Factors Associated With Parental Distress

ORIGINAL
Blackwell
Malden,
Journal
JCAP
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1744-6171
1073-6077
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2006 of
Factors by
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Psychiatric
Distress Nursing

Catherine A. Duchovic, RN, MSN, CNS, Janis E. Gerkensmeyer, PhD, APRN, BC, and Jingwei Wu, MS

PROBLEM:
support, personal control, and child behavioral
problems to distress in parents of children with mental
health problems were examined.
METHODS: One hundred and fifty-five parents of
children 2–19 years old receiving community mental
health services participated.
FINDINGS:
internalizing and externalizing child behaviors,
perceived personal control, and tangible social support
as independent predictors of parental distress.
Independent predictors of objective distress included
internalizing child behaviors, perceived personal
control, and intangible social support.
CONCLUSIONS:
behaviors were significantly associated with parental
distress. Perceived personal control moderated the
relationship between internalizing child behaviors and
parental subjective distress.
Search terms: Caregivers, child and adolescent
mental health, child behavioral problems, parental
distress, personal control
Associations of perceptions of social
Stepwise regression analysis identified
Internalizing and externalizing child
Catherine A. Duchovic, RN, MSN, CNS, is Associate
Faculty, Department of Nursing, Indiana University–
Purdue University Fort Wayne, Fort Wayne, IN; Janis E.
Gerkensmeyer, PhD, APRN, BC, is Assistant Professor,
School of Nursing, Indiana University, Indianapolis, IN;
Jingwei Wu, MS, is Biostatistician, School of Medicine,
Indiana University, Indianapolis, IN.
A ccording to the Report of the Surgeon General’s Conference
on Children’s Mental Health (U.S. Department Health and
Human Services, 2000), a healthcare crisis exists for children
with mental health problems and their families that is
caused by unmet needs. These unmet needs include a deficit
of formal and informal social support resources (Lazear,
Worthington, & Detres, 2004). Parents caring for children
with mental health problems are extremely challenged in
getting both their child’s and their own needs met (Bode,
Weidner, & Storck, 2000).
Normal parenting includes concerns about growth and
development, child behavioral and social issues, emotional
well-being of the child, and financial responsibilities. These
concerns alone can result in parental distress (Ross & Blanc,
1998). Additional stressors for parents of a child with mental
health problems, however, increase parental distress
significantly (Ross & Blanc). Challenges experienced by
caregivers of children with mental health problems have
been associated with parental distress and feelings of being
stretched beyond their limits (Podolski & Nigg, 2001; Sharpley
& Bitsika, 1997).
The purpose of this study was to examine the association
of perceived social support, perceived personal control, and
child behavioral problems to distress in primary caregivers
of children with mental health problems. The primary
caregivers, henceforth referred to as parents, included
grandmothers and biological, adoptive, step, and foster
parents. Understanding the associations of social support
and personal control to distress will promote development
of interventions aimed at decreasing parental distress.

Conceptual Framework
doi: 10.1111/j.1744-6171.2008.00168.x
The Double ABCX Model (McCubbin & Patterson, 1983)
Journal of Child and Adolescent Psychiatric Nursing, Volume 22, provided a framework for assessing the relationship of
Number 1, pp. 40–48 perceived social support and personal control to distress for

