Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=gecd20

Download by: [eman al-zboon] Date: 22 September 2016, At: 07:56

Early Child Development and Care

ISSN: 0300-4430 (Print) 1476-8275 (Online) Journal homepage: http://www.tandfonline.com/loi/gecd20

Parents’ attitudes towards their children withcerebral palsy

Kholoud Adeeb Al-Dababneh & Eman K. Al-Zboon

To cite this article: Kholoud Adeeb Al-Dababneh & Eman K. Al-Zboon (2016): Parents’attitudes towards their children with cerebral palsy, Early Child Development and Care, DOI:10.1080/03004430.2016.1230737

To link to this article: http://dx.doi.org/10.1080/03004430.2016.1230737

Published online: 22 Sep 2016.

Submit your article to this journal

View related articles

View Crossmark data

Parents’ attitudes towards their children with cerebral palsyKholoud Adeeb Al-Dababneh and Eman K. Al-Zboon

Department of Special Education, Queen Rania Faculty for Childhood, Hashemite University, Al-Zarqa, Jordan

ABSTRACTA negative attitude towards disability from family not only impacts upon achild directly, but also adds to the existing stress levels of a family. It can beconcluded the parental attitudes are assumed to be associated with thepsychosocial development of children. The aim of this study was toassess parents’ attitudes towards their children with cerebral palsy (CP),and to examine the relationship between parental attitudes, emotionaland behavioural problems, and other factors related to a child with CPand their parents. Parents of 70 children with CP (aged 6–13 years)completed questionnaires assessing parental attitudes and the Socialand Emotional Behavioural Problematic scale. The results indicated thatmost parents had moderate attitudes towards their children with CP,although 40.7% of parents held negative attitudes. The results alsorevealed that there were statistically significant moderate negativecorrelations between parental attitudes, internalising behaviouralproblems and child order, and significant moderate positive correlationsbetween parental attitudes, level of education, and type of school.Regression analysis revealed that internalising behaviour problems,aggression, child order, level of disability, parental income, and type ofschool contributed significantly to the variation in the prediction ofparental attitudes towards their children with CP. Based on the findings,appropriate recommendations are suggested.

ARTICLE HISTORYReceived 8 July 2016Accepted 27 August 2016

KEYWORDSparental attitudes;internalising problems;externalising problems;children with cerebral palsy;inclusion schools

Introduction

Among the many different childhood developmental disabilities, cerebral palsy (CP) is considered tobe a major physical disability affecting the functional development of children (Jones, Morgan,Shelton, & Thorogood, 2007), with a prevalence of 2 to 2.5 per 1000 live births (Dolk, Parkes, & Hill,2006; Hutton & Pharoah, 2006).

Children with CP have difficulty moving due to injury to their brains. In addition to their movementdifficulty, children with CP often have associated learning and communication difficulties, epilepsy,and hearing or visual impairments (Colver, 2006), as well as emotional and behavioural problems(Al-Dababneh, Fayez, & Bataineh, 2012; Parkes & Hill, 2010). For parents, caring for a young childwith CP can be a challenging experience and usually requires a significant amount of energy forthe entire family over a long period of time (Barnett, Clements, Kaplan-Estrin, & Fialka, 2003;DeMarle & Roux le, 2001; Piggot, Paterson, & Hocking, 2002). As a result of the characteristics of chil-dren with CP, such children need a great number of services, which require parents to coordinate theservice providers with their child (Saleh & Almasri, 2015).

