Locus of Control, Perceived Parenting Style, and Anxiety in Children with Cerebral Palsy

ORIGINAL ARTICLE

Locus of Control, Perceived Parenting Style,and Anxiety in Children with Cerebral Palsy

Esther Cohen & Gali Biran & Adi Aran &

Varda Gross-Tsur

Published online: 12 June 2008# Springer Science + Business Media, LLC 2008

Abstract In this study we examined interrelations among locus of control (LOC),disease severity, anxiety, and parenting style (PS) in children with cerebral palsy(CP). Thirty children with CP and their 30 healthy siblings completed self-reportmeasures of LOC, anxiety, and perceived PS of the mother. A neurologicalassessment determined severity of CP. Children with CP, regardless of severity, didnot differ from their siblings in LOC, anxiety, or perceived PS. Multiple-regressionanalyses showed that LOC was predicted only by the acceptance/rejection dimensionof PS in children with CP; whereas for their siblings, age, and anxiety were the bestpredictors. The findings suggest a central influence of the home environment onchildren’s psychological development. For children with CP, experiencing parentalacceptance may enhance development of resilience-related qualities, such as aninternal LOC.

Keywords Locus of control . Parenting style . Anxiety . Cerebral palsy . Siblings

Cerebral palsy (CP) is the most prevalent cause of serious physical disability inchildhood (Kuban and Leviton 1994). In recent years, there is growing recognitionthat the prognosis for a child with CP depends not only on the medical, physical andfunctional aspects related to the disability, but also, and perhaps primarily, on thechild’s psychological characteristics, as well as on psychosocial family variables(Majnemer and Mazer 2004; Schuengel et al. 2006).

A review of the literature on mental-health and adjustment of children with CP, incomparison to typically developing children, reveals a complex picture of both riskand resilience. A number of studies, based on varied populations of children with

J Dev Phys Disabil (2008) 20:415–423DOI 10.1007/s10882-008-9106-8

E. Cohen (*)School of Education, The Hebrew University of Jerusalem, Mount Scopus, Jerusalem 91905, Israele-mail: [email protected]

G. Biran : A. Aran :V. Gross-TsurThe Neuropediatric Unit, Shaare-Zedek Medical Center, Jerusalem, Israel

CP, show that they may be at risk for various psychological problems such as:generalized feelings of helplessness, low self-esteem, anxiety, low academic achieve-ments, social problems and dependency, as well as, headstrong behaviors (Breslau andMarshall 1985; Heller et al. 1996; Manuel et al. 2003; McDermott et al. 1996).However, McDermott et al. (1996) reported that although a substantial proportion ofchildren with CP experience significant behavioral problems, most do not developsuch problems, thus showing resilience. Similarly, children with CP do not differfrom children without disabilities in their ability to maintain, in general, positiveself-worth, and to perceive their competence as adequate in meeting the demandsand expectations appropriate to their developmental stage (Schuengel et al. 2006).

It thus becomes clear that a general risk model based on physical disabilities maybe too simple for understanding adaptational outcomes in children with CP. Thisstudy focused on psycho-social factors: namely, the child’s cognitions with regard tocontrol of personal consequences and their interrelations with perceptions ofparenting style as well as with symptoms of anxiety.

Locus of Control

The generalized beliefs held by individuals about their ability to control dailyreinforcements appear to play a significant role in various aspects of their adaptationand subjective wellbeing (Chorpita and Barlow 1998). Locus of control (LOC)orientations reflect these enduring beliefs along a continuum ranging from “internalLOC”—the perception of being able to control one’s own life events through effortor talent—to “external LOC”—indicating beliefs that one’s life is controlled bypowerful others or by chance (Carton and Nowicki 1994; Rotter 1990). In childrenand adolescents, external LOC orientations are associated with poorer schooladaptation, involvement, and achievements (Kee 2005; Nesselroade et al. 2002), aswell as with an increased vulnerability towards anxiety and depression (Chorpita andBarlow 1998).

LOC has also been found to serve as a predictor of psychological adjustment inyouth with chronic illness (Meijer et al. 2002), and as a mediator between illnessseverity and well-being in children and adults affected by chronic illness (Murray2003; Ostrander and Herman 2006). LOC in children with CP may therefore beassumed to play an important role in their emotional and behavioral adjustment, andan internal LOC may be considered a protective factor in face of the increased risk ofadjustment problems.

