Parenting stress factors among Egyptian and American parents of school-age children with significant disabilities

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Parenting stress factors among Egyptian and American parents of school-age children with significant disabilities
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PARENTING STRESS FACTORS AMONG EGYPTIAN AND AMERICAN
PARENTS OF SCHOOL-AGE CHILDREN WITH SIGNIFICANT
DISABILITIES: A CROSS-CULTURAL STUDY












By

NADIA ADIB BAMIEH


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1997

























Copyright 1997

by

Nadia Adib Bamieh















ACKNOWLEDGMENTS
Words are not sufficient to express my gratitude to the many
individuals whose valuable assistance, encouragement, and support

guided me toward the completion of this dissertation. I would like,
first, to thank the members of my doctoral committee: Dr. Ronald
Spitznagel for his constructive suggestions, Dr. Hazel Jones for her
thoughtful insights and instruction in writing, Dr. David Miller for
patiently providing expertise in statistical design and analysis, and
Dr. Cary Reichard for his continuous encouragement and unlimited

support. I would especially like to thank my chair, Dr. Mary Kay
Dykes. Dr. Dykes' belief in my ability to pursue a Ph.D. degree in
special education helped me overcome any difficulty in my doctoral
program and dissertation. Her enthusiasm, expertise, and dedication
have been an inspiration and helped me formulate my ideas into
researchable questions. She, along with the other committee

members, rendered the tedious tasks into pleasurable ones.
I would like to thank the special education faculty for their
support throughout my tenure at the university. Their willingness to
share their expertise and experience was greatly appreciated.
Special thanks are due to the special education doctoral students, in
particular Mary Sarver, whose friendship and support were much
appreciated throughout my doctoral program and dissertation. Mary









Sarver has been the friend on whom I could count whenever I
needed her.
Thanks are due as well to the parents who volunteered to
participate in this doctoral research. Without their willingness to

share with me their perceptions of and their feelings about raising a
school-age child with significant disabilities, this dissertation would
not have been completed.
My family deserves a special appreciation that no words can

possibly convey. I want to thank my mother, whose unconditional
love has always been a source of comfort for me. I send my thanks
to my father, whose spirit continues to motivate me to reach for
higher goals. My brother, Nabil, my sister, Lina, and my niece,
Yasmine, have applauded my efforts and encouraged me to continue
my task. Last and most important, I would like to thank my sister,
Aida, for her unwavering belief in my ability to succeed. She
supported me financially and emotionally and helped me pursue this
endeavor. I hope that Aida will understand the depth of my
appreciation when I say that I thank her for everything.
To each of them, I extend my gratitude when I thank them in
Arabic by saying "Shukran."














TABLE OF CONTENTS

Page

ACKNOW LEDGMENTS ....................................................................................... iii

ABSTRACT ........................................................................................................... ix

CHAPTERS

ONE STATEM ENT OF THE PROBLEM ............................................. 1

Introduction................................................................................. 1
Rationale for the Study............................................................ 6
Purpose of the Study............................................................... 9
Research Questions.................................................................... 9
Procedures for Implementing the Study........................ 10
Scope of the Study..................................................................... 11
Definition of Terms.................................................................... 12
Summary and Overview......................................................... 13

TW O REVIEW OF THE LITERATURE.............................................. 15

Conceptual Framework of Stress........................................ 15
The Effect of Parenting a Child with Disabilities ......... 25
Gender Difference in Parental Stress Level................... 42
Relationship of Support with Stress.................................. 50
Cross-Cultural Studies and Trans-Cultural Research.. 57
Problems in Cross-Cultural Research................................. 73
Implications for Research....................................................... 78

THREE METHODS AND PROCEDURES.................................................. 80

Introduction................................................................................. 80
Questions........................................................................................ 80









Parent Assessment Instruments......................................... 81
Participants................................................................................... 83
Research Instrumentation...................................................... 84
Description of the Procedure................................................ 92
Treatment of the Data.............................................................. 93

FOUR RESULTS........................................................................................ 97

Description of the Sample....................................................... 98
Analyses of the Data................................................................. 1 06
Summary of Findings............................................................... 127

FIVE DISCUSSION OF THE RESULTS AND IMPLICATIONS
FOR FURTHER RESEARCH..................................................... 1 3 1

Summary of the Study............................................................. 1 3 1
Discussion of the Results......................................................... 1 32
Implications of Research Findings...................................... 1 50
Limitations of the Present Study........................................ 153
Recommendations for Future Research............................ 1 57
Summary....................................................................................... 1 5 8

APPENDICES

A GENERAL INFORMATION SURVEY AND
FAMILY SUPPORT SCALE..................................................... 162

B PARENT LETTER AND CONSENT FORM............................... 1 7 3

C PERMISSION AND APPROVAL DOCUMENTS.................... 17 9

REFERENCES........................................................................................................... 1 8 5

BIOGRAPHICAL SKETCH................................................................................... 1 9 8















LIST OF TABLES


Table Page

1 Coefficient Alphas for Family Support Scale................. 91

2 Descriptive Information of the Egyptian Sample ......... 101

3 Reported Monthly Income for the Egyptian Sample.. 102

4 Descriptive Information of the American Sample....... 105

5 Reported Annual Family Income for the American
Sam ple............................................................................................ 10 6

6 Descriptive Information of the Egyptian and
Am erican Children..................................................................... 107

7 Mean Scores of Child and Parent Domains Subscales
and Total Stress by Country.................................................. 108

8 Analyses of Variance of Stress............................................. 110

9 Mean Scores of Child and Parent Domains Subscales
and Total Stress by Gender.................................................... 11 5

1 0 Mean Scores of Child and Parent Subscales and
Total Stress for American Parents by Gender ............... 1 17

1 1 Mean Scores of Child and Parent Subscales and
Total Stress for Egyptian Parents by Gender................. 1 18

1 2 Follow-up Analyses for Competence, Isolation,
Depression, and Spouse Subscales...................................... 11 9










13 Results of Multiple Regression Analyses of Support
and Stress ..................................................................................... 12 1

14 Mean Scores of Support Factors and Total Support
by G ender...................................................................................... 12 3

15 Analyses of Variances for Support by Gender .............. 124

16 Mean Scores of Support for Egyptian Parents ............... 126

17 Mean Scores of Support for American Parents ............. 126














Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

PARENTING STRESS FACTORS AMONG EGYPTIAN AND AMERICAN
PARENTS OF SCHOOL-AGE CHILDREN WITH SIGNIFICANT
DISABILITIES: A CROSS-CULTURAL STUDY

By

Nadia Adib Bamieh

December 1997

Chairperson: Mary Kay Dykes, Chair
Major Department: Special Education
The purpose of this cross-cultural study was to compare
similarities and/or differences in parenting stress factors among
Egyptian and American parents of school-age children with
significant disabilities. The comparison included the relationship

between stress and support in relation to the country of residence
and to the gender of the parent. Gender differences in response to
support were also compared. The Mash and Johnston Model of Stress
was used as the theoretical framework of the study. Participants (80
Egyptian and 70 American parents) were birth parents of children
ranging in age from 6 to 12 years and living with both parents at the
time of the interview. The Parenting Stress Index, Family Support
Scale, and a questionnaire of parents' demographic information were
completed by the parents.









The analyses of data were divided into three major sections.
First, country effect, gender effect, and interaction of gender and
country were examined using a series of tests of analyses of variance
(ANOVA). Second, a multiple regression procedure was employed to
investigate the relationship between stress and support among
mothers and fathers of school-age children with significant
disabilities. Third, the relationship between stress and support for

Egyptian and American parents was examined using multiple
regression analyses.
Research findings yielded similarities and differences among
the Egyptian and American parents. The difference in parental
stress factors was primarily related to parent characteristics, with
American parents indicating higher parenting stress than Egyptian
parents. Results revealed gender differences in total stress, with
fathers reporting higher levels of stress. There was no significant
interaction between country and gender or support and country.
Gender differences did not depend upon country.
Overall, the American parents identified more parenting stress
factors than did the Egyptian parents. In general, gender differences
were not culturally determined. This knowledge will demonstrate
the importance of considering the uniqueness of each parental
couple, of addressing the unique needs of each individual parent,
and, finally, of avoiding generalization that might bias the perception
of service providers.














CHAPTER ONE
STATEMENT OF THE PROBLEM

Introduction
Typically, in most cultures, the birth of a child brings joy and
excitement to the expecting parents and ends a period of
expectations about the unborn baby. The arrival of an infant brings
new challenges and responsibilities for the parents as they adjust to
the new family member. The period of parental adjustment,
however, does not stop at the early years of a child's life; rather, the

development of a child can be a potential source of stress for the
parents as the child advances through the different phases of
physiological and psychological development.
The birth of a child with disabilities brings greater challenges.
Demands for prolonged hospitalization or medical care,
developmental or educational services, and the need for additional

support from family members and friends may cause heightened
stress and strained reactions between parents and parent and child.
Thus, the process of parenting a child with disabilities becomes a
more complex process (Hanson & Hanline, 1990). An additional
increase in stress is experienced by the parents when the child's
disability is significant (Breen & Barkley, 1988). The parents realize
early on that they have to deal with more than one area of
developmental delay. They become aware of the fact that the
disability has caused the child to have some noticeable physical,







2

mental, and/or behavioral characteristics not typically observed in
other children. The child's disability characteristics, the child's age,
the parents' own experience and competence in responding to the
additional demands that arise over the years with the growing child,
and the types and availability of support systems cause parenting to
become a complex interaction of extrafamilial, interparental, and
child factors (Webster-Stratton, 1990). Understanding the stressors
which affect the relationship between a school-age child with
significant disabilities and the parents requires that professionals
identify the sources of the stressors and assess their adverse
consequences if effective interventions are to be undertaken.
According to Byrne and Cunninghan (1985), three assumptions
have guided stress research as it relates to parents of children with
disabilities. The first assumption emphasized that the presence of a
child with disabilities results in high parental stress and concomitant
dysfunction. The second assumption suggested that high levels of
stress are caused by unmet family service needs. The third
assumption assumed that all families have stress and that it is
important to explore the sources of stress and resources families use
to mediate stress. Abidin (1995) conceptualized parental stress in a
theoretical model in which he related parental stress to two major
factors. The first factor was the parent personality and pathology
component. The second was the child characteristics component.
Abidin noted that children may display qualities (i.e., mood,
distractibility/hyperactivity) that contribute to parental stress and
make parenting difficult.









A preponderance of literature, both clinical and empirical, has
linked child disability characteristics to levels of stress experienced
by the parents (Hanson & Hanline, 1990). For decades, researchers
examined the difficulties experienced by mothers and studied their
perceptions and responses to parenting a young child with
disabilities. Fewer studies, however, investigated fathers'
perceptions and responses and the impact they have on father-child
interaction. Although a new style of fatherhood has emerged since
the 1970s in which fathers have become major participants in the
details of day-to-day child care (Rotundo, 1985), parenting stress
research is still focusing mainly on mothers as care providers of
young children. In recent years, however, public policies such as PL

99-457 recognize the importance of addressing the needs and/or
strengths of the family as a whole unit. The report accompanying PL
99-457 stated that, when desired, instruction for parents may be
provided and did not limit this support to one parent over the other
(Bailey & Simeonsson, 1988).
In 1992, Hanson reported that the stress of parenting of a child
with disabilities varies by cultural groups. Different cultures
attribute different meanings to the presence of a disability within
the family. Hanson noted that reactions to disability may range from
views related to the role of fate to those placing the responsibility on
either parent of the child with disability or his/her family. A limited
number of studies have investigated the sources of stress in relation
to culture among parents who belong to ethnic and racial groups
other than the Anglo-American population. The researchers who
studied sources of parental stress factors of parents of children with









disabilities among other populations limited their efforts to primary
American minority populations, African-Americans and Hispanics
(Bendell, Stone, Field, & Goldstein, 1989; Hanline & Daley, 1992).

Given the growing diverse cultural composition of the United
States, the focus of research can no longer be restricted to studies
that address only the needs of the Anglo-American and/or African-
American and Hispanic populations. As society becomes more
heterogeneous, the need for cross-cultural research gains importance
and relevance for those working with parents who belong to other
ethnic groups, such as Arab-Americans. The current number of
Arab-Americans living in the United States is 3 million, with the
largest population located in the metropolitan Detroit area (Hassoun,
1995). According to the 1990 United States census data concerning
social and economic characteristics, there were a total of 870,738
citizens of Arab ancestry in the United States at that time (Bureau of
the Census, 1993). It was reported that a total of 355,150 persons in
the United States 5 years and older speak Arabic at home (Bureau of
the Census, 1992). The census information provided does not specify
the number of Arab-Americans who are considered to be bilingual or
monolingual by the time they start school. Arab immigration to the
United States is more than 100 years old. It began in 1875 and is
expected to increase in the future due to the political instability in
the Middle East.
By the year 2000, it is estimated that 38% of all American
children under 18 will be nonwhite and of non-Anglo heritage
(Research and Policy Committee of the Committee for Economic
Development as cited in Hanson, 1992). It is projected that "the









proportion of children from nonwhite, non-Anglo groups will rise
from 28% to 41%, and the total number of children in these groups
will have increased by 53%" (Hanson, 1992, p. 7) in the 45-year
period between 1985 and 2030. These figures document the need
for a wider interest in cross-cultural comparative studies that
investigate the impact and variances of native culture on the parents
of school-age children with significant disabilities. In conducting
such research, it becomes possible to understand the cultural beliefs
and practices that shape the parents' stress resulting from rearing
school-age children with significant disabilities and to study the
nature of support systems (formal and informal) in the different
cultures that help parents to respond to the additional
responsibilities of having a school-age child with significant
disabilities.
Typically, researchers have adopted one of two approaches to
study variances between cultures, the cross-cultural approach or the
trans-cultural approach. The cross-cultural approach compares one
or more specific areas across two or more different cultures. The
trans-cultural approach examines concepts that are applicable across
cultures. For the purpose of this study, a cross-cultural approach
was used to investigate parenting stress in order to study and
compare perception of stress in two dissimilar cultures. To date,
there have been several trans-cultural studies conducted to
investigate the concept of parenting stress within various cultures
(Cameron & Orr, 1989; Noh, Dumas, Wolf, & Fisman, 1989; Pearson &
Chan, 1993).









