Journal of Pediatric Psychology, Vol. 21, No. 1, 1996. pp. 25-41
Hope, Coping, and Adjustment Among Children
with Sickle Cell Disease: Tests of Mediator and
Moderator Models1
Hellen A. Lewis and Wendy Kliewer2
Virginia Commonwealth University
Received June 6, 1994; accepted March 9, 1995
Tested mediator and moderator models of hope, coping, and adjustment in 39
children with sickle cell disease. In home interviews parents provided information on demographics and functional adjustment. Children self-reported levels of
hope, coping strategies, and psychological adjustment. Coping strategies moderated, but did not mediate, the relationship between hope and adjustment. Hope
was negatively associated with anxiety when active coping, support coping, and
distraction coping was high. Avoidance coping did not moderate the hopeadjustment relationship but was positively related to anxiety. No effects were
found for depressive symptoms or for the functional measures of adjustment.
KEY WORDS: sickle cell disease; hope; coping; adjustment.
Sickle cell disease (SCD) is a chronic hereditary disease for which there is no
cure (Charache, Lubin, & Reid, 1985). It is quite common, occurring in one of
every 400 to 500 African American live births in the United States (DesFbrges,
Milner, Wethers, & Whitten, 1978). Children with SCD commonly experience
recurrent and unpredictable episodes of pain. They may also experience chronic
hemolytic anemia that results in excessive fatigue, retarded growth, and delayed
'We thank Florence Neal-Cooper, Jene Radcliffe-Shipman, Brenda Norman, and participants in the
Sickle Cell Awareness Program at the Medical College of Virginia for their efforts in recruiting
families for this study. This study was based on the master's thesis of the first author, under the
direction of the second author.
2
A1I correspondence should be sent to Wendy Kliewer, Department of Psychology, PO Box 842018,
Virginia Commonwealth University, Richmond, Virginia 23284-2018.
25
0I44-8693/96/02OHI025109 *W0 O 19% Plenum PUMMMJH CaporaHon
26
Lewis and Klkww
puberty (Bowman & Goldwasser, 1975; Charache et al., 1985). Along with the
physiological complications that result from SCD, individuals may experience
psychological maladjustment (Briscoe, 1987; Gil, 1989); however, these findings are equivocal. Perhaps a more important question to ask is: Within the SCD
population, why do some children show good adjustment and others show poor
adjustment?
Disease parameters alone do not completely explain variations in adjustment (Hurtig, Koepke, & Park, 1989; Thompson, Gil, Burbach, Keith, & Kinney, 1993). As a result, research efforts have shifted to the study of dispositional
influences and coping processes to help understand adjustment in children with
SCD and other chronic illnesses (Wallander & Varni, 1992). A novel example of
such an approach involves the construct of hope.
Hope is a particularly relevant concept to populations experiencing srressors
that are likely to be appraised as threatening, such as persons with SCD. The
chronic nature of the illness, the unpredictability of painful episodes, and the
lack of control over the course of the disease make it likely that SCD would be
experienced as threatening. Further, person-based factors, such as hope, are
likely to have their greatest influence on appraisal processes when environmental
conditions are not clearly defined, such as in SCD (Snyder et al., 1991).
The theoretical and empirical underpinnings of the hope construct were
developed from research with adults (Synder et al., 1991) and little research has
focused on hope in children. However, the construct of hope is relevant to
children in that, like adults, children are goal-directed. Their goal-directed
thoughts can be understood in terms of two components that constitute the hope
construct: agency and pathways. Agency refers a person's belief that they can
meet a goal, while pathways refers to a person's perception that strategies are
available to achieve a goal (Synder et al., 1994). For example, a child with
sufficient pathways could generate a number of strategies for reducing pain, such
as distracting himself or calling on others to provide her with comfort. A child
with sufficient agency believes that he or she will be efficacious in achieving a
desired outcome, such as resolving a conflict with a friend. Theory suggests that
the basic components of hope are established during infancy and toddlerhood,
and are relatively stable by middle childhood (see Synder et al., 1994, for
review).
