Stress and Marital Satisfaction of Parents with Children with Disabilities in Hong Kong

This study examined the associations among sources of parenting stress, sharing of child care responsibilities, and marital satisfaction of parents with children with disabilities in Hong Kong. This is a cross-sectional quantitative study. Seventy-two parents completed a survey about their sources of parenting stress, sharing of child care responsibilities and marital satisfaction. Results indicated that handling their children’s emotions and behaviours was the most stressful experience. Linear regression analysis showed that the amount of sharing of child care responsibilities and the stress of time allocation were significant predictors for marital satisfaction. Implications for providing support to parents with children with disabilities in Hong Kong were discussed.


Introduction
Parenting children with disabilities may influence the parents positively or negatively (Hock, Timm, & Ramisch, 2012).While it is helpful for social workers to be aware of the positive impacts, the negative impacts on the parent, the marital relationship and the family are often the focus of attention for designing and implementing prevention and intervention services for families with children with disabilities.
Although substantial research has been done on parents with children with disabilities, most research has been conducted in Western cultures with very few exceptions (e.g.McConkey et al., 2008) and overlooked potential cultural differences.According to Markus and Kitayama (1991), Western cultures and many Asian cultures differ in their construals of the self, others, and the interdependence between self and others.These differences in turn have implications for cognition, emotion and motivation (Markus & Kitayama, 1991).For example, Chinese culture values group harmony whereas American culture typically emphasizes independence (Higgins, Zheng, Liu, & Chun, 2002).These fundamental cultural differences are likely to influence the experience of parenting children with disabilities, the susceptibility to different sources of parenting stress, the perception of sharing of child care responsibilities and the evaluation of marital satisfaction.Hence, the objective of this study was to explore the associations among different sources of parenting stress, marital satisfaction, and sharing of child care responsibilities of parents with children with disabilities in a Chinese culture, namely, Hong Kong.

The Chinese Experience of Stress
According to Phillips and Pearson (1996), Chinese people experience stress differently compared to individuals in Western cultures.Chinese people tend to keep stressful events to themselves and Chinese parents are not encouraged to express their emotions (Bond, 1993;Kim & Wong, 2002;Lai & Salili, 1997).Rogers and Hogan (2003) suggested that the stress of one family member asserts a reciprocal effect on other family members, and parenting stress is associated with children's negative outcomes such as behavioural problems and affects parent-child interaction negatively (Åsberg, Vogel, & Bowers, 2008).Therefore, it is important to understand the sources of stress of parents with children with disabilities for tailoring interventions for the children and responding to the needs of the parents (Smith, Oliver, & Innocenti, 2001).

Marital Satisfaction, Parenting, and Children with Disabilities in Chinese Culture
Research on marital satisfaction in Chinese couples has been rare as Chinese culture considers marital satisfaction "a private matter between a husband and wife rather than an issue that can be comfortably subject to open discussions" (Guo & Huang, 2005: p. 22).Research has found cultural differences in the differentiation of good and bad marriages (Pimentel, 2000).With regard to marital satisfaction, Wong and Goodwin (2009) found that British participants valued companionship more but Hong Kong participants placed more emphasis on harmonious marital relationship.For Chinese couples, divorce was less frequently considered a resolution to marriage compared to Westerners (Pimentel, 2000).Consequently, Chinese couples may endeavor to avoid the development of disharmony as divorce is not a culturally appropriate exit for marriage (Pimentel, 2000).
Traditionally, in Chinese culture, "the ultimate purpose of a marriage is to produce an heir to carry on the family line" (Lu, 2006: p. 475).Therefore, in the Chinese cultural context, children are expected to be an essential element of a family whereas many Westerners may be more ambivalent about childbearing (Pimentel, 2000).Consequently, the birth and subsequent care of a child with disabilities may have a particularly strong impact on Chinese couples who view children as the purpose of marriage (Lu, 2006).Moreover, given the traditional Chinese belief that the disabilities of a child are the consequences of something that the mother or her family has done (Holroyd, 2003), such cultural uniqueness in the conceptualization of marital satisfaction, parenting and attribution of children with disabilities warrants the examination of the associations among the sources of stress and marital satisfaction of parents with children with disabilities in Chinese culture.