It has beenwell documented that CP impacts upon the psychological development of a child, and ithas been found that children with CP are at a higher risk of experiencing behavioural and emotionalproblems compared to their peers without CP (Goodman, 2002; Parkes, Carvale, Marcelli, Franco, &

© 2016 Informa UK Limited, trading as Taylor & Francis Group

CONTACT Kholoud Adeeb Al-Dababneh dababneh@hu.edu.jo

EARLY CHILD DEVELOPMENT AND CARE, 2016http://dx.doi.org/10.1080/03004430.2016.1230737

Colver, 2011; Sipal, Schuengel, Voorman, Van Eck, & Becher, 2010; Yamaguchi, Perry, & Hines, 2014).These problems have an added impact upon a parent’s ability to undertake the numerous tasks associ-atedwith care-giving, and thus the burden of care for parents is increased (Plant & Sanders, 2007). Con-sequently, parents of children with CP are more likely to experience significant stress compared toparents of children without a disability (Gupta & Singhal, 2004; Ong, Afifah, Sofiah, & Lye, 2016).Parents may react to and manage their child differently compared to siblings without disabilities;this may be due to the increased stress that families experience in bringing up a child with a disabilityor due to overprotective feelings towards their child. Some children with CP may have unrecognisedsubtle learning difficulties, which make many situations difficult to cope with (Colver, 2006).

A negative attitude towards disability from family members, relatives, friends, and/or society notonly impacts upon a child directly, but also adds to the existing stress levels of a family (Abasiubong,Ansa, Udoh, Edemeking, & Akpan, 2010). A lack of public awareness about the potential of peoplewith disabilities often acts as a barrier to their acceptance and to the active participation ofpeople with disabilities (Thomas, 2002).

In contrast, literature focuses on examining the correlation between parental attitudes and behav-iour problems among children (Yurdusen, Erol, & Gencoz, 2013). In addition, there is increasing evi-dence that the social and developmental status of children with CP is influenced by family factors,including the form of parenting that children receive (Plant & Sanders, 2007; Vermaes, Janssens, Mul-laart, Vinck, & Gerris, 2008).

Children with CP need help to reflect about themselves; they deserve respect and a positive per-ception from their families, schools, and communities. Effective parenting can offer the help requiredfor these children to cope emotionally and socially with their disabilities, and parents can play a keyrole in encouraging children with CP to determine how to think about themselves, to promote com-munication, independence, and socialisation in their child, and how to see their disability (Heward,2006; Whittingham, Wee, Sanders, & Boyd, 2011). Finally, parents can enable them to live ahealthy life which is full of achievement according to their abilities (Whittingham et al., 2011).Wong (2015) reported that children and adolescents are influenced by the culture in which theygrow up, including beliefs and others’ perceptions, specifically those of their parents, who sharpentheir values and socialised practices. When raising children with CP, both overprotection and thenegative attitudes of other people may interact with the emotional development of the children(Wiegerink, Roebroeck, Donkervoort, Stam, & Cohen-Kettenis, 2006).

Empirical studies have found that parental expectations of children with a disability were mostlynegative and unrealistic (Gupta & Singhal, 2004), including children with CP (Colver et al., 2011).Dalal and Pande (1999) revealed fatalistic attitudes and external dependence in Indian families withchildren who had a disability. In addition, most of the participants felt that the individual with a disabil-ity in their family could not do anything and simply needed help and sympathy. Yurdusen et al. (2013)examined the association between emotional and behavioural problems in Turkish preschool childrenand maternal attitudes. Their results revealed that when considered jointly, maternal anxiety but notmaternal depression explained the variability observed in preschool children internalising and externa-lising their problems. Mothers’ rejecting attitudes towards family life and child-raising styles were alsofound to be closely associated with emotional and behavioural problems in their children. Jankowska,Włodarczyk, Campbell, and Shaw (2015) also compared parenting attitudes in mothers of children withCP to mothers of children without disabilities. Their results revealed that although acceptance was themost common parental attitude among all participants, mothers of children with CP presented with astronger tendency towards overprotectiveness and demanding attitudes. Furthermore, mothers of chil-dren with CP declared a higher level of distress than mothers of children without disabilities.

