. From the child’s perspective, reframing connotations
that are appealing to adult family members may not be equally
helpful, unless they are adequately explained on the child’s
cognitive level. If patients or their relatives report these as their
main coping patterns, this may reflect helplessness rather than
an effective way of self-regulation and stabilization, and thus
may be carefully questioned by health professionals. Further-
more, our data suggest that adolescents with an ill parent are
especially vulnerable for internalizing problems, if families
have a low ability to share feelings and are having weak intra-
familial boundaries with an increased danger of intrusion,
over-involvement or enmeshment (Minuchin, 1998). If one
acknowledges that in families facing the existential threat of
serious parental illness the attachment system is highly acti-
vated and therefore cohesive forces are stimulated together with
all resources and competencies involved in mutual support and
problem solving, which are already evoked to the greatest pos-
sible degree, it becomes plausible that these families have a
specific vulnerability to dysfunctional affective involvement, if
there are not enough intra-familial boundaries to counterbal-
ance the strong cohesive forces. Therefore, systemic interven-
tions, besides encouraging open expression and sharing of feel-
ings between parents and children, should at the same time
focus on strengthening clear boundaries between individuals, so
that children will be able to feel empathy for their ill parents’
harm and distress without getting contaminated by these in their
intra-psychic world.
Despite a number of strengths of this study, it is not without
its limitations. These limitations do not affect its main findings,
but bear on how they are interpreted. Taking into consideration
that this study investigated a novel area in child mental health
(in Romania this was actually the first study on children of
somatica lly ill parents), one could admit that a mere exploratory
approach would suffice. For this study, an important emphasis
on hypothesis testing, which for some research questions was
supplemented by an exploratory analysis. Also, because the
sample size was relatively limited, it was decided to use both
effect sizes and statistical significance in hypothesis testing.
The inclusion criteria established in the project, which ex-
clude the families with problems prior to current illness, or
single parent families, divorced, not legally constituted, could
exclude exactly the kind of family which, perhaps, are in more
need of psychological support for their children than the fami-
lies included in the rese arc h.
The use of data from the other European partners involved in
the project, although highly desirable, was unfortunately im-
possible, primarily due to the fact that the Romanian subproject
was focused on a different type of disease, acute central nerv-
ous system injuries, while our partners were focused on chronic
illnesses like cancer or multiple-sclerosis. Yet, some of the
findings (e.g. affective responsiveness and affective involve-
ment FAD subscales roles in children and adolescents psycho-
logical symptomatology) are mirrored both in German and UK
data (Edwards et al., 2006; Romer et al., 2006), in spite of dif-
ferences in parental illnesses, which is evidence for the fact that,
the life threat or absence of the ill parent, his suffering, depress-
sion and burden on the healthy parent and the need of reorgan-
izing the roles in family are effects encountered across different
designs and samples.
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