Hope is related to, yet conceptually distinct, from optimism and self-efficacy. Optimism, as conceptualized by Scheier and Carver (1985) parallels the
notion of pathways but does not include the concept of agency. Conversely, selfefficacy, as conceptualized by Bandura (1989), parallels the notion of agency but
does not include pathways. Snyder (1989) argues that both agency and pathways
are necessary to the definition of hope but neither is sufficient.
Hope is also related to, yet distinct from, the concept of coping. Coping has
been defined as "constantly changing cognitive and behavioral efforts to manage
Hope, Coping, and Adjustment to Sickle Cell Disease
27
specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person" (Lazarus & Folkman, 1984, p. 141). According
to Lazarus and Launier (1978), person- and situation-based factors may affect the
appraisal process by influencing whether particular events signal threat, challenge, or loss. Hope would be considered a person-based factor in the appraisal
process in that it is conceptualized as a cognitive set (Snyder et al., 1991). That
is, different levels of hope may dispose persons to view stressors in different
ways. For example, persons with high levels of hope may be more likely to view
stressors as challenging, as opposed to threatening (Snyder et al., 1991). The
theoretical relation between hope and coping, therefore, is based on the assumption that the appraisal of stressors affects coping efforts (Lazarus & Folkman,
1984). Lazarus and Lanier (1978) argue that challenge and threat appraisals lead
to different types of coping. Empirical evidence supports this notion in that threat
appraisals have been found to be related to wishful thinking and support seeking,
whereas challenge appraisals have been related to problem-focused coping (Folkman & Lazarus, 1985). Along these lines, positive correlations between hope
and problem-focused and active coping (Holleran & Snyder, 1990; Sigmon &
Synder, 1990) have been reported.
Although hope is related to better mental and physical health (Elliott, Witty,
Herrick, & Hoffman, 1991; Holleran & Snyder, 1990), the mechanisms through
which it operates and the conditions under which it has beneficial effects are just
beginning to be studied. The present study investigates links between hope,
coping, and adjustment in a sample of children with SCD by testing two alternative models that may explicate the relationship between these variables.
The first model is a mediator model (see part A of Figure 1). In this model,
the mediator (coping) explains "why" a relationship exists between the predictor
(hope) and criterion (adjustment) variables (Baron & Kenny, 1986). In the present study, we are testing the belief that hope affects the choice of coping strategies which in turn affects adjustment. This is consistent with the notion that
appraisal precedes coping efforts (Lazarus & Folkman, 1984), given that hope is
a factor involved in the appraisal process (Snyder et al., 1991), and that coping
affects adjustment (Ebata & Moos, 1991; Felton & Revenson, 1984; Holahan &
Moos, 1985, 1986; Sandier, Tein, & West, 1994). A fairly large body of research
with diverse samples has demonstrated that in general, active coping strategies
(i.e., efforts aimed at directly addressing the stressor) are associated with good
adjustment and avoidance coping strategies (i.e., efforts to avoid the stressor or
to avoid thinking about the stressor) are associated with poor adjustment. Although a few researchers have studied coping in children and adolescents with
SCD (Gil et al., 1991; Gil, Williams, Thompson, & Kinney, 1993; Thompson et
al., 1993, 1994), the literature is fairly sparse and most studies on this topic focus
only on the pain coping strategies of youth with SCD. Even though pain coping
strategies of individuals with SCD have been associated with their adjustment
Lewis and Kliewer
28
(A)
HOPE
COPING
ADJUSTMENT
(B)
COPING
HOPE
ADJUSTMENT
Fig. 1. (A) Schematic diagram of the mediating role of coping. (B) Schematic diagram of the
moderating role of coping.
(Gil et al., 1991, 1993), it is important to look at the concept of coping more
broadly, particularly because children with SCD are faced with many other
stressors in addition to painful episodes.
To date, there is encouraging but limited empirical evidence suggesting that
the effects of dispositional motivational constructs, similar to hope, on adjustment are mediated through coping efforts (Carver et al., 1993). Carver et al.
assessed level of optimism, coping behaviors, and general distress in a sample of
59 breast cancer patients at different periods. Results indicated a mediational
effect of coping in predicting distress at all time points except at long-term
follow-up.
