- Email: [email protected]
Severity of asthma and parental discipline practices
Patient Education and Counseling, 17 (1991) Elsevier Scientific Publishers Ireland Ltd.
227
227-233
Severity of Asthma and Parental Discipline Practices Christine ‘Department
Eisera, J. Richard of Psychology,
eter and “Department
University
of Child Health,
Eisera, Carole
of Exeter,
hDepartment
Postgraduate
(Received August 31% 1990) (Accepted February 27th, 1991)
Medical
Townb and John H. Tripp’ of Clinical and Community
Psyc,hology. Chuwh Lune. Heuvitree.
School, Church Lane, Heuvitrer,
Exeter
E.Y-
c UK)
.
Abstract
Introduction
This study investigates the responses of both mothers and fathers to childhood asthma, and the implications of parents’ ratings of the severity of the condition for perceptions of the child and discipline practices. Young children (6 years and under) with asthma were divided into two groups according to the severity of their disease. A mild group (= 19) received treatment medication only and a moderately affected group (= 18) receivedprophylactic daily medication. Mothers and fathers differed in their ratings of how severely the child was affected. Neither did they agree about triggers which precipitated asthma attacks. There were few differences in terms of parental involvement or discipline practices as a function of severity. Children with moderate asthma were perceived to enjoy life more, were less dtjficult in certain situations and more affectionate than those with milder asthma. The results point to the need to understand the fathers’ role in caring for a chronically sick child, and the implications of asthma for parents’ perceptions of: and behavior toward the child.
Asthma is a relatively common chronic condition of childhood, affecting between 5 and 10% of the population [l]. It is associated with considerable morbidity and school absence [2], and disturbances in family functioning and parent-child relationships [3]. Research is not always unequivocal however, and recent work particularly emphasizes that child and family functioning is not inevitably compromised by childhood asthma [4,5].
Keywords: Asthma; pectations; Severity.
Child-care;
Parental
ex-
Much of the ambiguity in asthma research may be accounted for by the variation in severity of the condition, and extent to which children may consequently be restricted or limited in their activities. While there is no single acceptable measure of severity [6,7], it has been shown that parental estimates of severity may have more far-reaching consequences for the child’s adjustment and parents’ mental health than any more objective measure [5]. The present report is an extension of our previous study [8], concerned with investigating the relationship between parental perceptions of severity, in relation to more objective measures based on treatment. In addition, we were concerned with the extent to which the severity of the child’s condition is associated with differences in parenting prac-
073%3991/91/$03.50 0 1991 Elsevier Scientific Publishers Ireland Ltd. Published and Printed in Ireland
228
tices. From previous work [5], we might expect that parents’ perceptions of severity will have implications for child-rearing practices. Greater severity would be expected to be associated with an increase in stress-related situations [9]. For example, the more severely affected child might experience more hospitalization and more treatment generally. Increased stress associated with these situations might be accompanied by a perception of increased stress in other situations. Parental perceptions of severity may also influence child-rearing practices by altering parents’ perceptions of the child and preparedness to implement stricter methods of control. In addition, we attempted to investigate how mothers and fathers respond to the severity of the child’s condition. Most work in this area has focused on the consequences of chronic disease for mothers’ mental and physical health [lo]. Zrebiec [ 1l] found that mothers of children with diabetes tended to be more responsible for day-to-day care than fathers. In asthma, it is likely that increased house-keeping demands resulting from dust allergies fall on mothers. There are also indications in previous work that parents and children do not agree about factors which trigger attacks, and these disagreements can be associated with family conflict [8]. Parents also differ in perceptions of the implications of the disease. Fathers of children with cancer tend to be more optimistic than mothers about the child’s future health [12], as are fathers of infants in intensive care [ 131. There are few other indications in the literature as to how fathers may respond to their child’s illness or how his role in the family may be affected [ 141. A related aim was to explore discipline practice, involvement, perceptions of the child and difficulties experienced between mothers and fathers.