Chinese Concept of Sharing of Responsibilities between Spouses
There has been research on the division of labor between parents of children with disabilities (Cohen & Petrescu-Prahova, 2006).For instance, Simmerman, Blacher, and Baker (2001), in a longitudinal study, found that the mother's satisfaction with the father's involvement in helping their children with disabilities was associated with both parents' marital adjustment.According to McConnell, Futris, and Bartholomae (2009), if mothers of children with physical disabilities were satisfied with the father's parenting, they would perceive the behavioural problems of the children as less influential.Zuo and Bian (2001) found that although housework was unevenly distributed between Chinese couples, most of the husbands and wives thought it was fair.There was also a trend that the wife contributed three times more to child care compared to the husband (Zuo & Bian, 2001).Nevertheless, little is known about Chinese couples' division of labor in caring for children with disabilities.In the current study, the sharing of child care responsibilities and its associations with sources of parenting stress and marital satisfaction were examined.

Significance of the Study
Very few studies (e.g.Keller & Honig, 2004) investigated the sources of stress and their associations with marital satisfaction of parents with children with disabilities.Though there were studies in Hong Kong that examined the stress faced by families with children with disabilities (e.g.Ma, Lai, & Pun, 2002), none has looked at the associations among sources of parenting stress, marital satisfaction and sharing of child care responsibilities.Shek (2006) highlighted the importance of research on Chinese families based on the huge size of the Chinese population and the strong emphasis of family in Chinese culture.This study will provide theoretical implications for furthering the understanding of how different sources of stress affect marital satisfaction of parents with children with disabilities.In addition, since supportive services for families with children with disabilities are crucial for adaptation (Tétreault et al., 2012), the findings of this study can inform social workers and other professionals such as family therapists and nurses about how to provide specialized assistance and counseling to parents with children with disabilities in Chinese culture.

The Context of Hong Kong
The current study focused on parents with children with disabilities in Hong Kong.The Government of Hong Kong provides various types of special services for disabled pre-school children, including Early Education and Training Centre (EETC), Integrated Programme in Kindergarten-Cum-Child Care Centre, Special Child Care Centre, Residential Special Child Care Centre and Small Group Home for Mildly Mentally Handicapped Children.In 2010 and 2011, approximately 5982 disabled children received early intervention (Social Welfare Department, HKSAR, 2011).EETC accommodates the largest number of disabled pre-school children and referrals are made either by social workers or government-run children assessment centres.Participation is voluntary.In 2010 and 2011, there were 37 centres in Hong Kong with a total of approximately 2341 cases (Social Welfare Department, HKSAR, 2012).Participants for this study were parents from two EETC in Hong Kong.

Hypothesis
In this study, the main hypothesis was that marital satisfaction would be negatively correlated with parenting stress in parents with children with disabilities in Hong Kong.In addition, the associations between sharing of child care responsibilities and marital satisfaction were explored.

Participants
The final sample consisted of 72 participants (either the father or mother of a family).There were 55 female participants and 17 male participants.The mean age of participants was 35.11 years (SD = 5.64 years).All of the participants were married and the mean duration of marriage was 8.77 years (SD = 4.65 years) (range: 2.17 years to 24.08 years).Of the participants, 40% were employed, 58% were unemployed and 1% did not report the employment status.For the spouses of the participants, 82% were employed and 18% were unemployed.In this sample, 33% of both the participants and their spouse were unemployed.The family income per month of 74% of participants was over HKD 10000 (~USD 1289); 13% were between HKD 7001 to HKD 10,000 (~USD 902 -1289); 7% were between HKD 4001 to HKD 7000 (~USD 516 -902); 3% were between HKD 1001 to HKD 4000 (~USD 129 -515) and 3% had less than HKD 1000 (~USD 129), 1% did not report the monthly family income.The average number of members per household including the participant was 3.65 (SD = .68).

Procedures
Parents with children with disabilities including developmental delay, physical and mental handicap, and psy-chological problems, and had been admitted to two branches of Early Education and Training Centre in Hong Kong were recruited for this study.A total of 80 questionnaires with consent forms were distributed to the parents either in person or via mail.Eight questionnaires were discarded either because they were missing important data or the participants were not married.The participants did not receive any monetary compensation for their participation.The participants either returned the questionnaires in person or via mail.The questionnaires were anonymous.

