The Volta Review, Volume 115(2), Fall/Winter 2015

MATERNAL STRESS: A STUDY

OF MOTHERS WITH TYPICAL
HEARING WHO HAVE
CHILDREN WHO ARE DEAF AND
HARD OF HEARING IN SPAIN
Joucelyn Rivadeneira, Ph.D., Núria Silvestre, Ph.D., and Cristina Laborda,
Ph.D.

This study examined the association between parenting stress, family

functioning, child behavior problems, language development, mother’s
education, child’s sex, child’s age, and child’s hearing device in a cross-
sectional sample of 37 mothers with typical hearing who have children who
are deaf and hard of hearing enrolled in early childhood programs using oral
methodology in Spain. Mothers completed the Parenting Stress Index/Short
Form, the Family Adaptability and Cohesion Scale questionnaire, and the
Behavior Assessment System for Children. Their children completed the
Reynell test for language. Utilizing linear model analysis, we identified
that family cohesion, internalizing problems, and adaptive skills in children
who are deaf and hard of hearing explain 66% of the variance of parenting
stress. Evidence supports the relevance of considering family functioning in
parenting stress assessment in families with typical hearing who have children
who are deaf and hard of hearing. Along with helpful existing research,
greater insight might facilitate the support of intervention programs.

INTRODUCTION
Scholastic literature has thoroughly established that diagnoses
of deafness and hearing loss in children of parents with typical
hearing has a profound impact on families (Calderon & Greenberg,

Joucelyn Rivadeneira, Ph.D., is adjunct professor in the Departamento de Ciencias Sociales at Uni-
versidad del Bío-Bío, Chillán, Chile. Núria Silvestre, Ph.D., is professor emeritus in the Departament de
Psicologia at Universitat Autònoma de Barcelona, Spain. Cristina Laborda, Ph.D., is senior lecturer in the
Departament d’Educació at Universitat Autònoma de Barcelona, Spain. Correspondence concerning this
manuscript may be addressed to Dr. Rivadeneira at jrivadeneira@ubiobio.cl.

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2011; Jackson, 2011; Luckner & Velaski, 2004; Luterman, 1997, 2004;
MacKellin, 1995; Marschark, 2007; Stahlman, 1994). As to the family
experiences after the diagnosis in the child, parenting stress has
been widely examined over the past two decades. Previous studies
have explored the stress levels in families with typical hearing
who have children who are deaf and hard of hearing, and certain
factors have been found to be predictors of parenting stress, such
as language ability, mode of communication, age of identification
of hearing loss, and social support (Hintermair, 2006; Pipp-Siegel,
Sedey, & Yoshinaga-Itano, 2002; Sarant & Garrard, 2013). However,
the literature has failed to focus on the relationship between family
functioning and levels of parenting stress. In fact, little research
has been conducted on the comprehension of family functioning
—specifically, cohesion and adaptability (Ahlert & Greeff, 2012;
Henggeler, Watson, Whelan, & Malone, 1990; Weisel, Most, & Michael,
2007)—as variables that may contribute to explain the experience of
rearing a child with hearing loss in a family with typical hearing.
In this sense, the term “family cohesion” represents the emotional
bond between family members, while “family adaptability”
represents familial reactions to situational or developmental stress.

Stress in Families with Children Who Are Deaf and Hard of Hearing
The implications of hearing loss in families with typical hearing
has been a permanent focus of interest over time, and perhaps one of
the most extensively revisited areas may be parenting stress;
however, studies comparing parenting stress levels have shown
inconclusive findings. A few studies have found that mothers with
typical hearing who have children who are deaf and hard of hearing
show higher levels of parenting stress compared with mothers with
typical hearing who have children with typical hearing, yet the
majority of parents and children with hearing loss included in these
studies were recruited from early intervention programs. This could
be a significant factor to consider when analyzing the results.
Some of the first data came from the early 1990s. Quittner,
Glueckauf, and Jackson (1990) compared the impact of stressful life
events and chronic stressors related to parenting a child with
hearing loss. They assessed mothers of young children (2 to 5 years
of age) with severe to profound hearing loss (with no additional

