Simposium Sains Kesihatan Kebangsaan ke 7
Hotel Legend, Kuala Lumpur, 18 – 19 Jun 2008 : 205 – 211
Parental stress in parents of special children:
The effectiveness of psycho education program
on parents’ psychosocial well beings.
Kartini Ilias, *Ponnusamy, S & Normah, C. D.
1
Health Psychology Unit, Faculty of Allied Health Sciences,
Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz,
50300 Kuala Lumpur
*Corresponding author: Tel: +60123267165, Fax: +603-26911052; E-mail address: ponnu@medic.ukm.my
This study examines the effectiveness of psycho education
program in reducing parental stress and increases their
psychological well being. A half day program has been
conducted. The study used a quasi-experimental pre-post
design. Twenty parents with various kinds of disabled
children have participated in the study. The age-range of the
participants is between 31-60 years old. Quantitative pre-post
measures included Parenting Stress Index (PSI) and General
Health Questionnaires (GHQ-28). A non parametric statistic
was used to analyze the data. Results showed that there were
differences in term of parental stress as well as psychological
well being before and after they attended the program. There
were also positive relationship between the child
characteristics as well as parent characteristics and parental
stress. These mean that the more parent attribute the child
characteristics as well as parent characteristics as the sources
of stress, the more stress they are. While overall findings
support the hypotheses, additional research is necessary as
this study has a small sample size and no comparison group.
The duration of time and module of the program also need to
be restructured for future research.
Keywords: Parental Stress, Special Children, Psychoeducation,
Psychological Well Being
Introduction
Numerous studies have been demonstrated that parents of child
with an intellectual disability (ID) are likely to experience
significantly higher levels of parenting stress than parents of
nondisabled children (Rodrigue, Morgan, & Geffken, 1990;
Dyson, 1997; Roach, Orsmand & Barrat, 1999). However despite
these broad findings, it is also acknowledge that parents of
children with a disability vary in the levels of stress they
experience and that their levels of stress levels are associated with
a wide range of variables (Frey et al. 1989; Quine & Pahl 1991;
Baxter et al. 2000). A few studies have found that parenting
stress is associated with the severity of the child ID’s (Minnes,
1998). Although others have failed to find any similar
associations. (Beckman, 1983; Walker, Van Slyke, &
NewBrough, 1992). Generally it seems that specific
characteristics associated with disability are more important
correlates of parental stress (Minnes, 1998). These include child
communication skills (Frey et al. 1989) and particularly the levels
of the child’s behavioural and difficulties (Friedrich et al. 1981;
Konstantareas & Homaditis, 1998; Quine & Pahl, 1991).
In the study by Perry, McGarvey and Pastor (1992)
highlighted that specific child characteristics are directly
correlated with the parents' level of stress. These include age, sex,
diagnosis, IQ, level of self-help skills, and so forth. Clearly, these
characteristics do make an important contribution to parents'
Sihat2008
ISBN 978-983-43150-9-2
stress level (De-Myer, 1979), but it is not a simple linear function
and many other factors must be taken into account (Perry et. al.,
1992). Parental stress is a factor in adjustment and was shown to
be a function of the child’s presenting symptoms (such as hyper-
irritability, sleep problem, self-abuse, etc.) and the family’s
characteristics (e.g. support from father, stay at home)
(Konstantareas & Homatidis, 1998). The child’s behavioural
problems were the most common source of stress among mother
and father in the study of 219 Australian parents who felt “
stretched beyond the limits” (80%) and “unable to cope” (52%)
(Sharpley, Bistika, & Efremidis, 1997).
Thus, parents’ knowledge and involvement are crucial in
dealing with their special need child. Today, integral to any early
intervention programme is the recognition and the participation of
the family. They are an essential part of the professional team.
They should not be regarded as patients or silent extras but should
think as teachers –in – partnerships or co-therapists. It’s important
for professionals, who seriously want to help parents with special
needs children, to work with parents in such way that they can
start to and eventually rely on themselves and on fellow parents