Measures
Demographics.Participants provided information about their gender, age, marital status, duration of marriage, their employment status and that of their spouse, monthly family income and the total number of family members in the household.
Marital satisfaction.A single-item measure was used for measuring marital satisfaction (Fowers, 1991).Participants responded to the question "What is your level of satisfaction with your marriage?" on a 10-point scale (1 = extremely dissatisfied to 10 = extremely satisfied).
Stress level.Similar to previous research (Baxter, Cummins, & Yiolitis, 2000), we developed items to measure the different sources of stress of parents.Participants evaluated their stress level with regard to seven sources of stress on 7-point scales (1 = do not feel any pressure to 7 = feel a lot of pressure).The seven sources of stress were as follows: 1) accompanying child to training in the centre (the Early Education and Training Centre), 2) domestic training with child, 3) allocating time between child care and work or housework, 4) guiding child to learn, 5) handling the emotions and behaviours of child, 6) the differences between the development of their child and that of other children of the same age, and 7) other people's view of their child care.The Cronbach's alpha of the scale was 0.90, indicating high internal reliability.
Sharing of child care responsibilities.Participants assessed their spouse's level of sharing of child care responsibilities using a single item similar to previous research (Goff, Mount, & Jamison, 1990) on a 7-point scale (1 = does not share responsibility to 7 = sharing much responsibility).

Statistical Analysis
IBM SPSS Version 21 was used for data analysis.Descriptive statistics, correlational analyses and linear regression analysis will be reported.

Marital Satisfaction and Sharing of Child Care Responsibilities
On a scale from 1 -10, the level of marital satisfaction was considered as relatively high (M = 7.96, SD = 1.62) and on a scale from 1 -7, the level of sharing of child care responsibilities was above mid-point (M = 4.46, SD = 1.77).

Sources of Stress
Among the sources of stress, handling the emotions and behaviours of child induced the highest level of stress, followed by guiding child to learn and stress brought by the differences between the development of child and other children of the same age.Parents had moderate level of stress from domestic training and other people's views of their child care.Parents had the least stress from accompanying child to attend training in centres.The means and standard deviations of the stressors are listed in Table 1.

Correlations of Demographics, Sources of Parenting Stress, Sharing of Child Care Responsibilities and Marital Satisfaction
Demographics including age, duration of marriage, employment status of the participants and their spouses, number of members in the household, and level of family income per month were not significantly correlated with marital satisfaction.Sharing of child care responsibilities was positively correlated with marital satisfaction.Among the sources of stress, only one source which was "accompanying child to training held in the center" was not significantly correlated with marital satisfaction.All the other sources were negatively correlated with marital satisfaction (see Table 2).

Linear Regression Analysis
Variables that had significant correlations with marital satisfaction were then entered as predictors in a linear regression with marital satisfaction as the dependent variable.Linear regression analysis was used to examine the effects of six sources of stress and sharing of child care responsibilities on marital satisfaction.The results showed that the model explained 27% of the variance in marital satisfaction (R 2 = .34,F(7.64) = 4.79, p < .001).
Only sharing of child care responsibilities (β = 0.24, p < .05)and the source of stress "allocating time between child care and work or housework" (β = −.36,p < .01)were significant predictors in the model.Please refer to Table 3.

Sources of Parenting Stress
Among the seven sources of parenting stress, handling the emotions and behaviours of children with disabilities was the most stressful for parents.This is consistent with previous findings in Western culture which showed that the behavioural and emotional problems of children with disabilities had impacted their parents' level of stress (Baker, Blacher, Crnic, & Edelbrock, 2002;Baker et al., 2003;Hastings, 2002;Herring et al., 2006).According to Howe (2006), children with disabilities may have difficulty in expressing their mental states, therefore, social workers and other professionals may endeavor to tailor training programs to enhance the communication between parents and children which may help reduce parents' stress in managing the behaviours and emotions of the children.
In contrast, accompanying their child to training in the Early Education and Training Centre was the least stress-inducing for parents.It could be due to the effectiveness of the training programs or opportunities to interact with other parents.According to Resch, Benz, and Elliott (2012), compared to demographics of parent and child as well as the severity of the child's disability, the availability of social support and resources had a larger direct effect on the well-being of the parents.Previous research has also shown that parents with children with disabilities benefited from receiving emotional, social as well as practical support from other parents with children with disabilities (Kerr & McIntosh, 2000).These centres might have served as a platform for parents to provide mutual support to each other, hence alleviating their level of stress of accompanying their child to training.According to Glidden, Billings, and Jobe (2006), finding resources and accessing care services are challenges for parents with children with disabilities.Therefore, the government and non-government organizations need to collaborate to maximize the capacities of training and child care centres for children with disabilities to assist the parents.Among the sources of stress, only the source "allocating time between child care and work or housework" was a significant predictor of marital satisfaction.The more stress parents had with time allocation, the less satisfied they were with their marriage.Therefore, professionals who work with these parents can equip them with time management skills.