Studies examining LOC in children with CP report mixed results. WhereasEggland (1973) found children with CP to demonstrate more beliefs in externalcontrol than non-handicapped schoolchildren, Center and Ward (1986) did not findsuch differences. Moreover, findings by Schuengel et al. (2006) show no differencesbetween children with CP and local norms in their perceptions of personalcompetence, except for their lower perception of competence in athletic activities.These finding suggest the possibility that the sense of reduced control may beexperienced by children with CP only in the specific areas of their handicap, or thatit may be generalized to other areas of functioning, depending on other variablesunrelated to the disability.

416 J Dev Phys Disabil (2008) 20:415–423

Parenting Style

Development of LOC in children has been linked to parenting style (PS). InternalLOC was shown to be associated with an accepting and autonomy-supporting PS(Carton and Nowicki 1994; Chorpita and Barlow 1998), parental warmth (Dew andHuebner 1994; Krampen 1989; Suchman et al. 2007), and parental protectivenessand attentiveness (Dew and Huebner 1994). Parents raising a child with CP are facedwith the special challenge of successfully conveying to these children a sense ofparental acceptance and support of their autonomy, in spite of the children’s greatneed for tangible help. Very limited research has been conducted on the perceptionsof children with CP with regard to their parents’ PS (Harper 1984), but it appears tobe significant for their quality of life (Aran et al. 2007).

Anxiety

There is some evidence showing that children with CP exhibit higher levels ofanxiety in comparison to typically developing children (McDermott et al. 1996). Innon-handicapped children, anxiety was found to be associated both with parentalchild-rearing practices, and with perceived control (Barlow 2002; Bõgels andBrechman-Toussaint 2006; Chorpita et al. 1998; Muris et al. 2004; Rapee 2001).However, interrelations among these constructs remain unclear. Some models ofanxiety, implicate cognitive factors such as children’s locus of control as a mediatingfactor linking parental over-control to child anxiety (Barlow 2002; Chorpita et al.1998; Rapee 2001), but strong evidence for this model is still lacking (Muris et al.2004).

The present study aimed to investigate the interrelations among LOC, perceivedparenting style, and anxiety in children with CP. We used the children’s siblings as acontrol group to decrease the levels of variance due to familial influences.Additionally, we examined differences in LOC, anxiety, and perceived parentingstyle as a function of the severity of CP.

Method

Participants

Participants comprised 30 children with CP (15 males, 15 females; ages: M=11.66,SD=3.17; range=6–18) and their 30 siblings (13 males, 17 females; ages: M=12.16,SD=3.67; range=6–18). Six of the sibling pairs were twins. No significant agedifference emerged between the two groups. Inclusion criteria for children with CPwere: an unequivocal diagnosis of CP, age 6–18, normal intelligence, attendance in aregular school, and no other known major disorders. Inclusion criteria for siblingswere: a healthy child, closest in age to the sibling with CP, attending a regularclassroom in a regular school. Fifty families with mainstreamed school-age childrenwith CP were approached, and 42 (84%) agreed to participate. Nine children wereexcluded due to intellectual limitations, and three others were excluded because no

J Dev Phys Disabil (2008) 20:415–423 417

sibling met the inclusion criteria. The group of children with CP included 27diagnosed with spastic CP (12 quadriplegic, eight diplegic, and seven hemiplegic),two were hypotonic, and one was dyskinetic. The mean IQ score, available only forthe children with CP, was 92.52 (SD=17.91; range=72–124), based on either theverbal score of the Revised Wechsler Intelligence Scale for Children (Wechsler1974), or the achievement score on the Kaufman Assessment Battery for Children(Kaufman and Kaufman 1983). Using Abramson et al. (1982) criteria forsocioeconomic level, participants’ socioeconomic status was almost equally dividedbetween high (36.7%), middle (30%), and low (30%),

Measures

Locus of control was assessed by the children’s self-report on the Locus of ControlScale for Children (Nowicki and Strickland 1973) in its Hebrew version (Lufi andParish-Plass 1995). The 40-item scale yielded a single score, with higher scoresindicating more external LOC. Internal reliability was α=0.63, similar to thatreported by Nowicki and Strickland.