40 JCAPN Volume 22, Number 1, February, 2009

parents of a child with mental health problems. In the
Double ABCX Model, a stressor event and pile-up of stressors
(aA) produce tension within the family unit that requires
management. Both existing and expanded resources within
the family and the community (bB) can be used to deal with
stressors. Family members’ perceptions of the stressor
events, family demands, and resources (cC) are a reflection
of cultural and social meanings attached to both current life
events and previous experiences with stressors and crises. A
state of crisis (x) may emerge as a result of the inability to
restore stability in the family system. Exhaustion may result
when crises are not resolved, and distress may emerge
(Brannan & Hefflinger, 2001). On the other hand, family
adaptation (xX) may occur as a result of efforts to restore
balance within the family system after a state of crisis.
Factors Associated With Parental Distress
Konstantareas and Homatidis (1991) described child
behavioral problems as energy-consuming demands
that exceed the productive and rewarding capabilities of
parenting. Demands of caring for a child with mental
health problems are at least as taxing as the demands of
caring for a child with physical health problems (Cronin,
2004). Higher levels of distress have been reported by
parents of children with behavioral problems than for parents
of children with developmental delays, including Down
syndrome (Baker et al., 2003). Weiss (2002) found significantly
higher levels of distress in parents of children with autism
as compared to parents of children with mental retarda-
tion or normal development.
Distress experienced by parents of children with
attention-deficit/hyperactivity disorder (ADHD) has been
positively associated with child symptoms, especially
externalizing behaviors (Bussing et al., 2003; Podolski & Nigg,
2001). Perceptions about the intentionality of child behaviors
have also been associated with parental distress, with lower
distress experienced when behavior was believed to be
unintentional (Harrison & Sofronoff, 2002). The additive
effects of ADHD symptoms and oppositional-defiant child
behaviors have been found to increase parental distress
and decrease parental role satisfaction more than ADHD
symptoms alone (Podolski & Nigg).
Parental Distress
Chou (2000) described the experience of caregiving as
dynamic, whereby all aspects of distress might not be
experienced at a given time. Overload from an imbalance
between perceived demands and resources when caring for
a child with mental health problems may have negative
psychic consequences for the parent. Worry, guilt, sadness,
fatigue, embarrassment, resentment, and anger directed
JCAPN Volume 22, Number 1, February, 2009
toward the child have been described as indications of the
subjective dimension of distress (Brannan & Hefflinger,
2001). Observable occurrences, including demands on time,
friction in family life, disruption in social life and employ-
ment, and financial concerns, have been identified as objective
dimensions of distress (Brannan & Hefflinger; Rosenzweig,
Brennan, & Ogilvie, 2002).
Social Support
Distress for parents of children with mental health
problems has been found to be ameliorated by social
support from spouses, relatives in an extended family
network, school and mental health professionals, family
support groups, informal respite services, and other com-
munity resources (Bussing et al., 2003; Lazear et al., 2004;
Weiss, 2002). Socioeconomic status is inversely related to the
amount of support from the informal kin network and
positively related to support from formal community resources
(McDonald & Gregoire, 1997). Bussing et al. found that
African American caregivers experienced higher levels of
support through extended family networks than did
Caucasian caregivers. Types of support provided to family
members include tangible aid (respite, loans, gifts, or
information) and intangible aid (emotional support and
empathy; Puotiniemi, Kyngas, & Nikkonen, 2002). Dis-
crepancies between need for support and type of support
actually received can exist (e.g., needing child care to
maintain employment, but receiving only emotional
support; Puotiniemi et al.; Rosenzweig et al., 2002).
Parent support group members become both providers
and recipients of social support within the group (Lazear
et al., 2004; Papaikonomou & Nieuwoudt, 2004). Puotiniemi
et al. (2002) identified involvement with other parents as a
valuable means of learning to cope with the mental health
problems of children. Professional support within these
groups increased parents’ sense of control and decreased
objective burden. Counseling and effective coordination of
professional services can also reduce parents’ distress
(Lazear et al.; Yatchmenoff, Koren, Friesen, Gordon, &
Kinney, 1998).
Perceived Personal Control
According to Dunn, Burbine, Bowers, and Tantleff-Dunn
(2001), locus of control is related to both stress and learned
helplessness. Interventions to increase parental perceptions
of self-efficacy and perceived personal control have been
implemented with success (Dempsey & Dunst, 2004). Weiss
(2002) found that coping of parents of children with autism