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disabilities) in comparison to mothers of age- and gender-matched

children with typical hearing. Mothers were recruited through
educational programs serving children with hearing loss in Canada.
Higher levels of stress were found for both measures in the parents
of children with hearing loss.
More than a decade later, Spahn, Richter, Burger, Lohle, and
Wirsching (2003) found similar results. The authors compared stress
in parents of children (2 to 16 years of age) using hearing aids or
cochlear implants under support and treatment in Germany. Both
groups of parents showed high stress levels, especially at the time of
diagnosis.
Alternatively, we found some results with a different
tendency. Lederberg and Golbach (2002) assessed parental stress in a
longitudinal comparative study with mothers of children with
severe to profound hearing loss and mothers of children with typical
hearing at 22 months, 3 and 4 years of age. In this study, mothers
were recruited through parent intervention programs, and most
families primarily communicated through speech occasionally
accompanied by signs. Some of the results revealed that differences
between stress levels in mothers of children who are deaf and hard
of hearing and mothers of children with typical hearing are only
evident at 22 months.
Likewise, Pipp-Siegel and colleagues (2002) examined
mothers with typical hearing of children (6 months to 5 years of age)
with hearing loss diagnosed from mild to profound. Forty percent of
the children sampled were diagnosed with additional disabilities.
The majority of mothers were recruited from early intervention
programs (90%), and the majority of families (60%) used some sign
in combination with speech. Findings showed significantly lower
levels of stress in mothers of children with hearing loss than the
established norm, especially in the subscale of parental role.
Similarly, Åsberg, Vogel, and Bowers (2008) assessed parents
with typical hearing of children (2 to 16 years of age) with hearing
loss diagnosed from mild to profound. Children attended schools for
the deaf in the United States. Of the families assessed, 51% used
listening and spoken language only, 29% used sign language only,
and 20% used a combination of both. The results indicated that 83%
of parents were less stressed than the normative sample.

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Furthermore, a review of research literature in Spain revealed

a general scarcity of studies to determine the stress levels of mothers
with typical hearing who have children who are deaf and hard of
hearing. Only Silvestre & FIAPAS (2009) studied a sample of
mothers with typical hearing of children (1 to 7 years of age)
recruited from early intervention programs with mild to profound
hearing loss (with no additional disabilities). All families used
listening and spoken language only. They explored the relationship
between maternal stress and others maternal variables, including
demographics and maternal input to language development.
Overall, findings showed that mothers with typical hearing with
children who are deaf and hard of hearing did not report higher
levels of stress. Also, results showed a positive correlation between
mother’s age and education with stress levels; as such, younger
mothers presented lower levels of stress compared to older mothers.
In this regard, Spain, along with several countries throughout
the world, has established newborn hearing screening. Since 2011,
100% of babies born in Spain have been screened for hearing loss at
birth under the Spanish Government’s Universal Newborn Hearing
Screening program. Less information is available concerning the age
of hearing aid fitting or cochlear implantation in the country. There
are some studies that only show data for a specific population area
or sample. For example, Palomeque, Fernández, Gómez, and Sainz
(2013) have provided some evidence that in the region of Andalucía,
the mean age at implantation in 2010 was 2.8 years. With this lack of
wider information, it is difficult to know the real impact of new
technologies and advances in early support in Spain; however, it is
possible that early identification and early intervention programs
help to cope with some stressors as others authors have suggested
(Pipp-Siegel et al., 2002; Weisel et al., 2007).
More recently, Prakash, Prakash, Ravichandran, Susan, and
Alex (2013) compared the levels of stress and depression in mothers
of children with hearing aids and cochlear implants (4 to 7 years of
age) attending early intervention programs, schools, and hospitals in
India. Findings revealed high stress levels in the mothers of children
using hearing aids as compared to mothers of children using
cochlear implants.
Finally, Sarant and Garrard (2013) compared the stress

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experience in parents of children with cochlear implants and parents

of children without disabilities in Australia. All children were
between 5 and 8 years of age, and children with hearing loss
received early intervention support. More than 80% of families of
children with hearings loss used listening and spoken language only
as their communication mode. Parents of children with hearing loss
in this study did not show higher levels of stress compared with the
normative population. However, 20% of these parents obtained a
clinically significant Defensive Responding score on the stress test,
indicating that parents are responding in a defensive manner. The
total stress was examined removing these scores, and results this
time showed significantly higher levels of stress in parents of
children with hearing loss compared with the normative population.
As can be deduced from the aforementioned studies, findings
regarding parenting stress in families with children who are deaf
and hard of hearing vary, but differences may be due to the
characteristics of the samples, the assessment instruments used, the
age of the children, the degree of deafness, or even the treatment of
data (Pipp-Siegel et al., 2002). Yet despite all the advances made,
greater insight is still needed about the family context in order to
facilitate the support of intervention programs
Regarding factors which have been identified to contribute to
parenting stress in parents of children who are deaf and hard of
hearing, some demographic characteristics of the child (i.e., age,
presence of additional disabilities, degree of hearing loss, age of the
child at identification of hearing loss, language ability, mode of
communication) may be related to parenting stress (Hintermair,
2006; Pipp-Siegel et al., 2002), while other key family indicators, such
as lower maternal education, may predict higher levels of parenting
stress (Deater-Deckard & Scarr, 1996).
The implications of parent involvement, parent attitudes, and
the overall role of the family have been recognized as important
factors in the socio-emotional development of children who are deaf
and hard of hearing. Calderon and Greenberg (2011) described the
relevance of the family in promoting healthy emotional development
of children who are deaf and hard of hearing, given that it is a
“critical foundation for life success” (p.188).
Previous studies examined emotional/behavior problems in