The second alternative model we are testing is the moderator model (see
part B of Figure 1). In this model, coping moderates the relationship between
hope and adjustment. That is, coping efforts specify "when," or under what
conditions, a relationship between hope and adjustment exists. The moderating
effect is typically expressed as an interaction between the predictor and criterion
variables (Barron & Kenny, 1986). In the present study we evaluate the effects of
hope with different coping strategies. Because both hope and active coping
strategies are associated with good adjustment, we expected hope to be most
strongly related to adjustment when active coping was high. Conversely, avoidant coping is typically associated with poor adjustment. Therefore, we expected
Hope, Coping, and Adjustment to Sickle CeU Disease
29
hope to be most strongly related to adjustment when avoidant coping was low.
Because of their equivocal relationships to adjustment, specific predictions were
not made for support seeking or distraction coping.
METHOD
Subjects
Participants were 39 children and adolescents with SCD (64% girls) and
their primary caregivers: mothers (79.5%), fathers (10.3%), grandmothers
(7.7%), and a stepmother (2.6%). The mean age of the child participants was
11.0 years (SD 2.9, range = 7-16.4). Grade in school ranged from 1st to 1 lth,
with a median of 5th grade, thus the sample was heterogeneous in regard to
developmental level. Names of all potential study participants were obtained
from the directors of two regional SCD organizations. These regional SCD
organizations primarily provide support for families and screening for infants,
and were not part of a comprehensive SCD medical center. Seventy-four families
with children in the target age range were identified by the directors of these
organizations. Of these 74 families, only 43 could be reached by phone or mail to
request their participation. Of these 43 families, only 4 refused to participate.
Family constellations included homes with two parents and children (46%) and
single parent or primary caregiver and children (54%). Families fell into the
following socioeconomic status (SES) categories (Hollingshead, 1957): Levels
1-4 = 40%; Levels 5-9 = 60%. This sample has a higher SES level than many
SCD studies (Hurtig et al., 1989).
Information about disease-type and frequency of SCD-related medical complications in the past year was obtained from the primary caregivers. Participants
had the following types of sickle cell disease: SS (56.4%), SC (28.2%), and beta
thalassemia (15.4%). There was considerable variability on the number of SCDrelated complications, with at least some caregivers reporting no complications.
Fatigue was the most common symptom (M — 62.0, SD = 132.0), followed by
organ complications (M = 5.8, SD = 32.0), painful episodes (M = 5.0, SD =
11.0), hand-foot syndrome (M = 1.9, SD = 8.0), serious bacterial infections
such as pneumonia, infections of the blood, bone, or meningitis (M = 0.7, SD =
1.7), and leg ulcers (M = 0.2, SD = 1.3). Because the study participants'
families use multiple medical resources, caregivers' reports of SCD-related complications were considered to be more comprehensive and practical than chart
reviews at any given area hospital. This approach is consistent with methods
used to obtain this type of data on children with SCD in other studies (Gil et al.,
1991; Thompson et al., 1993, 1994).
30
Lewis and Klkwer
Procedure
After agreeing to participate, home interviews were arranged with the families. The home interviews were conducted by two trained interviewers per
child/caregiver dyad. Prior to any data collection, informed consent was obtained from the child and his/her primary caregiver. One interviewer read measure items aloud to the child and recorded the child's responses while the other
interviewer obtained demographic information and data on functional measures
of adjustment from the caregiver in a separate room. Child interviews lasted
approximately 45 minutes. Rapport between the interviewer and the child was
established prior to beginning the interview. The children were cooperative and
the majority remained engaged throughout questioning. Families were informed
that if they participated they would be eligible to win one of two $100 lottery
drawings.