was influenced by perceptions of personal control which
reflected the degree of perceived influence over life’s events.
Parents’ expectations about life and children, along with
41
Factors Associated With Parental Distress
attributions about the causes of mental health problems, atti-
tudes about mental health services, and perceptions of what
others think help shape the perceptions of parental personal
control (Brannan & Hefflinger, 2001). Harrison and Sofronoff
(2002) found lower perceived parental control over child
behaviors to be associated with higher levels of parenting stress.
Research Questions
Based upon the conceptual framework and review of the
literature, the following research questions emerged. Are child
mental health problems (internalizing and externalizing
behavioral problems), perceived social support (tangible and
intangible), and perceived personal control significantly
associated with parental distress (subjective and objective)?
Do perceived personal control or social support mediate or
moderate the association of child mental health problems
and parental distress? Which variables independently
predict parental distress, both subjective and objective?
Methods
Procedure
This study analyzed cross-sectional data collected from a
larger research project that investigated variables associated
with quality of life among parents of children with mental
health problems. A convenience sample of parents from one
Midwestern state was utilized. Clinical nurse specialists
employed at community mental health centers and a psy-
chologist from a child psychiatric clinic recruited participants.
In addition, some participants were self-referrals.
Parents participating in the study were identified as the
primary caregiver of a child between 2 and 19 years of age
who was receiving community mental health services and who
had been living at home with the caregiver for at least 20 of
the past 24 months. Institutional review board approval was
obtained for the study, and Health Insurance Portability and
Accountability Act (HIPPA) rules were observed.
Parents who agreed to participate were provided a survey
packet either in person or by mail and were given a choice of
completing the survey independently or over the phone.
Surveys took approximately 45 min to complete. Surveys not
completed within approximately 2 weeks were followed up
with a phone call to verify that the survey had been received,
that there were no questions about procedures, and if the
participant preferred to be interviewed over the phone. Each
parent returning a completed survey received $25.
Sample
Primary caregivers (N = 155) included biological mothers
(81%), adoptive mothers (8%), grandmothers (7%), and 1%
42
each stepmothers, foster mothers, biological fathers, and
adoptive fathers. They ranged in age from 23 to 62 years
(M = 37.7, SD = 8.3); 46% were married, 23% divorced, 5%
separated, 17% single, and 9% living with a partner. Most
participants were Caucasian (80%), and the rest were African
Americans (17%), Native Americans (2%), and Hispanic
(1%). Twenty-six percent of the participants were employed
full-time, 17% were employed part-time, 30% were home-
makers, 12% were unemployed, and other (12%). Median
household income was between $20,000 and $30,000, with
63% having an annual income of less than $30,000. Only 10
participants had attended a parent support group. Most
children were male (67%). Mean age was 10 years (SD = 3.9);
72% were Caucasian, 17% were African American, 1%
were Hispanic, and 2% were Native American. Mean
reported length of time of the mental health problem was 5.2
years (SD = 4.2).
Variables and Instruments
Mental health problems were viewed as stressors in this
study and were measured by externalizing and internalizing
t scores on the Child Behavior Checklist (CBCL), which has
strong support for validity and reliability (Achenbach, 1991;
Harrison & Sofronoff, 2002). Externalizing child behavioral
problems included hyperactivity, hyperirritability, impulsivity,
self-abuse, fighting, destructiveness, and disobedience at home
or school. Internalizing child behavioral problems included
symptoms of anxiety and depression, fearfulness, loneliness,
social withdrawal, and compulsive or suicidal thoughts.
Two versions were used (ages 1.5 to 5 years and 6 to 18 years).
Mental health problems were viewed as
stressors in this study and were measured by
externalizing and internalizing t scores on the
Child Behavior Checklist.
Dimensions of social support were examined, including
tangible aid (respite, loans, gifts, or information) and intan-
gible aid (emotional support). The 40-item Inventory of
Socially Supportive Behaviors (ISSB) measured perceived
social support, with both reliability and internal consistency
being strong for this scale (Barrera, Sandler, & Ramsay,
1981). ISSB’s 5-point Likert response scale measured the
frequency of social support from 1 (not at all) to 5 (about every
day). Factor analysis with varimax rotation resulted in two
factors, tangible and intangible, with alpha coefficients in
this study of .92 and .95, respectively.
JCAPN Volume 22, Number 1, February, 2009
Table 1. Correlations

