are maternal anxiety/depression/insomnia symptoms and
TRANSCRIPT
Are maternal anxiety/depression/insomnia symptoms and executive functioning related to
perceived parenting stress at one year postpartum?
Ronny Di Iorio, 40889
Master Thesis in Psychology
Supervisors: Mira Karrasch, Matti Laine & Elisabeth Nordenswan
Faculty of Arts, Psychology and Theology
Abo Akademi University
ABO AKADEMI – FACULTY OF ARTS; PSYCHOLOGY AND THEOLOGY
Summary of Master’s Thesis
Subject: Psychology
Author: Ronny di Iorio
Title: Are maternal anxiety/depression/insomnia symptoms and executive functioning related to
perceived parenting stress at one year postpartum?
Supervisors: Mira Karrasch (Abo Akademi), Matti Laine (Abo Akademi) and Elisabeth
Nordenswan (Abo Akademi/ FinnBrain)
Abstract: Parental stress can have severe repercussions on the mother’s and the child’s health, and
on the everyday functioning of the family. Psychiatric symptoms of the mother, especially anxiety
and depression, are well-known predictors for parental stress. There are also indications that sleep
disturbance of the parent is associated with parental stress. On the other hand, the relationship
between maternal executive functions and parental stress is less clear. The present study
investigated whether maternal depression, anxiety, sleep disturbance, and executive functions are
associated with maternal parental stress. The sample (n = 57) was drawn from the FinnBrain Birth
Cohort study. Symptoms of depression, anxiety and sleep disturbance were measured with self-
report questionnaires (EPDS, SCL-90, AIS). Executive functions were assessed with five tasks
from a computerized neuropsychological test battery (Cogstate). The dependent variable, mothers’
parental stress, was evaluated by a questionnaire (SPSQ). Multiple regression analyses showed that
depression and anxiety was positively associated with the SPSQ sum score and the subscale
Incompetence. Higher rates of sleep disturbance were related to lower subjective estimation on the
parental stress subscale Health .Worse executive functioning was related to the subjective
estimation of more dysfunctional relationships within the family. The results highlight the
importance of detecting potential psychiatric symptoms to reach out to mothers at risk for
developing parental stress, and indicate that different aspects of maternal well-being and
functioning can be related to different aspects of parental stress.
Keywords: Mother, parental stress, depression, anxiety, sleeping disturbance, executive functions
Date: 6.5.2021 Number of pages: 44
ABO AKADEMI – FAKULTETEN FOR HUMANIORA, PSYKOLOGI OCH TEOLOGI
Abstrakt for avhandling Pro Gradu
Ämne: Psykologi
Författare: Ronny di Iorio
Titel: Är moderns symtom av depression, ångest och sömnsvårigheter samt exekutiva funktioner
relaterade till upplevd föräldraskapsstress tolv månader postnatalt?
Handledare: Mira Karrasch (Abo Akademi), Matti Laine (Abo Akademi) och Elisabeth
Nordenswan (Abo Akademi/ FinnBrain)
Abstrakt: Föräldraskapsstress kan ha allvarliga följder på moderns och barnets hälsa samt
familjens fungerande i vardagen. Både ångest och depression är psykiatriska symtom hos modern
som relaterats till föräldraskapsstress. Sömnsvårigheter har likaså relaterats till föräldraskapsstress.
Däremot finns det inte mycket forskning om sambandet mellan moderns exekutiva funktioner och
föräldraskapsstress. I denna studie undersöktes sambandet mellan depression, ångest,
sömnsvårigheter, exekutiva funktioner och föräldraskapsstress. Samplet (n = 57) till studien
utgjordes av ett delsampel från the Finnbrain Cohort Study. Symtom av depression, ångest och
sömnstörningar bedömdes med frågeformulär (EPDS, SCL-90, AIS). Exekutiva funktioner testades
med deltest från det datoriserade testet Cogstate. Den beroende variabeln föräldraskapsstress
bedömdes med frågeformuläret SPSQ. Multipelregressionsanalysen visade att depression och
ångest hade ett samband med föräldraskapsstress (SPSQ) samt delskalan Inkompetens. Högre grad
av sömnsvårigheter förknippades också med högre grad av föräldraskapsstress på delskalan för
upplevd hälsa. Lägre poäng för exekutiva funktioner förknippades också med högre
föräldraskapsstress på delskalan för relationer inom familjen . Resultaten indikerar vikten av att nå
ut till mödrar med psykiatriska symtom som löper risk för att utveckla föräldraskapsstress, och
antyder att olika aspekter av mödrars välmående och fungerande kan vara relaterade till olika
aspekter av föräldraskapsstress.
Nyckelord: Moder, föräldraskapsstress, depression, ångest, sömnstörning, exekutiva funktioner
Datum: 6.5.2021 Sidoantal: 44
Acknowledgments
Turku, May 2021
To begin I would like to thank the Finn Brain cohort study group for giving me the opportunity to
work on the project. I would also like to thank all the mothers taking part in the study who offered
their time to take part in the cognitive measurements and who had the patience to fill in all of the
questionnaires that was used for the study. I would also like thank my supervisors at Åbo Akademi
professor Matti Laine and docent Mira Karrasch for their comments, thoughts, support and smooth
co-operation. Further, I would like to thank my unbelievably helpful supervisor at the Finnbrain
project, M.S., doctoral student Elisabeth Nordenswan. I thank you for believing in me and the
process and for your enthusiasm. Especially I would like to thank you for your emotional support
during these rather challenging years and your flexibility with the study and the timetables. I could
not have wished for a better supervisor. Lastly I would like to thank family and friends for all the
love and support.
Content
1. Introduction .................................................................................................................................... 1
1.2 Postpartum depression and anxiety .............................................................................................. 3
1.3 Sleep disturbance and parenthood ................................................................................................ 4
1.4 Executive functioning and motherhood ......................................................................................... 4
2. Aims of the study ............................................................................................................................ 5
3. Methods ........................................................................................................................................... 5
3.1 Participants .................................................................................................................................. 5
3.2 Measures ..................................................................................................................................... 6 3.2.1 Edinburgh Postnatal Depression Scale (EPDS) and The Symptom Checklist-90 Anxiety Subscale (SCL-90)..... 6 3.2.2 Athens Insomnia Scale (AIS) ............................................................................................................................. 7 3.2.3 Cogstate ........................................................................................................................................................... 8 3.2.4 The dependent variable: Swedish Parenthood Stress Questionnaire (SPSQ) .................................................. 9
3.3 Procedure .................................................................................................................................. 10
3.4 Data analysis .............................................................................................................................. 10
4. Results ........................................................................................................................................... 11
4.1 Descriptive statistics ................................................................................................................... 11
4.2 Results from the multiple regression analyses ............................................................................. 13
5. Discussion ...................................................................................................................................... 16
Swedish summary/Svensk sammanfattning: ................................................................................. 18
Introduktion .................................................................................................................................... 18
Syftet med studien ........................................................................................................................... 20
Metod ............................................................................................................................................. 20
Resultat ........................................................................................................................................... 22
Diskussion ....................................................................................................................................... 23
Slutsats ............................................................................................................................................ 24
References ......................................................................................................................................... 26
6. Appendix ....................................................................................................................................... 35
1
1. Introduction
Becoming a parent is probably one of the most demanding tasks in human life. Parenting can be
challenging even when the child is healthy and life is hassle-free, but when stress factors come into
play, the mothers health and the child’s development may be at risk. Parental stress can be defined
as the experience of stress caused by the demands in everyday family life (Deater-Deckard, 1998).
Johannsson, Svensson, Stenström & Massoudi (2017) emphasizes the importance of paying
attention to parents’ mental health because of the negative effects that parental stress can have on
the child’s early development. Different factors can contribute to parental stress, including
psychiatric symptoms of the parents, available economic resources, the child’s sleeping pattern,
maternal age and education (Hildingsson & Thomas, 2014; Österberg & Hagekull, 2000). Östberg,
Hagekull and Hagelin (2007) highlight that parental stress is also relatively stable over time.
It has been argued that parental stress may have a vast impact on child development, affecting
cognitive, socio-emotional behavioral and psychomotor development (Beeglhy, Wheinberg, Olson,
Kernan, Riley, Tronick, 2002; Austin, Tully & Parker, 2007; Kingston, Tough & Whitfield, 2012).
The most severe form of parental stress is the relatively recently coined condition of parental
burnout where parents experience feelings of overwhelming exhaustion of parenthood, feelings of
emotional disconnection to the child, and experiences of parental ineffectiveness. Parental burnout
may also result in neglecting the child, being violent towards the child and in increasing escape
ideation (Mikolajczak., Gross, & Roskam, 2019). To enable prevention of the negative effects of
parental stress, it is crucial to better understand which factors can increase the risk for parental
stress during early parenthood. The present study examined whether four different factors,
depression, anxiety, sleep disturbance, and executive functions, are associated with parental stress
at one year postpartum.
1.1. Parental stress
Deater‐Deckard (1998) defines parental stress as an adverse psychological reaction to the demands
of being a parent. According to Deater-Deckard (1998), parental stress includes several
simultaneously occurring factors such as a) the task demands of parenting, b) the quality of parent-
child interaction, c) the parents’ psychological well-being and behavior, and d) the child’s
psychosocial adjustment. Parental stress could also be seen as a conflict between the demands
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defined by the parent and the situations in real life (Scher & Mayseless, 2000; Östberg et al., 2000).
