Mothers' Reflective Functioning and Resilience of Children with Cancer: The Mediating Role of Maternal Empathy

Document Type : Original Article


1 Department of Psychology, Faculty of Educational sciences and Psychology, Shahid Beheshti University, Tehran, Iran

2 Department of Psychology, Faculty of Educational Sciences and Psychology, Shahid Beheshti University, Tehran, Iran

3 Clinical and Health Psychology Department, Faculty of Psychology and Educational Sciences, Shahid Beheshti University, Tehran, Iran.

4 MAHAK Hematology Oncology Research Center (MAHAK-HORC), MAHAK Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

5 Department of Psychology, faculty of Educational Sciences and Psychology, Shahid Beheshti University, Tehran, Iran


Introduction: The purpose of this study was to examine the hypothesized model of the causal relationship between mothers' reflective functioning and resilience of children with cancer through mothers’ empathy.
Method: The present descriptive and correlational study lay within the Structural Equation Modeling (SEM) framework. For this purpose, 207 mothers of children aged 5 to 12 years with cancer who had referred to Mahak Hospital and Tehran Children's Medical Center joined this study. Participants completed the Parental Reflective Functioning Questionnaire (2017), the Child and Youth Resilience Measure-Revised Person Most Knowledgeable version (2018), and the Empathy Quotient Questionnaire (2004). The statistical procedures were run in SPSS21 and AMOS22.
Results: The results showed that the hypothetical model has a good fit with the data. Based on the findings of this study, it is presumed that due to the positive impact of mothers' reflective functioning on their psychological abilities and interpersonal relationships, strengthening this capacity can lead to improved resilience in children with cancer.
Conclusion: According to the findings of the present study, mothers' empathy plays a mediating role in the relationship between mother's reflective functioning and children’s resilience.