Methods Subjects
All families (n = 37) with a child under 6 years being treated at the Royal Devon and Exeter Hospital for asthma were asked to take part in the study. Thirty families agreed; seven families,did not reply to letters or had moved out of the area. In addition, in order to increase the sample size, a further seven families were recruited through the local branch of the Asthma Society. The mean age of the total group was 54.24 months (range = 33-70 months). The children had been diagnosed at a mean age of 16.52 months (range = f&48 months). There were 25 boys and 12 girls. Thirty-two of the children had visited a general practitioner at least once in the previous year because of an asthma-related problem. Procedure
Details of the study plus the questionnaires and interview schedules were approved by the appropriate ethical committees. A letter explaining the study was sent to the parents of the children enclosing a post-paid reply slip for them to indicate their willingness to take part. Mothers and fathers were interviewed separately (except for the mothers of six children who were single parents). Additional information relating to the child’s asthma was provided by both mothers and fathers. All the interviews were conducted in the families’ homes by the same female psychologist. Measures Parent questionnaires. The following mea-
sures were completed separately by mothers and fathers: (1) Involvement: Parents were asked to rate on six 7-point scales (from 1 = not at all to 7 = everyday) how often they helped the child dress in the morning, undress at night, bath and go to bed. They also rated the frequency
229
with which they read to and played with, the child. (2) Styles of discipline and control: Measures of frequency of different discipline strategies and perceived effectiveness were developed, from pilot interviews (conducted by CT). These interviews were conducted with mothers of 12 healthy children recruited from local playgroups. Each measure consisted of 11 items (e.g. smack the child, reward for good behavior, deprive of sweets etc.) which were rated on separate 7-point scales. First, items were rated in terms of the frequency with which they were adopted (where 1 = never to 7 = very frequently) and second in terms of perceived effectiveness (where 1 = more harm than good and 7 = very effective). (3) Parental perceptions: This 16 item scale was based on previous work with handicapped children. Parents were asked to rate their child on a series of 7-point scales (from 1 = not at all applicable to 7 = very applicable), on items such as “enjoys life”, “mixes with other children”, “demands attention” and “catches colds easily”. (4) Situations: Parents were asked to rate 16 situations (mealtimes, going shopping, visiting friends) on a series of ‘I-point scales, in terms of the frequency with which difficulties arose (1 = never and 7 = always). Internal consistency of measures. Although the main analyses preserve distinctions between individual items, the scales were assessed for internal consistency. The 11 items comprising the discipline scale yielded alphas of 0.74 for mothers and 0.69 for fathers when rated for frequency, and 0.68 and 0.74 respectively when rated for effectiveness. The scale measuring parental perceptions gave alphas of 0.84 and 0.76 for mothers’ and fathers’ responses. Alphas of 0.61 for mothers and 0.87 for fathers were obtained over the 16 items measuring different situations, and of 0.59 for mothers and 0.81 for fathers on those items measuring involvement. In addition,
children were assessed by the Vineland Social Maturity Scale [15] and the British Ability Scales [ 161. The short form IQ with four subscales was used. These measures were chosen as broad indications of social and intellectual development, and were used simply to compare children in the two severity groups. Severity was assessed in terms of prescribed drugs and frequency of administration as reported by mothers and fathers. We arbitrarily categorized children receiving treatment medications only as necessary into a mild group (n = 19) and those receiving daily prophylactic medication as moderately affected (n = 18). Six of this latter group were regularly treated by courses of oral steroids. All but one of those in the moderate group were attending hospital, where management of asthma by the four consultants concerned follows a similar protocol. The mild group included the six remaining children recruited through the Asthma Society, and who were under the care of separate doctors in the community. Perceived
severity
and
causes
of attacks.
Mothers and fathers were each asked to rate their own perceptions about the severity of the child’s asthma, on a 5-point scale, from 1 = not at all severe to 5 = very severe indeed. They were also asked to rate the extent to which they believed attacks were caused by common precipitating factors (dust, exercise, food, animals, colds and emotion). Results Severity
There was no difference between the mild and moderate groups in terms of the children’s age (t = 1.40) or scores on the Vineland social maturity scale (t = 1.10) or the BAS (t = 0.84). Neither were there any indications of social class differences between the groups, as indexed by fathers’ occupation (Kendall’s
230
Tau = 0.12), age mother left full-time education (t = 0.65) or age father left full-time education (t = 1.42). However, the two groups did differ in number of hospital admissions (Tau = 0.38, P < 0.01, see Table l), and the maximum number of days for any one admission (Tau = 0.21, P < 0.02), which lends further support to the distinction between mild and moderate groups on the basis of drug treatments. There was some relationship between mothers’ ratings of perceived severity of the child’s asthma and severity as assessed by prescribed drugs (Tau = 0.36, P < 0.05). A similar relationship held between father’s estimates of severity and severity assessed by medication (Tau = 0.37, P < 0.05). However, fathers rated their children as more severely affected than mothers (means for fathers = 4.12, mothers = 3.51). There was no signiticant agreement between these ratings (Tau = 0.05). Neither did parents agree in their reports of specific triggers to the child’s asthma. A series of Pearson correlations were conducted between mother’s and father’s reports of specific triggers. Correlations ranged from 0.02 to 0.16 (all nonsignificant). Parental ratings of children with mild and severe asthma A series of MANOVAS was then conducted with disease severity (mild and moderate) as a between subjects factor. Each child was treated as a single variable, with mother and father ratings treated as repeated measures. Table 1. Differences between mild and moderate groups in terms of number of hospital admissions. Severity
