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. Author manuscript; available in PMC: 2010 Feb 1.
Published in final edited form as: J Child Adolesc Psychiatr Nurs. 2009 Feb;22(1):40–48. doi: 10.1111/j.1744-6171.2008.00168.x

Factors Associated with Parental Distress

Catherine A Duchovic 1, Janis E Gerkensmeyer 2, Jingwei Wu 3
PMCID: PMC2669749  NIHMSID: NIHMS101373  PMID: 19200291

Abstract

Problem

Associations of perceptions of social support, personal control, and child behavior problems to distress in parents of children with mental health problems were examined. Methods: 155 parents of children 2–19 years old receiving community mental health services participated.

Findings

Step-wise regression analysis identified internalizing and externalizing child behaviors, perceived personal control, and tangible social support as independent predictors of parental distress. Independent predictors of objective distress included internalizing child behaviors, perceived personal control, and intangible social support.

Conclusions

Internalizing and externalizing child behaviors were significantly associated with parental distress. Perceived personal control moderated the relationship between internalizing child behaviors and parental subjective distress.

Search terms: Child behavior problems, child and adolescent mental health, parental distress, personal control, caregivers

According to the Report of the Surgeon General’s Conference on Children’s Mental Health (U.S. Department Health and Human Services [DHHS], 2000), a health care crisis exists for children with mental health problems and their families that is caused by unmet needs. These unmet needs include a deficit of formal and informal social support resources (Lazear, Worthington, & Detres, 2004). Parents caring for children with mental health problems are extremely challenged in getting both their child’s and their own needs met (Bode, Weidner, & Storck, 2000).

Normal parenting includes concerns about growth and development, child behavioral and social issues, emotional well-being of the child, and financial responsibilities. These concerns alone can result in parental distress (Ross & Blanc, 1998). Additional stressors for parents of a child with mental health problems, however, increase parental distress significantly (Ross & Blanc). Challenges experienced by caregivers of children with mental health problems have been associated with parental distress and feelings of being stretched beyond their limits (Sharpley & Bitsika, 1997; Podolski & Nigg, 2001).

The purpose of this study was to examine the association of perceived social support, perceived personal control, and child behavior problems to distress in primary caregivers of children with mental health problems. The primary caregivers, henceforth referred to as parents, included grandmothers and biological, adoptive, step, and foster parents. Understanding the associations of social support and personal control to distress will promote development of interventions aimed at decreasing parental distress.

Conceptual Framework

The Double ABCX Model (McCubbin & Patterson, 1983) provided a framework for assessing the relationship of perceived social support and personal control to distress for parents of a child with mental health problems. In the Double ABCX Model, a stressor event and pile-up of stressors (aA) produce tension within the family unit that requires management. Both existing and expanded resources within the family and the community (bB) can be used to deal with stressors. Family members’ perceptions of the stressor events, family demands, and resources (cC) are a reflection of cultural and social meanings attached to both current life events and previous experiences with stressors and crises. A state of crisis (x) may emerge as a result of the inability to restore stability in the family system. Exhaustion may result when crises are not resolved, and distress may emerge (Brannan & Heflinger, 2001). On the other hand, family adaptation (xX) may occur as a result of efforts to restore balance within the family system after a state of crisis.

Factors Associated with Parental Distress

Konstantareas and Homadtidis (1991) described child behavior problems as energy-consuming demands that exceed the productive and rewarding capabilities of parenting. Demands of caring for a child with mental health problems are at least as taxing as the demands of caring for a child with physical health problems (Cronin, 2004). Higher levels of distress have been reported by parents of children with behavior problems than for parents of children with developmental delays, including Down Syndrome (Baker et al., 2003). Weiss (2002) found significantly higher levels of distress in parents of children with autism as compared to parents of children with mental retardation or normal development.