Measures
Hope. Hope was assessed with the Children's Hope Scale (Synder et al.,
1994), a self-report measure. The Children's Hope Scale was developed for
children ages 8 to 16 and is a downward extension of the adult version of the
Hope Scale (Snyder, 1989; Snyder et al., 1991). The Children's Hope Scale
consists of six statements, which are rated using a Likert-type format from 1
{none of the time) to 6 {all of the time). A principle components factor analysis
with varimax rotations yielded two factors that represented the agency and pathways components of hope. Consequently, three of the six statements reflect the
agency component of the hope construct (e.g., I think the things I have done in
the past will help me in the future), and three statements reflect the pathways
component (e.g., When I have a problem, I can come up with lots of ways to
solve it). The Children's Hope Scale has been used with samples of normal
children as well as with children with psychological and physical disorders
(Snyder et al., 1994). Internal consistency (assessed with Cronbach alpha coefficients) has ranged from .70 to .86 across samples, and temporal stability over a
1-month interval has ranged from .71 to .73 across samples. The Children's
Hope Scale has also been found to exhibit convergent validity in regard to its
predicted positive and negative relationships with odier self-report measures, as
well as incremental validity in predicting academic achievement beyond projections made by competency-based scales. For instance, cross-validational data
(Synder et al., 1994) have indicated that die Children's Hope Scale is associated
with children's internal locus of control (r = —.29 to - . 3 5 , as measured by
Nonvicki-Strickland Locus of Control; Norwicki & Strickland, 1973), overall
competence (r = .22 to .59, as measured by all six subscales of the Selfperception Profile for Children; Harter, 1985), academic achievement (r = .50,
Hope, Coping, and Adjustment to Sickle CeU Disease
31
as measured by the Iowa Test of Basic Skills), and parent's reports of hope (r =
.37 to .53, as measured by a modified version of the Children's Hope Scale), and
negatively associated with depression (r = —.19 to - . 4 8 , as measured by the
Child Depression Inventory (CDI; Kovacs, 1980/1981), and anxiety (r = - . 2 3
to —.28, as measured by the Revised Children's Manifest Anxiety Scale
(RCMAS; Reynolds & Richmond, 1978).
Coping Responses. Dispositional coping strategies were assessed with the
Children's Coping Strategies Checklist (CCSC; Sandier et ad., 1994). This 60item instrument asks children to rate how often they typically used coping strategies when faced with problems in the past few months. Items are rated on a scale
from 1 (never) to 4 (most of the time). Items reflect 11 conceptually distinct
dimensions. Confirmatory factor analyses (Sandier et al., 1994) indicate that
these dimensions form four coping factors: Active, Avoidance, Distraction, and
Support Seeking. Extensive reliability and validity data are reported in Sandier et
al. (1994). For example, in several validity studies using causal modeling techniques, active coping has been associated with positive psychological adjustment
while avoidance coping has been associated with negative adjustment. The active
coping factor comprises direct problem solving, cognitive decision making,
seeking understanding, and positive cognitive restructuring. Both cognitive and
behavioral avoidance form the avoidance coping factor. The distraction coping
factor comprises distracting actions and physical release of emotions. Problemand emotion-focused support form the support-seeking factor.
Psychological Measures of Adjustment. Self-report measures of both depressive and anxious symptoms were obtained. The 27-item CDI (Kovacs,
1980/1981) was used to measure level of depression. This measure is used
extensively with both clinical and nonclinical populations. Each item consists of
three statements graded in level of severity and scored from 0 to 2, yielding a
range of possible scores from 0-54. The psychometric properties and normative
data of this measure have been investigated previously (Kovacs, 1980/1981;
Smucker, Craighead, Craighead, & Green, 1986). Reliability was also assessed
and proved acceptable (Smucker et al., 1986). The RCMAS, also known as
"What I Think and Feel," (Reynolds & Richmond, 1978) was administered to
assess anxiety in the study sample. This measure consisted of 28 true-false items
which are scored either 0, indicating absence of the symptom, or 1, indicating
the presence of the symptom. This yields a possible range of scores from 0—28.
Reliability coefficients have been acceptable (Reynolds & Richmond, 1978).