A systematic review by Kingston et al., (2012) concluded that maternal stress during the prenatal
and postnatal period has an impact on child development. Especially postpartum maternal stress
was associated with socio-emotional and cognitive child development problems. In a study by
Pereira, Vickers, Atkinson, Gonzales, Wekerle & Levitan (2012), high levels of parenting stress
among mothers were associated with the mothers showing less warmth and paying less attention to
the child’s needs. Everyday parental stress might also impact the interaction between the parent and
the child, and also affect the child’s future mental health (Belsky, Woodworth & Crnic, 1996;
Crnic, Gaze & Hoffman 2005). Moreover, parental stress may result in feelings of being less
involved in the child’s life, and it may also lead to a harder and more authoritarian parenting style
(Deater-Deckard, 2004). Problems in attaching to the child, keeping interpersonal contact and
providing sensitive caregiving are also associated with parental stress (Aktar & Bögels, 2017;
Grace, Evindar, & Stewart, 2003; Kingston, et al., 2012; Tronick & Reck, 2009).
Hildingson & Thomas (2013) highlights that parental stress has mainly investigated among parents
who are at high risk to experience parental stress, such as parents with a history of psychopathology
and children with special needs. Studies with more typical samples would thus be needed to
determine whether parental stress has similar effects in less burdened parents. Here the mothers are
of particular interest: Hildingson et al., (2013) showed also that mothers to one-year-old children
score higher on three of the five subscales on the Swedish Parenting Stress Questionnaire (SPSQ)
than the fathers.
Factors that can contribute to parental stress are numerous. They include daily tasks and everyday
problems and situations in family life (Crnic & Low, 2002). Income worries, baby’s health
problems, lack of confidence in motherhood and a problematic relationship with one’s partner are
all factors contributing to the unhappiness of the mother and parental stress (Romito, Saurel-
Cubizolles & Lelong, 1999). Parental stress has also been related to divorce (Widarsson, Nohlert,
Öhrvik & Kerstis, 2017). Furthermore, in a study by Österberg, et al., (2000), older mothers
experienced more parental stress. An increased number of children and higher education are also
associated with increased parental stress, even if the findings concerning associations between
education and parental stress are inconsistent (Perren, von Wyl, Burgin, Simoni & von Klitzing,
2012; Skreden, Skari, Malt, Pripp, Björk, Faugli & Emblem, 2012). According to Huizink & De
Rooji (2017), maternal coping abilities may be affected by the way mothers perceive the demands
3
of motherhood postpartum. A discrepancy between these two factors may produce biological,
cognitive and behavioral outcomes that affect negatively early motherhood by increasing stress.
Physiological and psychological changes prenatally and postnatally are also factors that make the
transition to motherhood challenging and may increase parental stress (Teixeira, Figueiredo, Conde,
Pacheco & Costa, 2009). The stress-provoking role of the affective and physiological risk factors
probed in the present study, namely depression, anxiety and sleep disorders, is handled in more
detail in the following chapters.
1.2 Postpartum depression and anxiety
Depression is the major non-obstetric reason for hospitalization for women between the age 18-44
(Jiang, et al., 2002). Psychological anxiety and depression during pregnancy are well known
phenomena which may last for several years after childbirth (Priest, Austin, Barnett & Buist, 2008;
Woods & Joseph, 2010). Postpartum depression is found in up to 19.2% of the mothers when both
minor and major depression criteria are employed (Gavin, Gaynes, Lohr, Meltzer-Brody, Gartlehner
& Swinson, 2005). The most frequent time for onset of depression is the childbearing period, and
maternal depression is likely to also influence the infant and the family (Goodman, 2007; O’Hara,
1995). The depressed behavior of the mother impacts the infant, resulting in less playing, higher
levels of insecure attachment and withdrawal behavior, lack of positive affect and being less content
(O’Hara, 2009). In a meta-analysis by O’Hara and Swain (1996), postpartum depression was found
to be triggered by stressful life-events and a history of psychiatric and mental health problems.
According to Perren, von Wyl, Burgin, Simoni and von Klitzing (2012), psychiatric symptoms
during pregnancy increase parental stress, with a peak appearing at one year postpartum.
Furthermore, postpartum depression is the strongest predictor for parental stress, and mothers with
depression experience more parental stress than mothers without depression (Gelfland, Teit &
Radin, 1992; Leigh &Milgrom, 2008). Sepa, Frodi, & Ludvigsson (2004) also found that depression
is related to parental stress and that parental stress leads to feelings of incompetence as a parent.
With regard to anxiety, Fairbrother, Janssen, Anthony, Tucker & Young, (2016) estimated that
around 15% of mothers are at risk for an anxiety disorder during pregnancy and during the postnatal
period. Anxiety among mothers during the prenatal and postpartum period may have negative
effects on the development of the child, maternal caregiving, and attachment formation (Huizink &
de Rooij, 2018; Korja, Nolvi, Grant & McMahon, 2017). Prenatal anxiety has been identified as a
4
predictor for parental stress (Misri, Kendrick, Oberlander, Norris, Tomfohr, Zhang, & Grunau,
2010). It is common during early parenthood that symptoms of depression and anxiety may exist
simultaneously and should therefore be assessed together (Canário & Figueiredo, 2017).
1.3 Sleep disturbance and parenthood
Mindell, Sadeh, Kwon, & Goh (2015) observed that almost 30% of mothers experience that their
functioning during day time was impacted by the sleep of their under three-year-old child. There is
evidence that sleep disturbance has a negative impact on executive functioning which in turn is
associated with a more harsh parenting style (Ballesio, Aquino, Kyle, Ferlazzo, & Lombardo,
2019, Chary, McQuillan, Bates, & Deater-Deckard, 2020). There seems to be differences among
caregivers in how well they cope with own sleep disturbance caused by the child’s sleeping
problems, and for some parents it may lead to parental stress (Meltzer & Mindell, 2007; Mindell,
Sadeh, Kwon, & Goh, 2015). Thunström (1999) asserts also that parental stress is associated with
severe sleeping problems in young children. The same conclusions were drawn by Sepa, et al.,
(2004), too.
1.4 Executive functioning and motherhood
Executive functioning (EF) refers to higher-order cognitive control functions that can be divided
into the domains of inhibition, working memory updating and attentional set-shifting (Friedman,
Miyake, Young, De Fries, Corley & Hewitt, 2008). According to Miyake & Friedman (2012), EF
has a central role in regulating cognitions, emotions and behavior. In a review of associations
between maternal cognitive and emotional control capacities and parenting, Crandall, Deater-
Deckard, and Riley (2015) concluded that maternal self-regulation capacity (including EF) is
crucial for well-functioning child rearing. Maternal EF seems to moderate the maternal caregiving
behavior in stressful situations (Sturge-Apple, Jones, & Suor, 2017). Deficits in EF are shown to
moderate the association between harsh parenting patterns and challenging child behavior, so that
mothers with low working memory capacity show more harsh parenting when the child’s behavior
is challenging (Deater-Deckard, Sewell, Petrill & Thompson, 2010; Deater-Deckard, Wang, Chen
& Bell, 2012). EF can also be related to how one experiences stress and stress-related symptoms
(Williford, A, Calkins & Keane 2007). However, Pechtel & Pizzagali (2011) highlight the lack of
5
larger-scale studies in the area of parental cognitive functioning. Thus, the possible association
between executive functions and parental stress has not been investigated.
2. Aims of the study
This study examined how maternal depression, anxiety, sleep disturbance, and executive functions
are associated with perceived parental stress at one year postpartum. Based on the earlier literature
reviewed above, it was hypothesized that symptoms of depression, anxiety, and sleep disturbance,
as well as lower executive functioning would be related to increased maternal parenting stress. Due
to the negative impact of parental stress on the child’s development, it is crucial to better understand
which circumstances increase the risk for parental stress during early parenthood, as this would
enable early interventions.
3. Methods
3.1 Participants
The present study was conducted as a part of the Finnbrain Birth Cohort Study (www.finnbrain.fi).
Starting in 2011 at the University of Turku in Finland, the Finnbrain Birth Cohort Study is an
ongoing study with approximately 4000 participating families. The aim of the Finnbrain Birth
Cohort Study is to examine the effects of early life stress on child development and health
(Karlsson, Tolvanen, Scheinin, Uusitupa, Korja, Ekholm & Karlsson, 2018). The families were
recruited through maternal welfare clinics in Southwest Finland. Sufficient knowledge of Finnish or
Swedish and a normal ultrasound screening result at gestational week 12 were required for
participation.
For the current study, a sub-sample of 77 mothers was drawn from the Finnbrain birth cohort.
which explores maternal cognition and child self-regulation development. The mothers were tested
during pregnancy with the Cogstate testbattery. At one year postpartum the mothers participated in
a study visit, which included computerized EF measures, verbal intelligence tasks, and depression,
anxiety and sleep disturbance questionnaires.
All of the 77 mothers participated in the study-visit, but only 57 returned the questionnaire
assessing parenting stress, which was sent home to the participants. For the present study both the
6
data from the study visit and the home sent questionnaire was necessary and therefore only 57
participants were included. The demographic characteristics of the study sample are presented in
Table 1. All data included in this study was collected at one year postpartum.
