CHILD-REARING PRA CTICES: CHILD WITH CHRONIC ILLNESS AND WELL SIBLING

ELLEN H. KING, R.N., Ph.D. Nisonger Center, Ohio State University, Columbus

The purpose of this study was to identify and compare child-rearing practices concerning children with chronic illness as compared to their siblings and to answer the following question: What are the differences in combined patterns of child-rearing when compared to child-rearing patterns of fathers and child- rearing patterns of mothers where there is one child in the family with chronic illness?

The sample was the available population of parents who had two children between the ages of 4 and 14, one of whom had a chronic illness and sought health care iri a large, private family practice. Nineteen parent pairs were selected. Each parent was asked to fill out two Child-Rearing Practices Ques- tionnaires (CRPQ). One questionnaire related to the child with chronic illness and one related to the sibling. The following four factors were used in the analysis: factor I , use of punishment vs. reason; factor 11, promotion of independence vs. dependence; factor 111, levels of rules of behavior; and factor IV, amount of spouse involvement. Factor VII was used to check motivational distortion.

A multiple analysis of variance (MANOVA) was used to test the hypothesis. There was no significant difference in child-rearing practices related to health status of the child. Interaction between sex of the parent and health status of the child produced no significant difference. There was a significant differ- ence, p = .05, between mothers and fathers on factor IV, amount of spouse involvement. Fathers saw mothers as more involved in child-rearing than mothers saw fathers. Factors I and VII were inversely correlated in mothers of children with chronic illness. The mothers were more inclined to distort their answers when they used punishment.

The health status of families and their individual members is a primary concern of the discipline of nursing. It is the responsibility of nursing, therefore, to document those factors that influence family functioning with regard to health. It is assumed that chronic illness in a child affects other members of the family, most particularly parents. Parents are responsible for the child’s growth

Issues in Comprehensive Pediatric Nursing, 5:185-194, I981 Copyright 0 I981 by Hemisphere Publishing Corporation

01~6-0862/8lf030l85-10$2.25 185

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186 E. H. King

and development. Child-rearing practices or consis tent approaches to interacting with children are a result of this social responsibility.

Child-rearing practices are a part of family functioning. They are the result of the social environment within which the family resides as well as the unique characteristic of individuals. Sex of the parent and sex of the child (cross-sex variation) has been shown to influence child-rearing practices. It would be logical to assume that chronic illness in a child would also affect child-rearing practices. The purpose of this study was to describe child-rearing practices in families that had a child with chronic.illness.

THE PROBLEM

The problem was derived from both a review of relevant literature and from experience with parents of children with chronic illness. Parents of children with chronic illness are asking for guidance. “Can I do anything that will make a difference?’’ is a question often heard by nurses in clinical practice. In her study of deaf children, Meadows (1) discussed parents’ expressed need for alliance with a knowledgeable lay person who has successfully dealt with illness and handicap. Voysey (2) stressed the importance that parents attached to sources of information for and by other parents and the need for parent associations. This study gives parents and professionals baseline information about child-rearing practices in families in which there is a child with chronic illness.

The research problem is stated as follows: What are the perceived differences in child-rearing practices of fathers and mothers when there is one child in the family with chronic illness?

THEORE TICAL MODEL

Since the research problem was derived from clinical practice and a review of the literature, the choice of a theoretical model was a major problem. Bandura’s Social Learning Theory (3) was chosen because it has an interactionist view of child rearing. Reciprocal determinism is the concept in Social Learning Theory, which explains the relationship between man and his environment. This concept implies that behavior, other personal factors, and environ- mental factors operate as interlocking determinants of each other (see Fig. 1). One can separate the parts for purposes of study, but in reality they are always mutually interactional. Environmental determinism, symbolized B = [f (E)] , is the study of the environ- ment’s effect on behavior. Personal determinism, symbolized

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Chronic I1lne.w and Well Sibling 187

P

Fig. 1 Man and his environment.

B = [f (P)], is the study of the effect of personality factors on behavior.