for innovative ideas and tips for the caring and teaching of their
child. They should be empowered to draw upon their own
strengths to help each other (Zuckerman, Lawrence, Yura &
Michael 1979). The emphasis of providing parents with education
and training is on long-term effects, on informed and skills follow
up through time. Parents are usually the first to encounter and deal
with the problematic behaviours. They are the best person to
facilitate their children.
In our country, there are various places and centre that cater
for the special needs children. At the same time they also act as a
parents support group. The KIWANIS (Center for Learning
Disabilities), Dyslexic Centre, TAS PUTRA (Taman Asuhan
untuk Kanak-Kanak Cacat), and many more are among the
establish centre for special children as well as support group for
parents. Their aim basically to help those children to maximize
their potential and achieve independent, fulfilled life. Besides,
they also aim to provide a holistic programmes and training for
the parents, families and caregivers. They constantly conduct the
programs and training for the parents. However, there are no
studies that really focus on the effectiveness of those programs on
the parents’ psychosocial well being.
Parent education, training or psychoeducation has been
defined as “treatment procedures in which parents are trained to
alter their child’s behaviour at home” (Kazdin, 1997). Educating
parents has become widely regarded as a necessary component of
treating children with disabilities (Sofronoff& Farbotle, 2002).
Parent training has been seen as more efficient as opposed to
clinician-delivered program (Koegel et al., 1984). Beside the cost
effectiveness, the parents in the parent training program were able
to decrease their custodial care, had more time for leisure
activities, decreased isolation, increased self efficacy and
confidence. Parent training was seen as the most useful
206 Kartini Ilias et al./Sihat2008 : 205 – 211
interventions in helping them deal with their child on a daily
basis. Research has consistently shown that parent education is
beneficial both the child and parent. Taking example of children
with ASD whose parents participate in parent education show
better generalization and maintenance of learned skills (Lerman,
Swiezy, Perkins-Parks & Roane,2000) improved joint attention,
engagement, and communication skills, decreased behavioural
problems ( Feldman & Werner,2002) and more appropriate
behaviour and fewer stereotypes. In addition, the treatments
effects of parent training are longer, lasting than clinician-
delivered intervention.
A few intervention studies have addressed the information
and support needs of the parents of children with other chronic
diseases. Psycho-educational interventions have been tested with
positive results for parents of children with other chronic
conditions such as diabetes (Anderson & Ho, 1990; Mc Nabb,
Quinn, Murphy, Thorp, & Cook, 1994), asthma, cystic fibrosis,
congenital heart disease (Campbell, Clark, & Kirkpatrick, 1995)
and cancer (Kazak et al., 1997). There few of intervention studies
that focus on its effectiveness on the parents’ psychosocial well
being have been reported in the literature. Therefore this is a
preliminary research that intends to study how effective the
psycho educational programme in helping parents to deal with
their special needs children in Malaysia.
Materials and methods
This study were using quasi experiment method, in which a type
of experiment whereby the experimenter does not have complete
control over all central variables. The reason why this type of
design has be chosen because it is more natural experiment and it
is more to real life field settings. The CADS (Center for Autism,
Down Syndrome, Dyslexia, and Slow Learner) in which is located
in Jalan Semarak Kuala Lumpur will be chosen as a research
location. This place is one-stop center for the various kind of
special children and it open an inclusive school (Semarak
Elementary School) whereby the normal children and special
children are learning together in the classroom.
The sample of research was the parents of special children
who are recruited through the CADS center. The ages of the
parents in this research ranged from 35-58. The ages of the special
children ranged from 4 to 14 years old. The first language for all
the parents is Bahasa Melayu but nearly all the parents speak
English in their everyday life. The ethnic backgrounds are Malay,
Chinese and Indian. Most of the parents are working in
professional lines and have at least degree in their education