Subjective Objective Internal External Tangible Intangible Family Personal

Distress Distress t score t score Support Support Support Control

Subjective Distress —
Objective Distress .636*** —
Internal t score .466*** .347*** —
External t score .496*** .287*** .529*** —
Tangible Support −.203** −.192* −.054 −.006 —
Intangible Support −.211** −.238** −.162* −.035 .721*** —
Family Support −.368*** −.275*** −.307*** −.272** .265*** .481*** —
Personal Control −.458*** −.313*** −.314*** −.328*** .084 .234** .364*** —

*p < .05; **p < .01; ***p < .001.

An additional measure of family social support was
utilized to assess parents’ perceptions of adequacy of family
assistance, availability, and support. The five-item Family
Apgar (Smilkstein, Ashworth, & Montano, 1982) was utilized.
Items were rated on a Likert response scale from 1 (not at all)
to 5 (a great deal). Alpha was .92 in this study.
Participation in a parent support group was indicated by
a dichotomous response of yes or no. Type of support
group, interest in participating in a support group, and
perceived barriers to support group involvement were not
investigated in this study.
Perceived personal control reflects a general sense of hav-
ing the intrapersonal resources to deal with stressors (Reinhard,
1994). The Pearlin Mastery Scale (Pearlin & Schooler, 1978)
was used to measure parents’ general sense of personal control
and mastery. Seven items were rated from 0 (strongly disagree)
to 3 (strongly agree). The alpha was .82 in this study.
The dependent variable, parental distress, was conceptu-
alized as both subjective and objective distress. Subjective
distress in this study refers to the degree parents were affected
intrapersonally, such as through fear, worry, or guilt related
to their child’s mental health problem. Objective distress
relates to the degree parents’ lives were disrupted, such as
through family or work disruption or lack of time for leisure
activities. Distress was measured by the 19-item Parent
Experiences Scale (PES), adapted by Gerkensmeyer and
Austin (2005) from Reinhard’s (1994) Burden Assessment
Scale. All items were rated from 1 (not at all) to 4 (a lot), with
0 (not applicable). In this study, factor analysis with varimax
rotation resulted in a 6-item objective distress factor (α = .78)
and a 13-item subjective distress factor (α = .88).
Data Analysis
Frequencies were generated for all categorical variables,
and descriptive statistics were calculated for all continuous
variables. The relationship of key variables to demographics
was examined. Bivariate correlations between and among
the CBCL internalizing and externalizing t scores, social
support variables, perceived personal control, and parental
distress were obtained using Pearson correlations (see
Table 1). Furthermore, bivariate correlations between key
demographic variable and the dependent variables, objective
and subjective distress, were examined. Mediation and
moderation of the relationships of child internalizing and
externalizing behavioral problems to subjective and objective
parental distress by social support variables and personal
control were examined using the regression methods of
Baron and Kenny (1986). Stepwise regression was used to
identify demographic variables, independent predictors,
and potential moderation effects of subjective and objective
distress.
Results
Means for total internalizing CBCL t scores (M = 67, SD =
8.9), total externalizing CBCL t scores (M = 69, SD = 9.6), and
total behavioral problems CBCL t scores (M = 70, SD = 8.8)
were at or above the standardized cutoff of 67 for clinical
behavioral problems, indicating a high level of severity of
behavioral problems among children in this sample. The
mean for tangible social support (M = 1.8, SD = 0.67)
reflected low levels of tangible support reported by these
parents. The mean for intangible social support (M = 2.5,
SD = 0.91) reflected low to moderate levels of intangible
support reported. Tangible social support was reported as
having been received only once or twice during the previous
month by 90% of the parents, as was intangible social
support. Similarly, intangible social support was reported by
60% of parents to be received less than once a week. The
Apgar mean score of 3.1 (SD = 1.2) reflected a mid-range
level of perceived adequacy of family support received. The

