Balancing work and family when parenting a child with mental health difficulties

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POSITIVE FUTURES Balancing work and family when

1 26 th Children s Mental Health Research and Policy Conference RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES Balancing work and family when parenting a child with mental health difficulties March 5, 2013, Tampa, FL

2 Authors RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES Claudia Sellmaier, Regional Research Institute for Human Services, School of Social Work, Portland State University Eileen M. Brennan, Regional Research Institute for Human Services, School of Social Work, Portland State University Judy Kendall, Regional Research Institute for Human Services, Portland State University Michael C. Leo, Center for Health Research Northwest; Kaiser Permanente Gail M. Houck, School of Nursing Oregon Health & Science University 2

Objectives RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES To review the impact of raising a child with mental health difficulties on parental employment.

3 Objectives RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES To review the impact of raising a child with mental health difficulties on parental employment. To present results of a longitudinal study of mothers raising children with mental health diagnoses. To examine the impact of child mental health on difficulty combining work and family, family conflict, and family functioning. 3

4 Work-Life Integration RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Is the degree to which people are able to find a fit between the responsibilities of their work and their personal lives (Lewis, Rapoport, & Gambles, 2003). Is particularly difficult for families raising children with mental health disorders, who report higher levels of caregiver strain, poorer health, and lower workforce participation (Brennan & Brannan, 2005; Powers, 2003; Witt et al., 2009). Child mental health disorders result in exceptional care requirements, e.g. arranging mental health treatment, participating in special education planning, and maintaining appropriate child care (Friesen, Brennan, & Penn, 2008). 4

5 Prevalence Estimates Based on CSHN Definition RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES In total, 11.3 percent of children aged 2-17 years were reported to have at least one of these seven conditions at the time of the National Survey of Children with Special Health Care Needs 5

6 Parent s Employment RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES 6

7 Service Utilization RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES 7

PACT Intervention RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES PACT: Parents and Children Together, a nursing intervention, provided home visiting and service brokering for families

8 PACT Intervention RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES PACT: Parents and Children Together, a nursing intervention, provided home visiting and service brokering for families in the study, support to relieve the caregiving burden of mothers in the study, and case management services tailored to individual families raising children with ADHD (Kendall & Tobacco, in press). 8

9 Exceptional Care: ADHD RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Attention deficit hyperactivity disorder (ADHD) is a serious and stigmatizing neurobehavioral disorder affecting approximately 3%-7% of children and adolescents worldwide (Barkley, 2006). ADHD is "a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than typically observed in individuals at a comparable level of development" (APA DSM IV, p. 48). ADHD undermines the executive functioning of young people, results in reduction of their adaptive capacity, and disrupts the functioning of the family (Kendall et al, 2005). 9

10 Exceptional Care: ADHD RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES ADHD symptoms include poor impulse control, disinhibition, egocentricity, poor delay of gratification, learning/processing difficulties, non-goal directed hyperactivity, and poor rule-regulated behaviors, which contribute to a lower self-concept (Houck, Kendall, Miller, Morrel, & Wiebe, 2010). Caring for these children often leaves parents feeling emotionally and physically overwhelmed by the frightening and discouraging events surrounding their child (Kendall & Shelton, 2003). Parents need to spend time coordinating the education and care for their children, and managing crises that result from children s difficulties in their social environments. 10

11 ADHD and Family Functioning RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Parents of children with ADHD have higher rates of depression, divorce, parenting stress, family conflict, disrupted parent-child relationships, and subjective feelings of parenting incompetence than parents of children without ADHD (Harpin, 2005). Family disruption has been identified as the central concern for families, which included episodes of aggression, out-ofcontrol hyperactivity, emotional and social immaturity, academic underachievement and learning problems, family conflicts), negative peer interactions, and isolation and rejection from extended family (Kendall, 1998). Maternal employment is linked to higher levels of child functioning (Brennan, Kendall, Houck, & Leo, 2010). 11

12 RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Children s Mental Health and Work- Life Integration Attaining a fit between work and family life will be based in part on the supports the parents have attained in their workplaces and communities (Gareis & Barnett, 2005; Voydanoff, 2005) Taking a person in environment perspective, Voydanoff (2005) argues that fit results from a match between the person and surrounding environment. When fit is poor, role strain results, often resulting in major adjustments in either work or family to decrease the incongruence and alleviate stress in the employed family member. Fit can be seen as having two types: demandsabilities and needs-resources. 12

