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Laura's past medical history includes a series of clinically unsatisfactory events before eventual diagnosis. This rollercoaster ride left Laura with psychological wounds. At 19 or 20, Laura admitted that she frequently felt forced to lie to her friends when they invited her out. She would fabricate previously arranged appointments to avoid social events. Laura wanted to be sociable, but she understood that if she went out she would not enough energy to go to work the next day. Wanting to be professionally successful meant this simply wasn't an option.
Prior to her diagnosis, Laura said she would swing from opposite ends of the emotional spectrum: one moment she might feel intense anger at the futility of her situation and her relentless pain; other times, she would doubt her own ability to assess her pain, wondering if she might be a hypochondriac when her doctors failed to find answers. Of her struggle, she concluded:
"Nobody understood my problem, and nobody understood me." 
I first met Laura in October 2008. She was visibly in pain, with splinted wrists, as she told me she worked as a full-time engineer to support her ten-year-old daughter, Rebecca. Having read her medical notes, I knew that Laura suffered with past bouts of depression. I asked her about the biggest daily challenge she confronted. She replied: "Raising Rebecca. At times, it has been terrible."  She explained:
"Sometimes Rebecca can act like a 'schizo' [schizophrenic]. If I ask make her bed she'll often get angry and scream at me. It's totally out of proportion at times." 
Further background information is required to fully understand the 'Parent-Child Relationship' (PCR) that Laura and Rebecca share. Although Laura is estranged from her family, she assured me that her family situation was entirely separate from her RA. Laura admitted that she has very few friends. As such, Laura's life revolves around her condition and her daughter, with few external influences. Laura explained the nature of her mother-daughter relationship:
"It has been really tough bringing up Rebecca; I have had literally no support. Even Rebecca's friends' parents don't help out- it always at my house that all the girls come to play. It's exhausting." 
To contrast this picture, I offer a description of my last meeting with Laura in March 2010. The impression Laura imparted then seemed much different compared to the woman I met 18 months prior. She was significantly forthcoming and in seemingly much less pain. Consequently, Laura described her relationship with Rebecca as being "much better."  I believe the reason for Laura's improved relationship stems from a series of small changes in attitude that Laura adopted as a patient. When I first met Laura, she had not come to terms with her condition, and she failed to become a patient. Her 'illness behaviour' was inappropriate. Now, Laura understands her condition. She acts like a good, well-informed patient.
In summary, Laura's medical history tells a story of the repercussions that can arise from delayed diagnosis. For example, the circumstances surrounding Laura's eventual diagnosis injured her psychological state, causing bouts of depression and resulting in her social alienation. Laura still struggles with reconciling her RA and her parental duties-two challenges that, at times, may seem debilitating. Using Laura as a case study, this essay discusses how a maladapted set of 'illness behaviours,' coupled alongside a chronic disease like RA, can affect the 'Parent-Child Relationship' (PCR).
The Parent-Child Relationship
In evaluating the 'Parent-Child Relationship' (P-CR), Paediatricians Simon Newell and Jonathan Darling highlight many causes of child behavioural problems, notably the 'family factor' of 'parental ill-health.'  This cause takes centre stage in the case study of Laura and the affects of her disease on her daughter, Rebecca. The question becomes: how has Laura's RA acted to create behavioural problems exhibited by her daughter's actions (which therein have contributed to undermining their P-CR)?. To understand Rebecca's behavioural problems, we must first examine how the RA has affected Laura's own behaviour. As I argue here, what affects Laura's behaviour in turn affects Rebecca (via their exceptionally isolated P-CR).
Social scientist Alfie Kohn defines the P-CR as a "combination of behaviours, feelings and expectations that are unique to a particular patient and a particular child." 
The concept of a dysfunctional P-CR might therefore be where the behaviours, feelings, and expectations between the parent and child are destructive and therefore promote negative interactions. Upon this review, after my first meeting with Laura in October 2008, I would define her P-CR as dysfunctional. However, Laura's case proves the flexibility of the P-CR, for upon my final visit in March 2010, I saw that relationship with Rebecca was far less dysfunctional.
Considerable debate surrounds the issue of whether a child's behaviour is either predetermined, entirely moulded in their home environment, or a blend of both nature and nurture. Paediatricians Tom Lissauer and Graham Clayden emphasise the 'nurture' aspect:
'Personal relationships are the major environmental factor in promoting psychosocial development (of the child) and the child's family is the principle source of these.' 