Mild Moderate
No. of admissions 0
1
2t
2
10 5
I 13
Involvement. Mothers and fathers differed in degree of involvement with their children (F(1,28) = 7.42, P < O.Ol), with mothers being more involved on all the items measured. However, there were no differences in parental involvement as a function of the severity of the child’s condition (F( 1,26) = 1.28). Discipline frequency and perceived effectiveness. Parents of children with mild asthma did not differ from parents of those with moderate asthma in the frequency with which they reported using different discipline strategies, (F(1,30) = 0.54). However, regardless of severity, mothers and fathers differed in the discipline strategies they adopted (F( 1,30) = 6.51, P < 0.02). Inspection of the univariate Fs suggested that fathers of children with mild asthma were more likely to threaten to smack their children (mean = 4.26) than fathers of those with moderate asthma (mean = 3.26) (F(1,30) = 4.64, P < 0.05). In addition, fathers of those with mild asthma were more likely to promise treats (mean = 3.26) compared with fathers of those with moderate asthma (mean = 2.31) (F(1,30) = 4.23, P < 0.05). Although the main effect for items was significant (F(21,lO) = 34.64, P C between O.OOl), none of the interactions parents, items and severity reached significance. In terms of perceived effectiveness of different strategies, there were no significant effects due to severity (F(1,22) = 2.36) or parents (F(1,22) = 0.26). Further indication that parents differed in the type of discipline strategies they employed and perceived to be effective was found in the lack of correlation between ratings made by mothers and fathers. Of the 22 items, only one was significant. Parental perceptions Although parents tended to endorse some items more than others, (F( 15,16) = 24.19 P < O.OOl), there were no effects on parental
231
perceptions either between mothers and fathers (F( 1,26) = 0.72) or as a result of severity (F(1,26) = 0.10). Inspection of the univariate Fs suggested that mothers of those with mild asthma rated their children as less affectionate (mean = 5.47) than mothers of those with moderate asthma (mean = 6.39) (F(1,30) = 4.02, P < 0.05). In addition, fathers of those with moderate asthma rated their children as more likely to do as they were told than fathers of the mildly affected (mean = 4.05 and 5.46 respectively, F(1,30) = 8.18, P c 0.01). They also perceived the moderately affected children to enjoy life more than the mildly affected (mean = 6.05 and 6.69 respectively, F( 1,30) = 4.81, P < 0.05) There was, in fact, a high correlation between mothers and fathers in their ratings of perceptions; all but one of the items yielded significant correlations. Situations
There were no main effects for severity (F(1,19) = 0.22) or parents (F(1,19) = 1.18). However, inspection of the univariate Fs (all with 1,19 dfs) suggested some differences between mothers and fathers in their perceptions of difficult situations depending on the child’s severity. Mothers reported that children with mild asthma were more difficult when visiting other peoples’ homes compared with mothers of moderately affected children (mean = 2.75 and 2.00 respectively, F = 4.49, P < 0.05). They were also more difficult when out shopping (mean = 3.91 and 2.67 respectively, F = 11.82, P < 0.01) and when being left at playgroup (mean = 2.08 and 1.33 respectively, F = 5.03, P < 0.05). Fathers of children with moderate asthma reported more difficulty at night compared with fathers of those with mild asthma (mean = 3.40 and 2.30 respectively, F = 5.78, P < 0.05). Again, mothers’ and fathers’ ratings of difficult situations were closely related, with all correlations reaching significance.
Discussion Although ratings of severity by mothers and fathers correlated with severity assessed by medication, there was no relationship between mothers and fathers in their estimates of the child’s severity or agreement about specific factors likely to trigger an asthma attack. Such discrepancies may have considerable implication for the parents’ relationship and agreement about how to manage the child. It is not possible from these data to understand why fathers see their children as more seriously affected than mothers. One hypothesis might be that their reduced involvement with the child leads to insufticient and understanding subsequently distorted perceptions about the disease and its implications. An important goal for educators would seem to be to make fathers more informed about the disease and more involved in the management of the condition, both for the benefit of the child, and other family members [14]. It is important that medical staff recognise and address the different concerns held by mothers and fathers, rather than rely on giving general information and counseling predominantly to mothers. In assessing our results concerned with parents’ behavior in relation to disease severity, it is important to note that our analyses were based on an objective measure, derived from treatment protocols. Analyses were conducted in this way largely for practical reasons, in that parents’ estimates of severity were based on 5-point scales which did not allow for easy division into two groups. An important extension for future work would be to consider differences in parent behaviors as a function of beliefs about illness, especially given the low agreement between mothers and fathers. In addition to the differential perceptions of severity, mothers and fathers of children with asthma differ in their reports about their own discipline practices, and their appraisals
232