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children who are deaf and hard of hearing. Evidence showed that
children who are deaf and hard of hearing exhibit greater amounts
of behavior problems compared with children with typical hearing.
The assessment of behavior or socio-emotional difficulties might
include two dimensions: externalizing problems such as aggression,
hyperactivity, and conduct disorders; and internalizing problems
such as anxiety, depression, and other physical symptoms.
Van Eldik, Trefferes, Veerman, and Verhust (2004) found
greater behavioral problems among children who are deaf between 4
and 18 years of age than that of the normative sample. The authors
determined the prevalence of emotional/behavioral problems from
the parental report. Previously, Vostanis, Hayes, Du Feu, and
Warren (1997) assessed behavioral and emotional problems in
children with severe to profound hearing loss between 2 and 18
years of age. They also found a very high rate of social
maladjustment of children who are deaf in the sample, according to
general population norms.
Much less is known about the relationship between parenting
stress and emotional/behavioral problems in children who are deaf
and hard of hearing, although it is possible to find studies with
inconclusive findings. Watson, Henggeler, and Whelan (1990)
evaluated the association between some aspects of family
functioning, including family stress, and the adjustment of youths
who are deaf and hard of hearing (mean age: 12.7 years) including
behavior problems. Eighty-seven percent of the participants had an
additional disability, and all were enrolled in a special education
program for children with hearing loss in the United States. Results
showed that high parenting stress was associated with high parental
ratings of child behavior. Nevertheless, when parental emotional
distress was controlled, this association was no longer significant.
In another study, Hintermair (2006) examined the correlation
between parenting resources, demographic variables, parenting
stress, and child socio-emotional problems in children who are deaf
and hard of hearing in Germany. In this study, children (4 to 12.9
years of age) ranged from mild to profound hearing loss.
Furthermore, about 80% of the families used only oral
communication, whereas the remainder families used at least some
sign in combination with spoken language. Eighty percent of

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children in the sample had no additional disabilities. Findings

showed positive association between high parenting stress and
socio-emotional problems in children. For the author, “the
importance of parental experience and behavior for child
development is thus corroborated” (p.508).
Recently, Plotkin, Brice, and Reesman (2013) examined the
impact and predictive ability of parental personality and perceived
stress on behavior problems in deaf and hard of hearing children.
The sample was composed of children recruited from support
programs for parents of children with moderate to profound hearing
loss between 3 to 10 years of age. Communication in families was
commonly reported to be spoken language. Main findings showed
that higher levels of parental stress were predictors for externalizing
behaviors in younger children who are deaf and hard of hearing.

Family Functioning
The family plays a crucial role in many areas of child
development, as it is considered the fundamental unit of society.
Moreover, Seligman (1991) stated that families are defined not only
by their structure, but also by the interactions that occur between
their members, such as cohesion, adaptability, communication,
and other domestic, recreational, and economic functions.
Family functioning is defined as the pattern of interactions
among family members and also the family members’ interactions with
social systems outside of the home (Rueschenberg & Buriel, 1995). These
interactions change throughout the family cycle and include variables
such as communication styles, traditions, clear roles and boundaries,
the ability to cope with adversity, the degree of cohesion between family
members, and the adaptability to change, among others (Winek, 2010).
One of the most widely used research tools for the assessment
of family functioning has been the circumplex model (Olson, Sprenkle, &
Russell, 1979). This model was used to develop the Family Adaptability
and Cohesion Scale (FACES) in 1980. Family cohesion is defined as the
emotional bonding that family members have towards one another.
Family cohesion includes variables such as bonds, interests, coalitions
(alliances between members), time together, friends, private space,
and recreation; whereas adaptability is defined as the ability of family
members to change their relationships, rules, and roles in response to