Concurrent validity has also been investigated by examining the convergent and
divergent validity of the scale (Reynolds, 1980). Factor analysis supported the
construct validity of this scale and yielded three factors: physiological manifestations of anxiety; worry and oversensitivity; and difficulty concentrating (Reynolds & Richmond, 1979). Reliability of all measures in the current sample are
reported in Table I.
32
Lewis andKliewer
Table I. Descriptive Statistics on the Study Measures
Variable
Predictor
Hope
Coping styles
Active
Support seeking
Distraction
Avoidance
Psychological outcomes
Depression
Anxiety (total)
Anxiety—physical
Anxiety-worry
Anxiety-concentration
Physical outcomes
Activity reduction
Health care utilization"
Control variables
Frequency of complications"
M
SD
Range
a
26.05
5.51
14-36
.75
2.70
2.38
2.48
2.80
0.43
0.56
0.57
0.53
1.73-3.80
1.00-3.50
1.44-3.78
1.50-3.60
.87
.63
.67
.73
8.51
13.62
5.46
4.90
2.72
5.83
6.81
2.64
2.63
1.84
0-26
1-26
0- 9
1-10
0- 6
.79
.79
.72
.74
.62
20.64
2.67
21.74
0.32
0-89.33
0-8.00
.83
2.38
0.46
0-14.28
"Square-root transformation performed on these variables due to skewness.
Functional Measures of Adjustment. Functional measures of adjustment included indicators of health care utilization and activity reduction, as assessed by
a modified version of the Structured Pain Interview (Gil et al., 1991). Primary
caregivers were asked to report the number of emergency room visits, hospital izations, and phone calls/visits to physicians for SCD-related complications
during the past year in order to access health care utilization information. These
numbers were summed to yield a total health care contact score. Caregivers were
also asked to estimate the percentage of time during the last year their children
reduced their level of involvement in household, school, and social activities
because of the physical problems imposed by their child's illness. This was done
by marking three 100-millimeter lines that ranged from 0% (no reduction) to
100% (complete reduction). The activity reduction score for each child was
obtained by calculating the mean for these three areas of functioning. Both of
these indicators have been used reliably in other studies as functional measures of
adjustment of SCD patients (Gil, Abrams, Phillips, & Keefe, 1989; Gil, Abrams,
Phillips, & Williams, 1992; Gil et al., 1993, 1991).
RESULTS
Descriptive Information
Analyses were conducted in several steps. Prior to addressing the central
research questions, distributional qualities of the measures were assessed and
Hope, Coping, and Adjustment to Sickle Cell Disease
33
square-root transformations were performed on variables which were not normally distributed. Descriptive information on each measure, including Cronbach
alpha reliability, is found in Table I. As a group, the study sample appeared to be
consistent with normative samples on measures of hope (Af = 25.89; SD = 5.41;
Synder et al., 1994), coping (M = 2.54; SD = .70; Sandier et al., 1994),
depression (M = 9.09; SD = 7.04; Smucker et al., 1986), and anxiety (M =
13.84; SD = 5.79; Reynolds & Richmond, 1978), but to exhibit better functional
adjustment compared to other study samples of children with SCD (Gil et al.,
1991).
Next, to determine appropriate control variables, relationships of gender,
age, family type, disease type, and frequency of complications to adjustment
were assessed. Variables correlated r > .15 with adjustment were controlled.
Zero-order correlations between control variables and adjustment can be found in
Table II.
Mediator Analyses
In addition to theoretical plausibility, several statistical criteria are required
to test the hypotheses that coping mediates the relationship between hope and
adjustment. First, after accounting for controls, a relationship between the predictor (hope) and the outcome (adjustment) needs to be established. Second, a
relationship between the mediator (coping) and the outcome needs to be established. Third, a relationship between the predictor and the mediator needs to be
established. Fourth, after controlling for the effects of the mediator on the outcome, the relationship between the predictor and the outcome should be significantly reduced (Baron & Kenny, 1986; Evans & Lepore, in press).
In the present study, prior analyses (see Table II) indicated that the first three
criteria for mediation effects were met in some cases. As seen in Table II,
functional measures of adjustment were correlated with coping or hope in only one
case, and depressive symptoms was related only to distraction coping. However,
anxiety was related to hope as well as to several coping factors. Zero-order
correlations between hope and coping indicated that among the four coping
variables, only active coping was significantly related to hope (r = .51, p < .01).