Distress experienced by parents of children with Attention Deficit Hyperactivity Disorder (ADHD) has been positively associated with child symptoms, especially externalizing behaviors (Bussing et al., 2003; Podolski & Nigg, 2001). Perceptions about the intentionality of child behaviors have also been associated with parental distress, with lower distress experienced when behavior was believed to be unintentional (Harrison & Sofronoff, 2002). The additive effects of ADHD symptoms and oppositional-defiant child behaviors have been found to increase parental distress and decrease parental role satisfaction more than ADHD symptoms alone (Podolski & Nigg).

Parental Distress

Chou (2000) described the experience of caregiving as dynamic, whereby all aspects of distress might not be experienced at a given time. Overload from an imbalance between perceived demands and resources when caring for a child with mental health problems may have negative psychic consequences for the parent. Worry, guilt, sadness, fatigue, embarrassment, resentment, and anger directed toward the child have been described as indications of the subjective dimension of distress (Brannan & Heflinger, 2001). Observable occurrences, including demands on time, friction in family life, disruption in social life and employment, and financial concerns, have been identified as objective dimensions of distress (Brannan & Heflinger; Rosenzweig, Brennan, & Ogilvie, 2002).

Social Support

Distress for parents of children with mental health problems has been found to be ameliorated by social support from spouses, relatives in an extended family network, school and mental health professionals, family support groups, informal respite services, and other community resources (Bussing et al., 2003; Lazear, Worthington, and Detres, 2004; Weiss, 2002). Socioeconomic status is inversely related to the amount of support from the informal kin network and positively related to support from formal community resources (McDonald & Gregoire, 1997). Bussing et al. found that African American caregivers experienced higher levels of support through extended family networks than did Caucasian caregivers. Types of support provided to family members include tangible aid (respite, loans, gifts, or information) and intangible aid (emotional support and empathy; Puotiniemi, Kyngas, & Nikkonen, 2002). Discrepancies between need for support and type of support actually received can exist (e.g., needing child care to maintain employment, but receiving only emotional support; Puotiniemi, Kyngas, & Nikkonen; Rosenzweig, et al., 2002).

Parent support group members become both providers and recipients of social support within the group (Lazear et al., 2004; Papaikonomou & Nieuwoudt, 2004). Puotiniemi, Kyngas, and Nikkonen (2002) identified involvement with other parents as a valuable means of learning to cope with the mental health problems of children. Professional support within these groups increased parents’ sense of control and decreased objective burden. Counseling and effective coordination of professional services can also reduce parents’ distress (Lazear et al.; Yatchmenoff et al., 1998).

Perceived Personal Control

According to Dunn, Burbine, Boweres, and Tantleff-Dunn (2001), locus of control is related to both stress and learned helplessness. Interventions to increase parental perceptions of self-efficacy and perceived personal control have been implemented with success (Dempsey & Dunst, 2004). Weiss (2002) found that coping of parents of children with autism was influenced by perceptions of personal control which reflected the degree of perceived influence over life’s events. Parents’ expectations about life and children, along with attributions about the causes of mental health problems, attitudes about mental health services, and perceptions of what others think help shape the perceptions of parental personal control (Brannan & Heflinger, 2001). Harrison and Sofronoff (2002) found lower perceived parental control over child behaviors to be associated with higher levels of parenting stress.

Research Questions

Based upon the conceptual framework and review of the literature, the following research questions emerged. Are child mental health problems (internalizing and externalizing behavior problems), perceived social support (tangible and intangible), and perceived personal control significantly associated with parental distress (subjective and objective)? Do perceived personal control or social support mediate or moderate the association of child mental health problems and parental distress? Which variables independently predict parental distress, both subjective and objective?

Methods

Procedure

This study analyzed cross-sectional data collected from a larger research project that investigated variables associated with quality of life among parents of children with mental health problems. A convenience sample of parents from one Midwestern state was utilized. Clinical nurse specialists employed at community mental health centers (CMHC) and a psychologist from a child psychiatric clinic recruited participants. In addition, some participants were self-referrals.

Parents participating in the study were identified as the primary caregiver of a child between 2 and 19 years of age who was receiving community mental health services and who had been living at home with the caregiver for at least 20 of the past 24 months. Institutional Review Board approval was obtained for the study, and HIPPA rules were observed.

