Vivek Ramanandi,Aparna Bachkaniwala,Aksh Chahal,Sakshi Vats,Mansi Jain,Abhishek Sharma,Nidhi Sharma,Kanika
The Parental Stress Scale: Validity and Reliability of Gujarati Translated Version in Parents of Children with Cerebral Palsy
Cerebral palsy,Health care,Outcome Assessment,Parents,Psychometrics
Background The parental Stress Scale (PSS) is an 18 item self-report scale that indicates positive (e.g., emotional benefits, personal development) and negative (demands on resources, restrictions) themes of parenthood. This study was aimed to study the reliability and validity of the Gujarati version of PSS (PSS-G) by a study performed among parents of children with Cerebral Palsy (CP). Methods In total, 152 parents of children with CP were assessed for evaluation of stress using the Gujarati version of PSS and the English version of the Parenting Stress Index– Short form. Concurrent validity was evaluated using Pearson’s correlations, internal consistency was evaluated using Cronbach’s alpha, and test–retest reliability was evaluated using the intraclass correlation coefficient value. Results The scales of the PSS-G revealed high internal consistency (i.e., Cronbach’s α = 0.923) and the intraclass correlation coefficient value for test–retest reliability of 0.987. Moreover, Pearson’s correlation coefficient also supports the concurrent validity of PSS-G for parents of children with CP. Conclusion The PSS-G is a valid and reliable outcome measure to evaluate parental stress in parents of children with CP. As the robust psychometric properties of PSS-G is already established, research can be performed to extend its utility and routine use in clinical and public health settings.
The Parental Stress Scale: Validity and Reliability of Gujarati Translated Version in Parents of Children with Cerebral Palsy

The parental Stress Scale (PSS) is an 18 item self-report scale that indicates positive (e.g., emotional benefits, personal development) and negative (demands on resources, restrictions) themes of parenthood. This study was aimed to study the reliability and validity of the Gujarati version of PSS (PSS-G) by a study performed among parents of children with Cerebral Palsy (CP).

In total, 152 parents of children with CP were assessed for evaluation of stress using the Gujarati version of PSS and the English version of the Parenting Stress Index– Short form. Concurrent validity was evaluated using Pearson’s correlations, internal consistency was evaluated using Cronbach’s alpha, and test–retest reliability was evaluated using the intraclass correlation coefficient value.

The scales of the PSS-G revealed high internal consistency (i.e., Cronbach’s α = 0.923) and the intraclass correlation coefficient value for test–retest reliability of 0.987. Moreover, Pearson’s correlation coefficient also supports the concurrent validity of PSS-G for parents of children with CP.

The PSS-G is a valid and reliable outcome measure to evaluate parental stress in parents of children with CP. As the robust psychometric properties of PSS-G is already established, research can be performed to extend its utility and routine use in clinical and public health settings.

Parenting stress can be understood as a complex process leading to aversive psychological reaction that occurs when caregivers feel overwhelmed and perceive that they lack the skills required to cope with their parental role [1,2]. Research has suggested that the parenting stress is associated with parenting processes across all developmental and is a normative process that can affect every parent. However, it may be more severe for parents of children with clinically significant emotional, behavioural, or health issues [3,4], and particularly challenging for families where parenting demands converge with negative situational circumstances (e.g., low-income) or personal difficulties (e.g., parents mental health problems, children with subclinical behavior problems) [5,6]. Higher levels of parenting stress have been found to be associated to depression and psychological difficulties in parents [7,8], behavior problems and self-regulation difficulties in children [9,10], and negative interactions between parents and children [11,12]. Children with cerebral palsy display prominent motor dysfunction associated with other developmental disorders. Parenting a child with cerebral palsy presents a number of challenges and stresses. Cerebral palsy (CP), as a common cause of disability in children, is a serious threat to parents’ psychological and physical health [13-15]. Previous researchers have demonstrated elevated levels of stress in parents of children with developmental disability globally including India [15-21]. Modifying factors of caregiver stress include (A) the characteristics of the caregiver (e.g., age, marital status, coping ability) [17,22], (B) characteristics of the recipient (e.g., the degree of disability) [15,23], (C) the shared history between the caregiver and the person being cared for [17], (D) social factors (e.g., access to social networks and social support) [17,24], (E) economic factors (e.g., socioeconomic status, ability to access formal care, employment) [14,21,25,26], and (F) cultural context [27,28]. The current concept of family-centered care focuses on supporting the parents in their natural care-giving by helping them to cope with the impact of experienced stresses, and also by building on their parenting strength [29]. It is proposed that understanding the factors associated with parental stresses can help clinical professionals develop appropriate strategies or to search for supportive sources, thereby enabling parents to cope with their difficult situation [14,30]. The Parental Stress Scale (PSS) was developed as a short measure of perceived stress resulting from being a parent. It measures “individual differences in the level of stress associated with raising children” [31]. It is based upon the dichotomy of parenting; that it is both stressful and satisfying. It includes both negative and positive aspects in the items, and then reverses the positive ones to make the overall scale a measure of stress. Berry and Jones found that the English PSS showed adequate reliability (Cronbach’s alpha = 0.83) as well as adequate reliability over time (test-retest correlation = 0.81 over six weeks) [31]. Other studies found corresponding reliability results for different language versions including Chinese [32], Spanish [33], Portuguese [34], and Urdu [35]. In India, Kannada and Gujarati translated versions of PSS have already been done validated for parents of normal children [36,37]. Gujarati version of PSS (PSS-G) has showed high Cronbach’s aplha co-efficient, thereby making it a reliable tool for identifying parental stress and so it can be used to assess whether an intervention has had a positive effect on parental stress or not among native Gujarati person [37]. The existing study using the PSS-G is based on relatively small sample and has only examined the use of the PSS among parents of normal children. Furthermore, its use for assessing the stress in parents of CP children has not been studied. Thus, the aim of this study is to investigate the psychometric properties of the PSS-G with emphasis on the sample of parents of CP children.