13 Work-Life Integration RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES Work Demands Family Resources Work Demands-Family Resources Fit Adapted from Voydanoff, 2005 Work-Family Integration Work-Family Role Performance & Quality Family Demands Work Resources Family Demands Work Resources Fit 13

14 Family Demands RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Exceptional care for children with ADHD involves serious time and emotional demands on parents. 15.5% of parents of children with mental health difficulties spend 11 or more hours per week coordinating care (US DHHS, 2008), which may also affect their workforce participation. Levels of caregiver strain are predicted by child internalizing (anxiety, depression, distorted thinking) and externalizing (aggression, hyperactivity, conduct problems) behavior (Brannan & Heflinger, 2001) Can affect family functioning: high levels of symptoms lead to greater maternal distress, and increased family conflict (Kendall, Leo, Perrin, & Hatton, 2005). 14

Family Resources RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Parental knowledge about ADHD and successful family management strategies serve as resources for family members

15 Family Resources RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Parental knowledge about ADHD and successful family management strategies serve as resources for family members (Barkley, 2006). Engagement in employment provides essential economic resources for families facing the additional expenses from caring for a child with mental health difficulties (Lynch & Brennan, 2008). In general, mothers with higher levels of education and fewer children are more likely to engage in paid work (O Connell, 2002; Smolensky & Gootman, 2003). 15

Work Demands RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Work demand experienced by employed parents is affected by the number of hours they work per week, and the types of

16 Work Demands RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Work demand experienced by employed parents is affected by the number of hours they work per week, and the types of schedules they are required to follow (Barnett, Gareis, & Brennan, 1999; Wight, Raley, & Bianchi, 2008). Time-based strain is especially prevalent for parents raising children with behavioral difficulties, such as ADHD, which make finding and maintaining off-hours or protracted child care particularly difficult (Rosenzweig, Brennan, Huffstutter, & Bradley, 2008). 16

17 Work Resources RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Flexibility in the work domain is particularly important for families providing exceptional care (Brennan et al., 2007; Emlen, 2010). Flexibility in location, timing, and duration of work hours provides relief from time-strain and job burnout, and allows employees to experience healthier lives (Grzywacz, Casey, & Jones, 2007; Grzywacz, Carlson, & Shulkin, 2008). Workplace flexibility has the potential to decrease exceptional caregivers difficulty combining work and family, and to increase their workforce participation. 17

18 PACT Intervention RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Families were randomly assigned to intervention or control conditions and participated in data collection at baseline, 6 months, 12 months, and 18 months. Aim of the current study was to analyze longitudinal data from mothers who were parenting a child with mental health difficulties to explore the factors predicting employment and difficulty combining work and family responsibilities. 18

19 Research Questions RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES 1. Over time do children s mental health symptoms relate to mother s employment status? 2. What is the relationship over time of children s mental health symptoms, family functioning, and mother s difficulty combining work and family? 3. Do family flexibility and workplace flexibility contribute to lower levels of family conflict and less difficulty combining work and family for employed mothers? 19

20 Method: Research Procedure RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES 174 families from the Pacific Northwest US, who had a principal caregiver and a school aged child with a diagnosis of ADHD willing to participate in the 18-month PACT study. Our sample consisted of 115 women who participated at the baseline data collection and completed data collection 12 months later. At the initial home visit, participants completed a short interview with the maternal caregiver regarding child services, and then were given a booklet of instruments in either English or Spanish. 20

21 Method: Procedure and Instruments RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES Instruments were completed by the mothers in the next week, and then returned by mail. Those who completed the instruments were given a $50 gift card. Questionnaires included measures of child behavior problems, family functioning, employment status, and demographics. Additionally instruments measuring severity of ADHD symptoms, maternal distress, acculturation (for Latino families), and engagement in clinical services were included for other studies. 21