Parents who agreed to participate were provided a survey packet either in person or by mail and were given a choice of completing the survey independently or over the phone. Surveys took approximately 45 minutes to complete. Surveys not completed within approximately two weeks were followed up with a phone call to verify that the survey had been received, that there were no questions about procedures, and if the participant preferred to be interviewed over the phone. Each parent returning a completed survey received $25.

Sample

Primary caregivers (N = 155) included biological mothers (81%), adoptive mothers (8%), grandmothers (7%), and 1% each stepmothers, foster mothers, biological fathers, and adoptive fathers. They ranged in age from 23–62 years (M = 37.7, SD = 8.3); 46% were married, 23% divorced, 5% separated, 17% single, and 9% living with a partner. Most participants were Caucasian (80%), with 17% African American, 2% Native American, and 1% Hispanic. Participants were employed full-time (26%), part-time (17%), homemakers (30%), unemployed (12%), and other (12%). Median household income was between $20,000 and $30,000 with 63% having an annual income of less than $30,000. Only ten participants had attended a parent support group. Most children were male (67%). Mean age was 10 years (SD= 3.9); 72% were Caucasian, with 17% African American, 1% Hispanic, and 2% Native American. Mean reported length of time of the mental health problem was 5.2 years (SD = 4.2).

Variables and Instruments

Mental health problems were viewed as stressors in this study and were measured by externalizing and internalizing t scores on the Child Behavior Checklist, which has strong support for validity and reliability (CBCL; Achenbach, 1991; Harrison & Sofronoff, 2002). Externalizing child behavior problems included hyperactivity, hyperirritability, impulsivity, self-abuse, fighting, destructiveness, and disobedience at home or school. Internalizing child behavior problems included symptoms of anxiety and depression, fearfulness, loneliness, social withdrawal, and compulsive or suicidal thoughts. Two versions were used (ages 1.5 to 5 years and 6 to 18 years).

Dimensions of social support were examined, including tangible aid (respite, loans, gifts, or information) and intangible aid (emotional support). The 40-item Inventory of Socially Supportive Behaviors (ISSB) measured perceived social support, with both reliability and internal consistency being strong for this scale (Barrera, Sandler, & Ramsay, 1981). ISSB’s 5-point Likert response scale measured the frequency of social support from 1 (not at all) to 5 (about every day). Factor analysis with varimax rotation resulted in two factors, tangible and intangible, with alpha coefficients in this study of .92 and .95, respectively.

An additional measure of family social support was utilized to assess parents’ perceptions of adequacy of family assistance, availability, and support. The five-item Family Apgar (Smilkstein, Ashworth, & Montano, 1982) was utilized. Items were rated on a Likert response scale from 1 (not at all) to 5 (a great deal). Alpha was .92 in this study.

Participation in a parent support group was indicated by a dichotomous response of yes or no. Type of support group, interest in participating in a support group, and perceived barriers to support group involvement were not investigated in this study.

Perceived personal control reflects a general sense of having the intrapersonal resources to deal with stressors (Reinhard, 1994). The Pearlin Mastery Scale (Pearlin & Schooler, 1978) was used to measure parents’ general sense of personal control and mastery. Seven items were rated from 0 (strongly disagree) to 3 (strongly agree). The alpha was .82 in this study.

The dependent variable, parental distress was conceptualized as both subjective and objective distress. Subjective distress in this study refers to the degree parents were affected intra-personally, such as through fear, worry, or guilt related to their child’s mental health problem. Objective distress relates to the degree parents’ lives were disrupted, such as through family or work disruption or lack of time for leisure activities. Distress was measured by the 19-item Parent Experiences Scale (PES), adapted by Gerkensmeyer and Austin (2005) from Reinhard’s (1994) Burden Assessment Scale. All items were rated from 1 (a little) to 3 (a lot), with 0 (not at all or not applicable). In this study, factor analysis with varimax rotation resulted in a 6-item objective distress factor (α = .78) and a 13-item subjective distress factor (α = .88).