Table 1.
Demographic characteristics of the study sample
Total sample N = 57
Mean Age (range) 32.8 (24-46)
Education (%) Secondary diploma or lower 10.7
Polytechnic 44.6
Undergraduate or higher 44.7
Number of children (%) 0 57.9
1 26.3
2 10.5
3 5.3
3.2 Measures
3.2.1 Edinburgh Postnatal Depression Scale (EPDS) and The Symptom Checklist-90 Anxiety
Subscale (SCL-90)
To measure postpartum depression among mothers, the Edinburgh Postnatal Depression Scale
(EPDS) was employed. EPDS is a widely used and well-studied subjective rating scale, measuring
depression symptoms in the last seven days (Cox, Holden, & Sagovsky, 1987; Gibson, McKenzie‐
McHarg, Shakespeare, Price & Gray 2009). The EPDS is also the most frequently used instrument
when measuring postpartum depression (Boyd, Le, & Somberg, 2005). The scale includes 10
7
questions. It is scored on a 4-point Likert scale (0 to 3 per question), with a total score between 0
and 30. Eleven points or more on the EPDS scale indicates diagnosable depression (Smith-Nielsen,
Matthey, Lange, Skovgaard Vaever, 2018).
The Symptom Checklist Scale-90 Anxiety Subscale (SCL-90) is a subjective rating scale and its
anxiety subscale is used for evaluation of general anxiety. The anxiety subscale consists of 10 items
scored on a 5-point Likert scale from 0 to 4. Thus, the range of the total sum for the subscale is 0 –
40. The anxiety subscale has been used both clinically and in research and is considered a valid and
reliable measurement in both settings, demonstrating good internal consistency (Derogatis et al.,
1973). The cut-off score for a healthy German student population was put at 7.5 point (Schmitz,
Hartkamp & Franke, 2000).
In the present study, EPDS and SLC-90 were combined into a sum score. As noted in the
introduction, depression and anxiety frequently coexist during early parenthood, and are often
jointly assessed. EPDS and SCL-90 co-varied strongly in our sample (r = .75, p < 0.01), allowing
them to be combined into a depression and anxiety composite score in order to reduce the amount
of independent variables and regression models. The EPDS and SCL-90 variables were
standardized by setting the sample mean in each task to zero with a spread of ±1 standard deviation.
The standardized variables were combined into a mean score, which was again standardized.
3.2.2 Athens Insomnia Scale (AIS)
The AIS is an instrument developed for the diagnosis of insomnia based on the ICD-10 criteria. It is
a self-administered questionnaire with a total of 8 items. The AIS assesses difficulty with sleep
induction, awakening during night time and early morning, overall sleep quality and the total
amount of sleep. The items are scored on a 4-point Likert scale, ranging from 0 to 3 (0 = “no
problem at all and 3 = “very serious problem”) (Soldatos, Dikeos, & Paparrigopoulos, 2000). Six
points or more indicates sleeping problems. Earlier research has indicated that the AIS has a good
internal consistency and external validity (Soldatos, Dikeos, & Paparrigopoulos 2003). The AIS
variable was standardized by setting the mean to zero with a spread to ±1 standard deviation.
8
3.2.3 Cogstate
The Cogstate computerized neuropsychological test battery measures a broad range of cognitive
abilities, including executive functioning, learning, memory, visuomotor functioning, processing
speed, attention and social cognition (Maruff, Thomas, Cysique, Brew, Collie, Snyder & Pietrzak,
2009). The Cogstate battery is used in several settings, e.g. in the clinic, in academic research,
workplaces and sports (Crook, Kay & Larrabee, 2009). The battery is suitable for repeated
measurements as practice effects are negligible (Hammers, Spurgeon, Ryan, Persad, Heidebrink,
Barbas & Giordani., 2011).
The participants completed 12 Cogstate tasks in the Finnbrain Birth Cohort Study. Based on a
previous factor analytic study (Nordenswan et al., 2020), five of these tasks thought to best measure
EF were included in the present study. Thus, the following Cogstate tasks were used: The
Continuous Paired Associate Learning Test (CPAL) The Groton Maze Learning Test (GML), The
International Shopping List Test (ISL), The Set-Shifting Test (SETS) and The Two Back test
(TWOB). The outcome variables for the Groton Maze Learning Test and for the Continuous Paired
Associate Learning Test were reversed, so that a higher value equaled a better result for all the
Cogstate tasks. The task scores were standardized, combined into an EF mean score, and re-
standardized. The five selected tasks are described below in more detail.
The Continuous Paired Associate Learning Test (CPAL) measures visual and episodic memory,
learning and executive functions (Harel, Darby, Pietrzak, Ellis, Snyder & Maruff, 2011). In this
task, the participant is to remember the location of the figures shown on the computer screen.
Afterwards, the participant recalls the correct location for each figure shown at the center of the
screen. To begin, the participant needs to remember the position of only two figures. Next the
participant will be taught eight more figures and their locations. The outcome variable is the
amount of errors made during the first test round.
The Groton Maze Learning Test (GML) is a task where the participant needs to find a hidden
pathway of 28 steps and 11 turns in a 10x10 grid of tiles. The participant moves from the upper
leftcorner to the lower right corner by clicking the tiles, which show green if the choice of the path
is correct, or red if the choice is incorrect. In order to succeed in the test, the participant has to
comply to the following rules: do not move backwards, do not touch the same tile twice, do not
move diagonally, and return to the last correct tile when an error is made. GML measures are
thought to tap executive functions and visuospatial memory (Pietrzak, Maruff, Mayes, Roman, Sosa
9
& Snyder, 2008). The outcome variable used here was the amount errors made during the first test
round.
The International Shopping List (ISL) is a test where the participant needs to memorize a shopping
list of 12 items. The shopping list is read out loud by the test leader, and the task for the participant
is to recall the items in any order. The shopping list will be read out by the test leader altogether
three times, with pauses between the trials. The outcome variable is the number of correctly recalled
items after the first test round. The test measures verbal memory (Cogstate, 2016). The test has
showed strong correlations with the Hopkins Verbal Learning Test Revised and therefore good
convergent validity (Pietrzak, Maruff & Snyder, 2009).
The Set-Shifting Test (SETS) is a task similar to the Wisconsin Card Sorting Test which is used to
assess working memory, suppression of irrelevant information, inhibition of prepotent responses,
shifting, planning, monitoring and controlling behavior (Rhodes, 2004). The main idea with the test
is to figure out if the playing card shown on the computer screen matches the target stimulus that is
chosen by the computer. If the participant’s answer is wrong, the target stimulus will not be
changed until the participant gives the correct answer. To complete the task, the participant will
need to give 120 correct answers (Cogstate, 2011). The outcome variable is the arcsine root of the
proportion of correct responses.
The Two Back Test (TWOB) measures working memory updating. The participant is asked “is the
card the same as that shown two cards ago?”, and each trial is responded by yes or no. The
participant needs to work as fast and accurately as possible. When 32 correct responses are reached,
the task ends (Cogstate, 2011). The outcome variable is the arcsine root of the proportion of correct
responses.
3.2.4 The dependent variable: Swedish Parenthood Stress Questionnaire (SPSQ)
SPSQ is a self-report questionnaire with 35 questions that measures the experienced burden/stress
that parents relate to their parenthood. The questionnaire is mainly based on the Parenting Stress
Index by Abidin (1990), with the questions being selected from the following subscales: Sense of
Competence (INCOMP), Restriction of Role (ROLER), Social Isolation (SOCISOL), Relation with
Spouse (SPOUSE) and Parent Health (HEALTH). According to Österberg et al. (2007), the
INCOMP subscale measures the parent’s experiences of incompetence as a parent. The subscale
ROLER measures the parent’s experience of not being able to focus on own interests and activities
10
because of parenthood. The subscale SOCIOSOL describes the parent’s relationships outside of the
family. The subscale SPOUSE measures the relationships in the family, and the last subscale
HEALTH measures physical health associated with parenthood. The items are scored on a 5-point
Likert scale, ranging from 1 to 5. Higher scores on the questionnaire indicate more parenting stress.
The participant’s score is the mean of all responses. The SPSQ has shown good reliability and
validity for measuring maternal stress in mothers of young children (Östberg, Hagekull, &
Wettergren, 1997).
3.3 Procedure
Ethical permission for the whole FinnBrain Study was obtained from the Joint Ethical committee of
the Turku University Hospital and the University of Turku. The participants were required to sign a
written informed consent before participation. The cognitive assessment was executed on a laptop
computer during a study visit in a quiet room, and guided by a graduate student. During the same
study visit, participants filled out questionnaires assessing symptoms of depression, anxiety, and
sleep disturbance. The participants filled out the questionnaire assessing parenting stress at home.
All assessments were completed at one year postpartum.
3.4 Data analysis
The statistical analyses were performed using the IBM SPSS 25 Statistical Program for Social
Sciences. Descriptive statistics (means, standard deviations and ranges) were calculated for the
SPSQ sum score and its subscales, the Cogstate tasks, EPDS, SCL and AIS. The Cogstate results
were compared with normative data for healthy adults (Cogstate, 2014), and the EPDS, SCL and
AIS results were compared with their respective cutoff values indicating diagnosable depression,
anxiety and insomnia, respectively. The Cogstate completion pass rate and integrity pass rate were
calculated.