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situational and developmental needs (Olson, 2000). Moreover, cohesion

and adaptability are two dimensions that have been identified as critical
resources in explaining family response to stress (Lavee & Olson, 1991).
Little research has been conducted on family functioning
in relation to parenting stress in families rearing a child with
disabilities. In their 1992 study, Morrison and Zetlin used the first
version of FACES to assess a sample of families with adolescents
both with and without disabilities, but hearing loss was not
specifically included in the study. Results indicated that cohesion
was a predictor of family members’ abilities to cope with disabilities.
Regarding the study of family functioning in families with
children who are deaf and hard of hearing, Henggeler and colleagues
(1990) studied families with adolescents with hearing loss (mild to
profound hearing loss). Families in this study were recruited through
education programs. Results indicated that levels of cohesion were
associated with better family functioning, specifically related to
marital satisfaction and low levels of maternal stress. Later, Weisel and
colleagues (2007) examined the relation between family functioning,
maternal stress, and mothers’ attitudes and expectations in three
groups of children who are deaf and hard of hearing at different
stages of the cochlear implant process: candidates for implants,
children 0–3 years post-implantation, and children with the implant
for more than 3 years. Mothers were enrolled from early intervention
programs, and children were between 9 months to 14 years of age.
Results showed no significant differences in the levels of cohesion
and adaptability in the families of the three groups. In addition, and
in concordance with the results of Henggeler and colleagues (1990),
families that showed high levels of cohesion also showed lower levels
of stress. The findings also indicated that mothers who reported
low levels of adaptability did not show higher levels of stress.
More recently, Ahlert and Greeff (2012) focused on
identifying significant resources that enhance adjustment and
adaptation in families with children who are deaf and hard of
hearing. They evaluated the family’s levels of attachment (cohesion)
and changeability (adaptability) in families with children who are
deaf and hard of hearing less than 10 years of age and enrolled in
a formal program in South Africa. Forty-two percent of families
used listening and spoken language only, 42% used sign language

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only, and the rest of families used a combination of both modes.

A strong positive correlation was found between the routines
and activities used by families and their level of adaptation. Also,
according to the authors, higher levels of adaptability allow families
to adapt more easily to a stressor because they might reorganize
their patterns of functioning to meet the demands they face.
But while cohesion and adaptability are important issues in
family functioning, research has failed to focus on family functioning
in relation to parenting stress in families with typical hearing who
have children who are deaf and hard of hearing.

METHOD

Participants
This study was part of larger research that examined the
influence of new technologies on the psychological and linguistic
development of children who are deaf and hard of hearing. This was
a cross-sectional study conducted from 2006 to 2009. The sample for
the present study consisted of 37 mothers with typical hearing who
had children who are deaf and hard of hearing. Without the use of
hearing aids or cochlear implants, the degree of hearing loss ranged
from severe to profound. The children were between 1 and 8 years
of age and presented no additional disabilities. The mothers were
recruited through three intervention programs in Catalonia (Centres
de Recursos per a Deficients Auditius—CREDAS) where the children
received speech therapy support. All the families used listening and
spoken language only.
The mothers ranged in age from 22 to 45 years (M = 34.43
years, SD = 4.885). The mean years of education of the mothers was
15.19 (SD = 4.898, range 6 - 23).
The mean age of the children in the sample was 4.11 years
(SD = 2.025, range 1 - 8). Boys comprised 54.1% of the sample (N
= 20), while girls comprised 45.9% (N = 17). Of the 37 children
observed, 37.8% used cochlear implants (N = 14), and 62.2% used
hearing aids (N = 23). The mean age of identification of hearing loss
was 17 months (SD = 12.41 range 1 - 54).

Measures

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Stress Experience. Parenting stress was assessed using the