I have already identified that Laura does not have a support system to call upon. This distinct lack of outside relationships available to help shape Rebecca's psychosocial development means that the responsibility falls to Laura alone. This lack of diversity, as Laura's case proves, hinders the initial success of any P-CR.
In 1966 sociologist David Mechanic created the 'Illness Behaviour' model, highlighting the five stages of behaviour that every person adopts over time when they become ill.  Any deviation from these stages can be considered maladaptive processes, with negative repercussions for the patient. In the following section, I shall apply Mechanic's model to Laura's handling of her RA.
Stage 1 - Evaluative Stage
In this stage, the patient analyses and interprets their symptoms. The patient has already decided that their health is compromised and has sought medical advice.
In Laura's case, this stage was initially unsuccessful. Having recognised her symptoms and presented them to her GP at the age of 19, Laura waited for nearly ten years until she received a formal diagnosis and appropriate treatment plan. Laura said she suffered significantly during this time and recalled:
"Sometimes I'd go and see the doctor, but I would have to decide which problem I wanted to speak to him aboutâ€¦ 'Which problem was the most distressing to me at the time?' I would have to ask myself. It was an absolute mess." 
Stage 2 - Assuming a sick role
In this stage, the patient releases specific responsibilities that they no longer can manage due to illness. In Laura's case, she focuses her energy on accomplishing three tasks daily: her work, her housework and raising Rebecca. Laura has demonstrated an admirable work ethic in putting her daughter's wellbeing and professional career ahead of her social life. She understands the complications of overexerting herself:
"I have to work long hours in a shift work pattern, which sometimes plays havoc with my sleep. Sometimes it is very stressful. I know that when I'm stressed it becomes even harder to fight off the tiredness." 
Laura frequently encounters distressing situations when her RA prohibits her from interacting with Rebecca.
"Sometimes [Rebecca] gets frustrated with me when I can't do things for her. If she wants to play or go to the cinema and I don't have the energy or am in too much pain she gets mad. One time she stamped on my foot in frustration when she knew that my foot was already really hurting me that day." 
It is questionable as to whether Laura has ever really embraced her 'sick role,' and this is one example that proves how she initially damaged her P-CR.
Stage 3 - Help seeking
In this stage the patient seeks out assistance with their illness. As previously discussed, with Laura's limited support network, even if she were to seek help she would find it difficult. Laura understands that 'stress' exacerbates her RA, which negatively affects her P-CR. In a notable help-seeking effort, Laura attended a 'stress management group,' but said she found no useful coping mechanisms there:
"The group was too much about talking and not hands-on enough for me." 
'Stress' is defined as an imbalance where a person's 'demands' exceeds their 'capabilities'.  Laura has not been successful in her attempts to gain help in order to allow her to become more of a patient. This help would have reduced the 'demands' placed on her. The subsequent reduction in stress would have helped Laura to deal with the symptoms of her RA and improved her P-CR.
Stage 4 - Becoming a patient
In this stage, the patient follows the advice and treatment of their physician in a concordant manner. In the treatment of RA, there are three principles for its management, as highlighted by the Davidson's Principles and Practice of Medicine: physical rest, anti-inflammatory therapy and passive exercises. 
Laura approached this stage with mixed results. She is diligent with her medication regime; she regularly performs the prescribed exercises on her troubled joints. However, the most important treatment listed in the literature is 'physical rest,' and this is where Laura emphatically fails:
"On the good days you just want to make the most of it and get everything done. You go to work, come home and do the housework and then take Rebecca out to the pictures or something. But then you've done too much haven't you? The next few days you suffer badly with it. RA treatment wants you to be lazy really." 
Laura's observation of her treatment wanting her to be 'lazy' sheds light into the mindset of a determined woman who works hard against the restrictive nature of her RA. When Laura overextends herself her fragile energy levels collapse. This collapse stresses her P-CR, as Rebecca does not respond well when Laura is incapacitated.
Stage 5 - Recovery or adaptation
Provided the patient follows the previous four stages successfully, the patient will then either fully recover, thus reassuming their normal roles and responsibilities, or they successfully adapt to their new circumstances. The aberrations in the previous four stages have meant that this stage has been particularly difficult for Laura to successfully achieve.