The participants’ age, education level and number of children were considered as potentially
relevant control variables. There were no significant associations between SPSQ sum score and age
(r = .13, p < .34), education (r = .18, p < .90) or number of children (r = .037, p < .78). When
examining correlations between the control variables and SPSQ subscales, age was correlated with
the subscales SPOUSE (r = .29, p < .03), and HEALTH (r = .28 p, < .04), and number of children
11
was correlated with the subscale HEALTH (r = .30, p < .02). These two control variables were
employed in the corresponding analyses.
Six multiple regression analyses were conducted, one for the sum score of SPSQ and five for the
separate SPSQ subscales. The first multiple regression analysis was performed with the SPSQ sum
score as the dependent variable, and the EPDS/SCL composite, the Cogstate EF composite, and AIS
as predictors. The predictors were entered simultaneously to the model to examine their single and
combined effects on SPSQ.
In the next five regression analyses, the predictor variables EPDS/SCL composite, Cogstate EF
composite, and AIS were all entered simultaneously to the model, to examine their single and
combined effects on the five different subscales of SPSQ, which were the outcome variables. For
the SPSQ subscales SPOUSE and HEALTH, the control variable age was also entered to the
models and for the subscale HEALTH the control variable number of children was included.
4. Results
4.1 Descriptive statistics
The means, standard deviation and range of the questionnaires and cognitive tests are presented in
Table 2. The SPSQ results of the present sample fell within the normal range (±1SD) of normative
data from Swedish mothers of one-year-old children. The present mothers scored low on the
depression scale, with only 12.3% of the mothers reporting depression symptoms exceeding the cut-
off value from 11 points, for a diagnosable disorder. Concerning anxiety, 13.2% of the mothers
reported moderate or severe anxiety symptoms when employing the cut-off of 7.5 points (Schmitz,
Hartkamp & Franke, 2000). On the AIS scale, 15.8% scored above the cut-off score. The Cogstate
task performances of the present sample fell within the normal range (±1SD) of Cogstate normative
data for the age groups of 18-34 and 35-49. It is noteworthy that the normative sample for the
Cogstate test CPAL is very small (Canário & Figueiredo, 2017). The Cogstate completion pass rate
was 100% for all tasks except for TWOB where one score was excluded. The Cogstate integrity
pass rate was 100% for all tasks.
12
Table 2.
Mean values, standard deviations and ranges for the questionnaires and cognitive tests.
Variable Mean SD Range
SPSQ 2.57 .51 1.68-3.62
INCOMP 2.21 .75 1.00-4.27
ROLER 3.69 .60 2.29-5.00
SOCIOSOL 1.97 .60 1.00-3.29
SPOUSE 2.59 .92 1.00-5.00
HEALTH 2.59 .80 1.50-5.00
EPDS 4.80 4.76 0-16
SCL-90 2.89 3.83 0-17
AIS 6.25 3.90 0-18
COGSTATE
CPAL 11.65 10.63 0-35
GML 8.56 4.36 1-27
ISL 7.89 1.63 4-12
SETS 1.24 .08 .98-1.32
TWOB 1.31 .16 .83-1.57
Note. SPSQ= Swedish Parenting Stress Questionnaire, INCOMP= SPSQ subscale Incompetence,
ROLER= SPSQ subscale Role Restriction, SOCIOSOL= SPSQ subscale Social Isolation,
SPOUSE= SPSQ subscale Spouse Relationship, HEALTH= SPSQ subscale Health, EPDS=
Edinburgh Postnatal Depression Scale, SCL-90= The Symptom Checklist-90 anxiety subscale,
AIS= Athens Insomnia Scale, CPAL= The Continuous Paired Associate Learning Test, GML= The
Groton Maze Learning Test, The International Shopping List Test, SETS= The Set-Shifting Test,
TWOB= The Two Back Test.
13
4.2 Results from the multiple regression analyses
Prior to the multiple regression analyses, multicollinearity was checked and was not a concern for
any of the models (range for Tolerance .448-.958., range for VIF 1.0-2.23). The first multiple
regression analysis included the predictor variables EPDS/SCL-90, Cogstate EF composite, and
AIS, and the dependent variable was the SPSQ sum score. All predictors were entered
simultaneously to the model. The analysis revealed that the model was statistically significant, with
the predictors accounting for 36 % of the variation on the SPSQ sum score, F(3,53)=10.017,
p<.001, R2= .36. Concerning the single predictors, EPDS/SCL-90 was positively associated with
SPSQ sum score, β=0.45, t(53)=2.76, p=.01, with the participants reporting higher scores for
depression and anxiety and also higher amount of parental stress.
In the next five models, the predictor variables listed above were regressed to the subscales of
SPSQ. In these models, at first the control variables were fed in, followed by the predictors. Thus,
the control variables were entered only for the subscales SPOUSE and HEALTH.
With the SPSQ subscale INCOMP as the dependent variable, the analysis revealed a statistically
significant model where the predictors accounted for 31% of its variation, F(3,53)=7.796, p=.000,
R2= .31. Concerning the single predictors, EPDS/SCL-90 showed a positive correlation with the
dependent variable, β=0.114, t(498)=2.539, p=.011, indicating that higher levels of depression and
anxiety symptoms were related to higher scores (more stress) on the subscale INCOMP.
The model employing the SPSQ subscale SOCIOSOL as the dependent variables turned out to be
also significant F(3,53)=2.991, p=.039, R2= .15. In this case, however, none of the single predictors
were significant. The same applied for the model with the subscale ROLER as the dependent
variable F(3,53)=3.639, p=.018, R2= .17.
With the SPSQ subscale SPOUSE as the dependent variable, the first analysis revealed a
statistically significant model where the predictors in this case accounted for 13.8 % of variance
F(2,54)=4.332, p=.018, R2= .138. The final model incorporating both the relevant control variables
and the variables of interest was statistically significant, with the predictors accounting for 29.2 %
of the variance F(5,51)=4.214, p=.017, R2= .292. The predictor variable Cogstate EF composite
showed a significant negative correlation with the subscale SPSQ-SPOUSE β=.35, t(51)=2.908,
p=.005, with participants scoring lower on the EF composite scoring higher (i.e., showing more
stress) on the subscale SPOUSE.
14
With the SPSQ subscale HEALTH as the dependent variable, the first analysis revealed a
statistically significant model where the predictors in this case accounted for 11.4 % of the variance
(2,54)=3.478, p=.038, R2= .114. The final model with both the relevant control variables and the
variables of interest reached statistical significance, with the predictors accounting for 38% of the
variance F(5,51)=6.257, p=.00, R2= .38. The control variable number of children β=.27, t(51)=2.19,
p=.03 and AIS β=.34, t(51)=2.61, p=.01 showed both significant positive correlations with the
subscale HEALTH.
15
Table 3.
Summary of the multiple regression analyses on the impact of age, number of children, EPDS & SCL-90, AIS and
Cogstate results on SPSQ sum score and the SPSQ subscales. For each analysis, the dependent variable is bolded.
Variable
R2
R2∆
F∆
F∆
p-value
B β
t B
p-value
95%
Confidence
interval for B
SPSQ sum score
EPDS&SCL
Cogstate
AIS
.36
.36
10.02
.000
.23
-.05
-.09
.45
-.10
.17
2.76
-.87
1.06
.01
.39
.29
.06/.40
-.16/.06
-.08/.26
INCOMP
EPDS&SCL
Cogstate
AIS
.31
.27
7.80
.000
.39
.10
.03
.52
.13
.04
3.05
1.11
.26
.00
.27
.80
.13/.65
-.08/.27
-.22/.29
ROLER
EPDS&SCL
Cogstate
AIS
.17
.12
3.63
.02
.19
-.03
.11
.28
-.04
.16
1.52
-.31
.84
.14
.76
.41
-.06/.45
-.20/.15
-.15/.36
SOCIOSOL
EPDS&SCL
Cogstate
AIS
.15
.10
2.99
.04
.19
-.03
.11
.28
-.04
.16
1.52
-.31
.84
.14
.76
.41
-.06/45
-.20/15
-.15/.36
SPOUSE
Step 1
Children
Age
Step 2
Children
Age
EPDS&SCL
Cogstate
AIS
.14
.29
.11
.22
4.33
3.70
.02
.02
.12
.07
.18
.05
.15
-.32
.02
.15
.03
.17
.03
.16
-.35
.02
.80
2.18
1.28
1.51
.91
-2.91
.10
.43
.03
.21
.14
.37
.005
.92
-.18/.41
.01/.13
-.10/.11
-.02/.11
-.18/.47
- .55/-.10
-.31/.34
HEALTH
Step 1
Children
Age
Step 2
Children
Age
EPDS&SCL
Cogstate
AIS
.11
.38
.08
.32
3.48
7.30
.04
.00
.20
.04
.25
.08
-.09
-.01
.34
.22
.18
.27
.09
.12
-.01
.34
1.53
1.25
2.19
.69
.71
-.09
2.61
.13
.22
.03
.50
.48
.93
.01
-.06/.46
-.02/.09
.02/.47
-.03/.07
-.17/.35
-.19/.17
.08/.61
Note. N =57, = p < .05, = p < .001
16
5. Discussion
The present study hypothesized that higher scores on scales measuring depression, anxiety and
sleep disturbance, and lower scores on tests measuring executive functions, would be associated
with more parental stress at 12 months postpartum. The results were in line with the hypothesis by
showing several significant associations between the three predictors of interest and parental stress
at 12 months postpartum, depending on which aspect of parental stress was analyzed. As what
follows, the observed associations are discussed in more detail.