Parenting Stress Index/Short Form (PSI/SF). This reduced version of
the Parenting Stress Index full-length test (Abidin, 1995)—validated in
Spain by Díaz-Herrero, Brito de la Nuez, Pérez-López, and Martínez-
Fuentes (2010)—consists of 36 items that evaluate three major source
domains of stress. As the author assumes that “stressors or sources of
stress are additive,” for the purpose of this study we employed the total
score on the PSI as an indicator of parenting stress. According to Abidin
(1995), the total stress score is designed to provide an indication of the
overall level of parenting stress that an individual is experiencing.
Family Functioning. Family functioning was measured using
the Family Adaptability and Cohesion Evaluation Scale (FACES II).
The second version of the questionnaire, developed by Olson, Portner,
and Bell (1982), was validated in Spain by Martínez-Pampliega, Iraurgi,
Galíndez, and Sanz (2006). FACES II consists of 20 items and assesses
the relationships and the attitudes towards family life through the
areas of cohesion and adaptability. Each item was assessed on a five-
point Likert-type scale ranging from “almost never” (1) to “almost
always” (5). Scores were averaged for each of the two scales. Higher
scores indicated higher levels of adaptability or higher levels of
cohesion.
Child Behavior. Child behavior was measured with the
Spanish version of the Behavior Assessment System for Children
(BASC) (González, Fernández, Pérez, & Santamaría, 2004). BASC
was developed as a multimethod, multidimensional system used to
evaluate the behavior and self-perception of children and adolescents
3 through 18 years of age. In the present study, we used the Parent
Rating Scale (PRS). The BASC-PRS is used to measure both adaptive
and problematic behaviors in the community and home setting.
Mothers completed forms at two age levels—preschool (ages 2
to 5) and child (ages 6 to 11)—in about 20 minutes. The statistical
analysis was conducted with the following composite scales: (1)
externalizing problems (EP): includes aggression, hyperactivity,
and conduct disorders; (2) internalizing problems (IP): includes
anxiety, depression, and other physical symptoms; (3) adaptive
skills (AS): includes adaptability, social skills, and leadership; (4)
behavioral symptoms index (BSI): includes aggression, hyperactivity,
attention problems, atypicality, anxiety, and depression. Higher

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BASC scores generally indicated worse behavioral problems,

except on the BASC-AS scale where higher scores were optimal.
Language Development. Language development was measured
with the Spanish version of the Reynell Developmental Language Scale
(Alonso & González, 1988). This scale has been used extensively to
examine the vocabulary and language skills in both children with and
without hearing loss (Cupples & Crowe, 2014; Hoffman, Quittner, &
Cejas, 2015). There are two scales: (1) the comprehension scale, which
explains aspects of a child’s understanding of selected vocabulary items
and grammatical features; (2) the expression scale, which examines the
child’s expression of the same features of language. The test consists
of 67 items and includes the use of supplied toys and finger puppets.

Procedure
After contacting mothers of children who are deaf and
hard of hearing, they were informed about the procedures and
objectives of the research and appealed to for written consent of
study. All of the children were tested in a room in their language
intervention program. The questionnaires were sent to mothers
directly through the speech-language intervention programs.
Statistical Analyses. Zero-order Pearson product-moment
correlations were calculated to assess simple relationships among
variables. Categorical variables were converted to a numeric
dichotomic scale (child’s gender: 1 = male, 2 = female; prosthetic
hearing device: 1 = hearing aid, 2 = cochlear implant). The relationship
between parenting stress versus family cohesion/adaptability and
demographic variables was analyzed using linear models. These
models assume that the response-predictor variables are linearly
related and were preferred for their simplicity over more complex
models. Multicollinearity (i.e., strong correlation among two or more
predictor variables) may introduce bias in the modeling, confounding
the relative importance of variables. In order to account for the
impact of possible multicollinearity on the model selection, variance
inflation factor (VIF) was estimated for the full model (i.e., containing
all 12 predictors) using the package HH in the freely available
software R (Heiberger, 2013); predictors with VIF > 5 (indicating a
high collinearity) were removed from further analysis (Table 1). See
O’Brien (2007) for a discussion on the use of different cut-offs for VIF.

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 Table 1. Summary of Pearsons’ correlations among the different variables (significant values (p < 0.05) indicated in bold). Also shown are the

140
variance inflation factors (VIF) for all predictors, and a subset of predictors.VIF > 5 indicate strong collinearity of the predictor.

VIF VIF

Parenting stress
Mother’s years of education
Family cohesion
Family adaptability
Child’s sex
Child’s age
Hearing device
Reynell’s test-comprehension
Reynell’s test-expression
BASC-EP
BASC-IP
BASC-AS