Hierarchical regression analyses were used to examine the relations between
hope and adjustment, after controlling for the effects of family type, type of
SCD, frequency of SCD-related complications, and the age of the child. Because
outliers can significantly distort relationships between predictor and outcome
variables, particularly in small samples, it is necessary to identify and evaluate
the influence outliers may have on regression equations (Neter, Wasserman, &
Kutner, 1989). One multivariate outlier, identified with Cook's distance measure
D (Cook & Weisberg, 1982), was removed in the analyses reported here. Hope
significantly predicted physical symptoms of anxiety, F(5, 32) = 6.02, p <
.06
.07
-.01
.17
.02
-.09
-.12
-.11
-.34'
.00
-.20
-.34'
-.06
-.10
Support
-.05
-.19
.37'
.13
.03
.10
.19
Distract
.10
-.04
.21
.33'
.21
.29
.35°
Avoid
.12
-.07
-.04
-.34'
-.40"
-.18
-.27'
Hope
.11
-.01
-.32'
-.38'
-.43*
-.24
-.28
Age
.07
.20
.21
-.02
-.11
.09
-.06
Gender
.12
.19
-.03
.23
.29
.25
-.02
type
Controls
-.22
.13
.09
.19
.16
.16
.17
type
.41
.75'
.16
.28
.25
.31
.06
complications
"Correlations with the four coping factors and control variables are two-tailed. Correlations with Hope are 1-tailed. SCD type was coded 0 for SC disease and
beta thalassemia and 1 for SS disease, the more severe form of SCD. Family type was coded 0 for families with one parent and 1 for two-parent families.
Gender was coded 0 for female and 1 for male.
k
Square-root transformations were performed on these variables due to slcewness.
c
p < .05.
"p< .01.
•p< .001.
Psychological adjustment
Depression
Anxiety (total)
Anxiety-physical
Anxiety-worry
Anxiety-concentration
Physical adjustment
Activity reduction
Health care utilization6
Active
type
Table n . Zero-Order Correlations Between Hope, Coping Factors, Controls, and Adjustment"
Hope, Coping, and Adjustment to Sickle Cell Disease
35
.001, explaining 21% of the variation in symptoms after accounting for the
controls. Because hope was significantly related to active coping strategies, a
mediator analyses was performed on the physical anxious symptoms. In this
analysis, the controls (age, family type, SCD type, and frequency of complications) were entered first, followed by active coping, then hope. After controlling
for the effects of active coping on adjustment, which explained an additional 9%
of the variance in adjustment after the controls, the relationship between hope
and adjustment was not significantly reduced. Therefore, coping did not mediate
the relationship between hope and physical symptoms of anxiety in this sample.
Moderator Analyses
Moderator analyses were performed to examine the interactive effects of hope
and coping in predicting adjustment, after controlling for the effects of family
type, SCD type, frequency of SCD-related complications, and the age of the
child when indicated. In these hierarchical multiple regression analyses, the
continuous-level predictor, moderator, and control variables were centered (e.g.,
the mean was subtracted), and the centered predictor and moderator terms were
multiplied to form the interaction term. This procedure is recommended by
Aiken and West (1991) to reduce problems with multicoUinearity and to facilitate
interpretation of significant interaction effects. Beta weights are reported from
the final step of the equation and therefore reflect the unique contribution of each
variable. When interaction terms were significant, the regression lines were
plotted using procedures described by Aiken and West. As stated previously,
multivariate outliers, identified with Cook's distance measure D, were removed
in the analyses reported here, as indicated by the degrees of freedom. Analyses
were conducted separately for the four coping factors because these factors are
both theoretically and empirically distinct. Although the factors are moderately
correlated, confirmatory factor analyses with diverse samples have indicated that
a four-factor model best fits the data. Additionally, these four coping factors have
distinct associations with adjustment indices (Sandier et ah, 1994).