The growth in trans-cultural research studies does not,
however, replace the need for cross-cultural investigations.
Although both types of research are important to professionals in
education, cross-cultural studies may be a higher priority since they
help professionals develop cross-cultural competence for today's
diverse school population. To date, no attempt has been made to
compare parenting stress factors of American parents of school-age
children with significant disabilities with those of parents of school-
age children with significant disabilities living in an Arab culture
outside of the United States.
According to Rugh (1984), the family is the absolute center of
life in Egypt. Relationships within the Egyptian family are
characterized by age differences, different expectations of the sexes,
and different expectations of specific roles. Each member of the
family has a clearly defined role and a set of mutual obligations to
reinforce the relationships within the family. Rugh (1984) described
the Egyptian individual as someone who manipulates kinship by
extending the warmth of his or her personal network to involve
others, thereby coopting their support whenever it is needed. The
comparison of Egyptian and American parents of school-age children
with significant disabilities makes it possible to understand the

extent of and depth of these beliefs and practices concerning
parenting stress related to raising a school-age child with significant
disabilities.

Rationale for the Study
In the family disability literature, children with disabilities
were found to heighten parental stress (Crnic, Friedrich, & Greenberg,









1983), and the presence of a child with disabilities was shown to
have an impact upon parental functioning (Erickson & Upshur, 1989;
Turnbull & Turnbull, 1990). The majority of studies, however,
focused on mothers and children; only a few studies included fathers.
For a long time, mothers were identified as the only caregivers as
well as the dominant socializing agent in most two-parent families
(Barnett & Baruch, 1987). Given the known differences in
childrearing experiences of mothers versus fathers (Mash &
Johnston, 1990), an investigation of the possible differential
determinants and outcomes of parenting stress in mothers versus
fathers is needed as a guide to understanding the determinants of
stress in parenting school-age children with significant disabilities
within two-birth parent families.
Because parents are the product of their own cultures,
parenting stress is likely to be different from one cultural group to
the other. Over the ages, different cultures have attributed different
meanings to disability and its causation (Hanson, 1992). In some
cultures, the presence of a child with disabilities was blamed on one
of the parents, in most cases the mother; in other cultures, the
presence of such a child was seen as a punishment for sins resulting
from some action undertaken by the mother or the father while the
mother was pregnant (Hanson, Lynch, & Wayman, 1990). Regardless
of the parent being held responsible for the disability, the views
regarding the causative factors are likely to cause both parents to
endure parenting stress. While much of the research on parenting
stress has been conducted with Anglo-American mothers, more
recently, research has been directed at identifying sources of









parenting stress factors among other minority populations (African-
Americans and/or Hispanics).
In order to begin to gain insight into understanding parenting
stress and identifying sources of parental stress in different cultures,
more cross-cultural studies are needed between American parents

and those in other cultural groups. The undertaking of a cross-
cultural comparative study between parents of school-age children
with significant disabilities of a single country, Egypt, and a similar
group of American parents will add to the limited cross-cultural

literature. A comparative investigation of differences between
mothers and fathers in Egyptian and American cultures will increase
the understanding of gender perception and responses to parenting a
school-age child with significant disabilities within a two-birth

parent family.
The results of the cross-cultural comparative study of Egyptian
and American parents of school-age children with significant
disabilities can assist service providers in both cultures to
understand the cultural patterns that influence the behavior of their
clients. Furthermore, professionals working with multicultural or
diverse populations in the United States may use the information
when working with Arab-American parents of school-age children
with significant disabilities. It is unclear, however, to what extent
Egyptian and American parents of school-age children with
significant disabilities are similar and/or dissimilar with respect to
parenting stress factors. It is also unclear what, if any, similarities
and/or dissimilarities exist between the two cultures regarding
gender responses to parenting school-age children with significant









disabilities. It is not known what, if any, similarities and/or
dissimilarities exist regarding the relationship between support and
stress in the two cultures. It is not known if there are any
similarities and/or differences in gender response to support
systems available to parents of school-age children with significant
disabilities between the two cultures.

Purpose of the Study
The purpose of this study was threefold. The first was to
investigate similarities and/or differences in parenting stress factors
of Egyptian and American parents of school-age children with
significant disabilities. The second purpose was to investigate gender
differences regarding parental stress and support in each culture and
across the two cultures. The third purpose was to study the
relationship between support and stress for parents of school-age
children with significant disabilities in each culture and across the
American and Egyptian cultures. Factors that affect parents in the
two cultures were identified by the investigator. The effect of these
factors on parental stress was explored.

Research Questions
This study answered the following questions:
1. What are the similarities and/or differences in parenting
stress factors experienced by Egyptian and American parents of
school-age children with significant disabilities?
2. Are there gender differences in parental stress levels among
parents of school-age children with significant disabilities?







10

3. Are there gender differences in parental stress levels among
Egyptian versus American parents of school-age children with
significant disabilities?
4. Is there a relationship between support and stress among
parents of school-age children with significant disabilities?
5. Does the relationship between support and stress differ for
Egyptian and American parents of school-age children with
significant disabilities?
6. Are there gender differences in response to support among
parents of school-age children with significant disabilities across the

Egyptian and American cultures?
Procedures for Implementing the Study
The Parenting Stress Index (Abidin, 1995) and the Family
Support Scale (Dunst, Trivette, & Jenkins, 1988) were translated into
Arabic. A panel of bilingual (Arabic and English) professionals with
expertise in the areas of language and literature, clinical psychology,
educational psychology, psychiatry, and community medicine revised
the proposed Arabic translation of the two instruments and agreed
on the final product. A translator who was not familiar with the
content area back-translated the scales into English. Abidin (1995),
the developer of the Parenting Stress Index, reviewed the back-
translation for accuracy. Prior to the process of translation, written
approval was obtained from the respective publisher and/or author.
These procedures followed the acceptable rules of back-translation
for cross-cultural research established by Brislin (1970) and Hui and
Triandis (1985).









Potential American participants were solicited through county
school boards and parents' organizations in North Central Florida.
Potential Egyptian participants were selected from schools and
special educational services programs in the city of Cairo, Egypt. A
total of 70 American and 55 Egyptian couples were contacted by mail

to request their participation, to explain the purpose of the research
study, and to inform them about the measures taken to protect their
identity. The letter also indicated that the investigator would be
contacting the parents by telephone to set up the time and location
for a personal interview with the parents. During the on-site
personal interview with the investigator, each parent responded
separately and independently of the other parent to a General
Information Survey and two questionnaires: the Parenting Stress
Index (PSI) (Abidin, 1995) and the Family Support Scale (FSS)
(Dunst, Trivette, & Jenkins, 1988). Finally, the data collected by
the investigator were analyzed with regard to the research
questions.

Scope of the Study
The delimitations and limitations of this research are described
in the following sections.
Delimitations
The scope of this study was delimited in three ways. First, the
subjects in this study were parents of school-age children with
significant disabilities, ages 6 through 12 years, at the beginning of
the academic year. Second, the information gathered in the study
was not selected to generalize from the sample to a general









population. Third, the study was delimited by geographical
restrictions to North Central Florida and the city of Cairo, Egypt.
Limitations
The scope of this study was limited in the following ways:
1. Data were collected from parents of children, 6 to 12 years
of age only. Results, therefore, were not generalizable to parents of
younger or older children with significant disabilities.
2. The size of the Egyptian sample (80 participants) was not
sufficient to establish a normative sample for standardization of the
Arabic version of the Parenting Stress Index (Abidin, 1995) or the
Family Support Scale (Dunst, Trivette, & Jenkins, 1988).
Definitions of Terms
The following definitions were used throughout this study:
Parenting stress as defined by Roggman, Moe, Hart, and
Forthun (1994) is "the parents' subjective feelings of irritation,
frustration, inadequacy, annoyance and distress in response to the
demands of daily interactions with their children" (p. 465).
Culture is defined as the social structures, dominant values, and
ideologies that characterize a society.
A significant disability is a physical, mental, and/or behavioral
variance to the extent that the child is characterized by obvious
differences that are observable to the general public.
Cross-cultural as defined in the Merriam Webster's Collegiate
Dictionary (1993) refers to "dealing with or offering comparison
between two or more different cultures or cultural areas" (p. 277).







13
Trans-cultural as defined in the Merriam Webster's Collegiate
Dictionary (1993) refers to "involving, encompassing, or extending
across two or more cultures" (p. 1253).

School-age children refer to children who are between 6 and
12 years of age at the beginning of the academic year.

Special educational services programs refer to educational
programs coordinated by private agencies.

Support refers to the assistance and help provided informally
by one of the parents to the other partner or by extended family
members, friends, neighbors, work colleagues, and community
members to either one or both birth parents, and formally by
professionals interacting with either and/or both birth parents and

the child.

Resources are physical, psychological, and social systems or
competencies available to parents which may reduce stress related to
parenting.

Summary and Overview
The focus of this investigation was the examination of parental
stress factors of American and Egyptian parents of school-age
children with significant disabilities, gender differences associated to
levels of parental stress in the American and Egyptian cultures,
gender differences to support, and the relationship of support with
stress in the two cultures. Chapter Two provides a review and
analysis of relevant professional literature regarding the
conceptualization of stress, parenting a child with disabilities, the
nature of parental stress, and a discussion of cross-cultural and
trans-cultural studies. Chapter Three includes a description of the







14

methods and procedures that were used in this study. Results of the
study are presented in Chapter Four. Discussion of the results and

their implications compose the fifth and final chapter of this
investigation.














CHAPTER TWO
REVIEW OF THE LITERATURE
Chapter Two includes a summary and analysis of the
professional literature concerning the nature and degree of stress

experienced by parents of children with disabilities. The chapter is
divided into several sections. The description of a theoretical model
of stress is discussed. The model is followed by a presentation of the
effects of parenting a child with disabilities. The subsequent sections
provide a summary and analysis of relevant studies about gender

differences among the parents of children with disabilities, an
examination of the relationship of support and stress, a discussion of
problems in cross-cultural research, and a discussion of relevant
cross-cultural studies and trans-cultural studies. The chapter
concludes with a summary of the research findings, including the
implications of previous research for this study.

Conceptual Framework of Stress
Historical Roots of the Concept of Stress
The study of stress in general and its consequences for
individuals has long been a subject of interest for researchers
(Gallagher, Beckman, & Cross, 1983). Individuals struggle with the
stresses of everyday life daily; however, stress does not become
problematic until individuals are unable to adapt to the demands
encountered in their lives (Burke, 1978).









A variety of related assumptions and/or theories constituted
the base for the development of conceptual frameworks of stress.
Rahe (1989) traced the historical roots of stress concepts to
philosophy and medicine. According to Rahe, Descartes, a French
philosopher, considered the articulation of stress as a dissociation

between mind and body, while Spinoza, a Dutch philosopher,
regarded the concept of stress as the integration of a person's
thoughts and emotions with his/her bodily functions and health.
Smith (1987) traced the original meaning of stress to physical
mechanics, and not biology, and confirmed that Selye, a leading
figure in conceptualization of stress, borrowed the term "stress" from
engineers. In the engineering model, according to Smith, stress is
defined as a force on a resisting body that may or may not operate
within normative limits. Selye (1956) theorized that the body uses

an adaptation syndrome to mobilize its resources in an attempt to
protect itself from stress. Rabkin and Streuning (1976) referred to
stress as the body's response to a crisis-provoking event or situation
for which one has little or no preparation.
In more recent years, researchers theorized models of stress
from developmental, clinical, and social psychology (e.g., Baucom,
Epstein, Sayers, & Sher, 1989; Goodnow, 1988; Weiner, 1980). These
models recognized the relative contribution of an individual's
characteristics, his or her environment, and the crisis-provoking
events to the manifestation of stress. In the following section, recent
theoretical models of the nature of stress in humans are described.









Description of Some Recent Theoretical Models
Folkman, Schaefer, and Lazarus (1979) developed a cognitive
theory of stress and coping. The authors maintained that no single
factor can be identified as a cause of stress independent of the
relationship between the individual and the event. The availability
and use of resources and coping strategies affect an individual's
appraisal of the event as stressful.
Lazarus and Folkman (1984) argued that the stress an
individual experiences is not affected by the number of demands
placed upon that individual. The researchers maintained that the
availability of adequate personal resources to meet situational
demands is the decisive factor that help the individual to adapt
successfully, even if environmental demands are considerable.
Lazarus and Folkman criticized unidimensional models of stress
assessment and conceptualized individuals as having five categories
of coping resources that assist some individuals to withstand high
levels of stress. The five categories are social networks, problem-
solving skills, general and specific beliefs, utilitarian resources, and
health/energy/morale.
Cohen, Kessler, and Gordon (1995) summarized stress-related
literature when they described three approaches to the development
of general concepts related to stress. These approaches include the
environmental approach, the psychological approach, and the
biological approach. The environmental approach focused on
assessment of environmental events or experiences associated with
substantial adaptive demands. The psychological approach was
concerned with the assessment of individuals' subjective evaluation









of their coping abilities with the demands of specific events or
experiences. The biological approach focused on assessment of
activation of specific physiological systems shown to be modulated
by both psychologically and physically demanding conditions.
Seeing a strong commonality among the three approaches,
Cohen, Kessler, and Gordon (1995) developed a theoretical model of
the stress process by integrating the environmental, psychological,
and biological approaches to stress measurement. The developers
identified their model as being heuristic. When facing environmental
demands, individuals usually evaluate the demands and the
availability of adaptive capacities to cope with them. If the
individuals find the environmental demands as being threatening,
and at the same time recognize their coping resources as inadequate,
they perceive themselves as being under stress. If appraisal of
stress results in negative emotional states, these emotional states
may trigger behavioral or physiological responses that place the
individual at risk for psychiatric and physical illness.
The integrated model proposed by Cohen et al. (1995) linked
environmental demands to physiological or behavioral responses in a
unidirectional path. Two possibilities of the role of feedback were
identified in the integrated model. One possibility referred to the
fact that emotional states may alter appraisals and result in
negatively biased views of either the threat posed by stressors or the
adequacy of the individual's own resources. The second possibility
referred to the fact that physiological arousal may alter appraisals
and emotional responses. The authors noted, as well, the possibility
that environmental demands can put individuals at risk even when