Depression and anxiety showed the most powerful associations, being the only significant predictor
to the sum score of the SPSQ and to the INCOMP subscale. These findings are in line with earlier
studies as anxiety and depression have been found to predict general parenting stress (Perren, et al.,
2012). The association between depression/anxiety and the subscale measuring feelings of
incompetence as a parent is not surprising as feelings of guilt and shame are central to depressive
symptomatology. The present results highlight the importance to screen mothers’ psychiatric
symptoms during the postpartum period. Regarding the association between depression, anxiety and
incompetence, it may be that symptoms of depression of the mother produces experiences of
incompetence as a parent due to a negative view of oneself. Another possibility is that feelings of
incompetence strengthen the symptoms of depression (Psouni & Eichbichler, 2020).
Executive functions were associated only with the SPSQ subscale SPOUSE. This subscale is
supposed to target the relations inside of the family. Associations between executive functions and
parental stress have not earlier been seen in the scientific literature. The associations between
executive functions and the subscale Spouse may be related to the fact that parenthood is more
demanding during the early years in parenthood. The demanding time of parenthood may also
impact the relationship between the parents and there for be more demanding on executive
functions. Eakin et al (2004) found that adults with Attention-Deficit/Hyperactivity Disorder (in
which compromised EFs are a central feature) reported significantly poorer overall marital
adjustment and more family dysfunction than healthy controls, exemplifying that poorer EFs can be
associated with poorer spousal relationships.
One possible explanation why there was not any further associations found between executive
functions and parental stress may be cause of the characteristics of the Cogstate tests. The Cogstate
tests are not unmitigated measurements of executive functions and could be more described as a
17
mixture of executive functioning and learning measurement. In addition, computerized tests done
during a study visit do not necessary measure the same dimensions of executive functioning as
everyday multitasking.
There was also a significant association between sleep disturbance and the SPSQ subscale Health
with more sleep problems being related to worse health scores, but not with the sum score of SPSQ.
The subscale HEALTH taps self-assessed physical health in relation to being a parent. These
findings are in line with the literature in the introduction and the findings of Sepa, et al., (2004), and
the findings of Thunström (1999). Mothers sleeping pattern is important not only because it is
related to parental stress, but also because it is related to less positive parenting and dysfunctional
parenting. (McQuillan, Bates, Staples, & Deater-Deckard, 2019). Sleep disturbances are also
closely related to postpartum depression (Munk-Olsen, Laursen, Pedersen, Mors, & Mortensen,
2006), which is a severe predictor for parental stress
There are several limitations that need to be taken into account when considering the present
results. To begin with, the sample size of the study is modest. Furthermore, the sample is rather
homogenous concerning education level, as well as symptoms of depression and anxiety. These
issues may decrease the ecological validity of the study, and therefore generalizing the results to the
general population may not be reliable. In addition, it is not possible to draw any conclusions about
causality in the present study. Possible interactions was neither controlled for.
Moreover, it is also important to consider the validity and reliability of the measurements. Self-
report questionnaires are based on subjectivity and may therefore lack validity. Combining self-
report questionnaires with clinical interviewing would increase the validity of the questionnaires,
but the combination is demanding to execute with larger sample sizes. Exaggeration or belittling of
symptoms are well known phenomena in self-report questionnaires and may affect the results. In
contrast to the self-report questionnaires, executive functions were measured with the computerized
cognitive test battery by Cogstate, which, as mentioned, has showed good reliability (Pietrzak et al.,
2009). However, it is important to note that the test battery by Cogstate do not measure purely
executive functions. Computerized test has the strengths of being suitable for larger sample sizes,
producing precise data and being undemanding to manage.
In conclusion, the present study found an association between depression, anxiety and parental
stress as measured with the sum score of SPSQ. Other, more specific associations were found when
the depression/anxiety, sleep disturbance, and the EF measures were regressed on the different
18
subscales of SPSQ. In more detail, depression/anxiety was associated with the subscale
Incompetence, EF was associated with the subscale Spouse and sleep disturbance was associated
with the subscale Health. The present results highlight the usefulness of screening for self-reported
depression, anxiety and sleep symptoms to identify mothers that potentially at risk to develop
parental stress. The differing associations between the different SPSQ subscales and
depression/anxiety/sleep disturbance symptoms, as well as EFs, indicate that different aspects of
maternal well-being and functioning can be related to different aspects of parental stress.
Identifying factors that can cause parental stress is crucial to be able to develop treatment and
prevention for parental stress at an early stage. Future studies should try to replicate and expand the
present findings with larger and more heterogeneous samples.
Swedish summary/Svensk sammanfattning:
Är moderns symtom av depression/ångest/sömnproblem och exekutiva funktioner relaterade
till upplevd föräldraskapsstress tolv månader postnatalt?
Introduktion
Föräldraskap är möjligen en av de mest krävande uppgifter i människans liv. Även om barnet är
friskt och livet är mindre stressigt kan föräldraskap vara påfrestande och utmanande. Speciellt
utmanande kan det dock bli när olika stressfaktorer dyker upp. Föräldraskapsstress kan definieras
som stress i det vardagliga familjelivet (Deater & Deckard, 1998). Johanson m.fl. (2017)
understryker vikten av att kartlägga föräldrars psykiska välmående med tanke på de negativa följder
som föräldraskapsstress kan medföra i barnets utveckling. Föräldraskapsstress är associerat med
psykopatologi hos föräldern, tillgängliga ekonomiska resurser, barnets sömnmönster samt moderns
ålder och utbildningsnivå. Studier har funnit samband mellan föräldraskapsstress och barnets
socioemotionella, kognitiva och psykomotoriska utveckling. För att kunna hindra negativa effekter
av föräldraskapsstress på barnets utveckling är det centralt att känna till de bakomliggande faktorer
till föräldraskapsstress. I denna studie undersöktes ifall depression, ångest, sömnproblem och
exekutiva funktioner är associerade med föräldraskapsstress 12 månader efter förlossning.
19
Deater‐Deckard (1998) definierar föräldraskapsstress som en negativ psykologisk reaktion till
föräldraskapskraven. Enligt Deater‐Deckard (1998) innehåller föräldraskapsstress flera
överlappande faktorer som a) krav på föräldraskapsrelaterade uppgifter, b) kvaliteten på
interaktionen mellan barnet och föräldern, c) förälderns psykiska hälsa och välmående och d)
barnets psykosociala anpassning. Ytterligare kan föräldraskapsstress också uppfattas som en
konflikt mellan förälderns krav på sig som förälder och situationerna i det vardagliga livet (Scher
& Mayseless, 2000; Östberg & Hagekull, 2000).
Kingston, Tough & Whitfield (2012) kom i sin studie fram till att prenatalstress och postnatalstress
påverkar barnets utveckling. Speciellt postnatal stress är associerat med barnets socioemotionella
och kognitiva problem. Pereira, Vickers, Atkinson, Gonzales, Wekerle & Levitan (2012) fann i sin
tur att mödrar med höga nivåer av stress visade mindre värme mot barnen och uppmärksammade
heller inte barnens behov på samma sätt. Föräldraskapsstress kan dessutom medföra känslor av att
inte vara delaktig i barnets liv och likaså medföra en mera auktoritär stil i föräldraskapet.
Hildingson och Thomas (2013) lyfter fram i sin studie att föräldraskapsstress har främst undersökts
bland föräldrar som har flera psykosociala belastningsfaktorer (t.ex. fattigdom, psykiatriska
diagnoser). Således skulle flera studier behövas med ett mera heterogent sampel.
Det finns flera faktorer som predicerar och bidrar till föräldraskapsstress. Crnic och Low (2002)
föreslår att dagliga göromål och vardagliga problem och situationer i familjen är faktorer som bidrar
till föräldraskapsstress. Ytterligare kan ekonomiska bekymmer, barnets hälsoproblem, lågt
självförtroende till eget föräldraskap och problem i parrelationen nämnas som faktorer som bidrar
till upplevd stress (Romito, Saurel-Cubizolles & Lelong, 1999). Likaså har också skilsmässa
associerats till föräldraskapsstress. Mödrar med högre ålder, flera barn och högre utbildning verkar
också löpa en större risk för att uppleva högre stressnivåer under föräldraskapet även om resultaten
är motstridiga. Både fysiska som psykiska förändringar prenatalt och postnatalt kan också öka
risken för föräldraskapsstress.