All Subset Variable

Parenting stress

Rivadeneira, Silvestre, & Laborda

1.5 1.4 Mother’s years of education -0.03
1.9 1.4 Family cohesion -0.54 0.03
2.7 1.6 Family adaptability -0.26 0.23 0.24
2.1 1.4 Child’s sexa 0.14 0.06 -0.29 0.09
1.7 1.5 Child’s age -0.08 -0.09 0.09 0.37 0.13
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1.8 1.4 Hearing deviceb -0.01 -0.49 0.26 -0.03 0.02 0.13
6.3 2.2 Reynell’s test-comprehension -0.06 0.28 0.22 0.54 -0.17 0.39 -0.16
6.8 Reynell’s test-expression -0.06 0.25 0.26 0.37 -0.15 0.46 -0.09 0.88
16.5 BASC-EP 0.64 0.18 -0.16 0.2 -0.14 0.02 -0.28 0.29 0.33
4.6 1.4 BASC-IP 0.5 0.24 -0.14 0.04 0.08 0.21 -0.22 0.23 0.28 0.72
2.9 1.8 BASC-AS -0.54 0.14 0.08 0.35 0.31 0.18 -0.17 0.17 0.16 -0.29 -0.15
15.5 BASC-BSI 0.72 0.14 -0.12 0.02 -0.04 0.1 -0.14 0.18 0.22 0.91 0.82 -0.41
a
1 = male, 2 = female
b
1 = hearing aid, 2 = cochlear implant
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A multi-model selection procedure was followed in order to

make more robust inferences. All possible additive linear models,
including all combinations of the remaining nine predictors, were
analyzed (512 total). The response was transformed using logarithms
to ensure normality (i.e., normal distribution) and homoscedasticity
(i.e., equality of variances) of errors. Best models were selected
according to the Akaike weights (AICw) and corrected for sampling
size to account for missing data. AICw represents the likelihood of a
model, pondering the degree of fit and the economy (i.e., number of
parameters) in a model. Thus, models with larger values of AICw were
best supported. Analyses were carried out using the package glmulti
in the software R (Calcagno, 2013; Calcagno & de Mazancourt, 2010).
The alpha level chosen for significance was set at p = 0.05 in all cases.

RESULTS
The mean stress score was 69.47 (SD = 19.93, range 39 - 116).
The mean family cohesion score was 69.94 (SD = 5.21, range 59 - 77).
The mean family adaptability score was 51.36 (SD = 3.96, range 41 - 58).
The results indicated a significant negative correlation between
parenting stress and family cohesion (r = -0.53, p = .00). No significant
correlation was found between family adaptability and parenting
stress (r = -0.26, p = .13). As for the family functioning results, except
for the findings regarding parenting stress, no significant correlation
was found between family cohesion and the other variables in
this study. Regarding family adaptability, the results indicated a
significant positive relation between family adaptability and the
child’s age (r = 0.36, p = .04) and between family adaptability and
language development (Reynell Comprehension Scale, r = 0.52,
p = .00). No significant correlation between family adaptability and
other variables was found. All measures for behavior problems in
the child who is deaf or hard of hearing were related significantly
to parenting stress: BASC-EP (r = 0.64, p = .00); BASC-IP (r = 0.49,
p = .00); BASC-AS (r = -0.54, p = .00); BASC-BSI (r = 0.72, p = .00).
Linear models were used to examine the relationship
between parenting stress versus family cohesion/adaptability
and other variables. Importantly, the BASC-EP, BASC-BSI, and
the Reynell’s expression scale showed a large correlation with
other predictors which increased its degree of multicollinearity

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(Table 1); hence, they were excluded from further analysis.

Removing these variables reduced the VIF (1.4 - 2.2, Table 1).
Table 2 summarizes the multi-model selection procedure,
showing the top 10 models with the highest statistical support. The
best model (AICw = 0.35) included the effect of BASC-AS, BASC-IP,
and family cohesion. All other models had much lower support (AICw
< 0.09). The model including the additive effect of these three variables
was highly significant and explained 66% of variance in parenting
stress index. BASC-AS and family cohesion were negatively related
to PSI (Figure 1A, C, Table 3), whereas the regression coefficient was
positive for BASC-IP (Figure 1B, Table 3).

Table 2. Multi-model selection of the predictors of Parenting Stress Index.

Ranking Model AICc AICw
1 PSI ~ 1 + cohe + bint + badp -7.31 0.326

2 PSI ~ 1 + cohe + cgen + bint + badp -4.73 0.09

3 PSI ~ 1 + cohe + prot + bint + badp -4.3 0.072

4 PSI ~ 1 + cohe + cage + bint + badp -4.12 0.066

5 PSI ~ 1 + mstu + cohe + bint + badp -4.12 0.066

6 PSI ~ 1 + cohe + adap + bint + badp -4.1 0.065

7 PSI ~ 1 + cohe + cgen + prot + bint + badp -1.36 0.017

8 PSI ~ 1 + cohe + badp -1.34 0.016

9 PSI ~ 1 + cohe + reyc + bint + badp -1.26 0.016

10 PSI ~ 1 + cohe + cgen + cage + bint + badp -1.24 0.016

Note: Only the top 10 models (out of 512 possible additive models) are shown. Abbreviations: AICc =
Akaike Information Criterion corrected for sample size; AICw = Weighted Akaike; cohe = Family Cohesion;
bint = BASC-IP; badp = BASC-AS; cage = Child’s age; cgen = Child’s sex; mstu = Mother’s years of study;
prot = Hearing device; reyc = Reynell’s test-comprehension