19
their appraisal of events does not necessarily result in perceptions of

stress and negative emotional responses.
According to the theoretical model developed by Cohen,
Kessler, and Gordon (1995), expression of stress is an outcome of the
individual's environmental experiences, of the subjective evaluations

of the stressfulness of a situation, and of the behavioral responses to
stressors. Together these elements play an important role in
determining both the form and the intensity of the response to an

event which is perceived stressful.
Recognizing stress as a potential disrupter of parent-child
interactions, Webster-Stratton (1990) based her conceptual model of
parenting stress on the concept of "pile up" factors or stressors that
affect parenting attitudes. Webster-Stratton identified two types of
factors in her model: the protective factors that mediate stress
response and the vulnerable factors that seriously disrupt the
parents' functioning. The protective factors included community
support, supportive family system, parental psychological well being,
and nurturing childhood. The vulnerable factors included
community isolation, nonsupportive family system, substance abuse,
and depressed childhood. Both protective and vulnerable factors are
interrelated with extrafamilial stressors, interpersonal stressors, and
child stressors. The extrafamilial stressors, according to Webster-
Stratton (1990), were factors such as low socioeconomic status,
unemployment, stressful life events, and/or daily demands. The
interpersonal factors referred to marital distress and divorce/single
parent. The child factors included difficult temperament and conduct
problems. Webster-Stratton (1990) developed the model of









parenting stress in relation to families with conduct-problem
children. She postulated that the extrafamilial, interparental, and
child stressors confront parents with situations that require coping
skills. Webster-Stratton recognized the importance of the complex
interactions of these variables, yet she placed primary emphasis on
the parents' psychological adjustment as a primary determinant of
the way stress influences parent-child interactions.
In concert with Webster-Stratton's (1990) concept of stress,
Mash and Johnston (1990) conceptualized parenting stress as a
complex construct involving behavioral, cognitive, and affective
components. Mash and Johnston stated that their conceptualization
of parenting stress was based on more recent research which aims to
identify determinants of stressful parent-child interactions. The new
trend includes consideration of three classes of events: characteristics
of the environment, characteristics of the child, and characteristics of
the parent. Although Mash and Johnston (1990) constructed the
theoretical model of stress (see Figure 1) to identify determinants of
parenting stress among families of hyperactive children and families
of physically abused children, the model may be used to discern
determinant sources of stress and to show how those sources exert
influence in parent-child relationships in families with a school-age
child with significant disabilities.
The Mash and Johnston Model of Stress
Mash and Johnston (1990) developed a theoretical model of
stress in parent-child interaction which was constructed based on
recent theories from developmental, clinical, and social psychology.











































Figure 1. A model of stress in parent-child interactions.
(Mash & Johnston, 1990)









The Mash and Johnston model is characterized by its specific focus on
understanding contributing factors to parent-child stress.
The first level of the model includes child and environmental
characteristics as influences, external to the parent, that determine
stress in the parent-child relationships. Temperament, cognitive or
physical attributes, and the presence of behavior problems constitute
some of the primary child characteristics that were considered to
have an impact on parental stress. The immediate interactional
context, daily demands, and major adverse life events were included
among the environmental characteristics that are likely to have
direct and indirect influences on the parent-child interactions.

The second level of the model includes parent characteristics,
limiting them to maternal characteristics. Cognition, affective state,
personality attribute, behavioral repertoire, and health constitute the
maternal characteristics. These characteristics were selected by the
developers because they are determinants of stress in parent-child
interactions and mediators of child and environmental effects.
Maternal cognition encompasses perceptions reflecting maternal
attributions for child problems, maternal expectations for child
behavior and outcomes, and mothers' expectations regarding their
own parenting behavior and ability to influence the behavior of their

child.
For the purpose of this study, the model of stress in parent-
child interactions developed by Mash and Johnston (1990) has been
used to investigate parental stress factors among Egyptian and
American parents of school-age children with significant disabilities.
(see Figure 1). The Mash and Johnston model of stress acknowledges









the reciprocal links between parent-child stress and parent, child,
and situational characteristics. The model is a complex construct that
involves behavioral, cognitive, and affective components. Such
components are useful in determining sources of stress among
parents of school-age children with significant disabilities. Since the
child's external variance has been shown to be an important factor in
determining how parents organize both their cognitions and their
behaviors (McCabe, 1984; Zembrowitz-McArthur & Kendall-Tackett
as cited in Mash & Johnston, 1990), the elements of cognition and
behavior included in the Mash and Johnston model (1990) justify the
use of this model to serve the purpose of this study which is the
identification of parental stress factors among parents of school-age
children with significant disabilities. Significant disabilities
throughout this investigation are defined as mental, physical, and/or
behavioral variance of obvious nature that is observable by the
general public. Although the Mash and Johnston Model of Stress
(1990) addressed maternal characteristics only in the parent
characteristics at the second level, its use with fathers of school-age
children with significant disabilities delineated the contributing
factors to father-child stress. Elements in maternal and paternal
characteristics were identified.
According to Mash and Johnston (1990), the parent perceptions
of child characteristics contribute directly to the parent-child
interaction. The attribution of child characteristics is important in
determining the degree of interactive stress experienced by parents.
Situational events interact with parenting efficacy to determine
interactive stress.









This study used the Mash and Johnston model (1990) to
investigate parental stress factors among Egyptian and American
parents of school-age children with significant disabilities. The first
level of this model assessed how child and environmental
characteristics contribute to the existence of stress in parenting
school-age children with significant disabilities. The second level of
the model was used to determine the parent characteristics that are
determinants of stress and/or mediators of child and environmental
effects. This model was used specifically because it incorporates the
reciprocal links from parent-child stress to parent, child, and
environmental characteristics.
In summary, the models of stress have delineated the relative
contribution of an individual's characteristics, his or her
environment, and the crisis-provoking event or events to the
manifestation of stress. No single factor was identified as a cause of
stress independent of the relationship between the individual and
the event. Individuals adapt to stress according to the availability of
adequate personal resources to meet situational demands.
Parenting stress was theorized as a complex construct that
involves behavioral, cognitive, and affective components.
Understanding these components helps to determine the contributing
factors to parenting stress. Influences such as child and
environmental characteristics, external to the parent, determine
stress in parent-child relationships. Parental characteristics were
considered as either determinants of stress or mediators of external
influences (e.g., child characteristics and/or environmental
characteristics).







25
Literature relevant to the study of parenting stress of children
with disabilities is reviewed in the following sections of the chapter.
Selection of literature for review was based on stress concepts and

subjects investigated.

The Effect of Parenting a Child with Disabilities
In the review of the literature discussed in the following
sections, numerous studies were identified in which researchers
measured parenting stress either by comparing parents of children
with disabilities to a control group of parents of children without

disabilities or by investigating differences in the degree of stress
among parents of children with various handicapping conditions.
Regardless of the approach used, parent-child interactions, child
characteristics, child's age, parent gender, and support have been
identified as determinant variables of parental stress in parent-child

dyad.

Parenting Stress Among Parents of Children With and Without
Disabilities
During the last two decades, researchers have become
concerned about families' adaptations to parental stress. Philip and
Duckworth (as cited in Dyson & Fewell, 1986) theorized that the
presence of a child with disabilities in the family is itself a factor
which produces numerous types of problems which lead to a stress
effect. Based upon this concept, Dyson and Fewell (1986) compared
stress and adaptation in families of children with and without
disabilities. The investigators' questions were established to
determine if parents of children with disabilities experienced more
stress than parents of children without disabilities, to identify the









sources of stress for parents of children with disabilities, and to
determine if stress in the parents of children with disabilities was
mediated by an external factor of social support.
The study included 15 families of children with disabilities and
15 families of children without disabilities. The two groups were
matched by the target child's age, sex, and socioeconomic status and
by the type of family structure (one parent or two parents). The
handicapping conditions included mental retardation, physical
disabilities, multiple impairments, blindness, or deafness.
Dyson and Fewell (1986) reported that parents of children with
disabilities experienced significantly more stress than the control
group of parents. Based upon the results of their investigation, the
researchers delineated four sources of stress: the child's
characteristics (e.g. child's behavior, inability to provide for one's
self-care, and inability to communicate with others), physical
incapacitation (e.g. child's limitations), parental pessimism in relation
to the child, and the severity of the child's handicapping condition.
The researchers pointed out that the identified sources of stress were
interrelated. Pessimism correlated with child characteristics (r = .45,
p. < .006) and with physical incapacitation (r = .40, p. < .001). Child
characteristics correlated with physical incapacitation (r = .55, p_<
.001). The researchers reported a moderately high negative
relationship between the amount of social support and the level of
stress. Although this finding suggested social rapport as a moderate
moderator, the statistical difference was not significant.
The psychological well-being of parents of children with
disabilities has always been an issue of concern for researchers.







27
Gowen, Johnson-Martin, Goldman, and Appelbaum (1989) examined
over a period of 16 months depressive feelings of mothers of
children with disabilities and mothers of infants without disabilities.
The researchers studied the relations between maternal depression
and both characteristics of the children and characteristics of the
mother's social support system. In addition, Gowen et al. (1989)
investigated the mother's feelings of parenting competence across
time and child characteristics and measures of social support system.
The study included mothers of 21 infants with disabilities and 20
mothers of infants without disabilities. The handicapping conditions
included Down syndrome, cerebral palsy, developmental delays,
spina bifida, tuberous sclerosis, and severe brain damage due to
birth anoxia. The infants with disabilities entered the study at age
11 months and were reassessed at ages 15, 19, and 27 months. The
infants without disabilities entered the study at age 6 months, with
full reassessments at ages 11, 15, and 27 months and partial
reassessments at age 19 months.
The mean levels of depression for all participants remained
fairly constant across time, with depression scores for some
individuals being not stable across assessments. Elevated levels of
depression at different times were reported by different mothers in
each of the two groups. A slightly higher percentage of the mothers
of infants with disabilities scored at or above the cutoff point for risk
for clinical depression at the 11- and 15-month assessments than did
mothers of infants without disabilities. Overall, the mean levels of
depression of mothers with infants with disabilities were not
significantly different from those of mothers of infants without







28
disabilities even though the target mothers had additional caregiving
demands. The researchers attributed these findings to the target
mothers' skill in mobilizing resources to deal with the stresses
associated with raising an infant with disabilities. The findings of
this study provide empirical evidence in contrast to results obtained
from other studies where mothers of children with disabilities
reported more depressive symptoms or higher levels of malaise than
did mothers of children without disabilities (Breslau & Davis, 1986;
Chetwynd, 1985; Cummings, Bayley, & Rie, 1966; Wilton & Renaut,
1986). Nevertheless, it is important to point out that the previous
studies investigated mothers of children with disabilities who were
older than the target infants of this study.
Salisbury (1987) focused her study on mothers of infants/
toddlers with disabilities. She investigated stressors among parents
of young children with disabilities (N = 31) and parents of young
children without disabilities (N = 33). The children's ages ranged
between 12 and 60 months. The disabling conditions included
speech/language impairment, multiple handicaps, developmental
delays, sensory impairment, and/or orthopedic conditions. The
general level of impairment of the children was moderate. The
researcher hypothesized that levels of parental stress would be
significantly different between groups and that mothers, single
parents, and parents of boys would report significantly more stress
within and between groups.
Salisbury (1987) compared mean stress scores for married
parents in each group. Comparisons were also made by group for
each gender of the child and each relation to the child. The findings









included no significant main effect for group, child's gender, and
relation to child with respect to married data set. The results did not
prove that parents of young children with disabilities were more
stressed than were parents of normally developing infants/toddlers
regardless of the gender of the child or that of the parent. Within
and between group differences, there were no significant
interactions. Married parents did not report significantly different
levels of stress for sons versus daughters. There were no significant
differences in the perceived levels of stress reported by mothers and
fathers. These findings did not support the researcher's hypothesis.
The t-test comparisons between single and married respondents
aggregated across groups and between single and married
respondents in the target group indicated significant differences in
reported/perceived levels of stress. Perceived levels of stress were
higher in families headed by a single parent. Single parents of
infants/toddlers with disabilities demonstrated significantly higher
stress than did married parents in the same group. These findings
supported the researcher's hypothesis concerning the presence of
higher levels of stress among single parents. There were no
significant differences in the two groups of married mothers.
Salisbury's (1987) findings with respect to reported levels of stress
support the conclusions of Gowen et al. (1989) that parents of
children with and without disabilities are equally affected by
caregiving stresses associated with the responsibilities of raising an
infant or toddler.
The findings of Salisbury (1987) provided data at odds with
prior comparative research by Friedrich and Friedrich (1981). The







30
latter compared parents of 34 children with disabilities to a control
sample of parents of children without disabilities. The handicapping
conditions included motor difficulties, mental retardation, and/or
multiple disabilities. The participants satisfied the characteristics of
two parents present in the home at the time the study was
conducted. Friedrich and Friedrich (1981) hypothesized that parents
of children with disabilities would experience more stress and less
marital satisfaction, psychological well-being, social support, and
religiosity than parents of children without disabilities. The results
of the study supported the investigators' hypotheses. Parents of
children with disabilities reported more stress and fewer
psychological assets to help ameliorate the continual impact of

parenting stress.
Minimal research has been conducted to examine parenting
stress among parents of school-age children with disabilities. In
more recent years, however, professionals have indicated the need
for and importance of investigating the parent-child interaction of
older children with disabilities and its contribution to the
development of problems between parent and child. Fine and Holt
(1983) pointed out that home and school environments are so
intertwined that what occurs in one domain may directly impact
upon the other.
Following the more recent trend of focusing attention to the
needs of parents of school-age children with disabilities, Fuller and
Rankin (1994) used the Parenting Stress Index (PSI) to examine the
amount of stress reported by 45 mothers of children in general
education and special education classes. The children with









disabilities, classified as learning disabled (N = 15) or emotionally
impaired (N = 15), attended resource classes in elementary and
junior high schools. The children's ages ranged from 6 to 13 years.
All participating parents responded to items on the PSI and a
demographic questionnaire. The investigators used a series of one-
way analyses of variance to assess differences in parenting stress
between the three groups of parents.
Mothers of children without disabilities scored within the
normal range (15th to 80th percentiles) on all subscales and domains
of the PSI. Mothers of children with a learning disability scored
within the normal range on the Adaptability, Mood, and
Distractibility subscales of the Child Domain. On the Acceptability,
Demandingness, and Reinforcement subscales of the Child Domain,
these same parents scored higher than the normal range (90th to
95th percentiles). With respect to parents' characteristics, these
parents scored within the normal range on all Parent Domain
subscales except for the Attachment subscale (85th percentile).
Parents of children with emotional impairment scored high on all of
the child domain subscales with the exception of Adaptability (70th
percentile). On the Parent Domain subscales, these parents scored
within the normal range except for the Attachment subscale (90th
percentile).
Based on the results reported by the investigators, mothers of
children with disabilities demonstrated higher stress levels than did
mothers of children without disabilities. These results suggest that
parents of school-age children with disabilities in special education
find their children's behavior problems difficult to handle. According









to the PSI manual, the high scores of mothers of children with
emotional impairments on the Acceptability, Mood, Distractibility,
and Reinforcement subscales are indicative of impairment in
maternal attachment to the children and poor parent-child