There are many other factors related to parental attitudes towards their child with a disability, forexample, gender and birth order. Omoniyi (2014) investigated the attitudes of parents towards theirchildren’s gender and disability conditions, and the results revealed significant differences related tothe gender of children regarding various domains of the scale. There was a significant differencebetween fathers’ and mothers’ attitudes, with fathers exhibiting more favourable attitudes towards

2 K. A. Al-DABABNEH AND E. K. AL-ZBOON

male children, while mothers’ attitudes were also significant for the domain of over protection andacceptance. Olawale, Deih, and Yaadar (2013) reported that families caring for children with CP gen-erally have a positive attitude towards their children. However, there is need to educate the public onthe causes of CP and the treatment options available to families. Kumar and Rao (2008) showed thatfirst children experience more positive parental attitudes compared to those who were born later.Furthermore, a study by Colver (2006) and Colver et al. (2011) indicated that parental attitudes arecorrelated with disability type, severity, and conditions. For example, children with severely impairedwalking ability experienced less favourable attitudes among their parents due to the high level ofneeds and demands they have (Colver et al., 2011). As well parental stress, which is correlated to par-ental attitudes, is more likely to increase if a child has pain, learning problems, or communication dif-ficulties, although parental stress is less likely to increase if a child has more severe movementdifficulties. Parents of children with CP are more likely to experience higher stress levels thanparents of children without disabilities, and a quarter of parents of children with CP experiencevery high stress associated with caring for their child, and require help and support from professionalservices (Colver, 2006). In contrast, a child’s behaviour may contribute to shaping parents’ function-ing, parental perceptions of a child’s competencies (Ketelaar, Volman, Gorter, & Vermeer, 2008), andlevel of parental stress (Sipal et al., 2010), as well child behavioural problems are the most importantpredictor of caregiver psychological well-being (Khayatzadeh, Rostami, Amirsalari, & Karimloo, 2012).

Another factor which might have an effect on parental attitudes is the presence of a supportiveenvironment, which may improve parents’ general dispositions, assist them in feeling less over-whelmed by parenting tasks, and allow them to access additional resources from which to drawsupport and information (Gupta & Singhal, 2004; Osofsky & Thompson, 2000). Supportive social net-works can reduce stress by serving as a buffer against threatening events, thereby influencing thecoping strategies of parents and providing emotional support. In contrast, when a conflict arisesamong members of a family or when there is an overload of information and interactions, networkscan contribute to reducing parental stress levels (Osofsky & Thompson, 2000).

According to family systems theory, the family is interactive, interdependent and reactive tochange. Phenomena impacting on an individual family member are also likely to impact on othermembers of the family system (Seligman & Darling, 2007). Lin (2000) found that families with childrenseemed to use more coping behaviours related to increased knowledge of CP and seek more externalresources than families with young adults. Parents of school-aged children appeared to use morecoping behaviours relating to a positive attitude towards the situation, called positive family apprai-sal, and had better positive social interactions than families with young adults. Physical limitations,often in combination with behavioural problems, can render parents more physically tired thanparents of children with other disabilities (Khayatzadeh et al., 2012). With respect to the resourcesparents use to deal with stressful situations, it has been suggested that a positive and goal-directedattitude of parents, which is characterised by problem-solving strategies, can be seen as a more effec-tive coping style in stressful situations than emotion-focused strategies (Sloper & Turner, 1993).

Hastings and Taunt (2002) identified some key themes concerning the nature and structure ofparents’ positive perceptions and experiences of their child with a disability and the care-givingexperience. These can be summarised as: (1) pleasure/satisfaction in providing care for their child;(2) their child as a source of joy/happiness; (3) a sense of accomplishment in having done one’sbest for their child; (4) sharing love with their child; (5) their child providing a challenge or opportu-nity to learn and develop; (6) a strengthened family and/or marriage; (7) giving a new or increasedsense of purpose in life; (8) the development of new skills, abilities, or new career opportunities;(9) becoming a better person (more compassionate, less selfish, more tolerant); (10) increased per-sonal strength or confidence; (11) expanded social and community networks; (12) increased spiritual-ity; (13) a changed perspective on life (e.g. clarified what is important in life, more aware of the future);and (14) making the most of each day and living life at a slower pace.