Data Analysis

Frequencies were generated for all categorical variables, and descriptive statistics were calculated for all continuous variables. The relationship of key variables to demographics was examined. Bivariate correlations between and among the CBCL internalizing and externalizing t scores, social support variables, perceived personal control, and parental distress were obtained using Pearson correlations (see Table 1). Further, bivariate correlations between key demographic variable and the dependent variables, objective and subjective distress, were examined. Mediation and moderation of the relationships of child internalizing and externalizing behavior problems to subjective and objective parental distress by social support variables and personal control were examined using the regression methods of Baron and Kenny (1986). Stepwise regression was used to identify demographic variables, independent predictors, and potential moderation effects of subjective and objective distress.

Table 1.

Correlations

Subjective Distress Objective Distress Internal t-score External t-score Tangible Support Intangible Support Family Support Personal Control
Subj Distress ---
Obj Distress .636*** ---
Internal t-score .466*** .347*** ---
External t-score .496*** .287*** .529*** ---
Tangible Support −.203** −.192* −.054 −.006 ---
Intangible Support −.211** −.238** −.162* −.035 .721*** ---
Family Support −.368*** −.275*** −.307*** −.272** .265*** .481*** ---
Personal Control −.458*** −.313*** −.314*** −.328*** .084 .234** .364*** ---
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*

p<.05

**

p<.01

***

p<.001

Results

Means for total internalizing CBCL t scores (M = 67, SD = 8.9), total externalizing CBCL t scores (M = 69, SD = 9.6), and total behavior problems CBCL t scores (M = 70, SD = 8.8) were at or above the standardized cutoff of 67 for clinical behavioral problems, indicating a high level of severity of behavior problems among children in this sample. The mean for tangible social support (M = 1.8, SD = .67) reflected low levels of tangible support reported by these parents. The mean for intangible social support (M = 2.5, SD = .91) reflected low to moderate levels of intangible support reported. Tangible social support was reported as having been received only once or twice during the previous month by 90% of the parents, as was intangible social support. Similarly, intangible social support was reported by 60% of parents to be received less than once a week. The Apgar mean score of 3.1 (SD = 1.2) reflected a mid-range level of perceived adequacy of family support received. The mean for perceived personal control (M = 2.0, SD = .55) indicated a moderate degree of perceived personal control, overall.

PES mean scores for subjective (M = 2.5, SD = .72) and objective distress (M = 2.4, SD = .88; see Table 2 for PES item means) reflected moderate to high levels of parental distress. The highest rated distress items were Worry about my child’s future, Experienced family frictions and arguments, Had financial problems, and Found the household routine was upset. The lowest rated items were Had to change your personal plans like taking a new job or going on a vacation and Resented your child because s/he made too many demands on you (see Table 2).

Table 2.

Parent Experience Scale

Objective Subscale M SD
Had financial problems 2.8 1.3
Found it difficult to concentrate on your own activities 2.7 1.1
Cut down on leisure time 2.5 1.3
Had less time to spend with friends 2.5 1.3
Had to change your personal plans like taking a new job or going on vacation 1.9 1.4
Missed days at work (or school) 1.6 1.3
Subjective Subscale
Worried about what the future holds for your child 3.4 .9
Experienced family frictions and arguments 2.9 1.2
Found the household routine was upset 2.8 1.1
Felt guilty because you were not doing enough to help 2.7 1.1
Became embarrassed because of your child’s behavior 2.6 1.1
Neglected other family members’ needs 2.5 1.2
Found the stigma of the illness upsetting 2.4 1.1
Worried about how your behavior with your child might make the illness 2.2 2.2
Felt trapped by your caregiving role 2.2 1.2
Were upset about how much your child has changed from his/her former self 2.1 1.3
Felt guilty because you felt responsible for causing your child’s problems 2.1 1.2
Experienced frictions with neighbors, friends or relatives outside the home 2.1 1.1
Resented your child because s/he made too many demands on you 2.0 1.0
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Child and parent’s age, parents’ educational level, household income, length of mental health problem, and number of siblings were not significantly related to internalizing and externalizing behavior problems, social support, perceived personal control, or parental distress. Family support and perceived personal control were associated with household income. All key variables were significantly associated with each other except for internalizing behavior problems and tangible social support, externalizing behavior problems with both tangible and intangible social support, and perceived personal control with tangible social support (see Table 1).