of care-taking situations that are most stressful. There was, however, greater agreement between parents in their perceptions of the child. In terms of their perceptions, mothers of the moderately affected rated their children as more affectionate than mothers rated mildly affected children. The mothers of the mildly affected were also more likely to rate their children as difficult when shopping and visiting other peoples’ homes. Fathers rated the mildly affected as less likely to do as they were told and to enjoy life less than fathers rated their moderately affected children. Taken together, these data in part support the popular image of more affected children being happy, cooperative and little trouble although of course it is not clear whether these results represent real differences in character between the mildly and moderately affected children, or parents’ efforts to cope with the knowledge of the potential disadvantage associated with a chronic condition. The data are consistent with previous work suggesting that behavioral and emotional difficulties are not linearly related to the severity of the child’s condition
describe their own responses to an asthma attack, but work with older children should include patients’ assessments of the severity of their disease. Until a standardized measure of severity is available, it is inevitable that definitions of mild, moderate and severe asthma will vary between studies. Children categorized as severely affected in one study may well be categorized as mildly affected in another, depending on characteristics of the clinic from which they are drawn. There has been a traditional assumption that parents tend to restrict and over-protect children with chronic disease [ 181. Recent work has failed to establish such a link and suggests instead that over-protection may have different implications for healthy and chronically sick children [ 191. In some situations, restriction or increased protection may be very necessary for a child’s wellbeing. Future work needs to address the issue of how parenting styles such as these are appropriate or inappropriate depending on the child’s age, condition and circumstances. Practice implications
151. Future work needs to consider the implications of different parenting practices for the child’s behavior. In this respect, Dolgin et al. [ 171 have shown that parents’ reported use of physical punishment is associated with increased treatment-related fear in the children. While the incidence of asthma in young children is relatively high, the range in severity of the condition is also very variable. Severity has been measured in a number of ways [6] and may include objective indices such as frequency and number of attacks, number of hospitalizations, or type of medication. More comprehensive measures of severity also need to take into account parental estimates, since these do not necessarily correspond well with more objective measures [5]. The children
in this study were too small to
Parents’ understanding of, and assessment of the severity of their child’s chronic condition is likely to influence their perception of the child and preparedness to adopt different discipline strategies. Our results confirm previous findings suggesting limited overlap between objective indices of severity and more subjective views of parents. In addition, we found that fathers rated their children as more severly affected than mothers, perhaps suggesting that education and counseling needs to be directed at particular concerns of both parents separately. Further, the extent to which asthma compromises parent-child relationships may well be affected by many factors, not least the severity of the condition. Measures of severity which take into account medical indices, as well as beliefs of parents and children, are necessary.
233
Acknowledgments This research was supported Christine Eiser is now supported
IO
by the HEC (now the HEA). by the E.S.R.C.. Swindon. We
are indebted to Drs. Richard Orme. David Kennaird and Leonard Haas for encouraging their patients to take part in this study and to Mrs. Robyn Connett and the local (Exeter) branch of the Asthma Society.
11
I2
References 13 Peckham C. Butler R: A national childhood. J Epidemiol Commun
study of asthma in Health 1978; 32:
79-85. Hill RA, Standen PJ, Tattersfield AE: Asthma. wheezing and school absence in primary schools. Arch Dis Child 1989; 64: 24&251.
14
Gustafssan PA, Kjellman NIM, Ludvigssan J, Cederland M: Asthma and family interaction. Arch Dis Child 1987: 62: 258-263. Kashani JH. Kvenig P, Shepperd JA, Wilfley D. Morris DA: Psychopathology and self-concept in asthmatic children. J Pediatr Psycho1 1988; 13: 509-520. Perrin JM, MacLean WE, Perrin EC: Parental perceptions of health status and psychologic adjustment of chil-
I5
dren with asthma. Pediatrics 1989; 83: 26-30. Renne CM, Creer TL: Asthmatic children and their families. Advances in Developmental and Behavioural Pediatrics, Vol. 6. Greenwich, CT, JAI Press, 1985. Mrazek DA: Childhood asthma: two central questions for child psychiatry. J Child Psycho1 Psychiatr 1986; 27: l-6. Eiser C, Eiser JR, Town C, Tripp JH: Discipline strategies and parental perceptions of pre-school children with asthma. Br J Med Psychol, in press. Kazak A: Families of chronically ill children: a systems and social-ecological model of adaptation and challenge. J Consult Clin Psycho1 1989; 57: 25-30.
16 17
18
I9
Eiser C: Chronic Childhood Disease: An Introduction to Psychological Theory and Research. Cambridge. UK, Cambridge University Press, 1990. Zrebiec JF: Psychosocial commentary on insulindependent diabetes in 5- to 9-year old children. In: JJ Brink ed. Pediatric and Adolescent Diabetes Mellitus. Chicago: Year Book Medical Publishers, 1987. Levenson PM, Copeland DR. Morrow JR, Pfefferbaum B, Silverberg Y: Disparities in disease-related perceptions of adolescent cancer patients and their parents. J Pediatr Psycho1 1983; 8: 3345. Ameck G. Tennen H. Rowe J: Mothers. fathers, and the crisis of newborn intensive care. Infant Mental Health J 1990; II: 12-25. Walker LS, Ortiz-Valdes JA. Newbrough JR: The role of maternal employment and depression in the psychological adjustment of chronically ill. mentally retarded and well children. J Pediatr Psycho1 1989: 14: 357-370. Doll EA: A genetic scale of social maturity. Am J Orthopsychol 1935; 5: 18&188. Elliott C. Murray D. Pearson L: British Ability Scales. Windsor, UK, NFER Publishing Co.. 1978. Dolgin MJ. Phipps S, Harrow E. Zeltzer LK: Parental management of fear in chronically ill and healthy children. J Pediatr Psycho1 1990; 15: 733-744. Tropauer A, Franz MA, Dilgard VW: Psychological aspects of the care of children with cystic fibrosis. Am J Dis Children 1970: 119: 42-32. Cappelli M, McGrath PJ. MacDonald NE, Katsanis J, Lascelles M: Parental care and overprotection of children with cystic fibrosis. Br J Med Psycho1 1989; 62: 28 I-290.