This study takes an environmental deterministic point of view: parental attitudes are shaped by their environment. The environ- ment for parents of children with chronic illness is different from the environment of the well child. The stigma of illness affects their decisions about and interaction with their child with chronic illness. Shere and Kastenbaum (4) studied interactions of mothers with children with cerebral palsy. Mothers spent less time talking and playing with their cerebral palsied child as compared to the well sibling. These mothers also restricted toys to those that the child with cerebral palsy could use appropriately (4). Swift e t al. (5) studied school-age children with juvenile-onset diabetes. They found that there were more extremes in parenting behavior.

The fact that parents seek contact with knowledgeable lay persons implies that different role models for child rearing are used for children with chronic illness. Different models would imply differences in attitudes toward child rearing.

INSTR UMENTA TION

The theoretical model did not identify particular child-rearing variables. The child-rearing variables chosen for study were based on two criteria: availability of appropriate instrumentation and evidence that the variable is associated with chronic illness.

The Child Rearing Practices Questionnaire (CRPQ), developed by the Institute for Personality and Ability Testing in Champaign, Illinois, was chosen. The CRPQ is a self-report questionnaire that gives scores for both fathers and mothers on the factors shown in Table 1 . The motivational distortion variable is used to evaluate truth telling on the other six variables. The variables are considered continuous, with high scores to the right and low scores on the left. Is

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188 E. H. King

Table 1. Description of CRPQ Factors ~

Factor High score indicates Low score indicates

I

111 IV

V

VI VII

~~

High use of reason with children (low use of punishment)

Promotion of dependence in children by parents

High use of rules in child rearing High level of spouse involvement

High use of rewards with child

Preference for older children High level of motivational

in child rearing

rearing

distortion

High use of punishment with children (low use of reason)

Promotion of independence in children by parents

Low use of rules in child rearing Low level of spouse involvement

Low use of rewards with child

Preference for younger children Low level of motivational

in child rearing

rearing

distortion

The questionnaire consists of 143 multiple-choice items that parents respond to with pencil on answer sheet. Each questionnaire took approximately 45 minutes to complete. The range of scores on each factor is 0 to 100. The tesl-retest reliability using Pearson’s r in a small group at 3-month intervals between testing is listed as follows: factor I, .843; factor 11, .691; factor 111, S47; factor IV, .959; factor V, .842; factor VI, .671 (D. Masden, personal communication, 1979). Previous forms of this tool have been validated for use with parents of children between the ages of 4 and 14. The CRPQ has been used to predict personality factors in school-age and teenage children, school achievement and behavior problems in children ages 6 and 7 (6, 7). Factor I, use of punishment vs. reason; Factor 11, promotion of independence vs. dependence; Factor 111, levels of rules of behavior; and Factor IV, amount of spouse involvement, were the variables used in the study.

HYPOTHESIS

The research hypothesis of the study stated globally is as follows: There will be a significant difference in mothers’ and fathers’ scores for children with chronic illness and their well siblings on the following four variables:

1. Use of punishment vs. reason 2. Promotion of independence vs. dependence Is

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Chronic Illness and Well Sibling 189

3. Level of rules of behavior 4. Amount of spouse involvement

The dependent variables will be sex of the parent and health status of the child (see Fig. 2). The dependent variables are listed as follows:

1 . Use o f punishment vs. reason 2. Promotion of independence vs. dependence 3. Level of rules of behavior 4. Amount of spouse involvement

PR 0 CED IJR E

Assuming that the environment is different for child-rearing practices of each child in the family, a population of children who had chronic illness that was not causing disability or handicap was chosen. The purpose of this strategy was to minimize the argument that these families were unique in some way other than the presence of chronic illness in one child.

The records of clients of a large family health facility were searched, and 120 families seemed to fit the criteria. A letter was sent to each of these families asking them t o participate in the study, and a follow-up letter was sent t o those who did not respond t o the first letter. A total of 68 persons responded t o the letter, with 50 positive responses. The total response rate was 57 percent, with a 42 percent positive response rate. Thirty-one families were excluded from the study. The reasons for exclusion are given in Table 2.