Parental expectations and attitudes are an important concern within the scientific literature onchildren with CP. One reason for this may be that positive perceptions play a central role in the

EARLY CHILD DEVELOPMENT AND CARE 3

coping process (Gupta & Singhal, 2004) and life satisfaction among children with CP (Chong, Mackey,Broadbent, & Stott, 2011). It has been proposed that positive perceptions may assist to better copewith stressful events as well as to promote creative thinking (Gupta & Singhal, 2004), while Trope andPomerantz (1998) indicated that a positive affect also facilitates the processing of important, relevantinformation, even if that information is negative and may potentially damage self-esteem. Gupta andSinghal (2004) reported that positive perceptions play a central role in the coping process and assistus in dealing with traumatic and stressful events. Not only do they benefit parents and siblings incoping with a child, their disability, and the difficulties associated with it, but they also help thefamily unit as a whole.

Chavira, Lopez, Blacher, and Shapiro (2000) and Kendziora and O’Leary (1993) emphasised thatparents’ reactions to their child’s disability are important and are related to the level of behaviouralproblems such children may show. Fox (2002) have found that physical disabilities are not the majorrisk factor for the emotional development of children suffering from them and showed that behav-ioural problems are related to the interaction between the behaviour of children with CP and environ-mental factors, such as parental perceptions. However, parental attitudes are considered a vitalsupportive environmental factor.

The literature supports the hypothesis that children adapt to their physical limitations and respondto social–interpersonal situations in ways that are strongly related to parents, siblings, teachers, peers,public perception, and reactions to them (Bigge, Best, & Heller, 2001; Heller, Alberto, & Meagher,1996). These perceptions and attitudes affect the way children with CP think and behave throughouttheir life, thus limiting our understanding of where opportunities for treatment or prevention mightlie (Parkes et al., 2011).

It can be concluded the parental attitudes are assumed to be associated with the psychosocialdevelopment of children and the risk of internalising problems and aggression among childrenwith disabilities, including those with CP (Cohen, Biran, Aran, & Gross-Tsur, 2008; Jankowska et al.,2015; McLeod, Weisz, & Wood, 2007a, 2007b) because children with CP are at high risk of behaviouralproblems (Brossard-Racine, Hall, Majnemer, & Rosenbaum, 2012; Sigurdardottir et al., 2010). However,little is known about parents’ perceptions of their child with CP (Gray, Q’callaghan, & Poulsen, 2008;Hinton, Nereo, Fee, & Cyrulnik, 2006). These little studies investigated parents perception about dis-ability causes, such as the study conducted by Maloni et al. (2011), who explored the parental beliefsregarding disability causes in their children with cerebral palsy in Cambodia. The researchers foundthat 10 participants had ‘no idea as to why their child had a disability’ (p. 2116). Eight of the respon-dents believed the cause to be partially biomedical (i.e. vaccinations or the mother’s health and nutri-tion during pregnancy), and eight believed to be partially related to traditional factors (e.g. spiritualforces). However, what distinguishes this study is its uniqueness in describing parental attitudestowards children with CP, and exploring the interrelations between parental attitudes and internalis-ing problems, aggression, and other factors related to children with disability characteristics, theirfamily, and school settings. The following questions are proposed:

1) What is the level of parents’ attitudes towards their children with CP?2) To what extent do parents’ attitudes towards their children with CP correlate with variables

related to their child (children’s external behaviour problems, internalised behaviour problems,gender of child, child age, child order, level of disabilities); with parents (level of education andincome), and with the type of school?

3) What predictor variables contribute to parents’ attitudes towards their child with CP?