Correspondence
to:
C. Eiser Department of Psychology University of Exeter Exeter, UK
227
227-233
Severity of Asthma and Parental Discipline Practices Christine ‘Department
Eisera, J. Richard of Psychology,
eter and “Department
University
of Child Health,
Eisera, Carole
of Exeter,
hDepartment
Postgraduate
(Received August 31% 1990) (Accepted February 27th, 1991)
Medical
Townb and John H. Tripp’ of Clinical and Community
Psyc,hology. Chuwh Lune. Heuvitree.
School, Church Lane, Heuvitrer,
Exeter
E.Y-
c UK)
.
Abstract
Introduction
This study investigates the responses of both mothers and fathers to childhood asthma, and the implications of parents’ ratings of the severity of the condition for perceptions of the child and discipline practices. Young children (6 years and under) with asthma were divided into two groups according to the severity of their disease. A mild group (= 19) received treatment medication only and a moderately affected group (= 18) receivedprophylactic daily medication. Mothers and fathers differed in their ratings of how severely the child was affected. Neither did they agree about triggers which precipitated asthma attacks. There were few differences in terms of parental involvement or discipline practices as a function of severity. Children with moderate asthma were perceived to enjoy life more, were less dtjficult in certain situations and more affectionate than those with milder asthma. The results point to the need to understand the fathers’ role in caring for a chronically sick child, and the implications of asthma for parents’ perceptions of: and behavior toward the child.
Asthma is a relatively common chronic condition of childhood, affecting between 5 and 10% of the population [l]. It is associated with considerable morbidity and school absence [2], and disturbances in family functioning and parent-child relationships [3]. Research is not always unequivocal however, and recent work particularly emphasizes that child and family functioning is not inevitably compromised by childhood asthma [4,5].
Keywords: Asthma; pectations; Severity.
Child-care;
Parental
ex-
Much of the ambiguity in asthma research may be accounted for by the variation in severity of the condition, and extent to which children may consequently be restricted or limited in their activities. While there is no single acceptable measure of severity [6,7], it has been shown that parental estimates of severity may have more far-reaching consequences for the child’s adjustment and parents’ mental health than any more objective measure [5]. The present report is an extension of our previous study [8], concerned with investigating the relationship between parental perceptions of severity, in relation to more objective measures based on treatment. In addition, we were concerned with the extent to which the severity of the child’s condition is associated with differences in parenting prac-
073%3991/91/$03.50 0 1991 Elsevier Scientific Publishers Ireland Ltd. Published and Printed in Ireland
228
tices. From previous work [5], we might expect that parents’ perceptions of severity will have implications for child-rearing practices. Greater severity would be expected to be associated with an increase in stress-related situations [9]. For example, the more severely affected child might experience more hospitalization and more treatment generally. Increased stress associated with these situations might be accompanied by a perception of increased stress in other situations. Parental perceptions of severity may also influence child-rearing practices by altering parents’ perceptions of the child and preparedness to implement stricter methods of control. In addition, we attempted to investigate how mothers and fathers respond to the severity of the child’s condition. Most work in this area has focused on the consequences of chronic disease for mothers’ mental and physical health [lo]. Zrebiec [ 1l] found that mothers of children with diabetes tended to be more responsible for day-to-day care than fathers. In asthma, it is likely that increased house-keeping demands resulting from dust allergies fall on mothers. There are also indications in previous work that parents and children do not agree about factors which trigger attacks, and these disagreements can be associated with family conflict [8]. Parents also differ in perceptions of the implications of the disease. Fathers of children with cancer tend to be more optimistic than mothers about the child’s future health [12], as are fathers of infants in intensive care [ 131. There are few other indications in the literature as to how fathers may respond to their child’s illness or how his role in the family may be affected [ 141. A related aim was to explore discipline practice, involvement, perceptions of the child and difficulties experienced between mothers and fathers.