22 Method: Major Study Instruments RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Child behavior problems Child Behavior Checklist (CBCL; Achenbach, 1991) a standardized 118-item schedule assessing problem behaviors and social competencies of children 4-18 years old, as reported by their caregivers; α =.868 for the internalizing subscale; α =.926 for the externalizing subscale, and α =.901 for the aggressive behavior subscale. This analysis only used the CBCL internalizing, externalizing and total subscales 22

23 Method: Major Study Instruments RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Family functioning Family Systems Scale (FSS; Kendall & Leo, 2005) measuring the level of family functioning, as rated by the mothers in the study with 56 items, grouped into four subscales measuring cohesion, conflict, communication, and behavior control. We get along well with everyone in our family Family members often criticize each other We find it hard to agree on things to do together I am happy in this family strongly disagree ; disagree ; agree ; strongly agree 23

24 Method: Major Study Instruments RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Employment measures Items adapted from the Employee Survey (Neal et al. 1993) collecting employment information, and rating work and family flexibility, and difficulty combining work and family. How many hours of paid employment did you work in your last full week of work? hours How much flexibility do you have in your family to handle work responsibilities? ( a lot of flexibility ; some flexibility ; hardly any flexibility ; no flexibility at all ) Circumstances differ and some people find it easier than others to combine working with family responsibilities. In general, how easy or difficult is it for you? ( very easy ; easy ; somewhat easy ; somewhat difficult ; difficult ; very difficult ) 24

25 Characteristics study participants RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Characteristics Mean age Range Living situation Two parent/adult household Single parent household Ethnicity of mothers European-American African-American Hispanic-American Employed mothers (n = 80) 42 (8.94) % 34% 83% 13% 5% Unemployed mothers (n = 35) 42 (11.28) % 23% 91% 9% 6% 25

26 Characteristics employed mothers RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Characteristics Mean hours worked weekly Range Impact of family responsibilities on career Definitely somewhat a little not at all Work flexibility a lot some hardly any none Employed mothers (n = 80) 31 (14) % 29% 21% 24% 39% 52% 9% 0% 26

27 Characteristics employed mothers RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Characteristics Family flexibility a lot some hardly any none Difficulty combining work and family very difficult difficult somewhat difficult somewhat easy easy very easy Employed mothers (n = 80) 21% 54% 18% 2% 10% 15% 38% 29% 7% 1% 27

28 Characteristics children RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Characteristics Mean age Range Gender of children with MH disorders Male Female Children (n = 115) 11 (3.41) % 34% Mean number of children Focus child + 1 Medication 82% 28

29 Results RESEARCH & TRAINING CENTER FOR PATHWAYS TO POSITIVE RESEARCH TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES FUTURES Mother s employment and child s CBCL scores over time * CBCL total T1 CBCL total T2 CBCL total T3 CBCL total T4 Employed Unemployed 29

30 Results: Employment RESEARCH & TRAINING CENTER FOR PATHWAYS TO POSITIVE RESEARCH TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES FUTURES Logistic Regression Predicting Mother s Employment at T3 Employment T3 Variable T1 β Constant -.07 Education.59*** CBCL total -.02* Family conflict -.03 Number of children -.00 Nagelkerke R².26 Chi-Square 23.39*** Note. N=115. *p <.05, ***p <

31 RESEARCH & TRAINING CENTER FOR PATHWAYS TO POSITIVE RESEARCH TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES FUTURES Results: Difficulty Combining Work and Family Multiple Regression Predicting Difficulty Combining Work and Family at T3 Diff. comb. T3 work-family Diff. comb. T3 controlling for Diff.comb. T1 Variable T1 β β Constant 1.79** Family conflict.26 *.13 CBCL internalizing.24 *.20* CBCL externalizing Number of children Family flexibility Difficulty combining T1.54*** R² F 2.85* 7.56*** Note. N=78. *p <.05, **p <.01, ***p<

32 Results: Family Conflict RESEARCH & TRAINING CENTER FOR PATHWAYS TO POSITIVE RESEARCH TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES FUTURES Multiple Regression Predicting Family Conflict at T3 Family Conflict T3 Family conflict T3 controlling for family conflict T1 Variable T1 β β Constant 2.27*** CBCL externalizing.32**.14 CBCL internalizing -.29* -.26*** Family Conflict T1.71*** R² F 4.93** 36.81*** Note. N=81. *p <.05, ** p<.01, ***p <.001, trend level 32