Jordanian context

Following the establishment of the International Year of the Disabled in 1981, there was a quantumleap forward in services for the disabled in Jordan, as well as a new focus on the concept of inclusion

4 K. A. Al-DABABNEH AND E. K. AL-ZBOON

and the principles of equality and equal opportunity for people with disabilities (Al-Khateeb, 2011). In1993, the Law for the Welfare of Disabled Persons was passed, which was subsequently reviewed andreplaced by the Disabled People Rights Law No. 31 (2007). Consistent with the provision of compre-hensive international agreements for persons with disabilities, this law emphasises the right of chil-dren with disabilities to be included in general life and to receive high-quality services in suitableenvironments, delivered by specialised staff. Since 1980, the Jordanian Ministry of Education (MoE)has participated in the development of services for children with disabilities (MoE, 2016). These ser-vices are implemented in numerous forms, including separated and inclusion programmes con-ducted by the MoE, community-based rehabilitation programmes, and day care and internalresidential special education centres run by the Ministry of Social Development (MoSD), theprivate sector and non-governmental organisations (MoE, 2016).

Since the declaration of the Salamanca Statement and Framework for Action on Special NeedsEducation in 1994, many countries have been striving to improve the quality of their educationsystems by adopting inclusive practices for children with disabilities (Thousand, Nevin, & Villa,2007). In Jordan, the integration phase began in the 1990s and children with disabilities were main-streamed or integrated into general education programmes when deemed appropriate (Abu-Hamour & Al-Hmouz, 2013).

In 1979, the first national survey of exceptional people was conducted in Jordan. Over 18,000 stu-dents with disabilities were recorded; by 1996, this number had increased to 55,000, and in 2012 to62,968, with 60.6% male. Physical disabilities accounted for 28.6% (18.024 students), and 5271 (9%)students had CP (2973 male and 2298 female) (Al-Jabery et al., 2008).

The MoE accommodates around 700 students with physical disabilities in public and specialisedschools (MoE, 2016). However, with regard to the characteristics of children with CP in Jordan, Salehand Almasri (2015) reported that affected children have spasticity (74.1%), speech (60.3%), and visual(40.5%) impairments. The most popular service supplied was physical therapy (90.3%) and occu-pational therapy, followed by educational and community services.

Two associations, the Al-Housain Association, which cares for physically challenged children, andthe Cerebral Palsy Foundation, provide students with convenient educational opportunities throughusing the standard Jordanian curriculum. In addition, they provide children with support services,such as physical therapy, occupational therapy, and hydrotherapy. These associations aim toprepare children to be integrated into standard schools after grade five; however, it seems thatvery few students with CP in Jordan are being provided with the appropriate educational and sup-portive services (Saleh & Almasri, 2015). For example, many children with CP do not receive treatmentfor major impairments such as speech and feeding problems, and in addition, learning, and behav-iour problems have been reported by most parents as not being treated. It is of note that according toSaleh and Almasri (2015), special education and psychotherapy are not available for children with CP.However, according to Almasri, O’Neil, and Palisano (2014), parents reported a lack of general infor-mation concerning the services available for their children. In addition, early intervention services inJordan are at present limited. In general, students with physical disabilities, including children withCP, and their parents are not provided with sufficient services and support across a range of areas,including medical, educational, emotional, social, physical, and intellectual aspects (Abu-Hamour &Al-Hmouz, 2013; Al-Dababneh et al., 2012).

Methodology

Participants

The study sample was randomly selected from five centres for children with CP within separate set-tings and public schools within inclusion settings in Amman, the capital and largest city in Jordan.Seventy parents with a child with CP between the ages of five and thirteen years were selected ran-domly from each school/centre: 14 parents from each centre/school. Parents were asked to complete

EARLY CHILD DEVELOPMENT AND CARE 5

two questionnaires, the first related to parental attitudes, and the second related to children’s behav-ioural problems. The demographics of the sample are shown in Table 1.