Methods Subjects
All families (n = 37) with a child under 6 years being treated at the Royal Devon and Exeter Hospital for asthma were asked to take part in the study. Thirty families agreed; seven families,did not reply to letters or had moved out of the area. In addition, in order to increase the sample size, a further seven families were recruited through the local branch of the Asthma Society. The mean age of the total group was 54.24 months (range = 33-70 months). The children had been diagnosed at a mean age of 16.52 months (range = f&48 months). There were 25 boys and 12 girls. Thirty-two of the children had visited a general practitioner at least once in the previous year because of an asthma-related problem. Procedure
Details of the study plus the questionnaires and interview schedules were approved by the appropriate ethical committees. A letter explaining the study was sent to the parents of the children enclosing a post-paid reply slip for them to indicate their willingness to take part. Mothers and fathers were interviewed separately (except for the mothers of six children who were single parents). Additional information relating to the child’s asthma was provided by both mothers and fathers. All the interviews were conducted in the families’ homes by the same female psychologist. Measures Parent questionnaires. The following mea-
sures were completed separately by mothers and fathers: (1) Involvement: Parents were asked to rate on six 7-point scales (from 1 = not at all to 7 = everyday) how often they helped the child dress in the morning, undress at night, bath and go to bed. They also rated the frequency
229
with which they read to and played with, the child. (2) Styles of discipline and control: Measures of frequency of different discipline strategies and perceived effectiveness were developed, from pilot interviews (conducted by CT). These interviews were conducted with mothers of 12 healthy children recruited from local playgroups. Each measure consisted of 11 items (e.g. smack the child, reward for good behavior, deprive of sweets etc.) which were rated on separate 7-point scales. First, items were rated in terms of the frequency with which they were adopted (where 1 = never to 7 = very frequently) and second in terms of perceived effectiveness (where 1 = more harm than good and 7 = very effective). (3) Parental perceptions: This 16 item scale was based on previous work with handicapped children. Parents were asked to rate their child on a series of 7-point scales (from 1 = not at all applicable to 7 = very applicable), on items such as “enjoys life”, “mixes with other children”, “demands attention” and “catches colds easily”. (4) Situations: Parents were asked to rate 16 situations (mealtimes, going shopping, visiting friends) on a series of ‘I-point scales, in terms of the frequency with which difficulties arose (1 = never and 7 = always). Internal consistency of measures. Although the main analyses preserve distinctions between individual items, the scales were assessed for internal consistency. The 11 items comprising the discipline scale yielded alphas of 0.74 for mothers and 0.69 for fathers when rated for frequency, and 0.68 and 0.74 respectively when rated for effectiveness. The scale measuring parental perceptions gave alphas of 0.84 and 0.76 for mothers’ and fathers’ responses. Alphas of 0.61 for mothers and 0.87 for fathers were obtained over the 16 items measuring different situations, and of 0.59 for mothers and 0.81 for fathers on those items measuring involvement. In addition,
children were assessed by the Vineland Social Maturity Scale [15] and the British Ability Scales [ 161. The short form IQ with four subscales was used. These measures were chosen as broad indications of social and intellectual development, and were used simply to compare children in the two severity groups. Severity was assessed in terms of prescribed drugs and frequency of administration as reported by mothers and fathers. We arbitrarily categorized children receiving treatment medications only as necessary into a mild group (n = 19) and those receiving daily prophylactic medication as moderately affected (n = 18). Six of this latter group were regularly treated by courses of oral steroids. All but one of those in the moderate group were attending hospital, where management of asthma by the four consultants concerned follows a similar protocol. The mild group included the six remaining children recruited through the Asthma Society, and who were under the care of separate doctors in the community. Perceived
severity
and
causes
of attacks.
Mothers and fathers were each asked to rate their own perceptions about the severity of the child’s asthma, on a 5-point scale, from 1 = not at all severe to 5 = very severe indeed. They were also asked to rate the extent to which they believed attacks were caused by common precipitating factors (dust, exercise, food, animals, colds and emotion). Results Severity
There was no difference between the mild and moderate groups in terms of the children’s age (t = 1.40) or scores on the Vineland social maturity scale (t = 1.10) or the BAS (t = 0.84). Neither were there any indications of social class differences between the groups, as indexed by fathers’ occupation (Kendall’s
230
