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Parenting Stress in Primary Caregivers of Psychiatrically Hospitalized Children

Michele Knox, Ph.D. and Tanvir Singh, M.D.
University Toledo Medical center

Parenting children with emotional and behavioral problems can be exhausting and distressing. Research has suggested an association between parenting stress and childhood externalizing behavior problems. That is, parenting stress is increased when children act out (Morgan et al., 2002). Parenting stress also appears to exacerbate children’s problem behaviors. Parental stress seems to increase parent irritability, influence their disciplinary practices and increase the likelihood that parents initiate or maintain aversive interchanges or counterattack in response to child aggression. Parents experiencing high levels of stress are likely to pay more attention to negative behavior and attribute them to child rather than to the situation. These factors seem to directly promote or mediate aggression and oppositional behavior in children (McCarty et al, 2003; Patterson & Forgatch, 1990; Patterson, Reid & Dishion, 1992Wahler & Dumas, 1989). The role parenting stress plays in subsequent externalizing behavior in children and adolescents makes it an important variable to address in planning effective treatments (Deater-Deckard, 1998; Takeuchi, Williams, Adair, 1991; Patterson, 1988); indicating parenting stress may be an appropriate target of treatment.

Previous research has also implicated level of parental stress with physical child abuse potential (Abidin, 95; Hillson and Kuiper, 94). Positive relationship was especially found in parents who had high belief in the value of corporal punishment (Crouch and Behl, 2001).It was suggested that high stress level can led parents to engage in rapid automatic information processing resulting in increasing influence of basic belief structure and increasing child abuse potential (Milner, 2000).
In 1997 Pelham et al did a study, which supports the hypothesis that deviant child behavior resulting in high parental stress also contributes to significant maladaptive coping like drinking problem in parents. Study proved that deviant child behavior could result in parental decreased perceived effectiveness, increased unpleasantness ratings, and increased depression, anxiety and hostility.
Basically review of previous literature seems to suggest that relationship between children deviant behavior and parental stress is bi-directional. And there is need to address both variables to improve treatment outcome.

The current study is about parenting stress in a very significantly affected group of caregivers. This group comprise of primary caregivers of psychiatrically hospitalized children. It is well acknowledged that parents who admit their children for inpatient psychiatric hospitalization often report high levels of parenting stress (Puotiniemi et al., 2001). Purpose of the study is to explore what variables are associated with heightened parenting stress in parents whose children are hospitalized in a child and adolescent psychiatric hospital. Variables addressed were externalizing child symptomatology, and family factors including number of children in the home, number of adults in the home and history of child’s placement outside the home.


Only primary caregivers living with the child receiving treatment were asked to complete the questionnaires. As a result, sixty-one parents/caregivers participated in the study. Respondents were 51 mothers, three fathers, four grandmothers, and one foster mother (two caregivers did not specify their status). The mean age of children was years. There were 15 female and 46 male children represented. Seventy-nine percent of the children were Caucasian, eight percent were African American, seven percent were Hispanic, and seven percent were described as Biracial/Other. Mean socioeconomic status, based on mother’s occupation (Stevens & Featherman, 1981) was 31.2.

Assessment instruments were administered to parents upon the child’s admission to a psychiatric hospital for children. All primary caregivers living with children aged 2 to 12 years who were admitted for inpatient hospitalization were asked to complete the instruments. Children were admitted to the hospital due to serious risk of harm to self or others or incapacitating mental illness. The Parenting Stress Index, a self-report measure of stress in the parenting role was used to measure stress in the parenting role. The internal consistency for the PSI total score has been estimated at .95 (Abidin, 1995)
The Child Behavior Checklist (CBCL) was used to measure externalizing symptomatology in children. The scale is very well established, and has been reported to have high test-retest reliability, internal consistency and discriminant validity.


Of the total sample, 24.6% of the children had been placed outside the home, in foster, residential, or group homes in the past. Forty-nine percent had a history of involvement with children services. The median number of other children in the home was one (ranging from 0 to 6). The median number of adults in the home was two (ranging from 1 to 3).

The mean total T-score on the Child Behavior Checklist for the sample was 75.7 (SD=9.5). The mean T-score on the externalizing subscale of this instrument was 74.4 (SD=9.5). The mean total score on the Parenting Stress Index was 103.0 (SD=19.5). Each of these scores falls in the clinically elevated range of the respective instruments.

T-tests were conducted to examine differences in parenting stress between groups with and without previous out-of-home placement. Results indicate that families who report a history of the child’s placement outside the home had lower levels of parenting stress (x=95.5; SD=14.3) than those without such a history (x=105.5; SD=20.5; T=2.08; p<. 05). T-tests also were conducted to examine differences in child externalizing behaviors in groups with and without a history of out-of-home placement. These results indicated significant difference between the two groups (t=2.38; p<. 05). Children without a history of out-of-home care had significantly higher levels of externalizing behavior x=76.4; SD=10.3) than children who had been placed outside the home (x=68.5, SD=13.2). Correlations between parenting stress and other factors including child age, number of adults the home, and number of children in the home were small and nonsignificant.