interaction.
Margalit, Raviv, and Ankonina (1992) investigated coping,
sense of coherence, and family climate by comparing parents of
school-age children with disabilities to parents of school-age children
without disabilities. Seventy-eight parental couples whose children
with disabilities attended special education schools participated in
the study. The control group of itrents consisted of 83 parental
couples whose children attended general education schools. The
handicapping conditions included learning disabilities (N = 40),
mental retardation (N = 26), and emuotional/behavioral disorders (N=
12). The researchers hypothesized that significant differences would
be indicated between the two groups of parents with respect to

personal coherence, avoidant coping, and interrelations and personal

growth.
Parents of school-age children with disabilities reported a
lower sense of coherence and an increased use of avoidant coping
than did parents of school-age children without disabilities. With
respect to family climate, the parents of school-age children reported
having less emphasis on family relations and fewer opportunities for
personal growth. Further analysis of the results showed great
discrepancies between the fathers and mothers of school-age
children with disabilities which were due to the parents' lower levels
of agreement regarding personal coherence, family opportunities for









personal growth, and avoidant coping. Comparisons between the
different groups of parents of school-age children with disabilities
showed that parents of school-age children with disruptive behaviors
seemed to use the most avoidant coping. This investigation suggests
that the increased use of avoidant coping methods demonstrate the
parents' need to employ varied coping measures to deal with the
increased demands made by the presence of a child with disabilities

in the family.
The empirical studies reviewed in this section provide evidence
of conflicting results regarding the levels of stress experienced by
parents of children with disabilities as compared to parents of
children without disabilities. There was no general consensus
supporting the fact that the presence of a child with disabilities
within the family triggers higher levels of parental stress. Some
investigators (e.g., Dyson & Fewell, 1986; Friedrich & Friedrich, 1981;
Fuller & Rankin, 1994) reported that parents of children with
disabilities had elevated parental stress while others reported that
these parents showed a lower sense of coherence and less emphasis
on family relations (e.g., Margalit, Raviv, & Ankonina, 1992). Child's
characteristics, severity of child's handicapping condition, and
parental pessimism in relation to the child were identified as sources
of parenting stress.
Other investigators reported that the parents of children with
disabilities did not experience greater stress (e.g., Salisbury, 1987) or
decreased feeling of parental competence (e.g., Gowen et al., 1989).
The discrepant findings may be related to the difference in the age of
the children with disabilities. In some of the studies, the sample









consisted of parents of younger children while other investigations
included parents of school-age children.
These inconsistencies in the literature increase the need for a
better understanding of parental stress factors to help professionals
develop appropriate interventions when working with parents of
school-age children with significant disabilities. In the following
section, studies that address parental stress associated with specific
handicapping conditions are discussed.
Parental Stress in Relation to Specific Handicapping Conditions
Differences in the amount of reported stress are not limited to
comparative studies between parents of children with disabilities
and parents of children without disabilities. Research reported in the
literature has provided empirical evidence for differences in the
degree of reported parental stress related to parenting children with
various handicapping conditions. However, some disabilities have
been described as easier to cope with in comparison to some forms of
developmental disabilities (Holroyd & McArthur, 1976; Marcovitch,
Goldberg, Lojkasek, & MacGregor, 1987) as they impose less
caregiving demands on the parents.
With the quest to demonstrate otherwise, Cahill and Glidden
(1996) designed a study to investigate whether raising a child with
Down syndrome affects a family and its members differently than
does parenting a child with other developmental disabilities. Besides
Down syndrome, the sample included disabilities such as cerebral
palsy, autism, seizures disorders, language problems, and
developmental delay of unknown origin. To compensate for the
popular belief that children with Down syndrome are easier to raise,







35

Cahill and Glidden (1996) used three methodological strategies. First,
the investigators compared families of children with Down syndrome
to families of children with other disabilities without attempting to
match the two groups. Second, the investigators conducted case-by-
case matching on four variables (child level of functioning, child age,
parental marital status, and family income); the investigators chose
these variables because they considered them to be different
between the diagnostic groups based on preliminary analyses and/or
theories or results of empirical studies on family functioning. Third,
the investigators used regression techniques to predict family
functioning outcomes for the entire sample.
The mean scores for the respondents in all groups indicated
healthy levels of family functioning. The investigators, however,
reported only one significant difference between the Down syndrome
and matched groups and the Down syndrome and unmatched groups.
That difference showed that the mothers who constituted the
unmatched group with other disabilities reported significantly more
family disharmony than did mothers in the Down syndrome group.
No significant differences were found between mothers raising
children with and without Down syndrome in the matched groups.
Multiple regression analyses did not reveal that child diagnosis
added significant predictive value for any of the outcome variables
after the four matching variables of level of functioning, child age,
marital status, and family income were entered into the equation.
Cahill and Glidden (1996) recommended that professionals needed to
re-examine the popular belief that children with Down syndrome
influence the family in a less negative way than do children with









other disabilities. Based on the results of their study, the
investigators implied that long-term adjustment to raising children
with other disabilities is comparable to that of raising children with
Down syndrome, even when the benefits and stresses are manifested
in different ways.
Hoppes and Harris (1990), on the other hand, obtained results
that do not lend support to the study by Cahill and Glidden (1996).
The researchers examined the extent to which the diminished
responsiveness of the child with autism decreases maternal
gratification. Hoppes and Harris (1990) assessed maternal
perception of child attachment and maternal gratification of 17
mothers of children with autism and 21 mothers of children with
Down syndrome. The children's ages ranged from 4 to 10 years. The
autistic children's expressive skills ranged from mute to relatively
well developed functional speech. The children with Down syndrome
had functional speech, with a range of expressive and receptive
skills. Results indicated highly significant differences between the
two groups of mothers. Mothers of children with autism reported
perceived attachment (M = 77.81) and maternal gratification (M=
61.81) quite different than attachment (M = 91.4) and gratification

(M = 67.06) of mothers of children with Down syndrome.
Findings indicated that parents of autistic children
characterized their children as significantly less responsive and
expressive of attachment and emotional closeness than did mothers
of children with Down syndrome. Findings of this investigation
demonstrated that the maternal role may be more stressful for the









mother who is raising a child with autism (Holroyd & McArthur,

1976).
Several researchers have linked stress levels to the degree of
severity or to the type of the child's handicapping condition (Kolin,
Scherzer, New, & Garfield, 1971; McCubbin, 1988; Minde, Hackett,
Killou, & Silver, 1972; Minde, Silver, & Killou, 1971). Anastopoulos,
Guevremont, Shelton, and DuPaul (1992) re-examined the
relationship between attention deficit hyperactivity disorder (ADHD)
and parenting by investigating not only the degree to which parental
stress was related to the child's handicapping condition but also to
various child, parent, and family environment circumstances. The
children's ages ranged from 4 to 12 years. The researchers used the
Parenting Stress Index (PSI) to measure the overall stress within the
parent-child dyad. Anastopoulos et al. (1992) hypothesized that
child characteristics would account for a substantial amount of the
variance in parenting stress.
According to the results reported in the study, child (43%) and
parent (41%) variables were more responsible for the variance in
overall parenting stress than did family-environment variables (e.g.
family demographics, socioeconomic status, psychological stress, and
problems exhibited by other family members). The overall severity
of the child's ADHD, maternal health, and psychopathology were the
significant predictors of stress. The findings of this investigation
demonstrated that parents of children with ADHD use up more time
and energy to cope with psychological problems and/or health
difficulties that little time and energy are left for parenting.







38
Since past investigations of parent stress considered only few
sources of stress, Boyce, Behl, Mortensen, and Akers (1991) gathered
a large variety of demographics and child and family process
variables in order to investigate the effects of child characteristics on
parental stress. The Parenting Stress Index (PSI), the Family Support
Scale (Dunst, Jenkins, & Trivette, 1984), and other measures were
used in this study. The sample included 479 participants. Most of
the participants were living in households where both mother and
father were present. Only 19% reported being single mothers, and

13% reported having no other adult in the home.
Parents of children with disabilities seemed to have increased
levels of stress, most generally child-related. Among the child-
related stress variables, the functioning level of the child (i.e., the
level of independence) had the strongest effect on the mother's
satisfaction in the parent-child interaction. Family cohesion, stressful
life events, followed by resources were also predictors of child-
related stress. The strongest demographic variables were the
mother's age and having other children with disabilities.
Boyce et al. (1991) reported that the predictors of parent-
related stress were family resources, support, cohesion, and stressful
life events. Other predictors included mother ethnicity and the
number of adults living in the home. The child gender appeared as a
predictor of parental stress only when all the variables were
considered together. The same family process variables (family
resources, cohesion, and stressful life events) were predictors of both
child- and parent-related stress.









As few studies had chronicled the relationship of child
characteristics, stress, support systems, and parent-child interactions
in a longitudinal manner, Hanson and Hanline (1990) compared
mothers' responses in a 3-year longitudinal study. The study sample
included 35 mother-child pairs. Down syndrome, hearing
impairment, and neurological impairment were the handicapping
conditions of the children. The investigators initially observed
children with disabilities and their mothers when the children were
infants/toddlers (12 to 30 months). During the second year of the
study, the children's ages ranged from 33 to 42 months and from 44
to 56 months during the third year of the study. Over the course of
the 3-year study, mothers and children were observed and
interviewed three times. The researchers used the Parenting Stress
Index (PSI) along with other instruments to collect information on
maternal stress and adaptation to parenting a child with disabilities.
The investigators' questions were established to determine the
influence of the type of child's disability on maternal stress and
adaptation to parenting and to identify changes over time in
mothers' reported stress and adaptation. At year 1 of the study,
statistically significant differences were found on mothers' ratings of
child demandingness. Children with neurological impairment were
rated as most demanding by their mothers which indicated a
negative rating. Mothers of children with hearing impairment
indicated the most stress on the subscale Relationship to Spouse of
the Parent Domain. On the measure of parental life experiences and
support, mothers of children with Down syndrome reported the
highest scores indicating the availability of support while mothers of









children with neurological impairment reported the lowest support
scores indicating very little support.
At year 2 of the study, only Acceptability, one of the subscales
of the Child Domain, showed differences among groups. Mothers of
children with hearing impairment reported the least stress. No other
significant differences were found among the mothers of children
from the three disability groups.
At year 3 of the study, statistically significant differences were
found in the Child Domain. Mothers of children with neurological
impairment scored much higher than did mothers of the other two
types of disabilities on the total Child Domain and the Demandingness
subscale. On the Acceptability subscale, mothers of children with
neurological impairment and parents of children with Down
syndrome reported higher levels of stress than did mothers of
children with a hearing impairment. The investigators indicated no
significant differences on parent-related stress.
Overall, according to Hanson and Hanline (1990), parents of
children with disabilities reported experiencing stress related to
characteristics of their children. Although few differences were
demonstrated between the participating parents, mothers of children
with neurological impairment reported the most stress. Mothers of
children with Down syndrome reported elevated levels of stress
related to the child's acceptability. This finding supports the belief
that the external appearance of the children places an added stress
on the parents. Hanson and Hanline (1990) reported significant
relationships between maternal stress and parenting experiences.
There were few differences across groups regarding reported









maternal stress and maternal report of satisfaction with parenting
and social support. Few differences were indicated across groups
with respect to mother-child interaction. Most importantly, there
was stability in the responses of mothers across the years and in
parental adaptation to parenting children with disabilities. Parents
of children with Down syndrome reported elevated levels of stress
related to their children's acceptability. Most often, high scores on
this subscale in the Parenting Stress Index occur when the child
possesses physical, intellectual, and emotional characteristics not
matching parental expectations. This finding is of special relevance
to the current investigation because parental stress was found to be
related to the significant disabilities of the children.

The empirical studies reviewed in this section provided
evidence that additional caregiving demands on the parent's time,
energy, and emotions accounted for the heightened stress
experienced by some parents. Parents of children with ADHD and
autism reported greater stress relative to that reported by parents of
children with Down syndrome. However, the external appearance of
the children with Down syndrome was reported to place an added
stress on the parents (Hanson & Hanline, 1990). The severity of the
child's disability, the maternal psychopathology, and the child's
degree of emotional responsiveness and reciprocity to the parent
were identified as predictors of parental stress.
In summary, although parental stress was manifested in
different ways (e.g., parental gratification, parental adaptation), the
overall influence on parents was quite similar. The findings showed







42
that rearing children with disabilities placed parents under an added

stress.
Gender Difference in Parental Stress Level
The majority of studies measuring parental stress have
concentrated on mothers' responses. Researchers have frequently
excluded fathers in their investigations of stress related to parenting
a child with disabilities (Crowley, Keane, & Needham, 1982;
Cummings, 1976; Linder & Chitwood, 1984). Most studies have
targeted the mother as the main respondent since mothers usually
spend a percentage of time each day caring for the child. Little
information is available on the factors which may relate to stress for
fathers of children with disabilities. According to Phares (1992),
fathers have been largely ignored. The recent trend in studying
family functioning is to recognize the role of the father in tandem
with that of the mother when addressing issues related to the well-

being of families of children with disabilities.

Goldberg, Morris, Simmons, Fowler, and Levison (1990)
compared parenting stress among parents of infants with cystic
fibrosis (N =15), parents of infants with congenital heart disease (N=
26), and parents of healthy infants (N = 30). The researchers used
the Parenting Stress Index to measure parenting stress. Significant

differences were found between the three groups of parents with
respect to child characteristics. Parents of healthy infants reported
the lowest amount of stress while parents of infants with congenital
heart disease reported the highest level of stress. Parents of infants
with cystic fibrosis reported the most stress arising from the burden
of extra parental care. With respect to parent-related factors,









parents of ill infants reported more problems with depression and a
lowered sense of competence than parents of healthy infants.
When probed on the gender difference issue, mothers reported
more stress than fathers. The sources of the mothers' increased
stress included depression, role restrictions, personal health, and
marital problems. In the area of stress related to the child, there
were fewer gender differences even though mothers reported more
problems than fathers.
Rosenzweig (1993) examined the gender differences in stress
levels among parents of chronically ill children with a diagnosis of
insulin-dependent diabetes mellitus. Using the Parenting Stress
Index, Rosenzweig hypothesized that gender effects would contribute
significantly to overall stress, particularly with respect to parent's
sense of competence. No significant differences were found between
genders as to the overall levels of stress reported; however, fathers
and mothers reported different patterns of stress. In areas related
to the child, fathers reported significant stress associated with the
acceptability of the child with diabetes. With respect to the child's
distractibility/hyperactivity, the differences in reported stress
between mothers and fathers were well below the levels of clinical
interpretation (20th percentile for mothers and 35th percentile for
fathers). Both fathers and mothers demonstrated an equal sense of
competence as a parent. In areas related to the parent, fathers
scored in the same or higher percentile rank than the mothers except
on the Parental Health subscale.
Meadow-Orlans (1994) investigated perceptions of infants'
mothers and fathers in a comparative study between 20 parents of







44
deaf or hard-of-hearing infants and 20 parents of normally hearing
infants. The researcher used the Parenting Stress Index to measure
parental stress. There were no significant differences between
groups on the measure of parenting stress or that of general life
stress. Meadow-Orlans (1994) reported no gender differences
between fathers and mothers of deaf infants regarding the degree of
parenting stress experienced. The findings, however, indicated
significant relationships between parenting stress and high general
life stress for both groups of mothers, but not for either group of
fathers. With respect to the relationships between parenting stress
and social support, there was a significant relationship for mothers of
deaf infants, a marginally significant one for fathers of deaf infants,
but no significant relationship for either gender of parents of infants
with normal hearing.
In order to determine if significant differences existed, Noh,
Dumas, Wolf, and Fisman (1989) used the Parenting Stress Index
(PSI) to compare the levels of perceived stress on several dimensions
of parenting in mothers and fathers of children with conduct
disorder, autism, Down syndrome, and children without disabilities.
The sample consisted of parents of 159 children, 159 mothers, and
126 fathers. All children lived with at least one birth parent.