The study was conducted for 1 year duration from July 2018 to June 2019 after taking approval from the institu tional ethics committee with ref. no. GSIIEC/12/18. The parents of clinically diagnosed CP children; aged 1 to 12 years; attending pediatric rehabilitation centers, physiotherapy clinics and special education schools in Ahmedabad, Vadodara and Surat; were invited to participate and were recruited for study if they were fit in the inclusion criteria and willingly signed the informed consent to participate. Parenting stress was measured using PSS-G and Parenting Stress Index–Short form (PSI-SF). The parents were Gujarati-speaking but had enough knowledge of English so that they could independently complete both the questionnaires. In total, 169 parents were invited and 152 parents (mothers = 126, fathers = 26) were recruited based upon the above criteria.

The PSS-G is the Gujarati translated version of PSS containing 18 item statements, with 10 statements addressing negative and stressful aspects of parenting and eight statements addressing positive aspects of parenting, thus taking into account the dichotomous nature of the parenting experience. The item statements are rated for agreement by parents using a 5-point response scale (1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, 5 = strongly agree). The eight positive items are reversed in the coding of the PSS, and a single parental stress sum score is calculated to indicate the degree of parental stress [31,37].

PSI-SF is a 36-item, self-report measure of parenting stress. It includes 3 subscales: Parental Distress (PD; e.g., “I feel trapped by my responsibilities as a parent”), Parent-Child Dysfunctional Interaction (PCDI; e.g., “Sometimes I feel my child doesn’t like me and doesn’t want to be close to me”), and Difficult Child (DC; e.g., “My child makes more demands on me than most children”). Each subscale consists of 12 items rated from 1 (strongly disagree) to 5 (strongly agree), with subscales scores ranging from 12 to 60. A total score is calculated by summing the three sub-scales scores, ranging from 36 to 180. Scores of 90 or above may indicate a clinical level of stress. Abidin and Brunner (1995) [38] reported Cronbach’s alpha coefficients of 0.91 for PSI-SF total score, and 0.87, 0.80, and 0.85 for PD, PCDI, and DC subscales, respectively. Psychometric data obtained in the present study are presented in the results section [39].

All the participant parents were informed of study goals, instructions and confidentiality terms; and gave informed consent. They completed the PSS-G at baseline and 1-months later in the presence of the researcher or one of the student volunteers. PSI-SF was completed by all the parents at the same time.

Analyses were performed using IBM SPSS Statistics 20.0 (IBM Co.,). Preliminary analyses were conducted to examine data characteristics. Internal consistency was examined by computing Cronbach’s alpha, test-retest reliability was assessed by computing intra-class correlation coefficient (ICC) value, whereas concurrent validities were assessed by computing Pearson’s correlations between the PSS-G and PSI-SF total as well as domain specific scores.

Kolmogorov - Smirnov statistics showed that the data of PSS-G scores obtained were normally distributed. As data was normally distributed, it was subjected to the parametric tests. Mean age of the participating parents and their children were 32.3 (±7) years and 3.3 (±7.5) years respectively. Table 1 depicts mean score of PSS-G and PSI-SF suggesting that there was no significant difference between mean scores obtained by both the scales (p = 0.284).

The internal consistency of PSS-G was examined by means of Cronbach’s alpha. Table 2 shows the reliability statistics for internal consistency of the instrument suggesting Cronbach’s alpha = 0.923. Table 3 shows Item-Total statistics for PSS-G and Cronbach’s alpha if the item is deleted. No significant difference was found among scale means of each item.

A comparison of mean total scores of PSS-G at baseline administration and after 1 month duration was done to assess test-retest reliability. Table 4 shows the values of Intraclass co-efficient (0.987) suggesting significant correlation at p < 0.001 (i.e., 95% CI). This is indicating good test-retest reliability of PSS-G for parents of CP children. PSS-G total scores at baseline and after 1 month for parents of CP children.