achievement.
The Parenting Stress Index (PSI) by Abidin (1995) is a
parent self report, 101- item questionnaire, designed to stressful
areas in parent-child interactions. An optional 19-item Life Events
stress scale is also provided. The PSI focuses intervention into
high stress areas and predicts children's future psychosocial
adjustment. This screening and diagnostic instrument was
developed on the basis that the total stress a parent experiences is
a function of certain salient child characteristics, parent
characteristics, and situations that are directly related to the role
of being a parent. As cited in a Professional Manual for Parenting
Stress Index- 3rd Ed., child characteristics, parent characteristics,
family context and life stress events are some of the facets of
them parent-child systems that has been identified as important
(Sheeber & Johnson, 1992), and the Parenting Stress Index (PSI)
was developed in response to the need for a measure to assess
these facets of the parent-child system. The child characteristics
are measured in 6 subscales: distractibility/hyperactivity,
adaptability, reinforces parent, demandingness, mood, and
acceptability. The parent personality and situational variables
component consists of 7 subscales: competence, isolation
attachment, health, role restriction, depression, and spouse. The
General Health Questionnaire (GHQ-28) by Goldberg & Williams
(1978) is a measure of current mental health and since its
development by Goldberg in the 1970s it has been extensively
used in different settings and different cultures. It focuses on
breaks in normal functioning, rather than lifelong traits and
concerns itself with two major classes of phenomenon: a) inability
to carry out one’s normal healthy functions b) appearance of new
phenomena of a distressing nature.
The permission was asked from the president of the center.
The principal of the school then contacted the parents to attend a
one-day intervention programme that held in that school. A one –
day workshop will be organized to the parents. The workshop is
intending to psycho educate the parents. Information on psycho
education of special children, such as how to deal with special
children, parent – child relationship, family support, stress
management, how to deal with stress, relaxation techniques etc.
were included in the programme. For each parent that participated
in this research were asked to sign the informed consent form for
the purpose of confidentiality. Then, before the programme starts
they were answered a set of questionnaire of Parenting Stress
Index (PSI).The questionnaire is to assess their knowledge and
their mental health before the programme starts (pre-test). A few
weeks later, the same set of questionnaire will be posted through
mail or to be sent via email to the same participants to be filled in
(post-test). The general view of the stages of the research is as
follows:
Stage 1
PRE Test
A set of questionnaire will be answered by parents before the
programme starts.
Stage 2
A one-day workshop will be held in the centre. The programme
will be covered three modules such as:
Module 1 : Understanding the needs of special children
Module 2 : Stress Management
Module 3 : Relaxation Techniques
Stage 3
POST-Test
The same set of questionnaire will be posted through mail or to be
sent via email to the same participants to be filled in
Results and discussion
A total of 20 parents with special needs children participated in
this study. Table 1 presents sociodemographic and psychosocial
profiles of the subjects.
Result in Table 2 represents the data of psychological well
being that was measured using the General Health Questionnaires
(GHQ-28) and parental stress that were measured using the
Parental Stress Index (PSI) among the parents with special needs
children. Based on the table 4.2 70 % (n=14) showed poor
psychological well being. In term of parental stress, 15 % (n=3) of
the subjects presented with high stress, followed by 45 % (n=9)
with moderate stress and 40 % (n=8) with low stress. Comparing
the factors that may contribute to the stress, 45% (n=9) of the
subjects associated their level of stress with children
characteristics. These types of parents relate their stress with the
qualities of the children that make difficult for them to carry out
their parenting role. On the other hand, only 5% of the subjects
relate their sources of stress and potential dysfunction of the
parent-child system to dimensions of the parents’ functioning.
207 Kartini Ilias et al./Sihat2008 : 205 – 211