Depression och ångest är välkända fenomen som kan förekomma redan under graviditeten och pågå
flera år efter förlossningen (Priest m.fl. 2008; Woods m.fl., 2010). Postnatal depression kan
förekomma hos upp till 19,2 % av mödrar. Det depressiva beteendet hos mödrar påverkar barnet
och resulterar i mindre lektid, ökad risk för otrygg anknytning, mindre positiva känslor hos modern
samt högre grad av missnöje. Depression anses också vara den prediktor som är starkast associerad
med föräldraskapsstress och således är mödrar med depression mera benägna att uppleva
föräldraskapsstress (Gelfland m.fl., 1992; Leigh & Milgrom, 2008). Sepa m.fl. (2004) fann likaså i
20
sin studie att depression är associerat med föräldraskapsstress, vilket i sin tur hade samband med
känslor av inkompetens som förälder. Fairbrother m.fl. (2016) estimerade att cirka 15% av gravida
mödrar löper risk för att utveckla ångeststörning under graviditeten eller postnatalt. Prenatal ångest
har identifierats som en riskfaktor för att utveckla föräldraskapsstress. Depression och ångest
förekommer ofta samtidigt under det tidiga föräldraskapet.
Mindell, Sadeh, Kwon, & Goh (2015) observerade i sin studie att nästan 30 % av mödrarna
upplevde att deras agerande i vardagen var påverkat av deras treåriga barns sömnmönster. Det finns
också belägg för att sömnproblem har en negativ inverkan på exekutiva funktioner, vilket i sin tur
har samband med ett mera strängt föräldraskap.
Exekutiva funktioner är kognitiva kontrollfunktioner på en hög nivå och kan delas in i följande
domäner: inhibering, uppdatering av arbetsminne och växlande av arbetssätt (eng. set-shifting)
(Friedman m.fl. 2008). Enligt Miyake och Friedman (2012) har exekutiva funktioner en central roll
vid reglering av tankar, känslor och beteende. Exekutiva funktioner verkar också moderera
moderns omvårdnad i stressfulla situationer (Sturge-Apple, Jones, & Suor, 2017). Ytterligare antas
sämre exekutiva funktioner också fungera som en individuell källa till stress (Williford, A, Calkins
& Keane 2007). Det finns en brist på forskning om eventuella samband mellan föräldrars exekutiva
funktioner och föräldraskapsstress.
Syftet med studien
I denna studie undersöktes hur depression, ångest, sömnproblem och exekutiva funktioner är
associerade med föräldraskapsstress hos mödrar ett år efter förlossning. Utgående från den ovan
nämnda litteraturen formades hypotesen att symtom av depression, ångest och sömnproblem samt
lägre nivå av exekutiva funktioner bidrar till högre nivåer av föräldraskapsstress. På grund av
föräldraskapsstressens negativa inverkan på barnets utveckling är det centralt att förstå vilka
omständigheter ökar risken till föräldraskapsstress i det tidiga föräldraskapet.
Metod
Samplet i denna studie (N = 77) kommer ur en kohortstudie vid FinnBrain (www.finnbrain.fi).
Finnbrain startades 2011 Åbo Universitet och pågår fortfarande med över 4000 deltagande familjer.
21
Samplet i Finnbrain kommer från sydvästra Finland och det samlades in vid moderskapskliniker.
Kriterierna för att kunna delta i studien var tillräckliga kunskaper i finska eller svenska och ett
normalt ultraljud under graviditetsvecka 12. Till denna studie användes ett delsampel på 57
mödrar. All data i denna studie samlades ett år efter förlossning.
För att mäta mödrarnas symtom av depression användes frågeformuläret Edinburgh Postnatal
Depression Scale (EPDS). Deltagarnas symtom av generaliserad ångest mättes med hjälp av en
underskala för ångest från Symptom Checklist Scale-90 (SCL-90). I denna studie sammanslogs
EPDS och SCL-90 till gemensamma summapoäng, eftersom depression och ångest ofta
förekommer samtidigt under tidigt föräldraskap. Frågeformuläret Athens Insomnia Scale (AIS)
användes för att kartlägga symtom av sömnproblem hos mödrarna.
Cogstate testbatteriet är ett neuropsykologiskt testbatteri som mäter olika delar av kognitiva
färdigheter till exempel exekutiva funktioner, inlärning, minne, visuomotorisk färdighet,
processeringshastighet, uppmärksamhet och social kognition (Maruff et al., 2009). I denna studie
användes resultaten från fem deltest som ansågs bäst mäta exekutiva funktioner enligt tidigare
faktoranalys (Nordenswan et al., 2020). Följande deltest inkluderades i denna studie: The
Continuous Paired Associate Learning Test (CPAL) The Groton Maze Learning Test (GML), The
International Shopping List Test (ISL), The Set-Shifting Test (SETS) and The Two Back test
(TWOB).
The Swedish Parenthood Stress Questionnaire (SPSQ) är ett frågeformulär med 35 frågor som
mäter föräldraskapsstress. Frågeformuläret är baserat på the Parenting Stress Index by Abidin
(1990) med frågor från delskalorna Sense of Competence (INCOMP), Restriction of Role
(ROLER), Social Isolation (SOCISOL), Relation with Spouse (SPOUSE) and Parent Health
(HEALTH). INCOMP delskalan mäter förälderns upplevelse av inkompetens som förälder.
Delskalan ROLER mäter förälderns upplevelse av att inte kunna ägna sig åt sina intressen och
aktiviteter på grund av föräldraskapet. Delskalan SOCIOSOL mäter förälderns sociala relationer
utanför familjen medan delskalan SPOUSE mäter relationerna inom familjen. Delskalan HEALTH
mäter upplevelsen av fysisk hälsa relaterat till föräldraskapet.
Denna studie erhöll tillstånd av den sammanslagna etiska granskningsnämnden vid Åbo
Universitetssjukhus och Åbo Universitet. Försöksdeltagarnas skriftliga samtycke erhölls före
deltagandet. Den kognitiva bedömningen utfördes på bärbar dator under försökssituationen och
under samma gång fyllde försökspersonen också i frågeformulären för depression, ångest och
22
sömnproblem. SPSQ skickades hem till försökspersonerna. Alla bedömningar gjordes ett år efter
förlossningen.
I denna studie utfördes de statiska analyserna med IBM SPSS 25 Statistical Program for Social
Scienses. Deskriptiv statistik (medeltal, standarfel och variationsvidd) räknades för SPSQ
summavariabel, SPSQ delskalor, Cogstate deltest, EPDS, SCL-90 och AIS. Resultaten för Cogstate
jämfördes med normativ data för friska vuxna (Cogstate, 2014) och resultaten för EPDS, SCL-90
jämfördes med gränsvärden för kliniska diagnoser.
Försökspersonernas ålder, utbildningsnivå och antalet barn antogs vara lämpliga kontrollvariabler.
Det förekom inget signifikant samband mellan ålder och SPSQ summavariabel (r = .13 p < .34),
utbildningsnivå (r = .18 p < .90) eller antalet barn (r = .037 p < .78). Kontrollvariablerna
granskades också i relation till SPSQ delskalorna och där korrelerade ålder signifikant med
delskalan SPOUSE ( r = .29 p < .03) och HEALTH (r = .28 p < .04). Antalet barn korrelerade
signifikant men delskalan HEALTH (r = .30 p < .02). Dessa kontrolvariabler inkluderades i
motsvarande analyser. Sex multipla regressionsanalyser utfördes. En analys för SPSQ
summavariabel och fem för de olika delskalorna av SPSQ. För samtliga analyser användes
EPDS/SCL-90, Cogstate och AIS som oberoende variabler och alla lades till samtidigt till
modellen. För delskalorna SPOUSE och HEALTH lades också till de signifikanta
kontrollvariablerna. På grund av den starka korrelationen mellan EPDS och SCL-90 sammanslogs
dessa till en gemensam variabel.
Resultat
Deskriptiva resultat presenteras i tabell 2. Resultateten av SPSQ var inom intervallet för vad som
anses vara normalt (±1SD) hos svenska mödrar med ettåriga barn. Mödrarnas resultat för depression
var låga och indikerade ingen depression på gruppnivå. Endast 12,3 % av mödrarna rapporterade
depressionssymtom som översteg gränsvärdet 11 poäng och kunde klassas som en diagnostiserbar
störning. Mödrarna rapporterade i 13,2 % av fallen symtom (från svaga till grava) för
ångeststörning med ett gränssnitt på 7,5 poäng (Schmitz, Hartkamp & Franke, 2000). I 15,8 %
översteg mödrarna gränsvärdet för sömnproblem. Beträffande Cogstate-testresultaten var mödrarnas
resultat i samtliga test över det normativa medeltalet för åldersgrupperna 18-34 och 34-49 för friska
deltagare. Det är värt att notera att det normativa samplet för deltestet CPAL är mycket litet
23
(Canário & Figueiredo, 2017). Slutförandegraden för Cogstate var för deltagarna 100 % förutom i
deltestet TWOB där två resultat exkluderades.
Innan de multipla regressionsanalyserna kontrollerades multikollinearitet för de oberoende
variablerna. En multipel linjär regressionsanalys gjordes med EPDS_SCL/90, Cogstate EF och AIS
som oberoende variabler EPDS_SCL/90, Cogstate EF composite och AIS och SPSQ summapoäng
som beroende variabel. Alla oberoende variabler lades till modellen samtidigt. Regressionsanalysen
visade att de oberoende variablerna förklarade 36 % av variansen F(3,53)=10.017., p=.000, R2= .36.
Beträffande de enskilda oberoende variablerna var EPDS_SCL/90 positivt samband med SPSQ
summapoäng β=0.45, t(53)=2.76, p=.01, försökspersonerna som rapporterade högre poäng på
EPDS_SCL/90 rapporterade mera föräldraskapsstress.