Concurrent validity of the PSS-G was assessed by finding out correlation of PSS-G total mean scores with PSI-SF total and domain specific total mean scores using Pearson’s correlation coefficient (Table 5).

Various studies in past have aimed at distinguishing stress levels among groups that are expected to show average parental stress levels and groups expected to show high parental stress levels and have showed positive findings, thereby indicating significant role of PSS as an instrument to evaluate stress in parents [31,32]. Gujarati translated version of PSS has been validated on small sample of normative parents but no study has studied its role in parents of CP children. The present study examined the psychometric properties of the Gujarati translated version of PSS, i.e., PSS-G, among parents of children with CP. The sample of this study included 152 parents of CP children from Gujarat state of India. The parents included mostly the mothers (n = 126) indicating that in India, caregiving is the process where mother has a major role to play and includes responsibilities such as cleaning, feeding, carrying, transporting, active role in rehabilitation, etc. The notion is accepted and supported by the results of various studies in India as well as in other countries [14,16,19,25,40,41]. Cronbach’s alpha is an indicator of one-dimensionality of any outcome measure’s construct. It indirectly indicates the degree to which a set of items measures a single dimensional construct. Value of Cronbach’s alpha usually increase as the internal correlations among test items increase, and is therefore an internal consistency estimate of reliability of test scores. Alpha value of more than 0.9 can be considered as an excellent internal consistency [42]. The ICC values for the internal consistency of PSS-G indicate that Cronbach’s alpha coefficients, i.e., 0.923, are higher enough to be acceptable when compared to those found in other studies for validation of the PSS in normative Indian samples [36,37]. An item-total correlation test is indicating if any item in the set of tests is inconsistent with the averaged behavior of the others, and thus needs to be discarded. The analysis is performed prior to determining the factors that represent the construct. A value less than 0.3 indicate that the corresponding item does not correlate very well with the scale overall and, thus; it may be dropped [43]. The item total statistics for the PSS-G in parents of CP children suggested that even when one of the items was deleted, the total scores for other scores were significantly indicating the overall results. This is suggestive of one-dimensionality of the scale and can be considered an important trait of any outcome measure for its wider applicability. In both the studies done on Indian population, Gujarati and Kannada versions were assessed for item-total correlations of item numbers 7 and 10 respectively were reported to have correlation values of less than 0.3. These findings suggested that these items can be dropped from the scale and may not show any significant changes in overall reliability of the scale [36,37]. Current study does not show any such findings and all the items of the scale are found to be equally relevant to the overall reliability of the scale. This difference in findings may be due to the fact that the previous studies have collected their data from normative sample and our study has focused on parents of CP children. Test-retest reliability suggests consistency of the test measure performed repeatedly over time. ICC does not overestimate the relationship for small samples and can be considered more reliable when the sample is of small size. The values of ICC more than or equal to 0.9 show excellent reliability, whereas values between > 0.8 and < 0.9 shows good reliability [43]. The findings of this study suggest that PSS-G has good test-retest reliability with ICC value of 0.897 and result is equivalent with the correlation coefficients of original and Kannada translated versions. The values of test-retest ICC have been reported to be in the range of 0.78-0.96 by different researchers [31,32,36]. Concurrent validity is a measure that displays correlation of the instrument with other instruments that are related to the construct measured by the instrument [44]. To examine the concurrent validity of PSS-G, the scores of PSI-SF measure were correlated with the scores of PSS-G in parents of CP children. It was hypothesised that the levels of parental stress expressed by PSS-G total scores will be reflected similarly through the individual domain scores as well as total scores of PSI-SF. Results of positive correlations of PSS-G with PSI-SF total (p < 0.01), PD (p < 0.01), PCDI (p < 0.5) and DC (p < 0.5) subscales indicated significant convergence of these measurements with the PSI-SF and support concurrent validity of the PSS-G. Previous studies have reported concurrent validity of PSS in Chinese language with Eyeberg child behaviour inventory - intensity, Eyeberg child behaviour inventory - problems and Parenting Stress Index [32,45]. Parent- reported symptoms of psychological distress (anxiety and depression) have been reported to have satisfactory convergent correlation with Norwegian version of PSS [46]. Berry and Jones (1995) [31] evaluated concurrent validity of PSS by correlating it with Parenting Stress Index and reported significant relationships between all of the subscales except parent health and parent relationship to spouse. Further research to assess correlations between PSS and other measures of interpersonal and social functioning, attitudes and emotions (e.g., family attitude, anxiety, social interactions, etc.) and to determine applications of PSS for broader socioeconomic and ethnic classes, single parents, various clinical populations, fathers of CP children, and on a larger sample from wider geographic background can be helpful in to support preliminary findings of this study. Based on the findings of this study, it can be concluded that the Gujarati version of PSS is a reliable and valid measure for assessment of parenting stress in parents of CP children. It can be used by health professionals in their clinical practice for early detection, assessment and intervention for parents of children with high scores. It can be used to find out whether an intervention has had a positive effect on parental stress or not among native Gujarati parents.