Changing Illness Behaviour
I was delighted by the different woman I met in March 2010 when I visited Laura. She appeared happier and in significantly less pain than at any other time I had met with her before. Consequently her P-CR with Rebecca had much improved. She owed the success to her own personal growth:
"I'm managing myself a lot better." 
Having reflected on our conversation, it occurred to me that reasons for Laura's personal success, and the improvement of her P-CR, were contingent upon the changes in her 'illness behaviour.' For example, after she 'assumed a sick role' (stage 2), Laura noted:
"Occy [occupational] health have been fantastic with work. I had a new manager who was kicking up a fuss about my sick days, so they decided to trial me on just 9-5 work instead of shift patterns. It's brilliant as I actually have energy at the end of the day! The new manager doesn't like it as I mess up his rotas but I'm working better now so why should he complain?" 
Whilst Laura has not entirely relieved herself of her work, it is clear that the change in working role has positively affected her health-specifically with the relationship between her energy levels and stress. Laura's 'sick role' was achieved by a change in her work pattern.
In examining her relationship with Rebecca, we can see how Laura employed stage 3 of Mechanic's model, and 'sought help':
"Rebecca has become more of a young woman these days - she has begun 'the change' [puberty] you see. Unfortunately she's becoming a bit more rebellious, as they all do, but she's also become more understanding as well. She knows if I'm having a bad day and doesn't antagonise me as much. I also trust her to look after herself more now as she's more independent, which gives me more time to myself." 
Laura has not gained any extra 'help', however with Rebecca's increasing maturity I feel that Laura's burden of work has reduced. The whole purpose of gaining 'help' is that the 'help' in some way assists with the patient's immediate responsibilities. This problem has been partially solved by an approach from a different angle. With Rebecca's naturally improving behaviour, I argue that the burden facing Laura has been reduced, and that the need for 'help' is consequently reduced.
In the positive development of their P-CR, Laura and Rebecca have embraced the concept of 'quality over quantity'. Whilst Laura and Rebecca now spend less time together, the time they do share is much healthier:
"We're becoming more like friends these days and less like mother and daughter. The screaming and violence is a thing of the past now." 
Laura's fundamental change in attitude in accepting her RA corresponds well with Mechanic's stage 4: 'Becoming a patient.'
"I'm paying more attention to the rheumy (rheumatology) nurses. I can hear their voices in my head saying to me 'No, stop and rest now!' when I've been thinking about doing more housework than I should be." 
With Laura consciously improving her attitude alongside her treatment, the symptomatic improvements have been dramatic and a delight to witness. Laura's reduced symptoms have elevated her mood, giving her extra resources to be the best mother possible. Ironically, going from trying to be 'super-mum' into 'lazy-mum,' as she told me, has been a great decision for Laura.
One possible confounding factor within my argument is the addition to Laura's medication of the TNF Inhibitor in August 2009. It is a very successful drug as a DMARD in RA and has played a part in Laura's success story. 
It is ineffective to describe which single factor has caused the greatest improvement in Laura's journey to become a patient. Each stage and subsequent modification to her 'illness behaviour' has helped Laura to achieve a better and stronger P-CR with Rebecca, as well as relationship with her own condition.
I have considered how a maladapted set of 'illness behaviours' within the setting of a chronic disease like RA can affect the P-CR. In reasoning through some theory as to why this is the case, an encouraging outcome presents itself. Namely, if a chronic disease can be managed by adopting the appropriate 'illness behaviours,' then following such logic, there is no reason that the disease should affect any of the patient's relationships, especially the highly-treasured P-CR. Using Mechanic's model as a central theory, I have explained how Laura and Rebecca have demonstrated this proposition.
It seems to me that this case follows just one of many that use a simple algorithm in medicine to prove a point: 'Identify the problem, change it, and try again.' Laura's main problems arose from her 'illness behaviour,' which she successfully managed to change and therein improve her quality of life (when measured specifically in relation to her P-CR).
During my last meeting with Laura, I asked what she thought the future held. She responded:
"The future is looking good. I hope Rebecca and I will have a stronger and closer relationship. It'll happen, but slowly." 
For the first time, Laura winked at me. She smiled. I could see that she was hopeful, and I could see then the immense of importance of both learning exactly how to be a patient and understanding, too, that P-CRs develop steadily and are always subject to change.