JCAPN Volume 22, Number 1, February, 2009 43

Factors Associated With Parental Distress

Table 2. Parent Experience Scale

M SD

Objective Subscale
Had financial problems 2.8 1.3
Found it difficult to concentrate on your own activities 2.7 1.1
Cut down on leisure time 2.5 1.3
Had less time to spend with friends 2.5 1.3
Had to change your personal plans like taking a new job or going on vacation 1.9 1.4
Missed days at work (or school) 1.6 1.3
Subjective Subscale
Worried about what the future holds for your child 3.4 0.9
Experienced family frictions and arguments 2.9 1.2
Found the household routine was upset 2.8 1.1
Felt guilty because you were not doing enough to help 2.7 1.1
Became embarrassed because of your child’s behavior 2.6 1.1
Neglected other family members’ needs 2.5 1.2
Found the stigma of the illness upsetting 2.4 1.1
Worried about how your behavior with your child might make the illness 2.2 2.2
Felt trapped by your caregiving role 2.2 1.2
Were upset about how much your child has changed from his or her former self 2.1 1.3
Felt guilty because you felt responsible for causing your child’s problems 2.1 1.2
Experienced frictions with neighbors, friends or relatives outside the home 2.1 1.1
Resented your child because she or he made too many demands on you 2.0 1.0

mean for perceived personal control (M = 2.0, SD = 0.55)
indicated a moderate degree of perceived personal control,
overall.
PES mean scores for subjective (M = 2.5, SD = 0.72) and
objective distress (M = 2.4, SD = 0.88; see Table 2 for PES
item means) reflected moderate to high levels of parental
distress. The highest rated distress items were Worry about
my child’s future, Experienced family frictions and arguments,
Had financial problems, and Found the household routine was
upset. The lowest rated items were Had to change your personal
plans like taking a new job or going on a vacation and Resented
your child because she or he made too many demands on you
(see Table 2).
Child and parent’s age, parents’ educational level, house-
hold income, length of mental health problem, and number
of siblings were not significantly related to internalizing and
externalizing behavioral problems, social support, perceived
personal control, or parental distress. Family support and
perceived personal control were associated with household
income. All key variables were significantly associated with
each other except for internalizing behavioral problems and
tangible social support, externalizing behavioral problems
with both tangible and intangible social support, and
perceived personal control with tangible social support (see
Table 1).
Perceived social support (tangible, intangible, and Family
Apgar) did not mediate or moderate the relationship
between child internalizing and externalizing behavioral
problems and parental distress (subjective or objective). This
is likely because of the nonsignificant relationships of
internalizing and externalizing behavioral problems to
tangible social support and between externalizing behavioral
problems and intangible social support. Perceived personal
control, however, did moderate the relationship between
internalizing behavioral problems and distress. As can be
seen in Figure 1, parents with the highest levels of perceived
personal control had more dramatic increases in subjective
distress in relation to increases in internalizing behavioral
problems. For parents with the lowest levels of perceived
personal control, subjective distress did not increase as
dramatically with increases in internalizing behavioral
problems as it did for those parents with higher levels
of perceived personal control. However, parents with
lower perceived personal control reported higher levels of
subjective distress even when internalizing child behaviors
were less intense.
Stepwise regression analysis was used to determine the
independent predictors of subjective and objective distress
in parents. Child internalizing and externalizing behavioral
problems, tangible and intangible social support, family
support, and perceived personal control were entered into
the stepwise regression. Since perceived personal control
also moderated the relationship between internalizing
behavioral problems and distress, the interaction between