33 Results: Changes Time 1 to Time 3 RESEARCH & TRAINING CENTER FOR PATHWAYS TO POSITIVE RESEARCH TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES FUTURES T-test for mothers whose children improved on CBCL total ** ** Difficulty combining Family Conflict Family Functioning Note. N=50. ** p<.01, ** T1 T3 33

34 Results: No Changes Time 1 to Time 3 RESEARCH & TRAINING CENTER FOR PATHWAYS TO POSITIVE RESEARCH TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES FUTURES T-test for mothers whose children did not improve on CBCL total Note. N=23. Difficulty combining Family Conflict Family Functioning T1 T3 34

35 Study Limitations RESEARCH & TRAINING CENTER FOR ON PATHWAYS TO POSITIVE FUTURES Participants of this study were all mothers who were willing to be enrolled in a home visitation intervention, presumably because of their experiences of disrupted family functioning. Additionally, the families all lived in one metropolitan area of the Pacific Northwest of the United States, and were demographically similar to the area residents, who are limited in their racial/ethnic diversity. Because the study was focused on testing the PACT intervention, and required extensive measurement of parent and child mental health and services, the workfamily measures that were used in this study were limited to brief and basic measures. 35

36 Discussion RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES The difficulty the parents in the PACT study experienced combining work and family was affected by the level of symptoms of their children and levels of family conflict at home. Family conflict/functioning Child s behavior Difficulty combining work and family Complex interplay between child s behavior, family variables and work-family conflict. 36

37 Discussion RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES Even when controlling for difficulty combining work and family at T1, children s internalizing behavior remained significantly correlated with difficulty combining work and family at T3 supporting the hypothesis that the change in work-family conflict is due to changes in children s behaviors. Family conflict does not remain significantly correlated when controlling for difficulty combining work and family at T1 which might be due to the small change between T1 and T3 and the high correlation of family conflict at T1 and difficulty combining work and family at T1. 37

38 Discussion RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES Child s internalizing behavior also remains statistically significantly correlated with family conflict at T3 when controlling for family conflict at T1, externalizing behavior remains at trend level strengthening the hypothesis that the change in family conflict is due to changes in child s behavior. Difficulty combining work and family, family conflict and family functioning only improved for mothers whose children scored lower on the CBCL total problem score at T3. 38

39 Practice Implications RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES Supports for families who raise a child with mental health difficulties need to focus on the whole family. Child s symptoms, family functioning and workfamily integration need to be addressed to provide comprehensive care. Family involvement in mental health treatment is crucial but work responsibilities can make this involvement difficult for parents. Employment is important for families with exceptional care needs to financially support those needs and employment can have positive effects on the mental and physical well-being of parents. 39

40 Future Research RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES Future studies might consider how specific treatment options can improve children s mental health difficulties and are linked to parental workforce attachment. Studies around children s mental health need to include parental employment. Research focusing on parental work and employment need to address the demands of exceptional care. 40

Acknowledgments/Funders This research and preparation of this presentation was supported by a grant from the National Institute of Nursing, Nurse Case

Research, United States Department of Education, and the Center for Mental Health Services Substance Abuse and Mental Health Services Administration,

41 Acknowledgments/Funders This research and preparation of this presentation was supported by a grant from the National Institute of Nursing, Nurse Case Management Intervention for ADHD families, NIMH R01 NR A2 and by a grant from the National Institute of Disability and Rehabilitation Research, United States Department of Education, and the Center for Mental Health Services Substance Abuse and Mental Health Services Administration, United States Department of Health and Human Services (NIDRR grant H133B090019). We would like to thank Nisreen Pediwala for her assistance with data management.

42 Our thanks also to the PACT families!! RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES 42

43 Thank you! RESEARCH & TRAINING CENTER ON PATHWAYS TO POSITIVE FUTURES Portland Oregon, Home of Pathways RTC Portland Oregon, Home of PATHWAYS RTC Slides will be posted at: Travel funds: Portland State University Academically-Controlled Auxiliary Activities (AAA) fund, Dean s Award, and Pathways RTC funds 43

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