Perceived social support (tangible, intangible, and Family Apgar) did not mediate or moderate the relationship between child internalizing and externalizing behavior problems and parental distress (subjective or objective). This is likely because of the non-significant relationships of internalizing and externalizing behavior problems to tangible social support and between externalizing behavior problems and intangible social support. Perceived personal control, however, did moderate the relationship between internalizing behavior problems and distress. As can be seen in Figure 1, parents with the highest levels of perceived personal control had more dramatic increases in subjective distress in relation to increases in internalizing behavior problems. For parents with the lowest levels of perceived personal control, subjective distress did not increase as dramatically with increases in internalizing behavior problems as it did for those parents with higher levels of perceived personal control. However, parents with lower perceived personal control reported higher levels of subjective distress even when internalizing child behaviors were less intense.

Figure 1.

Figure 1

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Moderating effect of perceived personal control on the relationship between internalizing child behaviors and subjective parental distress.

Stepwise regression analysis was used to determine the independent predictors of subjective and objective distress in parents. Child internalizing and externalizing behavior problems, tangible and intangible social support, family support, and perceived personal control were entered into the Stepwise regression. Since perceived personal control also moderated the relationship between internalizing behavior problems and distress, the interaction between perceived personal control and internalizing behavior problems was also included in the regression model. Externalizing behavior problems, perceived personal control, internalizing behavior problems, interaction between personal control and internalizing behavior problems, and reported tangible social support explained 39% of the variance in subjective parental distress (Table 3). Internalizing behavior problems, personal control, and tangible social support explained 18% of the variance in objective parental distress (Table 4).

Table 3.

Stepwise Regression Analysis Final Model: Parental Distress - Subjective

Beta p value
Total Externalizing CBCL t-score .02 <.0001
Mean of Personal Control Scale −1.79 <.0001
Total Internalizing CBCL t-score −.03 .216
Interaction between Personal Control and CBCL Internalizing .02 .029
ISSB Tangible Subscale −.16 .029
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Table 4.

Stepwise Regression Analysis Final Model: Parental Distress - Objective

Beta p value
Total Internalizing CBCL t-score .027 .001
Mean of Personal Control Scale −.341 .006
ISSB Tangible Subscale −.211 .03
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Discussion

Both internalizing and externalizing behavior problems in children were significantly associated with parent’s subjective and objective distress in this sample. The literature suggests that externalizing behavior problems are more highly correlated with distress than internalizing problems. In this study internalizing behavior problems were relatively more highly correlated with objective distress in parents than externalizing problems. This finding may also reflect the amount of energy expended by parents who seek to protect and support a child who is seen as being vulnerable or emotionally fragile. On the other hand, externalizing behavior problems were relatively more highly correlated than internalizing problems with subjective distress. When examining items loading on the subjective distress factor, this is not surprising. For example, due to externalizing behavior problems, parents would likely experience increased worry about their child’s future, disruptions in family routines, embarrassment by their child’s behaviors, and upset related to stigma of their child’s illness.

Perceptions of adequate social support from other family members was higher among these parents than were their reports of tangible and intangible support received. Parents reported receiving moderate levels of support over a six-month period in categories such as being satisfied that I can turn to my family for help when something is troubling me. Although parents reported receiving very little tangible or intangible social support, very few participated in formal support groups. Despite the reported positive value of support group participation, including an opportunity to vent and to explore options through a peer support network (Lazear et al., 2004), only 10 out of 155 parents in the study accessed this method of support.