I följande fem modeller användes samma oberoende variabler som i modell 1. Som beroende
variabel användes de olika delskalorna från SPSQ. Kontrollvariablernas korrelationer med de olika
delskalorna kontrollerades, vilket resulterade i att kontrollvariablerna togs med i
regressionsanalysen för delskalorna SPOUSE och HEALTH. I modell 2 förklarade de oberoende
variablerna 31% av variansen F(3,53)=7.796., p=.000, R2= .31 av delskalan INCOMP. Beträffande
de enskilda oberoende variablerna visade EPDS_SCL/90 ett positivt samband med delskalan
INCOMP β=0.114, t(498)=2.539, p=.011. I modell 3 och 4 delskalorna var båda delskalorna
signifikanta ROLER F(3,53)=3.639, p=.018, R2= .17 och SOCIOSOL F(3,53)=2.991, p=.039, R2=
.15, men inga signifikanta samban fanns för de enskilda oberoende variablerna. I modell 5
förklarade de oberoende variablerna 29,2 % av variansen F(5,51)=4.214., p=.017, R2= .292. I
modell 5 fans ett negativ samband mellan Cogstate EF och delskalan SPOUSE β=.35, t(51)=2.908,
p=.005. Försökspersoner med lägre poäng i Cogstate upplevde mera föräldraskapsstress på
delskalan SPOUSE. In modell 6 förklarade oberoende variablerna 38% av variansen F(5,51)=6.257,
p=.00, R2= .38. Både kontrollvariabeln ”antal barn” β=.27, t(51)=2.19, p=.03 och den oberoende
variabeln AIS β=.34, t(51)=2.61, p=.01 visade ett positivt samband med delskalan HEALTH.
Diskussion
I föreliggande studie var syftet att undersöka ifall symtom av depression, ångest, sömnproblem och
exekutiva funktioner predicerar föräldraskapsstress 12 månader efter förlossning. Hypoteserna var
att högre nivåer på symtom av depression, ångest och sömnproblem är relaterat med högre grad av
24
föräldraskapsstress. Ytterligare en hypotes var att sämre prestationer på mått för exekutiva
funktioner är associerat med högre grad av föräldraskapsstress.
Enligt tidigare litteratur är depression starkt associerat med föräldraskapsstress, vilket också
framkom i föreliggande studie. Variabeln för depression och ångest var den enda av de oberoende
variablerna som associerade till SPSQ summapoäng. Dessutom associerades den också till
delskalan som mäter inkompetens. Sambandet depression/ångest och inkompetens-delskalan verkar
logiskt med tanke på att skam och skuldkänslor är centrala symtom i depression.
Exekutiva funktioner hade ett samband med delskalan SPOUSE. Som tidigare nämnts finns det
ingen tidigare forskning om exekutiva funktioner och mödrars föräldraskapsstress, vilket betyder att
detta är ett nytt resultat. En möjlig förklaring till detta samband är att föräldraskap är mera krävande
när barnet är litet och kan således påverka också parrelationen.
Sömnproblem visade is sin tur ett samband med delskalan HEALTH. Detta resultat är likaså i linje
med tidigare forskning om att sömnproblem kan medföra föräldraskapsstress. Upplevelsen av att
känna sig konstant trött kan resultera i tankar om att ens fysiska hälsa lider på grund av
föräldraskapet.
Det finns flera begränsningar med studien som bör uppmärksammas. För det första kan nämnas
studiens sampelstorlek, vilken är blygsam. För det andra är samplet ett homogent sampel med tanke
på utbildningsnivå, depression och ångest. Ovan nämnda begränsningar kan möjligen påverka hur
resultaten kan generaliseras till övrig population. Vidare är det viktigt att påpeka att inga slutsatser
gällande kausalitet kan dras.
Flera av studiens variabler baserade sig på frågeformulär som fylldes i av försökspersonerna utan
vidare instruktioner. Det är möjligt att försökspersonens subjektiva upplevelsen inte
överensstämmer med verkligheten. En annan aspekt gällande frågeformulär är att det kan
förekomma över- och underdrift i svaren. Däremot erbjuder datoriserade test som användes för
bedömning av exekutiva funktioner mera noggranna svar.
Slutsats
Sammanfattningsvis fann studien belägg för att depression, ångest, sömnproblem och exekutiva
funktioner har ett samband med föräldraskapsstress. Resultaten är i linje med tidigare forskning och
25
stöder användandet av frågeformulär för att kartlägga psykiatriska symtom hos mödrar för att kunna
nå ut till de mödrar som ligger i riskzonen för att utveckla föräldraskapsstress. Det är viktigt att
kunna identifiera föräldraskapsstress med tanke på de negativa följder som föräldraskapsstress
medför för barnet, modern och familjen. Begränsningar med studien är bland annat liten
sampelstorlek, generaliserbarhet och begränsningar relaterade till instrument. Rekommendationer
för framtida studier är ökad sampelstorlek samt ett mera heterogent sampel.
.
26
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6. Appendix
__________________________________________________
Mieliala ____________________________________________________ Ole hyvä ja laita rasti ruutuun, joka parhaiten vastaa tuntemuksiasi kuluneen VIIMEISEN VIIKON AIKANA, ei ainoastaan tämänhetkisiä tuntemuksiasi. 1. Olen pystynyt nauramaan ja näkemään asioiden hauskan puolen.
Yhtä paljon kuin aina ennenkin
En aivan yhtä paljon kuin ennen
Selvästi vähemmän kuin ennen
36
En ollenkaan 2. Olen odotellut mielihyvällä tulevia tapahtumia.
Yhtä paljon kuin aina ennenkin
Hiukan vähemmän kuin aikaisemmin
Selvästi vähemmän kuin aikaisemmin
Tuskin ollenkaan 3. Olen syyttänyt tarpeettomasti itseäni, kun asiat ovat menneet vikaan.
Kyllä, useimmiten
Kyllä, joskus
En kovin usein
En koskaan 4. Olen ollut ahdistunut tai huolestunut ilman selvää syytä.
Ei, en ollenkaan
Tuskin koskaan
Kyllä, joskus
Kyllä, hyvin usein 5. Olen ollut peloissani tai hädissäni ilman erityistä selvää syytä.
Kyllä, aika paljon
Kyllä, joskus
Ei, en paljonkaan
Ei, en ollenkaan 6. Asiat kasautuvat päälleni.
Kyllä, useimmiten en ole pystynyt selviytymään niistä ollenkaan
Kyllä, toisinaan en ole selviytynyt niistä yhtä hyvin kuin tavallisesti
Ei, useimmiten olen selviytynyt melko hyvin
Ei, olen selviytynyt yhtä hyvin kuin aina ennenkin 7. Olen ollut niin onneton, että minulla on ollut univaikeuksia.
Kyllä, useimmiten
Kyllä, toisinaan
Ei, en kovin usein
Ei, en ollenkaan 8. Olen tuntenut oloni surulliseksi tai kurjaksi.
Kyllä, useimmiten
Kyllä, melko usein
En kovin usein
Ei, en ollenkaan 9. Olen ollut niin onneton, että olen itkeskellyt.
Kyllä, useimmiten
Kyllä, melko usein
Vain silloin tällöin
Ei, en koskaan
10. Ajatus itseni vahingoittamisesta on tullut mieleeni.
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Kyllä, melko usein
Joskus
Tuskin koskaan
Ei koskaan
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Ahdistuneisuus ____________________________________________________ Kuinka suuren osan ajasta sinua ovat vaivanneet seuraavat tuntemukset VIIMEISEN KAHDEN VIIKON AIKANA: koko ajan suurimman osan hieman yli hieman alle jonkin ei
ajasta puolet ajasta puolet ajasta verran lainkaan
_____________________________________________________________________________________________ 1. Hermostuneisuus, jännittyneisyys, sisäinen levottomuus 0 1 2 3 4 5
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2. Mitättömien arkipäiväisten asioiden murehtiminen 0 1 2 3 4 5 3. Ahdistusta herättävien asioiden, paikkojen tai tilanteiden välttäminen 0 1 2 3 4 5 4. Alkava ahdistuskohtauksen uhka (esim. alkava paniikin tunne) 0 1 2 3 4 5 5. Varsinaiset ahdistuskohtaukset (esim. paniikkikohtaukset) 0 1 2 3 4 5 6. Toistuvat tai jatkuvat, epämiellyttävät pakonomaiset ajatukset 0 1 2 3 4 5 7. Pakonomainen tarve tarkistaa tekemiäsi asioita uudelleen ja uudelleen 0 1 2 3 4 5 8. Pakonomainen tarve toistaa toimintoja, esim. peseminen, laskeminen 0 1 2 3 4 5 9. Voimakas ujous muiden ihmisten seurassa, esim. syöminen tai juominen muiden nähden 0 1 2 3 4 5
10. Vaikeus suoriutua arkipäivän toiminnoista tämän/näiden oireiden vuoksi 0 1 2 3 4 5 Missä määrin sinua on VIIMEISEN KUUKAUDEN AIKANA vaivannut: ei melko jonkin melko erittäin lainkaan vähän verran paljon paljon
_____________________________________________________________________________________________ 11. Vapina 1 2 3 4 5 12. Pelästyminen äkillisesti ilman mitään syytä 1 2 3 4 5 13. Pelokkuus 1 2 3 4 5 14. Sydämentykytykset tai – jyskytykset 1 2 3 4 5 15. Jännittyneisyys tai kiihtyneisyys 1 2 3 4 5
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16. Pelon tai pakokauhun puuskat 1 2 3 4 5 17. Levottomuuden tunne, joka estää rauhassa istumisenkin 1 2 3 4 5
18. Tunne, että tutut asiat ovat outoja 1 2 3 4 5 ja epätodellisia 19. Tunne, että sinua painostetaan tekemään tehtäväsi 1 2 3 4 5 20. Hermostuneisuus tai sisäinen rauhattomuus 1 2 3 4 5
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Nukkuminen ____________________________________________________ Vastaa kysymyksiin VIIMEISEN KUUKAUDEN KOKEMUSTESI perusteella.