No significant differences were found between parents in the
control group and parents in the three diagnostic groups after
adjusting for multiple comparison. Mothers of children with
disabilities, however, appeared to have more difficulties than did
mothers in the control group with respect to depression and sense of
competence in their parenting role. Mothers of children with







45
disabilities indicated that their daily activities were restricted by the
demands of child care, and they felt socially isolated. There were no
differences for fathers across all four groups.
With respect to child-related stress, children with conduct
disorder or autism were reported to be the most stressful. Both
mothers and fathers reported elevated stress related to child
characteristics. Parents of children with conduct disorder reported
significantly higher levels of stress on all child domain subscales
except the reinforcement subscale. Parents of children with autism
reported substantially increased difficulties because they felt that
their children were difficult to deal with in all dimensions except on
the mood subscale and the lack of positive reinforcement. Fathers of
children with autism showed elevated stress on the subscales of
adaptability, acceptability, and demandingness. Mothers and fathers
of children with Down syndrome reported an increased level of
stress on the acceptability subscale. The investigators noted that the
parents of children with Down syndrome tended to see their children
as happier and as a greater source of positive reinforcement than did
the parents of children without disabilities.
According to the investigators, parents of children with
disabilities are at elevated risk for parenting stress in comparison to
parents of children without disabilities regardless of gender. The
type of dysfunctioning condition was related to variances in the
degree of parenting stress much more than to the gender of the
parent.
The review of the literature on gender differences revealed
that the scores of fathers and the scores of mothers, on broad









measures of child-related stress, typically have not shown any
difference across families with children with a broad range of
developmental disabilities. Baker and Heller (1996) investigated the
extent of child externalizing behavior to parents' stress, adjustment,
and childrearing practices. They also examined whether fathers
differed from mothers in their perceptions of and reactions to a child
with externalizing behavior. The study sample consisted of 52
subject families, almost equally divided in gender (52% male). The
families were predominantly Caucasian (83%). Mothers and fathers
were of middle to upper socioeconomic status. The children were
classified as follows: 22 in the control group, 22 diagnosed with
moderate externalizing behaviors, and 8 diagnosed with high
externalizing behaviors. The externalizing behaviors were behaviors
of aggression, hyperactivity, and/or noncompliance. The Parenting
Stress Index was used along with several other instruments.
Mothers and fathers of children with externalizing behavior
problems reported higher child-related stress and impact and a
lower sense of parenting competence than parents in the control
group. The direct assessments of child problems administered to
mothers and fathers revealed no significant gender differences
though fathers saw "less to worry about," and mothers saw more
child problems. On measures of stress and impact, a more significant
gender difference was indicated. Mothers reported more negative
impact on social life, negative feeling about parenting, and daily
hassles. On measures of childrearing practices, fathers were more
authoritarian-autocratic, less indulgent-permissive, and more
indifferent-uninvolved. On the degree of perceptions and practices,









mothers and fathers did not correlate significantly in their
assessment of internalizing problems, sense of competence in
childrearing, or most childrearing practices dimensions. The findings
of this study did not report highly significant gender differences
among parents of children with externalizing behaviors.
In 1988, Webster-Stratton investigated mothers' and fathers'
perceptions of their children's deviant behaviors by comparing the
relation of the child's teacher's perceptions to those of parents and
by examining the relation of parent adjustment measures to
observed mother, father, and child behaviors. The research sample
consisted of 120 mothers, 85 fathers of children with conduct
problems (ranging in age from 3 to 8 years), and 107 teachers. The
conduct behavior problems were noncompliance, aggression, and/or
oppositional behaviors. The sample consisted predominantly of
white participants (83%) and covered all socioeconomic levels. The
investigators recruited the participants from a Nursing Parenting
Clinic affiliated with a major university. The Parenting Stress Index
was used along with several other instruments and home
observations.
There was a significant correlation between father's
perceptions of their child's behaviors and the teacher's ratings but
not with the mother's ratings. With respect to behavioral
observations of parent-child interactions, the mother's reports of
child behavior problems were positively correlated with home
observations. Webster-Stratton (1988) reported differences between
mothers and fathers regarding their perceptions of their child's
misbehaviors, personal adjustment measures, and behavioral









interactions with their children. Mothers estimated their child's
behavior problems as occurring more frequently than did fathers
and perceived the behaviors as a problem for themselves. There
were significant differences between mothers' and fathers' scores on
the Parent and Child Domains of the Parenting Stress Index. Mothers
perceived their child as more difficult temperamentally and
perceived themselves as more incompetent as parents than did
fathers. Fathers seemed to cope with stress and child problems
differently. There were no significant differences between mother
and father behaviors in the way they interacted with their children.
Fathers exhibited somewhat more command when interacting with
their child than did the mothers.
Krauss (1993) investigated similarities and differences
between mothers and fathers of children with disabilities concerning
child-related and parenting stress. The research sample consisted of
married mothers and fathers of 121 children. The handicapping
conditions included Down syndrome, motor impairment, and
developmental delay of uncertain etiology. The researcher used the
Parenting Stress Index and the Parent Support Scale (Dunst, Jenkins,
& Trivette, 1984) along with other instruments.
No significant differences were found to be related to the
child's type of disability between mothers and fathers for parenting
stress, locus of control, and family functioning, or size of support
networks. Parents of girls reported that social support was more
helpful than did parents of boys. Similarities and differences
between mothers and fathers were indicated mainly with respect to
the sources of and the contributors to child-related and parenting









stress. Mothers had greater belief in professional control over the

child's development. The levels of parenting-related stress overall
were similar for both mothers and fathers though differences were
indicated with respect to specific dimensions of parenting stress.
Mothers reported more difficulty than fathers in adjusting to the
personal aspects of parenting and parenthood, specifically in the
areas of parental health, role restrictions, and relations with spouse.
No gender differences between parents were reported in social
isolation, depression, or sense of competence. With respect to
parenting stress, fathers reported more stress associated with the
child's temperament and their relationships to the child (feelings of
attachment to and reinforcement by the child). Mothers and fathers
differed in their perceptions about family cohesiveness and
adaptability. Fathers perceived their families as being less cohesive
and less adaptable.
Overall, mothers of children with disabilities reported more
stress than fathers. Mothers' sources of stress were depression, role
restriction, personal health, and marital problems. In most studies
reviewed in this section, fathers reported significant stress associated
with acceptability of the child with disability than did mothers. In
general, there was no significant gender differences on measures of
stress related to feelings of parenting competence between mothers
and fathers except for mothers of children with conduct disorder.
In summary, the mothers of children with conduct disorder
reported higher child-related stress and low sense of parenting
competence. Mothers perceived their children as more difficult
temperamentally and perceived themselves as more incompetent as







50
parents than did fathers. Moreover, mothers reported more negative
impact on social life than fathers did.
Relationship of Support with Stress
Professionals in the field of special education had initially
focused on the child or the adult with disabilities (Hornby &
Seligman, 1991). Measures were taken to insure the comfort of the
person and supportive structures were provided for that individual.
Later, special education professionals recognized that a disability
could be burdensome for caretakers, and unless support was
provided for them, they would experience stress, anxiety, and
depression. The psychological well-being of the family as a unit
became a paramount concern since adjustment by the different
members of the family promoted healthy relationships which, in
turn, further nourished adaptive responses to the family member
with a disability. The tasks of coping and adapting within the family,
and for parents in particular, is made more difficult when external
supports are either poor or absent (Hornby & Seligman, 1991).
Historically, the concept of support has been used as a
mediating variable to reduce the negative consequences of crisis and
change in the family circumstances for a long time. Mitchell (1973),
for instance, considered support to be the adjustive resources.
Nuckolls, Cassel, and Kaplan (1972) defined it as the psychosocial
assets. Kaplan, Cassel, and Gore (1977) and Rabkin and Streuning
(1976) applied the term "social support" to the concept of support.
Regardless of the defining term being used, individuals need a type
of support to reinforce that they are loved, valued, and most
importantly part of a social network (Gallagher, Beckman, & Cross,









1983). Support to individuals or families may be available
informally (e.g., family, friends, neighbors, extended family
members, etc.) or formally (e.g., professionals such as teachers,
psychologists, therapists, medical staff, counselors, etc.).
Several studies have demonstrated that social support can
mediate stress and help families to cope (e.g., Cobb, 1976; Dean & Lin,
1977). Social support has been found to moderate maternal stress
and to influence parental attitudes and responsiveness (e.g., Crnic,
Greenberg, Ragozin, Robinson, & Basham, 1983; Mash & Johnston,
1983; Tolsdorf, 1976) and to affect the child's development (Cochran
& Brassard, 1979; McCubbin & Huang, 1989).
In the following section, the literature review covers both
formal and informal support provided to parents of children with
disabilities. Typically, social support had been investigated in
relation to the parental stress associated with parenting younger
children with disabilities.
Mahoney, O'Sullivan, and Robinson (1992) studied the family
environments and social support of mothers of birth to 6-year-old
children with disabilities. The study was part of a comprehensive
investigation involving a selected national sample of mothers. The
researchers examined the impact of having a child with disabilities in
relation to the quality of relationships and the general functioning of
the family. They examined the relationship between mothers' need
for early intervention services with family functioning and social
support. The research sample consisted of 503 mothers of children
who were between birth and 6 years of age. The handicapping
conditions included Down syndrome, cerebral palsy, medical









conditions associated with mental retardation, and sensory
impairment.
The investigators indicated that family participation in
recreational and intellectual/cultural activities was positively
associated with the socioeconomic status (SES) of the family. There
was little evidence to demonstrate that children with disabilities had
an adverse effect on family environments. However, the severity of
children's disability and the family's SES contributed significantly to

family problems.
Intervention needs of mothers were not significantly related to
the severity of the child's disability and family SES. Mahoney,
O'Sullivan, and Robinson (1992) reported that mothers' needs for
intervention services were greater when the mothers' needs for
support was high and satisfaction with support was low. Based on
the findings of this study, the investigators stated that "families of
children with disabilities have family environments comparable to
those of families without disabilities" (p. 399).
Kazak (1987) examined family stress and social support
networks by comparing mothers and fathers of children with a
disability or with a chronic illness with those in a matched sample of
parents of children without disabilities concerning the variables of
personal stress, marital satisfaction, and social network size and
density. The research sample consisted of 125 parents of children
with disabilities or with a chronic illness and 127 parents of same
age children without disabilities. The sample included parents of
children with mental retardation, parents of children with
phenylketonuria, and parents of children with spina bifida.









Mothers of children with disabilities appeared to experience
the highest levels of stress. Findings indicated no significant
differences between the groups with regard to marital satisfaction.
There were no group significant differences for fathers' stress and
marital satisfaction. There were no significant differences between
parents of children with disabilities or with chronic illness and
parents of children without disabilities with regard to social network.
However, mothers of children with disabilities appeared to have
higher density networks than did mothers in the control group or
mothers of children with chronic illness. Overall, parents of children
with disabilities and parents of children with chronic illness were not
more isolated than were parents of children without disabilities.
Typically, researchers have not investigated experiences such
as family leisure when they investigated the relationships of social
support to parenting stress. Roggman, Moe, Hart, and Forthun (1994)
examined whether Head Start mothers and fathers would increase
the frequency of leisure and use of support and whether such
changes would relate to differences in parenting stress and in
feelings of mastery or depression after 1 year with Head Start. The
research sample consisted of 72 mothers and 31 fathers who had
been identified as the hardest to serve or most in need of targeted
case management services. These parents were interviewed during
two 3-month periods at the beginning and end of the Head Start
program year. The Parenting Stress Index was used to measure
parental stress.
Increases in certain aspects of family leisure were related to
less parenting stress and/or greater psychological well-being for the









parents at the end of the program year. For both mothers and
fathers, there was a relationship between overall frequency of
leisure activity and parents' reports of more positive parental
functioning. There was a difference between mothers and fathers
with respect to other specific leisure contexts: leisure experiences
involving relatives and leisure time alone for mothers, and leisure
experiences involving children for fathers. Changes in leisure time
experiences were related to the parents' own functioning and to their
partner's parenting stress and psychological well-being. Mothers'
higher mastery and lower depression were related to leisure activity
alone. Mothers' experiences involving relatives were related to
lower parenting stress and more depression. Fathers' leisure
experiences involving children were related to less parental stress.
Increases in informal and formal social support were related to
positive parental functioning for fathers.
Shapiro (1989) investigated the relation of support group
participation and meaning attribution to maternal levels of stress
and depression. Meaning attribution was defined by the investigator
as the parent's ability to try to understand the stressful event of
having a child with disabilities within the family. The research
sample consisted of 56 mothers of children with disabilities. The
children's ages ranged from 1 to 5 years. The researcher reported a
strong association between mothers who participated in support
groups and mothers who received the highest scores in the area of
assignment of meaning. Mothers who participated in support groups
indicated less depression than those who did not (p < .01). These







55
mothers saw themselves as less burdened by their child and tended
to engage in more problem-solving strategies with their child.
Mothers with high scores in meaning attribution were
correlated with decreased depression scores and decreased perceived
stress for daily care for the child. Shapiro (1989) reported that the
sense of meaning was correlated with increased emotion-focused
coping and increased problem-focused coping.
Quittner, Glueckauf, and Jackson (1990) studied chronic
parenting stress by contrasting moderating effects of social support.
The research sample consisted of two groups of mothers: 96 mothers
of children with a hearing impairment, ages 2 to 5 years, and 118
matched mothers of normally hearing children. The researchers
used the Parenting Stress Index to measure parental stress. Mothers
of children with a hearing impairment experienced higher levels of
stress as parents and poorer emotional adjustment than did the
control group of mothers. Chronic parenting stress was related to
lowered perceptions of emotional support and greater symptoms of
depression and anxiety. Furthermore, mothers of children with a
hearing impairment had significantly smaller networks, with
substantially smaller support in the domains of family and friends
than did mothers of normally hearing children. They appeared to
rely more on health care professionals (e.g., speech therapists) to
meet their emotional support needs. There was an absence of group
differences on measures of perceived emotional support. Quittner,
Glueckauf, and Jackson (1990) reported that social support mediated
the relationship between stressors and outcomes.