With the severity of reported child behavior problems and the low levels of tangible and intangible social support received, both objective and subjective parental distress levels were moderate to high. Whereas the most highly endorsed distress items were related to concerns for the family and child, the lowest endorsed items on the PES were life of the caregiver being disrupted and feelings of resentment for the child’s demands on the caregiver. It appears that these primary caregivers were most distressed by the impact the situation was having upon their child and family, versus on themselves. Fear, worry, and guilt characterize subjective parental distress. It may be that chronic grief plays a role in explaining the level of subjective distress experienced by these parents (Mohr & Regan-Kubinski, 2001).

Externalizing behavior problems, perceived personal control, internalizing behavior problems, tangible support, and the interaction between perceived personal control and internalizing behavior problems independently predicted subjective distress, accounting for over one third of its variance. These independent predictors provide some clues to both stressors and potential targets for future interventions to decrease subjective distress, with behavior problems representing stressors, perceived personal control representing a resiliency resource, and tangible support a potential target for intervention. It could be argued that intangible support might also be a target for intervention, since it was most likely excluded from the model due to its shared variance with tangible support. Subjective distress may well be a caregiving consequence when, for example, a primary caregiver with a low sense of personal control is caring for a child with serious behavior problems and has little tangible support to provide a reprieve from that care.

In contrast, only 18% of the variance in objective parental distress was explained by the Stepwise regression model. The parental distress items used in this study may not adequately capture concerns of parents whose children exhibit predominantly externalizing behavior problems. Internalizing behavior problems, perceived personal control, and tangible social support were independent predictors of objective distress, with the latter two being potential targets for intervention. As with the model for subjective distress, it could be argued that intangible support might also be a target for intervention, since it was most likely excluded from the model because of its shared variance with tangible support.

Social support was not found to be a moderator of the association between child behavior and parental distress. This may be because of the overall low levels of social support reported by these caregivers. Similarly, effects of parent support groups could not be evaluated because of the small number of participants who had attended support groups.

Perceived personal control did moderate the association of child internalizing behavior problems to parent’s subjective distress. Parents with lower levels of perceived personal control had high levels of subjective distress, even when the child’s internalizing behavior problems were lower. These parents may benefit from efforts to increase their sense of personal control, especially when their child has lower levels of internalizing behavior problems. Parents with higher levels of perceived personal control were significantly less distressed than those with lower levels when their child’s behavior problems were less severe. However, these parents experienced more dramatic increases in subjective distress with the increasing severity of internalizing child behavior problems. Thus, interventions to support parents of children with high levels of internalizing behavioral problems are indicated regardless of their degree of perceived personal control. Even those parents with higher perceived personal control feel overwhelmed by increasingly severe internalizing behavior problems.

The Double ABCX Model was partially supported by the data from this study. The stressors and pile up of stressors (aA), represented by the internalizing and externalizing child behavior problems resulted in a crisis (x), as measured by the level of subjective and objective parental distress (see Figure 1). Tangible and intangible dimensions of social support, reflecting the resources (bB) available to deal with the stressor behaviors, did not mediate or moderate the relationship between behavior problems and parental distress. There were only low to moderate reported levels of social support, however, available to parents and an under utilization of support groups. Perceived personal control, representing the perceptions of stressors and available resources to deal with them (cC), did moderate the relationship between internalizing behavior problems and subjective distress. When internalizing behavior problems were lower, parents’ perceived personal control was related to lower subjective distress and, thereby, more positive adaptation (xX). With more severe levels of internalizing problems, even parents with higher levels of perceived personal control experienced high levels of subjective distress and problems with adaptation.

Limitations

The cross-sectional design of this study did not account for differences over time. In addition, with the use of a convenience sample, participants may have differed from non-participants. Further, all data were collected from a single informant, the primary caregiver, which might introduce bias.