44 JCAPN Volume 22, Number 1, February, 2009

Figure 1. Moderating Effect of Perceived Personal Control Table 3. Stepwise Regression Analysis Final Model:
on the Relationship Between Internalizing Child Parental Distress—Subjective
Behaviors and Subjective Parental Distress
Beta p value

Total externalizing CBCL t score 0.02 < .0001

Mean of personal control scale −1.79 < .0001
Total internalizing CBCL t score −0.03 .216
Interaction between personal control 0.02 .029
and CBCL internalizing
ISSB tangible subscale −0.16 .029

CBCL = Child Behavior Checklist; ISSB = Inventory of Socially

Supportive Behaviors.

Table 4. Stepwise Regression Analysis Final Model:

Parental Distress—Objective

Beta p value

Total internalizing CBCL t score 0.027 .001

Mean of personal control scale −0.341 .006
ISSB tangible subscale −0.211 .03

perceived personal control and internalizing behavioral
problems was also included in the regression model. Exter-
nalizing behavioral problems, perceived personal control,
internalizing behavioral problems, interaction between
personal control and internalizing behavioral problems,
and reported tangible social support explained 39% of the
variance in subjective parental distress (Table 3). Internaliz-
ing behavioral problems, personal control, and tangible
social support explained 18% of the variance in objective
parental distress (Table 4).
Discussion
Both internalizing and externalizing behavioral problems
in children were significantly associated with parent’s
subjective and objective distress in this sample. The liter-
ature suggests that externalizing behavioral problems are
more highly correlated with distress than internalizing prob-
lems. In this study, internalizing behavioral problems were
relatively more highly correlated with objective distress in
parents than externalizing problems. This finding may also
reflect the amount of energy expended by parents who seek
to protect and support a child who is seen as being vulnerable
or emotionally fragile. On the other hand, externalizing
behavioral problems were relatively more highly correlated
than internalizing problems with subjective distress. When
examining items loading on the subjective distress factor,
this is not surprising. For example, due to externalizing
CBCL = Child Behavior Checklist; ISSB = Inventory of Socially
Supportive Behaviors.
behavioral problems, parents would likely experience
increased worry about their child’s future, disruptions in
family routines, embarrassment by their child’s behaviors,
and upset related to stigma of their child’s illness.
Perceptions of adequate social support from other family
members was higher among these parents than were their
reports of tangible and intangible support received. Parents
reported receiving moderate levels of support over a 6-
month period in categories such as being satisfied that I can
turn to my family for help when something is troubling me.
Although parents reported receiving very little tangible or
intangible social support, very few participated in formal
support groups. Despite the reported positive value of
support group participation, including an opportunity to
vent and to explore options through a peer support network
(Lazear et al., 2004), only 10 out of 155 parents in the study
accessed this method of support.
With the severity of reported child behavioral problems
and the low levels of tangible and intangible social support
received, both objective and subjective parental distress
levels were moderate to high. Whereas the most highly
endorsed distress items were related to concerns for the
family and child, the lowest endorsed items on the PES were