None of the moderator analyses predicting activity reduction, health care
utilization, or depression were significant after accounting for control variables.
However, the active coping, support coping, and distraction coping factors significantly interacted with hope to affect anxiety, with interaction terms explaining
an additional 8-11% of the variation in anxiety. These results are summarized in
Table m .
Plots of the Hope x Active Coping interaction reveal a strong negative
relationship between hope and anxiety for children who use a high level of active
coping, but no relationship for children using low levels of active coping. For the
Hope x Support Coping interaction, the hope-anxiety relationship is again
Lewis and Kilmer
36
Table III. Regression of Total Anxiety Scores on Controls and the Interaction
of Hope and Coping"
Overall F
Step
Active coping
1. Age
Family type
SCD type
Complications
2. Hope
Active coping
3. Hope X Active coping
-.34'
.10
.26
2.95*
.34
.42
1.98
4.17'
f(7, 31) = 3.18"
-.07
.28*
-.34"
.15
-.31'
F(7, 30) = 2.89'
.38'
.07
.09
.09
.38'
.26
.37'
F(7, 29) = 3.59"
.36'
.08
.04
.15
.38'
.30*
.37'
Support coping
1. Age
Family type
SCD type
Complications
2. Hope
Support coping
3 Hope X Support coping
.22
2.34"
.30
.40
1.77
5.11'
Distraction coping
1. Age
Family type
SCD type
Complications
2. Hope
Distraction coping
3. Hope X Distraction
.23
2.35*
.35
.46
2.77*
6.30'
Avoidance coping
1. Age
Family type
SCD type
Complications
2. Hope
Avoidance coping
3. Hope X Avoidance
.24
2.43*
.48
.52
6.61"
2.25
.27*
.25*
.21
.17
.48"
.41'
F(l, 28) = 4.27"
.21
•Beta weights are from the final step of the regression equations and represent the unique contribution
of each variable.
*/> < . 10.
'/> < .05.
"p < .01.
negative for children and adolescents using high levels of support. A positive,
though weak, relationship was found between hope and anxiety for children who
use low levels of support seeking. Finally, there was a strong negative relationship between hope and anxiety for children who use a high level of distraction
coping, and a weak negative relationship for children who use low levels of
distraction.
Hope, Coping, and Adjustment to Sickle Cell Disease
37
Although there was not a significant Hope x Avoidant Coping interaction
predicting anxiety, both variables had unique main effects on anxiety. Hope was
negatively associated with anxiety, and avoidance coping was positively associated with anxiety.
DISCUSSION
The present study is the first investigation of the relationship between hope,
coping, and adjustment in children. In this study, we examined the relationship
between hope and adjustment in children with sickle cell disease, and tested
mediator and moderator models of the role that coping strategies play in the
relationship between hope and adjustment. Consistent with findings reported
with adults, we found that hope was negatively related to anxiety. However,
coping strategies moderated this relationship. Specifically, hope was negatively
related to anxiety when active, support, and distraction coping strategies were
high. That is, children with sickle cell disease who have high levels of hope and
who report often using active, support, and distraction coping strategies report
less anxiety. Thus, knowing both a child's level of hope and coping behaviors is
important in understanding variations in psychological adjustment. In contrast to
the moderator model, data from this study do not support a mediational role of
coping in the hope-adjustment relationship. That is, hope was not associated
with a reduction in anxiety by affecting coping efforts.
It is important to delineate distinctions between mediator and moderator
models because of their differing implications. Testing potential moderator effects may lead to the identification of subgroups that are more resilient or vulnerable under certain conditions, which has clinical implications. Additionally, such
findings may guide future research on why or how the links between variables
are conditional. Identification of mediational variables offer a potential explanation of why an independent variable has an effect on a dependent variable, and
such identification is important in the design and evaluation of intervention
programs (Evans & Lepore, in press).