Parents were contacted by phone. An appointment was made to visit the Family in the home. After informed consent was obtained, each parvnt was asked to fill out two CRF'Q questionnaires; one was related to the child with chronic illness and the other was

F M

S l l S F I(SM S

Sb 'Sb F %bM 'Sb

'F 'M 'P

Fig. 2 Diagram of independent variables. F = father; M = mother; S = child with chronic illness; Sb = sibling of child with chronic illness or disability; P = combined child rearing. Is

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190 E. H. King

Table 2. Reasons for Exclusion from the Study

Reason Number

Diagnostic error Age error All children ill Ill child not in family Ill child only child Family moved Parents divorced Unable to find family Unable to schedule appointment

Total

4 4 4 2 2 5 2 3 5

31

related to the well sibling. The order of filling out the question- naires was determined by a flip of the coin. The sibling in the study was determined by use of a random number table if more than one sibling was eligible.

SAMPLE

Nineteen parent pairs, the entire available population, were selected from clients of a large family health care facility. The subjects met the following criteria:

1. Had two children between the ages of 4 and 11, one of whom was a child with chronic illness.

2. Both parents resided in the home and were available for appointment. The characteristics of the parents are shown in Table 3.

Table 3. Characteristics of the Parents

Mother Fat her

Age Mean 36.21 1 f 4.708 SD 37.368 f 4.708 SD

Years Mean 1 5 f 3.261 SD 14.949 f 4.560 SD

Times Mean 1.3 16 f .465 SD 1.263 f .547 SD

Employed outside 12 19

Range 3 1-52 years 30-48 years

married Range 10-23 years 10-31 years

married Range 1-2 1-3

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Chronic Illness and Well Sibling 191

Eight of the mothers were older than the fathers. All of the parents characterized themselves as being white in origin. Four of the mothers stated further ethnic origin. One mother was Mexican- American, one was Polish-American, one was American Indian, and one was Chilean in origin. Three fathers stated further ethnic origin. One father was Mexican-American, one was Arcadian French, and one was Brazilian. The occupations of the parents were professional and blue collar in nature.

The characteristics of the children in the families are shown in Table 4.

A t-test: for dependent groups was done in order to determine if the ages of the children with chronic illness differed from those of their well siblings. The computed t of .0277 was not significant at the .05 level. The ages of the children did not differ significantly. The diagnoses of the children with chronic illness are listed as follows: asthma, seizure disorder, juvenile-onset diabetes, acute glomerulonephritis, bacterial endocarditis with heart block, and thalassemia. The mean number of years since diagnosis was 4.659 f 2.938 SD; the range was 6 months to 12 years.

TEST OF THE HYPOTHESIS

Multiple analysis of variance and covariance (MANOVA) was used to test the global null hypothesis. BMD 12V computer package was used for computation. The Box test was done to test the assumption of homogeneity of variance and covariance. An F of 1.4043 was obtained which had a p value of .1715. It is reasonable to assume homogeneity of variance and covariance. The assumption of independent groups could not be met since mothers and fathers and sibling were used for the cells of the MANOVA. Using MANOVA in this setting is a conservative test. The probability of rejecting the null hypothesis is less than the stated alpha level.

The computed F ratios are presented in Table 5.

Table 4. Characteristics of the Children

Ill Child Sibling

Age Mean 9.618 f 2.794 SD 9.603k 3.012 SD Range 5-1 4 years 5-14 years

Sex Male 12 12 Female 7 7 Is

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Table 5 . MANOVA Summary Table for CRPQ Scores

Source F ~~

Parent 3.4432* Health .1132 Parentlhealt h .3555

*Significant for F ( . 95 , 4, 69) = 2.490.

The computed F ratio for the parent variable was significant at p <.05. The null hypothesis that there was no difference in parents’ scores was rejected. The F ratio computed for health status of the child was not significant. The null hypothesis that there was no difference in scores related to health status of the child was retained. The F ratio computed for interaction of parent and health status of the child was not significant. The null hypothesis that there was no difference in scores related to an interaction of parent and health status of the child was retained.