JCAPN Volume 22, Number 1, February, 2009 45

Factors Associated With Parental Distress
life of the caregiver being disrupted and feelings of resent-
ment for the child’s demands on the caregiver. It appears
that these primary caregivers were most distressed by the
impact the situation was having upon their child and family,
versus on themselves. Fear, worry, and guilt characterize
subjective parental distress. It may be that chronic grief
plays a role in explaining the level of subjective distress
experienced by these parents (Mohr & Regan-Kubinski,
2001).
Externalizing behavioral problems, perceived personal
control, internalizing behavioral problems, tangible support,
and the interaction between perceived personal control and
internalizing behavioral problems independently predicted
subjective distress, accounting for over one third of its
variance. These independent predictors provide some clues
to both stressors and potential targets for future interventions
to decrease subjective distress, with behavioral problems
representing stressors, perceived personal control representing
a resiliency resource, and tangible support a potential target
for intervention. It could be argued that intangible support
might also be a target for intervention, since it was most
likely excluded from the model due to its shared variance
with tangible support. Subjective distress may well be a
caregiving consequence when, for example, a primary
caregiver with a low sense of personal control is caring for a
child with serious behavioral problems and has little tangible
support to provide a reprieve from that care.
In contrast, only 18% of the variance in objective parental
distress was explained by the stepwise regression model.
The parental distress items used in this study may not
adequately capture concerns of parents whose children
exhibit predominantly externalizing behavioral problems.
Internalizing behavioral problems, perceived personal
control, and tangible social support were independent
predictors of objective distress, with the latter two being
potential targets for intervention. As with the model for
subjective distress, it could be argued that intangible
support might also be a target for intervention, since it was
most likely excluded from the model because of its shared
variance with tangible support.
Social support was not found to be a moderator of the
association between child behavior and parental distress.
This may be because of the overall low levels of social support
reported by these caregivers. Similarly, effects of parent support
groups could not be evaluated because of the small number
of participants who had attended support groups.
Perceived personal control did moderate the association
of child internalizing behavioral problems to parent’s subjec-
tive distress. Parents with lower levels of perceived personal
control had high levels of subjective distress, even when the
child’s internalizing behavioral problems were lower. These
parents may benefit from efforts to increase their sense of
personal control, especially when their child has lower levels
46
of internalizing behavioral problems. Parents with higher
levels of perceived personal control were significantly less
distressed than those with lower levels when their child’s
behavioral problems were less severe. However, these
parents experienced more dramatic increases in subjective
distress with the increasing severity of internalizing child
behavioral problems. Thus, interventions to support parents
of children with high levels of internalizing behavioral
problems are indicated regardless of their degree of perceived
personal control. Even those parents with higher perceived
personal control feel overwhelmed by increasingly severe
internalizing behavioral problems.
The Double ABCX Model was partially supported by the
data from this study. The stressors and pile up of stressors
(aA), represented by the internalizing and externalizing
child behavioral problems, resulted in a crisis (x), as
measured by the level of subjective and objective parental
distress (see Figure 1). Tangible and intangible dimensions
of social support, reflecting the resources (bB) available to
deal with the stressor behaviors, did not mediate or moderate
the relationship between behavioral problems and parental
distress. There were only low to moderate reported levels of
social support, however, available to parents and an under-
utilization of support groups. Perceived personal control,
representing the perceptions of stressors and available
resources to deal with them (cC), did moderate the relation-
ship between internalizing behavioral problems and
subjective distress. When internalizing behavioral problems
were lower, parents’ perceived personal control was related
to lower subjective distress and, thereby, more positive
adaptation (xX). With more severe levels of internalizing
problems, even parents with higher levels of perceived
personal control experienced high levels of subjective distress
and problems with adaptation.
Limitations
The cross-sectional design of this study did not account
for differences over time. In addition, with the use of a
convenience sample, participants may have differed from
nonparticipants. Furthermore, all data were collected from a
single informant, the primary caregiver, which might
introduce bias.
Practice Implications
Raising a child with mental health problems has been
found to result in parental distress. Both internalizing and
externalizing child behavioral problems predicted parental
distress in this study. Distress, found to be at moderate to
high levels in this sample, needs to be assessed by mental