56
Frey, Greenberg, and Fewell (1989) examined the relationships
of child characteristics, family social network, parent belief systems,
and coping styles to parent outcomes such as parent's response to the

specific child, quality of general family interaction, and parent's
psychological functioning. The sample included 48 mothers and 48

fathers of young children with disabilities. The mothers and fathers'
level of education ranged from some high school to postmaster's
study. The combined income of mothers and fathers ranged from
$7,000 to $120,000. The children's ages ranged from 2 to 8 years.
The handicapping conditions included Down syndrome, cerebral
palsy, multiple sensory handicaps, trisome-19, and William
syndrome. All but one family were intact two-parent families.

Parents of boys with disabilities or those of children with low
communication skills experienced greater parenting stress than did
parents of girls. The child's gender seemed particularly important
for fathers. There was no significant relationship between child
characteristics and family adjustment. The father's level of
psychological distress was more strongly associated with the child's
communication skills than was the mother's.
The important component of social network varied by gender
of the parent. Mothers' family adjustment seemed to be better if
social support was higher but not related to amount of criticism.
Fathers' family adjustment, on the other hand, was better if criticism
was low and not related to amount of support. Parental religious
belief systems were significantly related to parenting stress, family
adjustment, and psychological distress. Mothers who were convinced
about their belief system appeared to have lower level of







57
psychological distress. Coping styles, avoidance, and wishful thinking
were related to greater psychological distress among mothers and
fathers and to poorer family adjustment for fathers. A problem-
focused coping style was associated with less parenting stress and
less psychological distress for mothers and fathers and better family
adjustment for fathers.
The review of the literature showed that social support,
whether formal or informal, mediated the relationship between
stressors and outcomes. Mothers' needs for intervention services
were greater when the mothers' need for support was low. Mothers'
family adjustment seemed to be better if social support was higher.
Moreover, mothers who were convinced about their belief system
appeared to have lower level of psychological distress. For fathers,
on the other hand, increases in informal and formal social support
were related to positive parental functioning.
There was a relationship between overall frequency of leisure
activity and parents' reports of more positive parental functioning.
Increases in frequency of leisure and use of support were related to
differences in parenting stress and feelings of depression.
Cross-Cultural Studies and Trans-Cultural Research
Although professionals have indicated the need for increased
professional awareness of cross-cultural sensitivity, a review of the
literature has revealed a scarcity in cross-cultural studies. The
following section includes two types of investigations: first, cross-
cultural studies of stress related to parenting a child with disabilities
and, second, trans-cultural studies examining the multicultural use of
the Parenting Stress Index.









Cross-Cultural Studies
Few studies have examined stress related to parenting a child
with disabilities across cultures. In the quest for understanding
parental stress factors across racial groups, Bendell, Stone, Field, and
Goldstein (1989) examined children's effects on 66 young African-
American urban mothers of low socioeconomic status. Almost half
(47%) of the participants were living in extended family units. The
researchers used a battery of instruments including the Parenting
Stress Index (PSI). Initially, the PSI had been standardized on a
group of older, higher income, mostly Caucasian mothers. The
investigators believed that their study would serve to provide initial
normative data and standardization of the PSI with a low income,
minority population. Findings revealed the absence of significant
differences with the PSI standardization sample on parent-related
characteristics. The young mothers in the study by Bendell et al.
(1989) did not experience more parenting stress than the older,
middle income mothers of the instrument's standardization sample;
however, there were significant differences on the child-related
characteristics concerning acceptability and reinforcement. The
investigators reported that child sources of parental stress were
higher among the African-American mothers than in the
standardization sample. In addition, life stress scores for the young
African-American low income mothers were lower than for the older,
middle income standardization sample of mothers. In this cross-
cultural investigation, differences were more evident in child
characteristics than in parent-related stress.









Waisbren (1980) addressed a number of issues when she
compared families of children with disabilities and families of
children without disabilities in the United States and Denmark. The
cross-cultural study examined the dimensions of circumstances of
the child's birth, mental health of the family, influence of the child on
the marriage, support networks, and plans for the future. Thirty
parent couples from each country participated in the investigation.
The families were closely matched for socioeconomic status and the
child's sex, age, and birth order. All of the subjects were Caucasian
native-born parents. The children were less than 18 months old.
The children with disabilities were diagnosed with Down syndrome,
blindness, cerebral palsy, or brain damage.
For both groups, the relationship between supports and coping
revealed that fathers with an extensive family support were highly
supportive, engaged in more activities with their children, had more
positive feelings about the child, and were willing to make plans for
the future. Mothers with supportive in-laws had more positive
feelings about their child and consulted fewer doctors.
There were no significant differences regarding the use of
professional support networks between the Danish and American
families of children with disabilities. The Danish sample indicated a
larger and more family-oriented social support than the American
sample. Findings regarding social networks indicated that the
supportive services in Denmark, though more comprehensive than
those of the United States, did not have a significantly greater impact
on the parents' adjustment than those in the United States.









The investigation by Shapiro and Tittle (1990) added to our
understanding of psychological adaptation of non-Anglo-American
parents to the presence of children with disabilities within the
family. The researchers' purpose was to determine how factors such
as psychosocial adjustment of the child with disabilities, externally
perceived maternal stress and burden, maternal communication
patterns, family function, and social support are associated with
maternal adaptation in a group of mothers exhibiting a range of
responses to their child's physical disability. The participants were
identified through a private orthopedic clinic in a Southern California
border town providing diagnostic and limited therapeutic services
for the Mexican community on the other side of the border. The
sample consisted of 38 Hispanic mothers of children with physical
disabilities and 35 teachers who were the primary instructors of
these children. The children's ages ranged from 5 to 12 years. The
children's handicapping conditions included early onset paralytic
polio, spina bifida, and a variety of congenital lower extremity
anomalies. The most significant factors associated with positive
maternal adjustment were the child's overall adjustment and the
presence of strong social support. Self-perceptions of loneliness,
isolation, and sadness were significantly affected by the mothers'
reliance on the emotional support from informal networks. Maternal
adaptation was strongly related to family function factors. Mothers
reported that spending significant time together as a family in
recreational activities and organized activities made them consider
their families as cohesive. The mothers' level of depression and the
beliefs which they formed about the child's abilities and rights were







61
positively related to the child's adjustment and support outside the
family. Social support, in general, was a significant factor in lower
maternal depression and more positive maternal attitudes. Mothers

who were able to communicate freely with family and friends about
their feelings were less depressed but did not show more positive
attitudes and beliefs about persons with a disability in general.
Conversely, mothers with more factual knowledge about their child's
medical condition had more positive attitudes and beliefs about
persons with disabilities in general but did not appear to be less
depressed. The Mexican mothers who interacted with American
medical professionals were exposed to the United States' perspective
of equality for persons with disabilities. These mothers reported
thinking about the opportunities for their children in more optimistic
and positive ways.
Shapiro and Tittle (1990) reported that, according to the
teacher perception of family function, increased maternal depression
was associated with family disruption. Conversely, maternal self-
report and rater evaluation of maternal interviews have associated
general level of family function with maternal negative cognitive
attitudes.

Although the study undertaken by Keefe (1982) is not directly
related to stress resulting from parenting a child with disabilities, it
is considered relevant to this investigation. It explores the diversity
found within an ethnic group and rejects the emphasis on
homogeneity. The researcher examined the distinction between
foreign-born and native-born Mexican Americans and the impact of
this distinction on correlated traits which are significant in the help-









seeking process: socioeconomic status, levels of acculturation,
intensity of religious affiliation, the presence of an extensive social
support system, and familiarity with public agencies.
All people of any culture are not alike or expected to have the
same perspectives, but trends across cultural groups over time are
guideposts to help professionals when providing assistance to
individuals of the group. The researcher reported considerable
intraethnic variation in the help-seeking process due to differences
in socioeconomic and cultural factors between foreign-born and
native-born American Mexicans. She indicated that foreign-born
American Mexicans had a lower average socioeconomic status than
did native-born Mexican Americans. Furthermore, they were less
likely to have established local, informal social support systems and
were less integrated into the Anglo-dominated social system and
network of public agencies. However, both foreign and native born
Mexican Americans differed little in their interpretation of the
causes of mental disorders. Friends and clergymen were seen as the
best providers of emotional support for both groups of Mexican
Americans. Keefe (1982) concluded that among Mexican Americans,
the distinction between foreign-born and native-born was correlated
with traits which are significant in the help-seeking process.
Foreign-born Mexican Americans tended to have a more limited
social network which reduced the amount of support available in
times of emotional stress.
To study parental stress and family functioning, Dyson (1991)
used a cross-cultural sample to examine the impact of the presence
of a child with disabilities on the families of children with







63
disabilities. The research sample consisted of 60 families residing in
a west coast city in Canada and 50 families living in a major
northwestern city in the United States. The majority of families
(87%) were Caucasian with two parents (91%) and of middle
socioeconomic status (84%). The children with disabilities were
under 7 years of age. It is important to note that Dyson's purpose
was not to compare American parents to Canadian ones.
As demonstrated by several studies previously reviewed in
this chapter, the results provided further evidence of the relation of
stress to the demanding care of a child with disabilities. However,
positive family interactions were indicated due mainly to the
families' emphasis on achievement, moral-religious beliefs, and
valued set rules for family life in the home.

As parents' interactions with their children with disabilities are
often compared to those of parents of children without disabilities, it
seems appropriate to review a cross-cultural investigation
addressing that same issue. Best, House, Barnard, and Spicker (1994)
examined gender differences in parent-child interactions in France,
Germany, and Italy. The researchers believed that a cross-cultural
investigation would provide evidence to counter the many
inconsistencies found in previous single-country studies. Both
mothers and fathers were observed in urban park playgrounds in
the three European countries. Public playgrounds were selected as
observational sites because parents and children show gender
differences when they are unaware of being observed in public
places.









Although the behaviors of the children in the three samples
were quite similar, a number of gender and country differences in
parent and child behavior patterns were found. During the
observation sessions of parent-child interaction, French children
showed and shared more with their parents than did German or
Italian children. French and Italian children showed and shared

more with their fathers than mothers, while German children showed
and shared more with their mothers than fathers. French girls and
Italian boys were more affectionate than the other groups of

children.
French and Italian fathers engaged in more play than did the
German fathers. Overall, French and Italian parents and children
demonstrated more interactive behaviors than did the German
parents and children. There were high positive correlations between

parental affection and child affection in Italy and France. Best et al.
(1994) reported that the association between parent and child
behaviors was most obvious in the Italian observation and least
obvious in the German sample. Findings of this investigation
demonstrated how culture modified the way gender differences are
displayed. Even in a sample of three Western culture groups
assumed to be similar, there were gender interactional differences.
Trans-Cultural Research Studies
Most of the studies reviewed in this section used the Parenting
Stress Index (PSI) to investigate parenting stress in their respective
cultures.
Cameron and Orr (1989) examined the stress level in families
of children with delayed mental development in Ontario, Canada.







65
The researchers used the PSI to identify sources of stress and child

characteristics (i.e., level of assistance, level of independence,
behavior problems, and handicapping conditions) in high and
low/moderate stress groups. Eighty-four parents (78 mothers and 6
fathers) whose children were identified by the school placement as
Trainable Mentally Retarded participated in the study. The
children's ages ranged from 5 to 21 years.
The sample parents were first compared to the PSI normative
group. Parents of developmentally delayed children experienced
more stress than the parents in the normative group, with the
greatest stress being related to child characteristics. This finding
supports the discriminant validity of the PSI when used to compare
cross-cultural groups.
Cameron and Orr (1989) divided the 84 families into groups
according to total stress experienced to examine differences between
high and low/moderate stress families. There were significant
differences between the two groups on all subscales, domain, and
total stress scores in the expected direction. Further analysis of
results indicated no significant differences between the high and
low/moderate groups based on the age of the target child, gender of
target child, marital status, socioeconomic status (SES), and financial
difficulties. The researchers attributed the lack of differences in
stress level according to the SES of the group to the availability of
universal health services provided in Ontario. The effect of SES as a
contributor of stress may have been reduced by the availability of
health care.