Tau = 0.12), age mother left full-time education (t = 0.65) or age father left full-time education (t = 1.42). However, the two groups did differ in number of hospital admissions (Tau = 0.38, P < 0.01, see Table l), and the maximum number of days for any one admission (Tau = 0.21, P < 0.02), which lends further support to the distinction between mild and moderate groups on the basis of drug treatments. There was some relationship between mothers’ ratings of perceived severity of the child’s asthma and severity as assessed by prescribed drugs (Tau = 0.36, P < 0.05). A similar relationship held between father’s estimates of severity and severity assessed by medication (Tau = 0.37, P < 0.05). However, fathers rated their children as more severely affected than mothers (means for fathers = 4.12, mothers = 3.51). There was no signiticant agreement between these ratings (Tau = 0.05). Neither did parents agree in their reports of specific triggers to the child’s asthma. A series of Pearson correlations were conducted between mother’s and father’s reports of specific triggers. Correlations ranged from 0.02 to 0.16 (all nonsignificant). Parental ratings of children with mild and severe asthma A series of MANOVAS was then conducted with disease severity (mild and moderate) as a between subjects factor. Each child was treated as a single variable, with mother and father ratings treated as repeated measures. Table 1. Differences between mild and moderate groups in terms of number of hospital admissions. Severity
Mild Moderate
No. of admissions 0
1
2t
2
10 5
I 13
Involvement. Mothers and fathers differed in degree of involvement with their children (F(1,28) = 7.42, P < O.Ol), with mothers being more involved on all the items measured. However, there were no differences in parental involvement as a function of the severity of the child’s condition (F( 1,26) = 1.28). Discipline frequency and perceived effectiveness. Parents of children with mild asthma did not differ from parents of those with moderate asthma in the frequency with which they reported using different discipline strategies, (F(1,30) = 0.54). However, regardless of severity, mothers and fathers differed in the discipline strategies they adopted (F( 1,30) = 6.51, P < 0.02). Inspection of the univariate Fs suggested that fathers of children with mild asthma were more likely to threaten to smack their children (mean = 4.26) than fathers of those with moderate asthma (mean = 3.26) (F(1,30) = 4.64, P < 0.05). In addition, fathers of those with mild asthma were more likely to promise treats (mean = 3.26) compared with fathers of those with moderate asthma (mean = 2.31) (F(1,30) = 4.23, P < 0.05). Although the main effect for items was significant (F(21,lO) = 34.64, P C between O.OOl), none of the interactions parents, items and severity reached significance. In terms of perceived effectiveness of different strategies, there were no significant effects due to severity (F(1,22) = 2.36) or parents (F(1,22) = 0.26). Further indication that parents differed in the type of discipline strategies they employed and perceived to be effective was found in the lack of correlation between ratings made by mothers and fathers. Of the 22 items, only one was significant. Parental perceptions Although parents tended to endorse some items more than others, (F( 15,16) = 24.19 P < O.OOl), there were no effects on parental
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perceptions either between mothers and fathers (F( 1,26) = 0.72) or as a result of severity (F(1,26) = 0.10). Inspection of the univariate Fs suggested that mothers of those with mild asthma rated their children as less affectionate (mean = 5.47) than mothers of those with moderate asthma (mean = 6.39) (F(1,30) = 4.02, P < 0.05). In addition, fathers of those with moderate asthma rated their children as more likely to do as they were told than fathers of the mildly affected (mean = 4.05 and 5.46 respectively, F(1,30) = 8.18, P c 0.01). They also perceived the moderately affected children to enjoy life more than the mildly affected (mean = 6.05 and 6.69 respectively, F( 1,30) = 4.81, P < 0.05) There was, in fact, a high correlation between mothers and fathers in their ratings of perceptions; all but one of the items yielded significant correlations. Situations
There were no main effects for severity (F(1,19) = 0.22) or parents (F(1,19) = 1.18). However, inspection of the univariate Fs (all with 1,19 dfs) suggested some differences between mothers and fathers in their perceptions of difficult situations depending on the child’s severity. Mothers reported that children with mild asthma were more difficult when visiting other peoples’ homes compared with mothers of moderately affected children (mean = 2.75 and 2.00 respectively, F = 4.49, P < 0.05). They were also more difficult when out shopping (mean = 3.91 and 2.67 respectively, F = 11.82, P < 0.01) and when being left at playgroup (mean = 2.08 and 1.33 respectively, F = 5.03, P < 0.05). Fathers of children with moderate asthma reported more difficulty at night compared with fathers of those with mild asthma (mean = 3.40 and 2.30 respectively, F = 5.78, P < 0.05). Again, mothers’ and fathers’ ratings of difficult situations were closely related, with all correlations reaching significance.