Results clearly show that parents who admit their children for inpatient psychiatric hospitalization report extremely high levels of parenting stress. Further, children present with clinically significant externalizing symptomatology. Results confirm the established associations between childhood externalizing and internalizing symptomatology and parenting stress. Results also suggest that families in which the child was never placed outside the home have more stressed parents and children with higher levels of externalizing behavior. This study affirms the positive role services like respite care and out-of-home placement can play in improving treatment outcome (Respite is defined as temporary short-term care provided to a disabled individual for the purpose of providing relief to parent or primary care giver). Similar findings have been found in some other studies which also support the use of respite care and temporary out-of-home placement to reduce the stress, improve the coping, and result in general improvement in quality of life for families (Chan and Sigafoos, 2002; Apolloni & Treist, 1983; Wilker et al, 1986) Authors believe that finding is especially significant in subjects of this study who seem to be more intensely affected as well least studied.


Our study supports the need for educating as well guiding parents of psychiatrically hospitalized children regarding possible benefits of temporary out of home services. It can be difficult for already overwhelmed parents to get the information and understand procedure all by themselves. But it must not be forgotten that respite care is not replacement for interventions like behavior management training, coping skills enhancement.
Our results also support the need for further research in the field.


1. Morgan, J., Robinson, D., Aldridge, J. (2002) Parenting stress and externalizing behavior: Research Review. Child and Family Social Work, 7, pp219-225.
2.McCarty, Carolyn, A., McMahon, Robert J., Conduct Problems Prevention Research Group. (2003) Mediators of the relation between maternal depressive symptoms and child internalizing and disruptive behavior disorders. Journal of Family Psychology, Vol. 17(4), pp 545-556.
3.Patterson, G.R., Forgatch, M.S. (1990) Initiation and maintenance of process disrupting single-mother families. In G.R. Patterson (Ed.), Depression and aggression in family interaction (pp209-245). Hillsdale, NJ: Erlbaum.
4.Patterson, G.R., Reid, J.B., Dishion, T.J. (1992) Antisocial boys. Eugene, OR: Castalia.
5.Wahler, R.G., & Dumas, J.E. (1989). Attention problems in dysfunctional mother child-interaction: An inter-behavioral model. Psychological Bulletin, 105,pp116-130.
6.Deater-Deckard, K. (1998). Parenting stress and child adjustment: Some old hypothesis and new questions. Clinical Psychology: Science and Practise, 5,pp314-332.
7.Takeutchi, D.T., Williams, D.R., & Adair, R.K. (1991) Economic stress in the family and children’s emotional and behavioral problems. Journal of Marriage and the Family, 53,pp1031-1041.
8. Patterson, G.R., (1988). Stress: A change agent for family process. In N. Garmezy & M. Rutter (Eds.), Stress, coping, and development in children (pp235-264). Baltimore: John Hopkins University Press.
9.Hillson, J.M.C., and Kuiper, N.A. (1994). A stress and coping model of child maltreatment. Clinical Psychology review, 13,275-294.
10.Crouch, J.L., Behl L.E. (2001). Relationship among parental beliefs in corporal punishment, reported stress, and physical child abuse potential. Child abuse and Neglect, 25,pp413-419
11.Pelham, W.E., Lang, A.R., Atkeson B., Murphy, D.A., Gnagy, E.M., Greiner, A.R.
, Hamilton, M.V., Greenslade, K.E. (1997). Effects of deviant child behavior on parental distress and alcohol consumption in laboratory interactions. Journal of abnormal child psychology, vol 25,No.5, pp413-424.
12.Milner, J.S. (2000). Social information processing and physical child abuse; theory and research. In D.J. Hansen (Ed), Nebraska symposium on motivation. Motivation and child maltreatment (vol. 45,pp39-84). Lincoln, NE: University of Nebraska Press.
13. Chan, Jeffery B., Sigafoos, Jeff (2002). Does respite care reduce parental stress in families with developmentally disabled children? Child and Youth Care Forum, 30(5), pp253-263.
14.Apollini, A.H., & Triest, G. (1983). Respite services in California: Status and Recommendations for improvement. Mental Retardation, 21, pp240-243.
15. Wilker, L.M., Hanusa, D., & Stoycheff, J. (1986). Home based respite care, the child with developmental disabilities, and family stress. In C.L. Salisbury & J. Intagliata (Eds.), Respite care: Support for persons with developmental disabilities and their families (pp243-261). Baltimore: Paul H Brookes.
16.Puotiniemi, T., Kyngas, H., Nikkonen, M. (2001). Factors associated with the coping of parents with a child in psychiatric inpatient care. International Journal of Nursing Practice; 7:298-305.
17.Steven G., & Featherman, D.L. (1981). A revised socioeconomic index of occupational status. Social Science Research, 10,pp 364-395.
18. Abidin, R.R., (1995) Parenting Stress Index: Professional Manual. 3rd edition. Psychological Assessment Resources Inc., New York.

First Published in November 2007

Copyright Priory Lodge Education Limited 2007

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