Hope and coping affected anxiety but did not make unique contributions to
functional adjustment or depression once control variables were considered. The
lack of relationship between hope, coping, and functional adjustment may be
explained by a lack of control by the child over such factors. For example, the
frequency of utilization of the health care system for SCD-related complications
may have more to do with availability, financial, and parent motivational factors
than the child's level of hope or coping style. The same reasoning applies to
reduction in activity during SCD-related complications. That is, parents may
insist on continued involvement in regular activities during these episodes.
Therefore, the child's level of hope or coping strategies has no direct effect on
their functional adjustment. The lack of effects on depression may be partially
38
Lewis and Kliewer
statistically explained by less variation in depression scores relative to anxiety
scores.
Results of the present study should be interpreted cautiously for a number of
reasons. First, because of the small sample the statistical power of the analyses
was restricted, which may explain nonsignificant findings. In addition, because
of the number of analyses, Type I error must be taken into consideration when
interpreting the results. A second limitation involves the heavy reliance on selfreport. Although self-report is crucial when assessing internalized states, such as
hope, depression, and anxiety, reports from other sources (e.g., from the children's primary caregivers and teachers) on the types of coping behaviors the
children use would have provided valuable information. Observational data on
coping behaviors would also complement the self-reports of coping. In addition,
conclusions that can be made about adjustment would be strengthened by assessing the construct more comprehensively, such as by assessing competence across
several domains, in addition to assessing emotional or behavior problems. Finally, while the analyses indicate how well hope and coping predicted adjustment,
these findings are based on cross-sectional, correlational data, and causal relationships between hope, coping, and adjustment cannot be inferred. The predictive power of the hope and coping constructs would be strengthened through the
use of longitudinal designs or, with larger samples, through statistical analyses
utilizing path analyses or structural equation modeling.
Despite the limitations of the present study, several strengths make it unique
and important. This is one of the first studies to examine hope in children and
explore how this construct affects adjustment. The present study is also important
in that it helps lends support to theoretical and empirical work in the area of stress
and coping. For example, the construct of hope can be accommodated within the
transactional stress and coping model proposed by Thompson and his colleagues
(Thompson et al., 1993; Thompson, Gustafson, Hamlett, & Spock, 1992). According to their model, SCD would be conceived as a stressor to which a child
must adjust and cognitive sets, such as hope, would be considered mediational
processes which influence variations in the child's adjustment to SCD (Thompson et al. 1992). This model takes an ecological-systems theory perspective and
has demonstrated utility in delineating the processes associated with adjustment
to illness (Thompson et al., 1992).
Another unique feature of the study is that we tested alternative models
(i.e., mediator and moderator models) of the relationships between hope, coping, and adjustment. The empirical support in the present study for the interaction of hope and coping in predicting adjustment has clinical implications given
that stress and anxiety can exacerbate the physical complications associated the
SCD (Charache et al., 1985). These data, therefore, suggest that knowing both a
child's level of hope and coping behaviors are important in understanding variation in psychological adjustment.
Hope, Coping, and Adjustment to Sickle Cefl Disease
39
Despite the fact that this study does not support the mediation effect of
coping in the hope-adjustment relationship, our data suggest that further work
with the hope construct is warranted. For example, systematic replication studies
would increase our knowledge of the alternative models through which hope
affects adjustment, as well as the generalizability of the findings for children of
different ages or with different medical complications. It is plausible that the
relationship between hope, coping, and adjustment in children may differ depending on their developmental level or the type of stage of stressor they are
experiencing. Therefore, future studies should sample from children within more
narrow age ranges (e.g., 9-11 years old, or 15-17 years old) so that the relationship between hope, coping, and adjustment can be assessed developmentally. In
addition, future investigations should examine the relationship between these
variables in children in more acute stages of a stressor, for example, with invasive medical procedures or soon after being diagnosed with cancer.
In addition to replication studies and improving study methodology, subsequent research might address the ways in which hope affects the appraisals
children make of specific stressful situations. Recent research has suggested that
appraisals are strongly related to psychopathology in children (Sheets, Sandier,
& West, in press), but little is known about the factors that influence children's
evaluations of stressful circumstances. For example, children with SCD are likely
to differ in their appraisal of how threatening their disease is to their physical and
psychological well-being and hope may play a role in these differences.
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