Parenting style was assessed via a shortened 40-item Hebrew version (Cohenet al. 2008) of the maternal form of the Children Reports of Parent BehaviorInventory (Schaefer 1965), with reported internal reliability of α=0.80. The child’sratings yielded a score on each of the following four scales: acceptance, rejection,autonomy, and control. In the present study, the high significant correlationsobtained between the acceptance and rejection scales (r=−0.70, p<0.01), andbetween the autonomy and control scales (r=0.39, p<0.05), suggested the suitabilityof collapsing these two sets of polar scales and treat them as a continua, as iscurrently accepted in research on PS (Wood et al. 2003). Internal reliabilities wereα=0.85 for the merged acceptance–rejection scale and α=0.74 for the mergedautonomy–control scale. The Pearson correlation between the two scales wassignificant (r=0.25, p<0.05)

Children’s anxiety was assessed using a Hebrew adaptation (Toren et al. 2000) ofthe Revised Children’s Manifest Anxiety Scale. The self-report scale, developed byReynolds and Richmond (1978), included eight “lie scale” items and 28 itemsmeasuring anxiety by positive endorsement. In the present study, similar internalreliability to that reported by the scale developers was obtained (α=0.83).

Child’s level of impairment was assessed by a child neurologist using the GrossMotor Function Classification System (Palisano et al. 1997). Each child was rated ona scale of 1 to 5; higher scores indicated more serious impairment in motorfunctioning and self-initiated motility. The internal reliability reported by Palisianoet al. (1997) was α=0.75.

Demographic information was collected using a brief questionnaire, assessingfamily composition, socioeconomic variables and the child’s development andcurrent functioning.

Procedure

All Hebrew speaking families in the Jerusalem area who participated in special after-school programs for mainstreamed children with CP were approached to take part in


the study. Consenting parents were given more detailed information about theresearch, and asked to sign informed consent. A joint meeting with a pediatricneurologist and a psychologist was scheduled to be held at the family’s home. Duringthe home visit, both siblings completed the various self-report questionnaires.Children who had difficulty in reading or understanding the meaning of some wordsin the questionnaires (mostly the younger ones) were helped by the psychologist,using a standard explanation. Parents completed a demographic questionnaire. Thechild with CP underwent a physical and neurological assessment to determine theseverity of CP.

Results

Preliminary Analyses

The relations between age of participants, gender, and socioeconomic status anddependent variables were calculated using Pearson correlations, separately for the CP andsibling groups. None of the correlations was significant except for age. In both groups,age correlated negatively with the autonomy–control dimension of PS (in the group withCP: r=−0.47, p=0.005; in the siblings group: r=−0.51, p=0.002). This indicates thatperceptions of autonomy-granting by mothers increased with age. In the sibling group,but not in the group with CP, age was also associated with LOC, indicating moreinternal LOC with age (r=−0.52, p=0.001). On the basis of these findings, and giventhe small sample size, we controlled only for age in further analyses.

Between-Group Comparisons

A series of t-tests for matched samples was conducted to examine differencesbetween the two groups in LOC, anxiety, and PS. None of the tests were significant.The mean anxiety scale score was 10.37 for children with CP (SD=6.19) and 10.10for the siblings (SD=4.61), placing both groups within the normal range reported byReynolds and Richmond (1978) for a similar age sample (M=13.84, SD=5.79).

Severity of CP, using the Gross Motor Function Classification System, wasclassified as mild (level 1+2) in ten children, as medium (level 3) in nine children,and as severe (level 4+5) in 11 children. Given the categorical nature of this scaleand the small number of participants, differences between these three subgroupswere examined by their frequency of scores above and below the median scores onLOC, anxiety, and PS, yielding no significant results using a chi-square test.

Associations Between LOC, Anxiety, and PS

Associations between psychological variables used in this study were examinedseparately for the two groups, using Pearson correlations. In the group of childrenwith CP, significant correlations were found between LOC and anxiety (r=0.43, p=0.009), showing that higher anxiety was associated with a more external LOC. Amore external LOC was also associated with a more rejecting PS (r=0.53, p=0.001),as well as with a more controlling PS (r=0.38, p=0.02). Higher anxiety correlated


significantly with a more rejecting PS (r=0.30, p=0.05). Similar results wereobtained in the sibling group, but only for the association between LOC and anxiety(r=0.49, p=0.003), and between LOC and the autonomy–control dimension of PS(r=0.36, p=0.03). Anxiety was not related with either aspect of PS for the healthysiblings (r=0.08, p=0.34 with rejection; r=0.12, p=0.26 with control).

Prediction of LOC

Variables that were significantly related to LOC were entered into regressionanalyses. A multiple regression model for LOC in children with CP was conductedwith anxiety, both dimensions of PS, and age as predictors. The regression wasstatistically significant: adjusted R2=0.24, F (4, 24)=3.24, p=0.03. An examinationof the beta weights indicated that only the acceptance–rejection dimension of PS wasa significant predictor, (β=0.42, t=2.06, p=0.05), whereas for anxiety (β=0.25, t=1.40, p=0.17), the autonomy–control dimension of PS (β=0.03, t=0.15, p=0.88),and age (β=−0.06, t=−0.35, p=0.73) the beta weights were not significant.