Stress Level and Marital Satisfaction
The stress level of the majority of stressors of parents in this study was moderate and marital satisfaction was high.Parents in this study might be similar to parents with children with autism in Western culture who demonstrated resilience and were highly adaptive (Twoy, Connolly, & Novak, 2007), and thus did not experience a high level of stress in most of the stressors.According to Eddy and Walker (1999), having a child with disabilities may not necessarily result in marital distress.The current study supports such claim.An alternative explanation is that the norms of harmony in Chinese culture might have led parents to report their marital satisfaction in a positive light (Stander, Hsiung, & MacDermid, 2001).

Sharing of Child Care Responsibilities
Sharing of child care responsibilities was a significant predictor of marital satisfaction.The more the spouse shared responsibilities of child care, the higher the marital satisfaction.In a collectivistic culture like Chinese culture which emphasizes social harmony and group needs, spouses may have more motivation to prioritize harmony of marriage as a subset of social harmony.For Chinese parents with children with disabilities, one of the means to achieve the goal of social harmony may be to share the responsibilities of child care.The results of the current study indicated that sharing of child care responsibilities should be encouraged to increase marital satisfaction.Social workers and other professionals can aim at equipping both parents with the skills of child care to increase the effectiveness of the division of labour.

Limitations and Future Research Directions
This study had several limitations.The participants were parents of children who attended two EETC.As these centres provide support for families with children with disabilities, this study was limited in its generalizability and might not represent parents who were not receiving support from these centres.As most of the participants were clients of one of the researchers, there might be the issue of social desirability.Parents might have underrated their stress level, or overrated their marital satisfaction.Future research can recruit parents from multiple sites for a more representative sample to increase the generalizability of the results.Only quantitative data was collected in this study, future studies may use interviews to understand the reasons behind the different sources of stress and other factors that contribute to marital satisfaction of parents with children with disabilities in a Chinese cultural context.In particular, females were over-represented in the participants.Given that previous research has found gender differences in marital satisfaction of parents with children with disabilities (Berge, Patterson, & Rueter, 2006), future research can aim at including both spouses to explore potential discrepancies in the experience of stress and marital satisfaction within a family.Future research can also compare maternal and paternal stress in parents with children with disabilities in Chinese culture.The current study did not differrentiate among the different types of disabilities that children had.Future research can examine the potential differences in stress and marital satisfaction of parents with children with different disabilities, different severities of disability, and at different stages in the developmental trajectory.Such knowledge would be essential for professionals when they provide services and counseling for families with children with special needs.

Conclusion
This is the first study to examine the associations among sources of parenting stress, sharing of child care responsibilities and marital satisfaction in parents with children with disabilities in a Chinese cultural context.The findings suggest that emphasis should be placed on helping these parents to handle the emotional and behavioural problems of their children to alleviate the stress of the parents.For enhancing marital satisfaction, alleviating the stress of time allocation and increasing the sharing of child care responsibilities will be beneficial.Social workers and other professionals working with parents with children with disabilities should pay more attention to educating parents about time management, sharing of child care responsibilities and how to handle the emotional and behavioural problems of the children.

Table 1 .
Sources of stress of parents with children with disabilities: descriptive statistics.

Table 2 .
Correlations of demographics, sources of parenting stress, sharing of child care responsibilities and marital satisfaction.

Table 3 .
Summary of linear regression analysis for variables predicting marital satisfaction of parents with children with disabilities.