When considering the four major characteristics of the child
which included level of assistance, level of independence, behavior
problems, and number of handicapping conditions, the characteristics
of behavior problems and number of handicapping conditions were
most strongly related to stress. This finding further confirms that
certain child characteristics contribute to the amount of stress
experienced by parents of children with disabilities. This
investigation demonstrated the effectiveness of the PSI as a
screening and diagnostic instrument across cultures.
In another Canadian study conducted in southwestern Ontario,
Noh, Dumas, Wolf, and Fisman (1989) compared the levels of
perceived stress on several dimensions of parenting in mothers and
fathers of conduct disorder, autistic, Down syndrome, and typically
developing children. This study was discussed earlier in more details
regarding gender differences in parental stress levels. In this
section, the review addresses issues related to the use of the PSI.
Although little difference between mothers and fathers was
noted, fathers of children with disabilities showed a significant
greater risk for increased stress level when compared to fathers of
normally developing children. The researchers attributed this
finding to the cutoff points of the PSI for being "high risk." The PSI
cutoff points, as established, have neglected gender-based norms in
parenting role and associated stresses; therefore, the relative risks of
fathers of children with disabilities may have been artificially
increased. The researchers' observation may not be confirmed until
more work in response by a gender is included. Upon completion of









this work, researchers would have a valid base for determining
scores which are indicative of high risk status for mother and father.
The use of the PSI in translation has not been limited to
Western cultures. Pearson and Chan (1993) conducted a research
study in Guangshou, Southern China, using the Chinese version of the
PSI along with the Chinese version of the Significant Others' Scale.
The Chinese PSI version, according to the researchers, was validated
for a Chinese population in Hong Kong. Numerical values for
reliability and validity of the Chinese instrument were provided by
Pearson and Chan (1993). Minor changes in wording were made to

that version to suit the region's context.
Although the parents of the target children were recruited
from a special school for children with mental disabilities, the Zhi
Ling Special School for Mentally Handicapped Children, the
researchers neglected to report the criteria for the diagnosis of a
learning disability in the Chinese educational system. The reader has
no evidence that the terms "mental retardation and learning
disability" were not being used interchangeably in this study.
Pearson and Chan (1993) examined the relationship between
parenting stress and social support among 83 mothers of school-age
children with learning disabilities and a control group of 60 mothers
with similarly aged children without disabilities. Participating
mothers were matched proportionately for children's grade school
levels: kindergarten, primary, or secondary levels.
Mothers of children with disabilities experienced greater stress
related to parenting and life events than did mothers in the control
group. Scores on both child and parent domains were greater for the









target mothers than those for mothers in the control group. Scores
on four of six of the subscales showed statistically significant
differences between the two groups of mothers except on the
attachment and reinforcement subscales. This finding suggested that
Chinese mothers of children with disabilities perceived their child's
characteristics as stressful for them in their parenting role more than
do mothers of children without disabilities.
Mothers in the target group scored less with respect to social
support provided by the spouse than did mothers of children without
disabilities. They seemed to receive less emotional and instrumental
support. There were statistically significant differences between the
two groups of mothers in sources of support. Mothers in the control
group perceived themselves as receiving more support from
professionals than did mothers of children with disabilities. There
were statistically significant differences in the categories of parents,
children, best friends, and colleagues. In the target group of
mothers, more support was provided by the extended family
members than by work colleagues or friends. The researchers
attributed this difference to cultural beliefs regarding the issue of
stigma where families would be reluctant to acknowledge to
outsiders the presence of a child with disabilities within the family.
Within the extended family support, the in-laws were less
supportive than natal family members because traditionally, in the
Chinese culture, daughters-in-law tend to be blamed for problems
associated with the child's normal development. On the professional
level, mothers in the target group received less support from







69
professionals and government officials because the focus of services
is still limited to the needs of the child with disabilities.
Based on the study's findings, Pearson and Chan (1993)
concluded that interventions with mothers of children with
disabilities in China should shift from an almost total concern with
the child to the child in relation to his environment. The researchers
pointed out that available professional resources in China were
neither sufficient nor fully utilized.
Chen and Tang (1997) investigated the source and nature of
stress and support among 30 Chinese mothers of adult children with
moderate to severe mental retardation in Hong Kong. The children
(10 females and 20 males) ranged in age from 18 to 35 years. The
mothers ranged in age from 40 to 68 years and lived with their
husbands. The majority of the participants came from low
socioeconomic classes and had low levels of education. Slightly more
than half of the sample (about 56.7%) consisted of full-time
housewives; the remainder had either part-time or full-time jobs.
The mothers of this investigation reported future planning for
their children and their own time management as the major sources
of stress, followed by stress coming from their own emotional
problems, health concerns, family relations, and rejection by others.
The child-related stress centered around the children's behavior
problems associated with sexual needs and curiosity, health concerns,
and self-care problems.
Findings of this study showed that the support network of the
Chinese mothers included both formal and informal support.
Mothers reported receiving support mainly from their family









members and from the staff at the day activities training centers
attended by their adult children with disabilities. Relatives, self-help
groups, and other professionals were perceived as relatively less
common sources of support. Like Pearson and Chan (1993), Chen and
Tang (1997) explained that Chinese parents do not generally seek
assistance outside their families because of the cultural stigma
attached to having children with mental retardation in the Chinese
societies that follow the Confucian teachings. These teachings imply
that the presence of child with disabilities within a family is the
punishment of a parent and/or both parents for violation of conduct
(e.g., dishonesty, misconduct, or filial impiety). Moreover, according
to Chen and Tang (1997), the parents are expected to bear the
consequences of their misconduct, and no sympathy or support
should be given to them.
Another study that used a translated version of the PSI was
conducted by Solis (1990). The purpose of the investigation was to
evaluate the psychometric properties of the Spanish version and to
apply it in a cross-cultural comparison. The investigator translated
the PSI into Spanish and then used the committee approach
(described earlier in this investigation) to achieve item agreement.
Along with the developer of the PSI, Solis (1990) reviewed the back
translation to determine whether the translated items maintained
the original intended meaning.
The study sample consisted of 223 Hispanic mothers who had
identified themselves as being of Spanish or Hispanic origin and who
could read and comprehend Spanish. All of the participants had
been living in the United States an average of 16 years. Their







71
children's ages ranged from 1 month to 19 years. The children were
not identified as having a disability.
Findings of cross-cultural comparison of the Hispanic sample
and the Anglo-American sample of the original version of the PSI
indicated that Hispanic mothers demonstrated higher stress in all
areas except in their relationship with their spouse and in the degree
of distractibility/ hyperactivity of their child. Overall, Hispanic
mothers perceived their child and their parenting role as a more
stressful experience than did Anglo-American mothers. Solis (1990)
suggested that cultural differences in child-rearing practices may
have contributed to the higher parenting stress scores among
Hispanic mothers. For instance, in the Hispanic culture, families do
not tend to emphasize independence among their children as it
occurs traditionally in the Anglo-American culture. The researcher
also suggested that availability or absence of support networks may
account for the differences in parenting stress. Hispanic mothers
traditionally have a large extended family network to support them.
Using a sample of French-Canadian mothers, Brigas, LaFreniere,
and Dumas (1996) conducted a study to validate further the French
version of the PSI as a measure of sources of stress. The total sample

consisted of 245 mothers of preschoolers (113 boys and 132 girls)
recruited from metropolitan Montreal. The children who ranged in
age from 33 to 74 months were not identified as having a disability.
The findings showed that mothers who reported more stress
also reported more isolation, more symptoms of depression, and
marital maladjustment. These mothers had more negative attitudes
toward their children's behavioral problems. The reported stress









seemed to be associated with independent assessment of more
negative and controlling parenting practices.
The findings of this study supported the discriminant validity
of the Parent and Child Domains of the French version of the PSI.
The Child Domain was a better predictor of a child's difficulties. Both
domains were related to measurement of similar constructs and
accounted for most of the variance in related constructs. This
supports the discriminant validity of the French version of the PSI.
Through this study, it was determined that the major scales of the
PSI (i.e., Parent and Child Domain) are relatively independent
measures of two important sources of stress.

The literature reviewed in this section provided evidence of
more similarities than differences among parents of different
cultural backgrounds. There were no significant differences in
coping and adapting to parenting stress and/or the use of support
networks. However, there were significant differences in how
culture modified the way gender differences were displayed. Among
non-Anglo-American parents, the most significant parental stress
factors associated with positive maternal adjustment were the child's
overall adjustment and the presence of strong support network. The
literature showed that there were intraethnic variations across same
cultural groups (Keefe, 1982). Individuals of the same culture
differed in the help-seeking process they adopted.
The review of trans-cultural studies in Western and non-
Western cultures provided evidence to show that parents of children
with disabilities experienced more stress related to child
characteristics. However, in non-Western cultures, specifically







73
Chinese cultures, the cultural beliefs seemed to affect the nature of
support systems available due to the social stigma attached to the

presence of a child with disabilities within the family.
The findings of the studies that have used the PSI to
investigate parenting stress supported the discriminant validity of
the instrument when used to compare cross-cultural groups.
Moreover, the review of the literature demonstrated the
effectiveness of the PSI as a screening and diagnostic instrument

across cultures.

Problems in Cross-Cultural Research
In this investigation, it is relevant to consider some of the
difficulties encountered in undertaking cross-cultural research.
Gordon and Kikuchi (1966) cautioned that in this type of research
two major aspects must be included. First, the construct being
measured must be understood to be the same thing and to be valued
similarly by both groups. Second, the construct must be relevant to
the two groups being compared in order to achieve valid cross-
cultural comparisons. Hui and Triandis (1985) stressed that cross-
cultural equivalence "is the prerequisite for comparisons across
cultural and ethnic boundaries" (p. 133).
Hui and Triandis (1985) reviewed cross-cultural measurement
and discussed the different strategies used in cross-cultural research.
The authors suggested that psychological concepts differ in their
levels of abstraction, some being very abstract and general, others
being concrete and specific. They also stated that differences in
concepts may be found in stability over time and space. Some
concepts appear to be meaningful only at a particular location or









time while other concepts may be universal and not restricted to a
certain location or time.
Four types of equivalence were presented by Hui and Triandis
(1985) in their review of cross-cultural measurement. They are
conceptual/functional equivalence, equivalence in construct
operationalization, item equivalence, and scalar equivalence. All four
aspects are considered essential in order to attain informative
quantitative comparisons between two cultures.

Conceptual/functional equivalence is considered to be the first
requirement for cross-cultural comparison. Hui and Triandis (1985)
cited three criteria for conceptual/ functional equivalence: "(1)
whether there is a universal learning situation; (2) whether the goal
can be identified; (3) whether the same antecedent-consequent

relations are demonstrable in all cultures" (p. 134).
Construct operationalization is the second type of construct
equivalence. In order to attain equivalence, the construct must be
operationalized using the same procedures in different cultures. The
third type of equivalence is the item equivalence which is more
specific or concrete. Only if the construct has conceptual/functional
equivalence and equivalence in construct operationalization can it be
measured by the same instrument. Every item needs to have the
same meaning to all respondents in the two cultures of comparison
otherwise it would seem as if two separate tests were administered,
one in each culture.
The last type of equivalence is scalar equivalence which is
considered the most concrete and difficult to achieve. Scalar
equivalence is attained if "a numerical value on the scale refers to







75
the same degree, intensity, or magnitude of the construct regardless
of the population of which the respondent is a member" (Hui &
Triandis, 1985, p. 135). It is difficult to achieve scalar equivalence
even though it is the ideal type of equivalence for concrete cross-
cultural comparison (Hui & Triandis, 1985).
The internal structure of the construct is another element in
cross-cultural equivalence. It is based on the rationale "that if a
construct is the same across cultures, it should have the same
components (or internal structures) and the same relations among
components across cultures" (Hui & Triandis, 1985, p. 141).
Hui and Triandis (1985) discussed several strategies that can
be used to attain equivalence. They are direct comparison and crude
translation, regression methods, coscoring methods, item response
theory approach, response pattern method, and translation
techniques. For the purpose of this investigation, the translation
technique is presented next in more detail since it applies directly to
the strategy used to measure similarities and/or differences between

two different cultural groups, Egyptian and American parents of
school-age children with significant disabilities.
Translation Strategy

Brislin (1970) presented four types of translation strategies for
use in cross-cultural research. They are the back-translation
technique, committee approach, bilingual strategy, and pretest
strategy. Brislin pointed out that the best approach for accurate
translation is the use of a combination of techniques since each
technique has its strengths and weaknesses.









A brief description of the bilingual strategy and the pretest
strategy is presented in this section. A more detailed presentation of
the back-translation and the committee approach follows since a
combination of the two approaches were used to translate the
measuring instruments of this investigation from English into Arabic
and back into English.
The bilingual technique is a strategy in which the instrument is
presented in alternating language order to bilingual individuals and
assessed accordingly (Prince & Mamboour, 1967). Items that
significantly differ are then revised. The second strategy is the
pretest technique which is used for instrument validation. Results of
the newly translated instrument are compared with the results of a
previously used and recognized scale that has been tested in the
same language (Sperber, Devellis, & Boechlecke, 1994).
The committee approach is the translation technique involving
a group of people translating from the original form to the target
language. Committee members check each others' translations, and
the best item translation is chosen. The committee approach in
combination with the back-translation technique was used in this
investigation. This researcher met individually with each member of
the panel of experts to check the revised translations and obtained a
consensus on the best translation of an item from each member. In
the back-translation strategy, the original translation is translated
back into the source language of the instrument by an independent
translator who has not seen the instrument before. Individual
translators revise the two source-language versions. For this
investigation, the back-translation of the Parenting Stress Index









(Abidin, 1995) was reviewed for accuracy by R. Abidin, the
developer of the instrument. All necessary changes were made
based on the feedback from him.
Although Brislin (1970) believed the back-translation
technique to be a powerful tool, he investigated two aspects of this
technique to check on translation quality and functional equivalence.
The researchers used an analysis of variance design to study the
variables of language, content, and difficulty. The research sample

consisted of 94 bilingual students from the University of Guam. The
students, representing 10 languages, translated or back-translated
six essays covering three content areas and two levels of difficulty.
Based on the results of this investigation, Brislin (1970) concluded
that translation quality can be predicted. He also stated that, if
responses to the original and target versions are studied, functionally

equivalent translation can be demonstrated.

Although the back-translation technique has proven to be a
powerful tool, it still may have flaws. Sperber, Devellis, and
Bochlecke (1994) listed three critical problems that may adversely
affect studies using this technique. The problems centered around
some translators' lack of awareness about the rigorous requirements
of cross-cultural translation, the linguistic difficulties of some content
areas, and translators' lack of sufficient knowledge about the specific
content area of the instrument. According to Schrest, Fay, and Zaidi
(1972), other difficulties regarding possible communication problems
in cross-cultural studies may be overcome when the researcher
communicates the purpose of the research to the respondents in a
clear and direct manner and when he or she translates and adapts









the instructions of the task in such a way that respondents
understand and respond in a meaningful way.

Implications for Research
The literature reviewed in this chapter provides an empirical
basis for the proposed study. Researchers have demonstrated the
importance of examining stress factors associated with parenting
children with disabilities. Although not extensive, empirical studies
have provided some evidence showing the need to investigate stress

factors of both mothers and fathers of those children as well as the
need to examine the relationship of existing social support to

parental stress.
Few studies, though, had been conducted to examine stress
factors among parents of school-age children with significant
disabilities. Most studies had investigated stress factors associated
with parenting infants/toddlers and/or children who were less than
7 years old. Furthermore, few researchers examined whether
parenting school-age children with significant disabilities would
place parents at high risk for increased stress. Although the effects

of stress factors on Anglo-American parents of children with
disabilities had been investigated, few quantitative studies had
compared such effects across cultures.
The present study built on the existing research by examining
an area that had been previously neglected, specifically parental
stress factors of parents of school-age children with significant
disabilities across cultures. This investigation of Egyptian and
American parents whose children attend elementary schools in
segregated, self-contained special education, and/or integrated







79
settings provides additional information for this particular age group
in each culture and across the two cultures. As interventionists
become more familiar with general beliefs and practices and the
ways in which those are expressed or not expressed among the
individual parents with whom they work, effective partnerships can

be developed.
Despite the attention given to the importance of the fathers'
roles in rearing children, only a limited number of researchers
addressed fathers' involvement and interactions with school-age
children with significant disabilities. This investigation adds to the
much needed information on fathers' perception of what constitute
sources of stress when caring and providing for their school-age
children with significant disabilities. Interventionists can use the
information to assess fathers' needs and plan an intervention

accordingly.
Overall, the investigation of Egyptian and American parents of
school-age children with significant disabilities adds to the
information available on cross-cultural research concerning sources
of stress in the populations. Thus, the findings will assist
professionals in the helping professions such as counselors,
educators, and health care providers to understand parents and to be
sensitive to gender issues related to stress in parenting a school-age
child with significant disabilities.