health professionals in order to comprehensively address
needs of both the child with mental health problems and his
JCAPN Volume 22, Number 1, February, 2009
or her parent. Periodic monitoring of the level of parental
distress is indicated. Fluctuations may occur as a result of
changes in the child’s mental health status or due to issues
related to aspects of family and environmental changes (i.e.,
pile-up of stressors). Furthermore, assessing the amount
of tangible and intangible support available to a caregiver
would provide the opportunity to discuss options for
increasing supportive resources. Additional support might
help to ameliorate the stressful effects of the child behavioral
problems and prevent a state of continuous disruption and
distress for these parents (McCubbin, Thompson, & McCubbin,
1996).
Parents’ levels of perceived personal control, found to
moderate the association of internalizing behavioral
problems to subjective distress, can serve as a target for
interventions to decrease subjective distress. Since parents
with lower perceived personal control reported higher levels
of subjective distress even when internalizing child
behaviors were less intense, then interventions to increase
perceived personal control would be indicated. However,
developing interventions designed to increase perceived
personal control should be emphasized for all parents,
such as use of problem-solving strategies to increase their
experience of success. Additionally, teaching parents
strategies to manage disruptive child behaviors, both
internalizing and externalizing, may allow the parents to
gain control of difficult situations.
Guiding parents to consider requesting assistance from
an existing support network may also be indicated. Pro-
fessionals can provide support to parents by validating the
acceptability of requesting respite care or other desired
services, and by providing opportunities to openly discuss
concerns in a nonjudgmental way. Referrals to agency
services and community-based support groups are two
ways to increase parents’ actual levels of social support and
should be incorporated into a holistic approach when
serving children with mental health needs and their families.
Efforts to strengthen and/or increase access to support
within the family and community could provide options
that parents can consider in efforts to successfully solve their
problems, and ultimately increase their personal control.
Providing appropriate interventional strategies and support
may allow the parents to transform crises into manageable
situations.
Research Implications
With the information gained from this study, a primary
target to decrease parents’ distress would be to examine
interventions to increase their perceived personal control.
We need to also examine provision of social support based
upon the needs of parents, children, and families. Further
longitudinal studies are needed to better identify how
JCAPN Volume 22, Number 1, February, 2009
parental distress fluctuates in response to changes within the
child such as age, psychosocial development, and symptom
variability. In addition, examination of the influences on
parental distress from changes in the family and the social
context, including school environment and access to formal
and informal support networks, are needed.
Examination of both subjective and objective distress is
warranted because interventions need to be directed to the
dimension of parental distress which is of primary concern
for each particular parent. Modification of the PES to
specifically address a child’s aggressive behaviors, including
physical injuries and damages to personal belongings or the
home, may capture other important factors that increase
caregiver distress. In addition, parents’ loss of sleep because
of negative child behaviors should be investigated in an
expanded instrument. A parent may be able to safely
manage a younger child who is acting out of control, yet the
realities of not being able to control an adult-size adolescent
may increase the level of distress experienced. Future
research needs to identify and describe the associations that
exist between the severity of a child’s aggression toward self
or others and the level of parental distress. Furthermore,
adding items related to chronic grief might help to capture
yet another important aspect related to parents’ distress.
Questions raised in this study can guide both research
and practice. As the Surgeon General’s report (U.S. Department
of Health and Human Services, 2000) indicated, we are in a
crisis related to children’s mental health. The impact of this
crisis is experienced most intensely by both the children
with mental health problems and their parents. It is
imperative that we identify ways to assist these children,
parents, and families in order to improve their well-being.
Acknowledgments. This research was funded in part by
grant no. 930 NR05035 from the National Institute of Nursing
Research, National Institutes of Health, to the Center for
Enhancing Quality of Life in Chronic Illness at Indiana
University School of Nursing; the Indiana Division of
Mental Health and Addiction; and the Association for the
Advancement of Mental Health Research and Education,
Inc. The authors thank the co-investigators, Erika Le Baron,
Brenda Costello-Wells, and Kim Walton for help with
recruitment; the participants; Phyllis Dexter for editorial
comments; and Susan Perkins for statistical consultation.
Author contact: duchovca@ipfw.edu; jgerkens@iupui.edu;
wujw@iupui.edu, with a copy to the Editor: poster@uta.edu
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