  1. Siegel RL, Miller KD, Goding Sauer A, Fedewa SA, Butterly LF, Anderson JC, et al. Colorectal cancer statistics, 2020. CA Cancer J Clin [Internet]. 2020 May 1;70(3):145–64. Available from:
  2. Steliarova-Foucher E, Colombet M, Ries LAG, Moreno F, Dolya A, Bray F, et al. International incidence of childhood cancer, 2001–10: a population-based registry study. Lancet Oncol [Internet]. 2017 Jun 1;18(6):719–31. Available from:
  3. Phillips SM, Padgett LS, Leisenring WM, Stratton KK, Bishop K, Krull KR, et al. Survivors of Childhood Cancer in the United States: Prevalence and Burden of Morbidity. Cancer Epidemiol Biomarkers Prev [Internet]. 2015 Mar 31;24(4):653–63. Available from:
  4. Grant J, Cranston A, Horsman J, Furlong W, Barr N, Findlay S, et al. Health status and health-related quality of life in adolescent survivors of cancer in childhood. J Adolesc Heal [Internet]. 2006 May 1;38(5):504–10. Available from:
  5. Kim DH, Yoo IY. Factors associated with resilience of school age children with cancer. J Paediatr Child Health [Internet]. 2010 Jul 1;46(7–8):431–6. Available from:
  6. Rutter M. Resilience concepts and findings: implications for family therapy. J Fam Ther [Internet]. 1999 May 1;21(2):119–44. Available from:
  7. Rutter M. Resilience in the Face of Adversity: Protective Factors and Resistance to Psychiatric Disorder. Br J Psychiatry [Internet]. 2018/01/29. 1985;147(6):598–611. Available from:
  8. Bonanno GA. Loss, Trauma, and Human Resilience: Have We Underestimated the Human Capacity to Thrive After Extremely Aversive Events? Vol. 59, American Psychologist. Bonanno, George A.: Department of Counseling and Clinical Psychology, Teachers College, Columbia University, 525 West 120th Street, Box 218, New York, NY, US, 10027, American Psychological Association; 2004. p. 20–8.
  9. Hjemdal O, Friborg O, Stiles TC, Rosenvinge JH, Martinussen M. Resilience predicting psychiatric symptoms: a prospective study of protective factors and their role in adjustment to stressful life events. Clin Psychol Psychother [Internet]. 2006 May 1;13(3):194–201. Available from:
  10. Min J-A, Yoon S, Lee C-U, Chae J-H, Lee C, Song K-Y, et al. Psychological resilience contributes to low emotional distress in cancer patients. Support Care Cancer [Internet]. 2013;21(9):2469–76. Available from:
  11. Ungar M, Liebenberg L, Boothroyd R, Kwong WM, Lee TY, Leblanc J, et al. The Study of Youth Resilience Across Cultures: Lessons from a Pilot Study of Measurement Development. Res Hum Dev [Internet]. 2008 Sep 5;5(3):166–80. Available from:
  12. Hasani J, Sheikhan R, Aryanakia E, Mahmoodzadeh A. Adolescents social anxiety :the role of attachment styles and cognitive emotion regulation strategies. JIP [Internet]. 2013;9(36):363–75. Available from:
  13. Svendsen S, Griffin J, Forkey H. Using the Attachment Relationship and Positive Parenting Principles to Build Childhood Resilience. Adv Pediatr [Internet]. 2020 Aug 1;67:15–28. Available from:
  14. Masten AS, Reed M-GJ. Resilience in development. In: Handbook of positive psychology. 2002. p. 88.
  15. Fergus S, Zimmerman MA. Adolescent Resilience: A Framework for Understanding Healthy Development in the Face of Risk. Annu Rev Public Health [Internet]. 2004 Oct 26;26(1):399–419. Available from:
  16. Fonagy P, Target M. Playing with reality: III. The persistence of dual psychic reality in borderline patients. Int J Psychoanal. 2000;81(5):853–73.
  17. Stein H. Does mentalizing promote resilience. In: Handbook of Mentalization Based Treatment. 2006.
  18. Staab JP, Fullerton CS, Ursano R. A critical look at PTSD: Constructs, concepts, epidemiology, and implications. In: Response to Disaster. Routledge; 2013. p. 101–28.
  19. Fonagy P, Target M, Steele H, Steele M. Reflective-functioning manual version 5 for application to adult attachment interviews. 1998.
  20. Morice-Ramat A, Goronflot L, Guihard G. Are alexithymia and empathy predicting factors of the resilience of medical residents in France? Int J Med Educ [Internet]. 2018 Apr 30;9:122–8. Available from:
  21. Jahedi R, Derakhshani R. The Relationship between Empathy and Altruism with Resilience among Soldiers. Mil Psychol [Internet]. 2020;10(40):57–65. Available from:
  22. Cao X, Chen L. The impact of empathy on work engagement in hemodialysis nurses: The mediating role of resilience. Japan J Nurs Sci [Internet]. 2020 Jan 1;17(1):e12284. Available from:
  23. Cánovas L, Carrascosa A-J, García M, Fernández M, Calvo A, Monsalve V, et al. Impact of Empathy in the Patient-Doctor Relationship on Chronic Pain Relief and Quality of Life: A Prospective Study in Spanish Pain Clinics. Pain Med [Internet]. 2018 Jul 1;19(7):1304–14. Available from:
  24. Rollins J, Rollins C, Boocks LA, Sitz T. Supporting Children Living with Chronic Medical Conditions Through Empathetic Art. J Child Fam Stud [Internet]. 2020;29(8):2218–33. Available from:
  25. Roth-Hanania R, Busch-Rossnagel N, Higgins-D’Alessandro A. Development of Self and Empathy in Early Infancy: Implications for Atypical Development. Infants Young Child [Internet]. 2000;13(1). Available from:
  26. Hooker CI, Verosky SC, Germine LT, Knight RT, D’Esposito M. Mentalizing about emotion and its relationship to empathy. Soc Cogn Affect Neurosci [Internet]. 2008 Sep 1;3(3):204–17. Available from:
  27. Borelli JL, Stern JA, Marvin MJ, Smiley PA, Pettit C, Samudio M. Reflective functioning and empathy among mothers of school-aged children: Charting the space between. Vol. 21, Emotion. Borelli, Jessica L.: Department of Psychological Science, University of California, Irvine, Health, Relationships, and Interventions Laboratory (THRIVE Lab), 4201 Social and Behavioral Sciences Gateway, Irvine, CA, US, 92697, American Psychological Association; 2021. p. 783–800.
  28. Meins E, Fernyhough C, Fradley E, Tuckey M. Rethinking Maternal Sensitivity: Mothers’ Comments on Infants’ Mental Processes Predict Security of Attachment at 12 Months. J Child Psychol Psychiatry [Internet]. 2001 Jul 1;42(5):637–48. Available from:
  29. Laranjo J, Bernier A, Meins E. Associations between maternal mind-mindedness and infant attachment security: Investigating the mediating role of maternal sensitivity. Infant Behav Dev [Internet]. 2008;31(4):688–95. Available from:
  30. Meins E, Fernyhough C, de Rosnay M, Arnott B, Leekam SR, Turner M. Mind-Mindedness as a Multidimensional Construct: Appropriate and Nonattuned Mind-Related Comments Independently Predict Infant–Mother Attachment in a Socially Diverse Sample. Infancy [Internet]. 2012 Jul 1;17(4):393–415. Available from:
  31. Blair RJR. Responding to the emotions of others: Dissociating forms of empathy through the study of typical and psychiatric populations. Conscious Cogn [Internet]. 2005;14(4):698–718. Available from:
  32. Singer T. The neuronal basis and ontogeny of empathy and mind reading: Review of literature and implications for future research. Neurosci Biobehav Rev [Internet]. 2006;30(6):855–63. Available from:
  33. Gallagher HL, Frith CD. Functional imaging of ‘theory of mind’ Trends Cogn Sci [Internet]. 2003 Feb 1;7(2):77–83. Available from:
  34. Lamm C, Decety J, Singer T. Meta-analytic evidence for common and distinct neural networks associated with directly experienced pain and empathy for pain. Neuroimage [Internet]. 2011;54(3):2492–502. Available from:
  35. Luyten P, Mayes LC, Nijssens L, Fonagy P. The parental reflective functioning questionnaire: Development and preliminary validation. PLoS One. 2017;12(5):e0176218.
  36. Jefferies P, McGarrigle L, Ungar M. The CYRM-R: A Rasch-Validated Revision of the Child and Youth Resilience Measure. J Evid Based Soc Work [Internet]. 2019 Jan 2;16(1):70–92. Available from:
  37. Baron-Cohen S, Wheelwright S. The Empathy Quotient: An Investigation of Adults with Asperger Syndrome or High Functioning Autism, and Normal Sex Differences. J Autism Dev Disord [Internet]. 2004;34(2):163–75. Available from:
  38. LAWRENCE EJ, SHAW P, BAKER D, BARON-COHEN S, DAVID AS. Measuring empathy: reliability and validity of the Empathy Quotient. Psychol Med [Internet]. 2004/07/07. 2004;34(5):911–20. Available from:
  39. Wang Y-W, Davidson MM, Yakushko OF, Savoy HB, Tan JA, Bleier JK. The Scale of Ethnocultural Empathy: Development, validation, and reliability. J Couns Psychol. 2003;50:221–34.
  40. Aboulghasemi A. The Reliability and Validation of the Empathy Quotient Scalr for High School Students. Q J Psychol Stud. 2010;5(4):9–25.
  41. Mousavi P, Khosravi Z, Dehshiri G. The Latent Structure of Empathy Based on Empathy Quotation in an Iranian Population. Adv Cogn Sci. 2017;19(1):76.
  42. Comer JS, Furr JM, Cooper-vince C, Madigan RJ, Chow C, Chan PT, et al. Rationale and Considerations for the Internet-Based Delivery of Parent–Child Interaction Therapy. Cogn Behav Pract [Internet]. 2015;22(3):302–16. Available from: