Laura Reinman

Date of Award

Summer 2019

Document Type

Open Access Dissertation



First Advisor

Jeffrey Schatz


Objective: Depression and anxiety are common problems for adolescents with sickle cell disease (SCD). It is important to understand both risk and resiliency factors contributing to psychological outcomes among youth with SCD in order to prevent and effectively treat such problems. To better elucidate contributing factors to depression and anxiety among youth with SCD selected risk and resiliency factors from the risk-and-resistance model adapted for SCD were examined (Barakat, Lash, Lutz, & Nicolaou, 2006). The risk factor of fatigue and resistance/resiliency factors of cognitive appraisal of stress and self-concept are of focus because they have been understudied, and their temporal relation with symptoms of depression and anxiety is not well understood in this population. The current study plans to add to the literature by examining fatigue, cognitive appraisal of stress, and self-concept, as well as mood symptoms on a daily basis to capture the broader context of functioning and the unique challenges of managing SCD.

Methods: Thirty youth (ages 11-18 years) with sickle cell disease and a primary caregiver were recruited from the Center for Cancer and Blood Disorders (CCBD) at Palmetto/Prisma Health Children’s Hospital in Columbia, South Carolina during a routine clinic appointment. Youth and caregiver approached at their clinic appointment could choose to complete baseline measures at that time or to schedule a future appointment. After the completion of baseline measures in the CCBD clinic, youth completed an online daily diary for eight weeks. Each daily diary took between five and fifteen minutes to complete. Twenty-one of 30 participants completed at least nine daily diaries (776 total daily diaries for analyses). At the completion of the eight-week diary period, youth and caregivers were asked to complete follow-up measures. Fifteen of 30 participants and a caregiver completed follow-up measures

Results: Significant relations were found between fatigue, mood, cognitive appraisal of stress, self-concept. Specifically, the pathway from fatigue to depression and anxiety was partially supported as fatigue was significantly associated with same day positive mood, t (1, 769) = -4.71, p < .001, and with same day negative mood, t (1, 769) = 4.29, p < .001. There was trend level support that depressive symptoms predict next day fatigue, t (1, 755) = -1.93, p = .05, but there was not support that anxiety symptoms predict next day fatigue, t (1, 755) = -.02, ns. Fatigue was found to be associated with primary, t (1, 769) = 2.98, p = .003, and secondary cognitive appraisal of stress, t (1, 769) = -2.55, p = .01. However, cognitive appraisal of stress did not moderate the fatigue/mood relations t (1, 754) = 1.52, ns. Finally, there was a possible association found between same day lower fatigue and higher global self-concept, t (1, 771) = -1.89, p = .06, but global self-concept was not found to moderate the fatigue/mood relationship. Finally, fatigue and pain intensity were found to have a mutually causal relationship, in that higher reported pain intensity predicted higher next day fatigue, t (1, 755) = 3.17, p = .001, and higher reported fatigue predicted increased next day pain intensity, t (1, 757) = -2.77, p = .006. Conclusions: The overall results showed support for many of the associations expected among variables in the same-day analyses. Fatigue was associated with positive and negative affect, as was primary and secondary cognitive appraisal of stress. However, few of the expected temporal relations predicting next-day variables were supported, which provides less evidence for the causal relationship among fatigue, cognitive appraisal of stress, self-concept and symptoms of depression and anxiety. Still, the current study highlights to importance of considering fatigue as another critical symptom to assess on a consistent basis, especially given the potential relation with pain. Future studies with larger sample sizes may be able to detect better the effects of fatigue, pain, cognitive appraisal of stress, and self-concept on internalizing symptoms, although the magnitude of the expected temporal associations was modest for most of the expected effects. Alternately, the risk-and-resistance model used to guide the present set of hypotheses may need further modification to address internalizing symptoms in SCD (including considering bidirectional relationships between risk/resiliency factors and mood). In addition, future studies with a larger sample size would allow for interpretation of baseline and follow-up data, as well as the examination of possible group differences between participants that completed daily dairies and those that did not.