DISCUSSION
Despite consistent evidence demonstrating relevant factors
related with parenting stress in families with typical hearing who
have children who are deaf and hard of hearing, the correlation
of family functioning, parenting stress, language development,

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behavior problems, demographic variables, and characteristics of the

children with hearing loss has not previously been surveyed in one
statistical model.
Table 3. Regression coefficients of the best model explaining the Parenting
Stress Index.
Variable Coefficient Std. Error t-value p-value
Intercept 6.022 0.563 10.697 < 0.00
Family Cohesion -0.023 0.007 -3.293 0.003
BASC-A -0.014 0.003 -4.161 < 0.001
BASC-IP 0.011 0.003 3.063 0.005

Figure 1. Univariate relationships between Parenting Stress Index (after log

transformation) and the top three predictor variables: A) BASC-adaptability,
B) BASC-internalizing problems, and C) Family cohesion. Lines show the fit of
linear models.

The present study examined associations between parenting

stress in mothers with typical hearing who have children who are
deaf and hard of hearing, family functioning, language
development, child behavior problems, mother’s education, child’s
sex, child’s age, and child’s hearing device. Our results showed that
a significant part of the variance in the parenting stress was
explained by the additive effect of the variables: family cohesion,
internalizing problems, and adaptive skills in the child who is deaf
or hard of hearing.

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Results showed that mothers with typical hearing with

higher levels of family cohesion tended to report lower levels of
stress. These results are consistent with those of other studies
(Henggeler et al., 1990; Morrison & Zetlin, 1992; Weisel et al., 2007).
According to Olson (2000), families with moderate levels of cohesion
have emotional closeness and loyalty to the relationship. There is an
emphasis on togetherness. Likewise, they share interests and
activities, and in general there is a greater balance between spending
time alone and sharing with other family members. It is possible that
families with typical hearing who have children who are deaf and
hard of hearing feel the need to be extremely attached as a way of
coping with hearing loss, and through cohesion, families shield and
protect their members from life stressors. Furthermore, in
accordance with Lavee and Olson (1991), more cohesive families
have stronger and more effective resources to cope with difficulties
than less connected families, which means that cohesive families are
expected to be less vulnerable and more adaptive. Thus, family
cohesion seems an important protective element for consideration by
intervention programs and support professionals to families with
children who are deaf and hard of hearing.
As for the association between parenting stress and adaptive
skills in children who are deaf and hard of hearing, findings showed
that mothers with typical hearing that experienced higher levels of
parenting stress have children who are deaf and hard of hearing
with lower abilities for adaptability, social skills, and leadership.
Several clinical implications for children who are deaf and hard of
hearing and their families with typical hearing can be drawn from
this result. For example, children who are deaf and hard of hearing
with poorer social skills or low levels of adaptability might be at risk
of isolation, because it is possible that they will be unable to respond
adequately in future social interactions and relationships. Also, it
has been established that poor social skills are predictive of
aggressive behavior in later years (Baker, Blacher, Crnic, &
Edelbrock, 2002). In children who are deaf and hard of hearing,
results showed a lack of consensus across studies (Batten, Oakes, &
Alexander, 2014).
Our analysis showed a strong and significant positive
correlation between parenting stress and the three scales of the