A multiple regression predicting LOC among the siblings by entering parentingstyle, anxiety, and age as independent variables proved highly significant: adjustedR2=0.48; F (4, 24)=7.48, p=0.000. Beta weights showed that the two uniquesignificant predictors of LOC were age (β=−0.52, t=−3.25, p=0.003) and anxiety(β=0.43, t=3.09, p=0.005), whereas the acceptance–rejection dimension of PS(β=0.25, t=1.80, p=0.08) and the autonomy–control dimension of PS (β=0.07, t=0.44, p=0.67) did not contribute significantly

Discussion

Results of this study show significant associations between LOC, PS, and anxiety.These factors interact differently in children with CP and their siblings. LOC inchildren with CP was best predicted by the acceptance–rejection dimension of PS:perceptions of higher acceptance by mothers predicted a more internal LOC.Although perceptions of autonomy–control and anxiety were each separatelyassociated with LOC, these variables did not add to predicting LOC beyond thecontribution of perceptions of acceptance–rejection.

LOC has been shown to become more internal with age in non-handicappedchildren (Muris et al. 2004; Nowicki and Strickland 1973), and in children withTourette syndrome (Cohen et al. 2008). In contrast to these findings, age in our studywas associated with LOC only for the sibling group, but not for the children with CP.

These finding may suggest that control orientations for children with CP are lessaffected by the consequences of their age-related range of experiences, and are moredependent on their experience with their parents’ responsiveness. The relationbetween parental acceptance and internal LOC has been previously documented(Carton and Nowicki 1994; Muris et al. 2004); however, it may be of particularsignificance for children who are highly dependent on parents and who maytherefore be preoccupied primarily with their ability to maintain and control thisemotional bond. This is further supported by the finding that, unlike their siblings,the perceptions of the children with CP of acceptance by their parents greatly


overlapped with their perceptions of being granted autonomy. However. it cannot bedetermined from our data (because of its correlational nature) whether parentalrejection contributes to an external LOC in children with CP, or whether an externalLOC sensitizes these children to project blame for their difficulties on theircaregivers. Most likely these two dynamics interact.

The sibling group perceived each of the dimensions of PS (acceptance–rejectionand autonomy–control) as independent dimensions and their anxiety seemed to berelated to sources other than PS (as evidenced by the non-significant correlationsbetween these variables). LOC among the siblings was significantly predicted byanxiety and age, confirming findings in earlier studies (Muris et al. 2004; Nowickiand Strickland 1973). Although contribution of perceived acceptance–rejection toLOC approached significance, it may be that the centrality of anxiety in the controlexpectations of siblings was affected by their experience of living with a disabledsibling, or on actual experiences outside the home, more than by their perceived PS.

In line with recent studies emphasizing resilience of children with CP (Schuengelet al. 2006) no differences in anxiety, LOC, or perceived PS were found betweenchildren with CP and their siblings. Furthermore, severity of CP did not explainindividual differences on these variables. The decision to recruit children with CP onthe basis of their average intelligence (and thus also being integrated into regularschools), as well as using their siblings as controls, helped reduce variance unrelatedto the illness itself. Our findings thus support earlier claims as to the centralinfluence of familial factors and shared environments on emotional adaptation andcoping of children with disabilities such as CP (Aran et al. 2007; Trute 1990).Furthermore, findings emphasize the subjective experience of impairment for thechild and for his or her family.

Cerebral palsy cannot be cured, but resilience can be promoted for coping withthe functional challenges faced by children with this condition and for increasingtheir independence (Rosenbaum 2003). Previous research showing that cognitionsrelated to control and efficacy contribute to resilience and successful adaptationshould guide our continued search for ways to promote these cognitions in thoseaffected by disability. Based on our findings, interventions with families of a childwith CP should include a focus on the communication and perception of parentalacceptance in order to promote a better sense of control in children with CP.

Limitations of our study include the small number of participants and the selectioncriteria, which indicate the need for caution in generalizing from the findings. Largerstudies, including both a wider range of children with CP, and employing measuresbased on multiple sources, are needed to strengthen our findings. Longitudinal studiesof children with CP and their siblings may further clarify the relations betweenparenting variables, LOC and social and emotional adaptation.

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Locus of Control, Perceived Parenting Style, and Anxiety in Children with Cerebral Palsy

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