The Wilcoxon Signed Ranks Test was conducted in order to .000 which less than .05. Therefore it can be conclude that the two
compare the level of parental stress before and after the sets of scores are significantly difference.
psychoeducation program. From Table 3, the significance value is

TABLE 1 Sociodemographic characteristics of parents with special needs children (N=20)

Variables Frequency (n) Percentage (%)

Gender Male 10 50
Female 10 50
Age 31-40 10 50
41-50 7 35
51-60 3 15
Education Sek Men Rendah 1 5
Sek Men Tinggi 2 10
Tertiary 13 85
Occupation Private 11 55
Government 5 25
Housewife 4 20
Salary RM 0-1999 4 20
RM 2000-RM2999 7 35
RM 3000-RM3999 3 15
>RM 4000 6 30
Child Gender Male 6 60
Female 4 40
Child Disability Autistic 2 20
Slow Learner 1 10
ADHD 2 20
Down Syndrome 2 20
Cerebral Palsy 1 10
Dyslexia 2 20

TABLE 2 Data of parental stress and psychological well being among parents
before attending the psycho education program

Variables Significant
N=20 %

Psychological Well Being (GHQ ≥ 3) 14 70

Parental Stress
 Low 8 40
 Moderate 9 45
 High 3 15

Child Characteristics
 Low 3 15
 Moderate 8 40
 High 9 45

Parent Characteristics
 Low 10 50
 Moderate 9 45
 High 1 5

TABLE 3 Comparison of parental stress before and after the program

Pre Test Post Test p

Mean N=20 N=20
Mean
SD SD
Total stress 63.30 20.94 42.90 16.98 .000
* p≤.05
208 Kartini Ilias et al./Sihat2008 : 205 – 211
Results showed that parenting stress among the subjects was
notably reduced after they had attending the psycho educational
programs. Based on the pre test scores, 15% of the parents
reported high stress, followed by 40% with moderate stress.
However after they have attending the program, 60% of the
participants reported with low stress, followed by 40% with
moderate stress. Parents of children with special needs have a
pressing need for emotional support and guidance during the time
of learning about and adjusting to their child disabilities and
difficulties. Responses from the parents on their impression of the
program signify that they valued the service. The experience had
during the programs had the potential to both decreased and
increased the parenting stress. Parts of the workshop that helped
to decreased parenting stress were having the information that
would help them to face the problems related to their children, the
opportunity to spend time for themselves and learned tips and
techniques in handling the stress and both couples attended the
programs together thus might decreased the conflict increased the
greater sense of teamwork between father and mother.
There was a pilot study that was conducted in which, it
offered the nursing intervention designed for parents of children
with ASD. The study also was to test the effects of the post
diagnosis nursing intervention on parents’ report of stress, impact
of diagnosis, and the use of service after a child is newly
diagnosed with ASD. Most of the parents felt that the psycho
educational program that has been conducted as a platform for
them to ventilate their stress, anger and anxiety. They also had
opportunities to share their experience with other people that had
to face the same difficulties and problems related to their child
disabilities. In some way they can get the social support from
other parents. It is crucial importance for parents with special
needs children to have good support system (Bristol, 1984 et.al.,
& Dyson, 1997). With lack of the social support, the outcomes
can be negative and disturbed parents’ quality of life. Gray and
Holden (1992) showed that parents who received less social
support are more likely to engage with depression, anxiety, and
anger.
The same procedure has been done in order to see the
difference of psychological well being among the subjects before
and after they had attended the psychoeducation program. From
Table 4, the significance value is 0.001 (which less than .05).
Therefore it can be conclude that the two sets of scores are
significantly difference.
TABLE 4 Comparison of psychological well being before and after the program
Pre Test
Mean N=20
SD
GHQ Score 3.40 1.53
* p≤.05
TABLE 5 Relationship between child characteristics and total stress before
the program Spearman Rho Correlation
Child Characteristics Pre (1)
Total Stress Pre (2)
** Correlation is significant at the 0.01 level (2-tailed).
The results show that parents with special needs children
reported a better psychological well being after they attended the
program. The pre tests scores indicated that 70% of then showed
poor psychological well being before they attending the programs.
Possible explanation for this outcome could be participated in the
programs as a couple may be one way to increase feelings of
mutual support and teamwork. As Herman & Thompson (1995)
have found out that the spousal support may be the most
beneficial types of social support to mothers of children with
Asperger Syndrome. An increased feeling of support could lead to
greater marital satisfaction, decreased stress in the mother, and
higher quality parenting as rated by outsider’s observers (Bristol
et.al., 1988)
Parent wellbeing is the importance aspect and maintenance
of a positive family climate. The three critical components of
parent well- being that have been studied in relation to the
functioning of typically developing children as well as children
with developmental disabilities; parental mental health (Downey
and Coyne 1990), parenting stress (Deater- Deckard 1998; Crnic
& Low 2000), and parenting efficacy (Coleman & Karraker 1998’
Jones & Prinz 2005). There were consistent findings, indicating
that parents with special needs children would have higher level
of stress and showed poor of psychological well being in which
they presented in increased of depressive symptomlogy (Kersh,
Hedvat, Cram, & Warfield, 2006)Consistent with the previous
findings, parents who participated in parent education report, (a)
reduced stress (Pisula, 2003), (b) decreased depression and
negative effect (Strain, 1987), (c) decreased time spent in
custodial care (Koeget et.al., 1984) (d) more opportunities to
participate in out of home activities and decreased isolation (
Feldman& Werner,2002), (e) greater quality of life, and (f)
increased self efficacy and confidence (Sofronoff &
Farbotko,2002).
The Spearman Rho correlation coefficient has been
performed in order to investigate the relationship between child
characteristics and total stress (as measured using the Parent
Stress Index) before and after the program. Table 5 represents the
results before they had attended the program. There was a positive
relationship between the two variables (r=.788, p < 0.01), with
high perceived on child characteristics associated with high level
of stress.
Post Test p
N=20
Mean
SD
2.45 1.31 .005
1 2
-
.788(**) -
209 Kartini Ilias et al./Sihat2008 : 205 – 211

TABLE 6 Relationship between child characteristics and total stress after

the program Spearman Rho Correlation

1 2
Child Characteristics Post (1) -
Total Stress Post (2) .650(**) -
** Correlation is significant at the 0.01 level (2-tailed).