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language test (BASC), yet only two of them were considered in the
linear multi-model approach. Given the impact that higher rates of
parenting stress may cause in social development, these findings
support the importance of guidance and support for families with
typical hearing raising a child who is deaf or hard of hearing. With
regard to the relationship between internalizing problems in the
child who is deaf or hard of hearing and parenting stress, results
showed that mothers with typical hearing that experienced higher
levels of stress have children who are deaf and hard of hearing with
greater behavior problems related to anxiety, depression, and other
physical symptoms. Therefore, parenting stress could be considered
a risk factor of child development, because a highly stressed parent
may demonstrate parenting behaviors which do not promote child
growth. The importance of parenting stress and behavior of children
who are deaf and hard of hearing has scarcely been studied;
nevertheless, these results extend those reported by Hintermair
(2006) and Plotkin and colleagues (2013) who found that behavior
problems in youths/children with hearing loss are associated with
parenting stress. Contrarily, in a previous study of Watson and
colleagues (1990), this association was not found.
Overall, other results in our study suggest that mothers with
typical hearing of children who are deaf and hard of hearing
experienced normal levels of parenting stress, which is consistent
with other earlier studies (Åsberg et al., 2008; Meadow-Orlans, 1994;
Pipp-Siegel et al., 2002; Weisel et al., 2007). Also, our findings
complement the early study of Spanish mothers with typical hearing
who have children who are deaf and hard of hearing by Silvestre
and FIAPAS (2009) in which mothers with typical hearing
experienced normal levels of parenting stress. Still, additional
information is required in order to make more generalizations in this
population.
Because mothers of the sample were recruited from early
intervention programs, we agree with Pipp-Siegel and colleagues
(2002) and Weisel and colleagues (2007) that support programs may
mitigate parenting stress. Moreover, these findings support the
importance of parental counsel and guidance, especially in the early
years of a diagnosis of child hearing loss.
With regard to other correlations in our exploratory study,

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we do not find significant associations between parenting stress and

some demographic variables, such as mother’s years of education,
child’s age, child’s sex, and hearing device. These variables have
shown to be predictors of parenting stress in early studies (Pipp-
Siegel et al., 2002); however, our results should be viewed as a
complement to the existing body of literature.
No association was found between family adaptability and
parenting stress. In line with Weisel and colleagues (2007), it might
be concluded that for some families, the ability to maintain routines
or to not adapt to the presence of stressors, like the presence of a
child who is deaf or hard of hearing, is functional. Other findings
suggested that family adaptability among mothers with typical
hearing in our sample was positively related to the age of the child
who is deaf or hard of hearing. This finding could be interpreted that
as the child with hearing loss grows, family members become more
adaptive, and family structure, roles, and dynamics are more open
to the challenges of raising a child who is deaf or hard of hearing.
Importantly, and according to Feher-Prout (1996), “as family
members adjust to the needs of a child with disability, changes in
roles may be necessary” (p.159).
Likewise, family adaptability among mothers in our sample
was positively related to language comprehension in the child who
is deaf or hard of hearing. This result suggests that language abilities
in the child who is deaf or hard of hearing are an important result of
family structure. As previously mentioned, family adaptability is
related to various structure concepts, such as negotiation styles, role
relationships, and relationships rules (Olson, 2000), so the
importance of a flexible structure instead of a rigid structure in
families with typical hearing is seemingly crucial for the successful
development of language in children who are deaf and hard of
hearing.
Several limitations of our study, however, should be
considered. The observations made in this study need to be further
explored regarding the limitations associated with the small sample
and the use of self-report measures. Likewise, as only maternal
reports were used to assess family dimensions, future research
should also consider other family members in order to complement
the findings. Additionally, the age range of the children in this study

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The Volta Review, Volume 115(2), Fall/Winter 2015

was limited to early childhood; an extension of this range might be

interesting to explore. Furthermore, this study only includes families
who used listening and spoken language as their sole method of
communication, and future research might involve a more diverse
sample.
The implications of family functioning should be considered
when evaluating the role of parents of children who are deaf and
hard of hearing. It is important to consider the family as a dynamic
system that is in constant interaction and flux; what affects one of its
members can affect the rest of the family. Specifically, results in our
study have important implications for intervention programs
considering a systemic approach to promote change and protective
behaviors in parents with typical hearing of children who are deaf
and hard of hearing. Also, our study seeks to contribute to building
professional understanding of family functioning in families with
typical hearing with children who are deaf and hard of hearing.
Moreover, the findings from this research may be particularly
relevant to complement existing literature when one considers the
lack of studies on families and their role in promoting healthy
socio-emotional development in Spain, and also the mixed results
and lack of consensus in studies about parenting stress in families
with children who are deaf and hard of hearing.
Furthermore, we sought to look at the actual need for
understanding the many challenges that parents of children who are
deaf and hard of hearing face. The importance of early intervention
services and a partnership between families and professionals is
critical for successful development of the child; therefore, this
evidence may contribute to enhance the support that families with
children who are deaf and hard of hearing receive.

ACKNOWLEDGMENTS
The study was supported by the Ministry of Science and
Innovation of the Spanish Government (SE 2006-100730). We are
grateful to all parents who took part in the study.
The corresponding author would like to thank K. De Bruyne, and
Alfred P. H. for their review and support, and to M. M. Rivadeneira
for his statistical advice.

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