CHAPTER THREE
METHODS AND PROCEDURES

Introduction

The purpose of this study was to investigate similarities and/or
differences in parenting stress factors among Egyptian and American
parents of school-age children with significant disabilities, to study
the differences between mothers and fathers within each culture and
across cultures, to examine the relationship of support with stress in
both cultures with respect to parenting stress factors, and finally to
investigate gender differences in response to support that may be
available to the parents. In Chapter Three, the methods and
procedures of the study are presented. The chapter begins with the
questions that were addressed in the study. The second section
provides a description of the methods, which includes description of
the participants and description of the measures. The subsequent

sections include a description of the research design and the
treatment of the data.

Questions
Six questions were tested. They are stated below. No
hypotheses were used to answer these questions.

1. What are the similarities and/or differences in parenting
stress factors experienced by Egyptian and American parents of
school-age children with significant disabilities?

80







81
2. Are there gender differences in parental stress levels among
parents of school-age children with significant disabilities?

3. Are there gender differences in parental stress levels among
Egyptian versus American parents of school-age children with

significant disabilities?
4. Is there a relationship between support and stress among
parents of school-age children with significant disabilities?
5. Does the relationship of support with stress differ for
Egyptian and American parents of school-age children with

significant disabilities?

6. Are there gender differences in response to support among
parents of school-age children with significant disabilities?

Parent Assessment Instruments
In recent years, research has focused on understanding the
factors associated with parenting stress through the study of the
parents' most central environment, their native culture. Researchers
are now focusing on investigating similarities and differences
between parents belonging to different cultures and studying how
mothers and fathers of children with disabilities in these cultures
differ in their perception of and responses to the experience of
parenting a child with disabilities.
The assessment of parenting stress factors can be conducted
using a variety of methods, including case studies, observations,
interviews, and self-report. The choice of methods is largely
dependent on the questions being asked and the theoretical model
upon which the investigator has based the research questions. No







82

single method is considered to be the best for collecting data (deGruy
& Dickinson, 1991).
The first instrument, the Parenting Stress Index (PSI) (Abidin,
1995), a self-report scale, is used to study similarities and/or
differences in parenting stress factors between American and
Egyptian parents. This instrument was selected based on its
successful use with multicultural populations in previous studies.
The PSI was found to be a robust screening and diagnostic tool that is
a valid measure across diverse English-speaking and non-English-
speaking groups (Abidin, 1995).
The second instrument selected for this study was the Family
Support Scale (FSS) (Dunst, Trivette, & Jenkins, 1988) which is a self-
report scale. A number of studies used the FSS to examine the effect
of support on parent health and well-being, parental perceptions of
child functioning, and styles of parent-child interaction (Dunst,
1985). The FSS explains the relationships between support and the
parent's ability to cope and manage various life crises. According to
Dunst, Jenkins, and Trivette (1984), the ease of administering the
FSS, its compactness, and its inclusion of a wide range of sources of
support constitute the strength of the instrument. For the purpose of
this investigation, the FSS was used to determine the relationship
between support and parental stress among Egyptian and American
parents of school-age children with significant disabilities.
The General Information survey (GI survey), the third
instrument used in this investigation, is a self-report questionnaire
used to collect descriptive, quantifiable information about Egyptian
and American parents of school-age children with significant







83
disabilities. The information provided by the respondents describes
the nature of existing conditions. The questionnaire requires
respondents to provide information about their age, occupation,
income, availability of support, and educational level as well as
background information regarding the target child (e.g., age and
gender, type of disability, cause of disability, number of siblings,
target child birth order, type of school attended).

Participants
Participants for this study consisted of 150 mothers and
fathers of school-age children with significant disabilities and whose

children ranged in age between 6 and 12 years. School-age children
with significant disabilities were those children who had a physical,
mental, and/or behavioral variance to the extent that the child was
characterized by obvious differences observable to the general
public. All children (Egyptian and American) lived with both birth

parents at the time of the investigation.

Parents' age, race, and socioeconomic status were not factors in
their selection. The Egyptian participants (N = 80) resided in the city
of Cairo, Egypt. The American participants (N = 70) lived in North
Central Florida. The Egyptian participants were selected from schools
and special educational services programs in the city of Cairo, Egypt.
The American participants were initially identified by the county
school boards and parents' organizations in North Central Florida.
Participants in the two geographical locations received no
remuneration. Participation was voluntary and confidentiality was

assured.









Research Instrumentation
During the on-site personal interview with the researcher, each
parent responded to the General Information survey (GI survey) and
two questionnaires: the Parenting Stress Index (PSI) (Abidin, 1995)
and the Family Support Scale (FSS) (Dunst, Trivette, & Jenkins, 1988).
A copy of the GI survey and the FSS are provided in Appendix A.
The selection of the research instruments was based on two criteria.
First, the two selected instruments had adequate reliability and
validity (Abidin, cited in Abidin, 1995; Bendell, Stone, Field, &
Goldstein, 1989; Dunst, Jenkins, & Trivette, 1984; Dunst, Trivette, &
Jenkins, 1988; Loyd & Abidin, 1985; Quittner, Glueckaul, & Jackson,
1990). Second, instruments selected for this investigation have been
used previously in published studies of parenting stress and support.
An Arabic version of each instrument was used with the
Egyptian parents in the sample. The Arabic versions of the FSS and
the General Information survey are provided in Appendix A. The
PSI and the FSS were translated from English into Arabic by this
investigator. A panel of bilingual (Arabic and English) professionals
with expertise in the areas of language and literature, clinical
psychology, educational psychology, psychiatry, and community
medicine revised the proposed Arabic translation of the two
instruments and agreed on the final product. The instruments were
then back-translated into English by a translator to assure linguistic
equivalence. Abidin, the developer of the PSI, reviewed the back-
translation of the PSI for accuracy. Prior to the process of
translation, written approval was obtained from the respective
publisher and/or author. The translation of the instruments followed









the acceptable rules established by Brislin (1970) and Hui and
Triandis (1985).
The PSI was chosen to investigate parenting stress factors
based on its validity as determined through numerous correlational
studies (Brigas, LaFreniere, & Dumas, 1996; Eyberg, Boggs, &
Rodriguez, 1992; Sexton, Burrell, Thompson, & Sharpton, 1992).
Furthermore, the validity of the PSI was demonstrated in trans-
cultural research involving non-English-speaking populations as well
as in non-Western cultures (Abidin, 1995; Chen & Tang, 1997;
Pearson & Chan, 1993). Permission for the translation and approval
of the back-translation were obtained from the publisher prior to the
implementation of the investigation.
The Family Support Scale (FSS) (Dunst, Trivette, & Jenkins,
1988) was chosen for this investigation because the scale is a
sensitive instrument for discriminating between individuals who
manifest differing levels of stress and coping." (Dunst, Jenkins, &
Trivette, 1984, p. 49). The scale includes a wide range of sources for
help and/or lack of help. Both formal and informal types of support
are included in the scale. Permission for translation and back-
translation was received from Carl Dunst, the major developer of the
instrument.
General Information Survey
The General Information survey (GI survey) was the
questionnaire developed to obtain demographic information
regarding the parents' age, occupation, profession, education, gender,
income, availability of support, and availability of financial
assistance. Statements included in the GI survey required









participants to provide information regarding the target child age,
gender and disability, birth order, number of siblings in the family,
and type of school attended. Information items required an
agreement, disagreement or brief statement response.
The GI survey questionnaire was designed to avoid complex
and/or controversial questions. The content of the questionnaire was
arranged to maximize cooperation from the respondents. There were
no questions that used negative statements. No sensitive personal
information was required from any parent. The respondents were
assured confidentiality. A code for each response was developed to
assist in data analysis.
The Parenting Stress Index
The Parenting Stress Index (PSI) (Abidin, 1995) is a screening
and diagnostic assessment instrument designed to measure
significant sources of parental stress in the parent-child dyad arising
from both child characteristics (Child Domain) and from parent
characteristics (Parent Domain), with an optional Life Stress section.
The instrument consists of 101 items rated on 5-point Likert scales
which are added to yield total child and total parent stress scores.
The sum of the Child Domain scores and the Parent Domain scores
constitute the Total Stress score for each respondent. The Child
Domain consists of 6 subscales: (1) Distractibility/Hyperactivity, (2)
Adaptability, (3) Reinforces Parent, (4) Demandingness, (5) Mood,
and (6) Acceptability. The Parent Domain consists of seven
subscales: (1) Competence, (2) Isolation, (3) Attachment, (4)
Health, (5) Role restriction, (6) Depression, and (7) Spouse. The PSI







87
may be used with parents of children ranging in age from 1 month to
12 years.
According to Abidin (1995), the PSI maintains its validity with
diverse non-English-speaking populations. Furthermore, several
trans-cultural research studies (Brigas, LaFreniere, & Abidin, cited in
Abidin, 1995; Chen & Tang, 1997; Forgays, cited in Abidin, 1995;
Pearson & Chan, 1993; Solis & Abidin, 1991) have demonstrated its
use in non-Western/non-English-speaking cultures.
The earlier form of the PSI was constructed in 1976 based on a
theoretical model of the determinants of dysfunctional parenting
(Abidin, 1995). The subsequent revised form (Form 6) permitted
easier hand scoring and reduced the length of the instrument from
150 to 101 items (Loyd & Abidin, 1985).
The internal consistency of the subscales of Form 6 was
considered to be adequate (Cronbach's alpha = .89 for child stress
and .93 for parent stress) and test-retest reliability over a 3-month
period was .77 for child stress and .69 for parent stress (Forgays,

1990).
The internal consistency of subscales of the third edition
(1995) of the PSI, used in this investigation, is good. Alpha
reliability estimates of the domain scores range from between .89
and .93, with a total alpha of .95. Domain scores of the test-retest
Spearman rank order correlations for a 3-week interval and a 1-year
interval ranged from between .70 and .80 and between .55 and .70,
respectively. For cross-cultural validation of the PSI, Hauenstein,
Marvin, Snyder, Clarke (cited in Abidin, 1995) reported that the









values obtained were similar to those obtained in the normative

sample.
The validity of the PSI was investigated using three factor
analyses (Abidin, 1995). The first analysis covered 47 items of the

Child Domain scale and accounted for 41% of the variance. The
second analysis covered 54 items of the Parent Domain and
accounted for 44% of the variance. The third analysis addressed
scores for each subject of the sample on the 13 subscales and

accounted for 58% of the variance.

Abidin (1995) stated in the manual that several studies
provided evidence for the construct and predictive validity of the
PSI. Brigas, LaFreniere, and Dumas (1996) confirmed the

discriminant validity of the Parent and Child scales of the PSI and
considered both domains as relatively independent measures of two

important sources of stress for parents.

According to Abidin (1995), the design of the PSI Child Domain
subscales provides information to the interventionists on important

aspects of the child's behavior and the parent's interaction with him

or her, while the Parent Domain subscales examine some of the
principal parent characteristics and family context variables which
impact upon the parents' ability to function in a competent way. The

Total Stress score provides an indication of the overall level of
parenting stress as experienced by a parent.
The Family Support Scale
Identification of existing sources of support to parents rearing
young children can be accomplished through the use of social support

scales. For the purpose of this study, the Family Support Scale


I







89
(Dunst, Trivette, & Jenkins, 1988) was used to investigate the sources

of support provided by others to parents of school-age children with
significant disabilities. The Family Support Scale (FSS) is of use in
determining the types of help and assistance that constitute the

parents' support network.
The FSS, developed by Dunst, Jenkins, and Trivette (1984) and
revised 4 years later (Dunst, Trivette, & Jenkins, 1988), is an 18-
item, self-report scale. The initial scale included 18 items (plus 2
respondent-initiated items) rated on a 5-point scale ranging from not

at all helpful (1) to extremely helpful (5). Respondents were
instructed to leave blank the item or items that did not apply to their
situation. The authors applied a principal components factor analysis

to discern the factor structure of the scale. Six factors were
identified: informal kinship, spouse/partner, social organizations,

formal kinship, professional services, and generic professional
services. These factors were used in this study as dependent
variables measuring parents' sources of support.
To establish the validity and reliability of the original form of
the FSS, Dunst, Jenkins, and Trivette (1984) studied 139 parents of
preschool children with mental disabilities or determined to be at

risk for developmental disabilities. Eighty-five percent of the
participants were married. The remaining 15% were single,
widowed, separated, or divorced. The FSS developers established
internal consistency by computing a coefficient alpha from the
average correlation among the 18-scale items (r = .77). They
reported that the coefficient alpha that was computed from the
average correlation of the 18 FSS items with the total scale scores









was .85. The split-half reliability which was corrected for length
using the Spearman-Brown formula was .75 (Dunst, Jenkins, &
Trivette, 1984; Dunst, Trivette, & Jenkins, 1988). When administered
1 month apart, the test-retest reliability of the FSS was reported to
be r = .75 (SD = .17, p. <.001) for the average correlation among the 18
scale items and r =.91 (p <.001) for the total scale scores. When
administered 18 months apart, the test-retest reliability was r = .41
(SD = .18, p. < .05) for the 18 scale items and r = .47 (p. < .01) for the
total scores. Construct validity of the FSS was established through a
principal component analysis. Content validity was established as
well. The total scale scores for criterion validity of the FSS
consistently related to several parent, family, and child outcomes,
including personal well-being (average r = 28, p. < .01), family
integrity (average r = .18, p. < .01), and parent perceptions of child
behavior (average r = .19, p. < .05). According to Dunst (1985), the
criterion and content validity of the total scale were established in a
number of studies. Dunst, Jenkins, and Trivette (1984) and Dunst,
Trivette, and Jenkins (1988) reported that the FSS is a reliable and
valid assessment instrument.
Reliability data for each of the factors were established for this
study based on the reliability reported by previous studies (e.g.,
Beverly, 1995). Beverly (1995) used a coefficient alpha method to
determine the internal consistency reliability of each factor as
reported in Table 1. The FSS is a multiple-scored format which has
no scored correct or incorrect or all-or-nothing system of response.
The FSS was an appropriate assessment tool for this
investigation based on its demonstrated psychometric properties; the