Discussion Although ratings of severity by mothers and fathers correlated with severity assessed by medication, there was no relationship between mothers and fathers in their estimates of the child’s severity or agreement about specific factors likely to trigger an asthma attack. Such discrepancies may have considerable implication for the parents’ relationship and agreement about how to manage the child. It is not possible from these data to understand why fathers see their children as more seriously affected than mothers. One hypothesis might be that their reduced involvement with the child leads to insufticient and understanding subsequently distorted perceptions about the disease and its implications. An important goal for educators would seem to be to make fathers more informed about the disease and more involved in the management of the condition, both for the benefit of the child, and other family members [14]. It is important that medical staff recognise and address the different concerns held by mothers and fathers, rather than rely on giving general information and counseling predominantly to mothers. In assessing our results concerned with parents’ behavior in relation to disease severity, it is important to note that our analyses were based on an objective measure, derived from treatment protocols. Analyses were conducted in this way largely for practical reasons, in that parents’ estimates of severity were based on 5-point scales which did not allow for easy division into two groups. An important extension for future work would be to consider differences in parent behaviors as a function of beliefs about illness, especially given the low agreement between mothers and fathers. In addition to the differential perceptions of severity, mothers and fathers of children with asthma differ in their reports about their own discipline practices, and their appraisals
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of care-taking situations that are most stressful. There was, however, greater agreement between parents in their perceptions of the child. In terms of their perceptions, mothers of the moderately affected rated their children as more affectionate than mothers rated mildly affected children. The mothers of the mildly affected were also more likely to rate their children as difficult when shopping and visiting other peoples’ homes. Fathers rated the mildly affected as less likely to do as they were told and to enjoy life less than fathers rated their moderately affected children. Taken together, these data in part support the popular image of more affected children being happy, cooperative and little trouble although of course it is not clear whether these results represent real differences in character between the mildly and moderately affected children, or parents’ efforts to cope with the knowledge of the potential disadvantage associated with a chronic condition. The data are consistent with previous work suggesting that behavioral and emotional difficulties are not linearly related to the severity of the child’s condition
describe their own responses to an asthma attack, but work with older children should include patients’ assessments of the severity of their disease. Until a standardized measure of severity is available, it is inevitable that definitions of mild, moderate and severe asthma will vary between studies. Children categorized as severely affected in one study may well be categorized as mildly affected in another, depending on characteristics of the clinic from which they are drawn. There has been a traditional assumption that parents tend to restrict and over-protect children with chronic disease [ 181. Recent work has failed to establish such a link and suggests instead that over-protection may have different implications for healthy and chronically sick children [ 191. In some situations, restriction or increased protection may be very necessary for a child’s wellbeing. Future work needs to address the issue of how parenting styles such as these are appropriate or inappropriate depending on the child’s age, condition and circumstances. Practice implications
151. Future work needs to consider the implications of different parenting practices for the child’s behavior. In this respect, Dolgin et al. [ 171 have shown that parents’ reported use of physical punishment is associated with increased treatment-related fear in the children. While the incidence of asthma in young children is relatively high, the range in severity of the condition is also very variable. Severity has been measured in a number of ways [6] and may include objective indices such as frequency and number of attacks, number of hospitalizations, or type of medication. More comprehensive measures of severity also need to take into account parental estimates, since these do not necessarily correspond well with more objective measures [5]. The children
in this study were too small to
Parents’ understanding of, and assessment of the severity of their child’s chronic condition is likely to influence their perception of the child and preparedness to adopt different discipline strategies. Our results confirm previous findings suggesting limited overlap between objective indices of severity and more subjective views of parents. In addition, we found that fathers rated their children as more severly affected than mothers, perhaps suggesting that education and counseling needs to be directed at particular concerns of both parents separately. Further, the extent to which asthma compromises parent-child relationships may well be affected by many factors, not least the severity of the condition. Measures of severity which take into account medical indices, as well as beliefs of parents and children, are necessary.
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Acknowledgments This research was supported Christine Eiser is now supported
IO
by the HEC (now the HEA). by the E.S.R.C.. Swindon. We
are indebted to Drs. Richard Orme. David Kennaird and Leonard Haas for encouraging their patients to take part in this study and to Mrs. Robyn Connett and the local (Exeter) branch of the Asthma Society.
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Eiser C: Chronic Childhood Disease: An Introduction to Psychological Theory and Research. Cambridge. UK, Cambridge University Press, 1990. Zrebiec JF: Psychosocial commentary on insulindependent diabetes in 5- to 9-year old children. In: JJ Brink ed. Pediatric and Adolescent Diabetes Mellitus. Chicago: Year Book Medical Publishers, 1987. Levenson PM, Copeland DR. Morrow JR, Pfefferbaum B, Silverberg Y: Disparities in disease-related perceptions of adolescent cancer patients and their parents. J Pediatr Psycho1 1983; 8: 3345. Ameck G. Tennen H. Rowe J: Mothers. fathers, and the crisis of newborn intensive care. Infant Mental Health J 1990; II: 12-25. Walker LS, Ortiz-Valdes JA. Newbrough JR: The role of maternal employment and depression in the psychological adjustment of chronically ill. mentally retarded and well children. J Pediatr Psycho1 1989: 14: 357-370. Doll EA: A genetic scale of social maturity. Am J Orthopsychol 1935; 5: 18&188. Elliott C. Murray D. Pearson L: British Ability Scales. Windsor, UK, NFER Publishing Co.. 1978. Dolgin MJ. Phipps S, Harrow E. Zeltzer LK: Parental management of fear in chronically ill and healthy children. J Pediatr Psycho1 1990; 15: 733-744. Tropauer A, Franz MA, Dilgard VW: Psychological aspects of the care of children with cystic fibrosis. Am J Dis Children 1970: 119: 42-32. Cappelli M, McGrath PJ. MacDonald NE, Katsanis J, Lascelles M: Parental care and overprotection of children with cystic fibrosis. Br J Med Psycho1 1989; 62: 28 I-290.
Correspondence
to:
C. Eiser Department of Psychology University of Exeter Exeter, UK