TABLE 7 Relationship between parent characteristics and total stress before

the program Spearman Rho Correlation

1 2
Parent Characteristics Pre (1) -
Total Stress Pre (2) .907(**) -
** Correlation is significant at the 0.01 level (2-tailed).

TABLE 8 Relationship between parent characteristics and total stress after

the program Spearman Rho Correlation

1 2
Parent Characteristics Post (1) -
Total Stress Post (2) .826(**) -
** Correlation is significant at the 0.01 level (2-tailed).

The results showed the positive correlation between child
characteristics and parental stress among the parents, before and
after the programs. These mean that the more they attribute the
sources of stress to the child characteristics, the more stress they
are.
According to Abidin (1995), 3 major source domains of
parenting stressors are: (1) child characteristics, (2) parent
characteristics, and (3) situational or demographic life stress.
Coping with parenting stressors may depend on the parents’
attribution to the sources of stress. Back to the Lazarus and
Folkman’s (1984) cognitive model of stress and coping, it
highlighted that the cognitive appraisal determines whether the
person- in- environment relationships is judged as stressful or not.
In this case, the parents’ cognitive appraisal towards their children
characteristics may become the determinants of their stress.
However, there are considerable research elucidate that parenting
stress, especially stress related to the child’s temperament (such as
demandingness, adaptability, acceptability, mood,
hyperactivity/distractibility), often appears to be higher in the
families with disabled child (Dyson, 1997; Barker et.al., 2002).
Another study by McBride, Schoppe, & Rane, 2002 highlighted
another significant way in which child characteristics, particularly
temperament, may influence parents through increased or
decreased parenting stress. In a model of parenting stress
analogous to Belsky’s (1984) model of the determinants of
parenting, Mash and Johnston (1990) proposed that child
characteristics such as temperament have an influence on parent-
child interactive stress. In support of this notion, research
indicates that mothers of temperamentally difficult children report
higher stress levels of parenting stress ( Gelfand, Teti, & Radin
Fox,1992) more psychological problems including doubts about
their parenting competence and feelings that parenting restrictive (
Sheeber & Johnson,1992) and higher levels of depression.
Table 6 represents the results after they had attended the
program. There was a positive relationship between the two
variables (r=.650, p < 0.01), with high perceived on child
characteristics associated with high level of stress
Table 7 represents the relationship between the parent
characteristics and total stress before they had attended the
program. There was a positive relationship between the two
variables (r=.907, p < 0.01), in which parents with high scores on
parent domain experience high level of stress.
Table 8 represents the relationship between the parent
characteristics and total stress after they had attended the
program. There was a positive relationship between the two
variables (r=.826, p < 0.01), in which the more they attribute their
sources of stress to the parent domain, the more distressed they
are.
There were also positive correlation between the parent
domain and level of stress in which parents with high scores on
parent domain will experience high level of stress.
As stated by Abidin (1995) beside child characteristics and
situational life stress as sources of stress, parent characteristics in
which parents’ personality, competency, and other dimensions as
measured by PSI also may link to the parenting stress. High
scores in Parent domain imply that the sources of stress and
potential dysfunction of the parent child system may be related to
the aspects of parent’s functioning. In a study of 94 fathers by Mc
Bride (1989) illustrated that these parents experienced less stress
when they feel more competent in their parenting role. On the
other hand, wives’ employment was linked to the higher levels of
stress, as related to the Role Restriction, Depression and
Demandingness subscales score. The fathers’ depression and their
perception of their children as demanding were the best predictors
of parental competence (Abidin, 1995).
Conclusion
A psycho educational program has been conducted for parents
with special needs children. The overall goal of the project was to
report the preliminary result on the effectiveness of the program
in reducing parental stress associated with their child disability as
well as other sources of stress such as parental attributions,
210 Kartini Ilias et al./Sihat2008 : 205 – 211
financial constraints, spousal support and etc. It also was trying to
examine on how the parental stress affected parents’
psychological well being. Other than that, it also meant to
investigate were there any relationship between child
characteristics as well as parent characteristics and parental stress.
As reported in the result section, there were differences of
parental stress and psychological well being before and after they
attended the program. It showed that the total stress among
parents was reduced after the program (as measured by PSI), at
the same time, they also presented with good psychological well
being as measured by GHQ. There were also positive relationship
between the child characteristics as well as parent characteristics
and parental stress. These mean, those parents that attributed their
sources of stress to their child characteristics as well as parent
characteristics will experience higher level of stress.
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