1. Kauanko (keskimäärin kuinka monta minuuttia) olet hereillä sängyssä ennen kuin nukahdat (sen jälkeen kun valot on sammutettu)? a. Työpäivinä kestää noin __________ minuuttia ennen kuin nukahdan b. Vapaa-aikana kestää noin ____________ minuuttia ennen kuin nukahdan 2. Kuinka usein olet herännyt yöllä viimeisen kuukauden kuluessa? 1. En koskaan tai harvemmin kuin kerran kuussa 2. Harvemmin kuin kerran viikossa 3. 1-2 päivänä viikossa 4. 3-5 päivänä viikossa
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5. Päivittäin tai lähes päivittäin
3. Kuinka pitkä on yöunesi yleensä? Nukun yleensä ___________ tuntia yössä. Ympyröi alla olevista vastausvaihtoehdoista se, joka kuvaa arviotasi mahdollisen ongelman vaikeusasteesta, jos kyseinen ongelma on ilmennyt VÄHINTÄÄN KOLME KERTAA VIIKOSSA VIIMEISEN KUUKAUDEN AIKANA. 4. Nukahtaminen (unen saamiseen kuluva aika sen jälkeen kun valot on sammutettu) 0 Ei ongelmaa 1 Hieman viivästynyt 2 Selvästi viivästynyt 3 Huomattavasti viivästynyt tai en nuku lainkaan 5. Yöheräily 0 Ei ongelmaa 1 Vähäinen ongelma 2 Huomattava ongelma 3 Vakava ongelma tai en nuku lainkaan 6. Viimeisin herääminen aamulla liian aikaisin 0 Ei lainkaan 1 Hieman aiemmin 2 Selvästi aiemmin 3 Paljon aiemmin tai en nuku lainkaan 7. Unen kokonaismäärä 0 Riittävä 1 Jossain määrin riittämätön 2 Selvästi riittämätön 3 Täysin riittämätön tai en nuku lainkaan 8. Unen laatu yleensä 0 Normaali 1 Hieman alentunut 2 Selvästi alentunut 3 Erittäin paljon alentunut 9. Hyvinvoinnin kokemus päivisin 0 Normaali 1 Hieman alentunut 2 Selvästi alentunut 3 Erittäin paljon alentunut 10. Toimintakyky (fyysinen ja psyykkinen) päivisin 0 Normaali 1 Hieman alentunut 2 Selvästi alentunut 3 Erittäin paljon alentunut 11. Päiväväsymys 0 Ei lainkaan 1 Jonkin verran 2 Huomattavaa 3 Erittäin voimakasta
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Kokemuksia vanhemmuudesta ____________________________________________________ Ympyröi sopiva vaihtoehto. 1. Kuinka usein tapaat ystäviä/sukulaisia, tai olet puhelinyhteydessä heihin? 1. En lainkaan 2. Melko harvoin 3. Ei harvoin eikä usein 4. Melko usein 5. Todella usein
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2. Kuinka usein sinulla on mahdollisuuksia saada apua lapsen isovanhemmilta? 1. Ei lainkaan 2. Melko harvoin 3. Ei harvoin eikä usein 4. Melko usein 5. Todella usein 3. Kuinka usein saat lastenhoitoapua, kun tarvitset sitä? 1. Ei lainkaan 2. Melko harvoin 3. Ei harvoin eikä usein 4. Melko usein 5. Todella usein 4. Kuinka usein olet yhteydessä naapureihin? 1. Ei lainkaan 2. Melko harvoin 3. Ei harvoin eikä usein 4. Melko usein 5. Todella usein 5. Kuinka usein sinä ja lapsen toinen vanhempi hoidatte lasta yhdessä (liittyen syömiseen, leikkiin ym.)? 1. Emme lainkaan 2. Melko harvoin 3. Ei harvoin eikä usein 4. Melko usein 5. Todella usein Seuraavaksi esitetään väittämiä, jotka käsittelevät sitä miten pienten lasten vanhemmat voivat kokea tilanteensa. Ympyröi miten hyvin väittämä kuvaa itseäsi. 1. Vanhempana oleminen on vaikeampaa kuin luulin. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 2. Lapsen saamisen jälkeen meillä ei ole ollut yhtä paljon yhteistä aikaa. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 3. Lasten tarpeet useimmiten määräävät elämääni. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 4. Muuttuneen unirytmin vuoksi tunnen itseni usein väsyneeksi ja huonokuntoiseksi. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 5. Vanhemmaksi tulon jälkeen olen tuntenut itseni alakuloisemmaksi ja masentuneemmaksi kuin odotin. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 6. Lasten ansiosta olen saanut aivan uusia kontakteja. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 7. Kun lasten kanssa on hankalaa tuntuu kuin en osaisi tehdä mitään oikein. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 8. Saatuamme lapsia olemme alkaneet seurustella useiden muiden pikkulasten vanhempien kanssa. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa
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9. Minusta tuntuu usein, etteivät ikätoverini ole erityisen ihastuneita seurastani. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 10. Saatuani lapsia olen sairastanut useita erilaisia tulehdussairauksia. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 11. Kun joudun vaikeuksiin lasteni kanssa on minulla useita henkilöitä, joiden puoleen voin kääntyä saadakseni apua ja neuvoja. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 12. Saatuani lapsia ei minulla juuri ole aikaa itselleni. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 13. Tarvitsen apua selviytyäkseni vanhemmuudestani. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 14. Saatuani lapsia olen saanut vähemmän apua ja tukea avio-/avopuolisoltani kuin olin odottanut. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 15. Lasten saaminen on lähentänyt minun ja avio-/avopuolisoni välejä. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 16. Tunnen itseni pääasiassa terveeksi ja fyysisesti hyväkuntoiseksi. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 17. Lähes kaikki aikani kuluu nykyisin lapsille. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 18. Olen mielelläni lasteni vanhempi. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 19. Lasten saaminen on aiheuttanut koko joukon ongelmia minun ja avio-/avopuolisoni välille. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 20. Lasten kasvattaminen on vaikeampaa kuin luulin. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 21. Kun minut on kutsuttu vierailulle ajattelen tavallisesti, ettei minulla ole hauskaa. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 22. Tunnen itseni kelvolliseksi ja hyväksi vanhemmaksi. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 23. Minulla on usein syyllisyydentunteita siitä, mitä tunnen lapsiani kohtaan. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 24. Viimeisen puolen vuoden aikana olen tuntenut itseni tavallista väsyneemmäksi. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 25. Saatuani lapsia minulla ei juuri ole mahdollisuutta tehdä asioita, joista itse pidän. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 26. Lasten saamisen jälkeen vietämme vähemmän aikaa perheenä kuin olin odottanut. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 27. Vanhempana oleminen on helpompaa kuin luulin. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa
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28. Suhtaudun nykyisin myönteisesti elämään. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 29. Tunnen itseni yksinäiseksi. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 30. Luovun lasten tarpeiden vuoksi omassa elämässäni enemmästä kuin aiemmin ajattelin olevan tarpeellista. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 31. Yritämme avio-/avopuolisoni kanssa järjestää aikaa toisillemme. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa 32. Minusta tuntuu usein siltä etten selviydy. Ei pidä paikkansa 1 2 3 4 5 Pitää erittäin hyvin paikkansa Ympyröi sopivin vaihtoehto. 33. Mielestäni 1. olen erittäin hyvä vanhempi. 2. olen hyvä vanhempi. 3. olen keskinkertainen vanhempi. 4. minulla on joitain ongelmia vanhempana olemisessa. 5. en ole erityisen hyvä vanhempi. 34. Saatuani lapsia 1. olen ollut sairaana huomattavasti useammin kuin aikaisemmin. 2. olen ollut sairaana jonkin verran useammin kuin aikaisemmin. 3. olen ollut yhtä usein sairaana kuin aikaisemmin. 4. olen ollut terveempi kuin aikaisemmin. 5. olen ollut huomattavasti terveempi kuin aikaisemmin.
The materials contained in SPSQ are partly adapted and modeled after the Parenting Stress Index, Copyright 1990 by Psychological Assessment Resources, Inc. and reproduced by permission
of PAR,
Inc. To obtain a copy of the Swedish Parenting Stress Index, please contact PAR, Inc. at P.O. Box
998, Odessa, FL (telephone: (813) 968-3003) or via their website at www.parinc.com.