A univariate analysis of variance (ANOVA) was computed on the parent scores. The following was the null hypothesis: There is no difference in fathers’ and mothers’ scores on the following variables:

1. use of punishment vs. reason 2. promotion of independence vs. dependence 3. levels of rules of behavior 4. amount of spouse involvement.

Table 6 presents the results of the ANOVA statistic. The null hypothesis that there was no difference between

parents’ scores on the spouse involvement was rejected with a

Table 6. ANOVA Summary Table for CRPQ Scores for Mothers and Fathers

Variable F P

Reason .0835 .773 Dependence 3.7020 .058 Rules ,8793 .35 1 Spouse 11.2600 .0013*

*Significant at the .01 level

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Chronic Illness and Well Sibling I 93

p = .0013. The mean score for mothers was 40.868, while the mean score for fathers was 47.184. High scores are a perceived high level of spouse involvement while low scores are a perceived low level of spouse involvement. Mothers see their spouses as being less involved; fathers see their spouses as more involved.

A discriminant analysis confirmed the results of the ANOVA. The program terminated after the first step; only factor IV, spouse involvement , was entered.

DISCUSSION

This study failed to confirm that there are differences in attitudes toward child-rearing practices based on the presence or absence of chronic illness in the child. There is a difference in child-rearing practices based on the sex of the parent. This result can be attributed to the instrument itself (D. Masden, personal communi- cation, 1980).

Child-rearing practices as measured by CRPQ within a family are not altered by the fact that one child has a chronic illness. This could be explained several ways. The amount of disability caused by the chronic illness of the children in the study was minimal. These children could have passed as able-bodied. The amount of disability might be a factor that would influence child-rearing practices. 'The stigma of the illness affects the whole family (1). Child-rearing practices would be altered toward all children in the family. Since there is no norming data on the CRPQ, this hypothesis can be neither confirmed nor denied at this time. The sample was derived from a relatively affluent community. A large proportion of the mothers were working mothers. A large proportion of the children were boys. Campbell (8) stated that socialization to the sick role (stigma) was less likely with older children, boys, and children of mothers with higher education and fathers with high socioeconomic status. Characteristics of the families made them resistant in some way to the effects of chronic illness on child rearing.

IMPLICA 1IONS FOR NURSING

Minde et al. (9) critique mind-body research by pointing out that it tended to look at the individual through an abnormal model. If one looks for deviance, deviance will be found. It is now appropriate to ask the question, do we see deviance because deviance is the only thing we know how t o look for? Prudence

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194 E. H. King

would suggest that until further testing has been done, nurses should be careful about the assumptions that they make about families wherein there is a child with chronic illness. We do not . know enough about how child-rearing variables affect and are affected by growth and development and disease processes.

REFERENCES

1. Meadows, K.: Parental responses to medical ambiguities of congenital deafness. J. Health SOC. Behav. 9:299-309, 1968.

2. Voysey, M.: Impression management by parents with disabled children. J. Health SOC. Behav. 13:80, 1972.

3. Bandura, A.: Social Learning Theory. Englewood Clifts, NJ, Prentice- Hall, 1972.

4. Shere, E., and Kastenbaum, G. G.: Mother-child interaction in cerebral palsy: environmental and social obstacles to cognitive development. Genet. Psychol. Monogr. 73:255, 1966.

5. Swift, C. R., Seidman, F., and Stein, H.: Adjustment problems in juvenile diabetes. Psychosom. Med. 29:55, 1967.

6. Barton, K., Dielman, R. E., and Cattel, R. B.: Child rearing practices related to child personality. J. Genet. Psychol. 124: 156, 1974.

7. Barton, K., Dielman, R. E., and Cattel, R. B.: Child rearing practices related to child personality. J. Genet. Psychol. 101:76, 1977.

8 . Campbell, J. D.: The child in the sick role: contribution of age, sex, and parental values. J. Health SOC. Behav. 19:35, 1978.

9. Minde, K. K., Hackett, J. D., Killow, D., and Silver: How they grow up: 41 physically handicapped children and their families. Am. J. Psychiatry 128:1544, 1972.

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