Practice Implications

Raising a child with mental health problems has been found to result in parental distress. Both internalizing and externalizing child behavior problems predicted parental distress in this study. Distress, found to be at moderate to high levels in this sample, needs to be assessed by mental health professionals in order to comprehensively address needs of both the child with mental health problems and his or her parent. Periodic monitoring of the level of parental distress is indicated. Fluctuations may occur as a result of changes in the child’s mental health status or due to issues related to aspects of family and environmental changes (i.e., pile-up of stressors). Furthermore, assessing the amount of tangible and intangible support available to a caregiver would provide the opportunity to discuss options for increasing supportive resources. Additional support might help to ameliorate the stressful effects of the child behavior problems and prevent a state of continuous disruption and distress for these parents (McCubbin, Thompson, & McCubbin, 1996).

Parents’ levels of perceived personal control, found to moderate the association of internalizing behavior problems to subjective distress, can serve as a target for interventions to decrease subjective distress. Since parents with lower perceived personal control reported higher levels of subjective distress even when internalizing child behaviors were less intense, then interventions to increase perceived personal control would be indicated. However, developing interventions designed to increase perceived personal control should be emphasized for all parents, such as use of problem-solving strategies to increase their experience of success. Additionally, teaching parents strategies to manage disruptive child behaviors, both internalizing and externalizing, may allow the parents to gain control of difficult situations.

Guiding parents to consider requesting assistance from an existing support network may also be indicated. Professionals can provide support to parents by validating the acceptability of requesting respite care or other desired services, and by providing opportunities to openly discuss concerns in a non-judgmental way. Referrals to agency services and community-based support groups are two ways to increase parents’ actual levels of social support and should be incorporated into a holistic approach when serving children with mental health needs and their families. Efforts to strengthen and/or increase access to support within the family and community could provide options that parents can consider in efforts to successfully solve their problems, and ultimately increase their personal control. Providing appropriate interventional strategies and support may allow the parents to transform crises into manageable situations.

Research Implications

With the information gained from this study, a primary target to decrease parents’ distress would be to examine interventions to increase their perceived personal control. We need to also examine provision of social support based upon the needs of parents, children, and families. Further longitudinal studies are needed to better identify how parental distress fluctuates in response to changes within the child such as age, psychosocial development, and symptom variability. In addition, examination of the influences on parental distress from changes in the family and the social context, including school environment and access to formal and informal support networks, are needed.

Examination of both subjective and objective distress is warranted because interventions need to be directed to the dimension of parental distress which is of primary concern for each particular parent. Modification of the PES to specifically address a child’s aggressive behaviors, including physical injuries and damages to personal belongings or the home, may capture other important factors that increase caregiver distress. In addition, parents’ loss of sleep because of negative child behaviors should be investigated in an expanded instrument. A parent may be able to safely manage a younger child who is acting out of control, yet the realities of not being able to control an adult-size adolescent may increase the level of distress experienced. Future research needs to identify and describe the associations that exist between the severity of a child’s aggression toward self or others and the level of parental distress. Further, adding items related to chronic grief might help to capture yet another important aspect related to parents’ distress.

Questions raised in this study can guide both research and practice. As the Surgeon General’s report (DHHS, 2000) indicated, we are in a crisis related to children’s mental health. The impact of this crisis is experienced most intensely by both the children with mental health problems and their parents. It is imperative that we identify ways to assist these children, parents, and families in order to improve their well-being.

Acknowledgments

This research was funded in part by grant # 930 NR05035 from the National Institute of Nursing Research (NINR), NIH, to the Center for Enhancing Quality of Life in Chronic Illness at Indiana University School of Nursing; the Indiana Division of Mental Health and Addiction; and the Association for the Advancement of Mental Health Research and Education, Inc. The Authors thank the co-investigators, Erika Le Baron, Brenda Costello-Wells, and Kim Walton for help with recruitment; the participants; Phyllis Dexter for editorial comments; and Susan Perkins for statistical consultation.

Contributor Information

Catherine A. Duchovic, Associate Faculty, Department of Nursing, Indiana University Purdue University Fort Wayne.

Janis E. Gerkensmeyer, Assistant Professor, School of Nursing, Indiana University, Indianapolis.

Jingwei Wu, Biostatistician, School of Medicine, Indiana University, Indianapolis.

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