Instruments

Instrument 1: Social and Emotional Behavioural Problematic Scale (SEBPS)This scale describes a broad range of childhood (age 5 through 18) behavioural problems (Dababneh,2012). The scale is composed of a scale for external problems, which is composed of an aggressivebehaviour scale (e.g. ‘annoys people around him without any excuses’, ‘is uncontrollable’), and asecond scale composed of four subscales for internalising problems, comprising shyness/withdrawn(e.g. ‘avoids interaction with others’, ‘selects individual activities’), depression (e.g. ‘feels he can’tachieve anything’, ‘has difficulty sleeping’), anxiety problems (e.g. ‘has a headache before and afterdoing a task’, ‘gets nervous when asked to talk about or express his feelings’), and social isolation pro-blems (e.g. ‘appears extremely quiet’, ‘tends to be alone most of the time’).

The original version of SEBPS (Dababneh, 2012) showed good reliability; internal consistency, test–retest. Cronbach’s alpha values for the current sample were 0.907 for the 51 items on the internalisingbehaviour problem scale and 0.796 for the 19-item aggressive behaviour scale.

Instrument 2: parents’ attitudes scaleIn order to investigate parent attitudes towards their child with CP, a survey questionnaire wasdesigned. A comprehensive review of the literature concerning parental attitudes towards childrenwith a disability in general, and attitudes towards their child with CP, was used as the basis for thestudy and as a source for designing the questionnaire (Jankowska et al., 2015; Yurdusen et al.,2013). Questions were framed so that each was designed to identify parents’ attitudes towardstheir child with CP.

The final draft of the instrument consisted of a list of basic information concerning the study vari-ables and the questionnaire comprised 15 items aimed at measuring the parents’ attitudes towardstheir child with CP, which covered parents’ attitudes towards their child’s competency and ability to

Table 1. The distribution of the sample by the study variables(N=70).

Variable F P (%)

Gender of childFemale 20 28.6Male 50 71.4

Child ageLess than 8 years 38 54.39–13 32 45.7

Child orderFirst born 22 31.4Middle born 29 41.4Last born 19 27.1

Level of disabilityCP 51 72.9CP with other disabilities 19 27.1

EducationPrimary school 30 42.8High school 16 22.9Undergraduate 24 34.3

IncomeLess than 600 JD 47 67.1More than 600 JD 23 32.9

Type of schoolsInclusion settings 31 44.3Special education settings 39 55.7

F: Frequency; P: Percentage (%)

6 K. A. Al-DABABNEH AND E. K. AL-ZBOON

work independently, their feelings towards their child’s disability, and its effect on their child’s com-petency to learn and perform like others. The questionnaire included both positive items and nega-tive items, and each item was rated using a 5-point Likert-type scale that ranged from 5 – stronglyagree, 4 – agree, 3 – neutral, 2 – disagree, to 1 – strongly disagree. For negative items, this was cor-rected by using the Statistical Package for the Social Sciences (SPSS) program to 1 – strongly agree, 2– agree, 3 – neutral, 4 – disagree, 5 – strongly disagree.

To determine the values of the levels of attitudes (positive attitudes, neutral attitudes, and nega-tive attitudes) to assist in the interpretation of the results, the range was extracted for each item bysubtracting the minimum value of the highest value, and then dividing by three (5–1 = 4, 4÷3 = 1.33) .This value (1.33) was then added to the lowest score, and the following ranges were derived: 3.68–5refers to a positive attitude; 2.34–2.67 refers to a neutral attitude; and 2.33–1 refers to a negativeattitude.

Validity and reliability of the parents’ attitudes scaleThe initial draft of the study instrument was written in English before it was translated into Arabic, asthe respondents were native Arabic speakers and most did not have an adequate knowledge ofEnglish. In order to ensure the validity of the questionnaire, only the Arabic version was distributedand piloted on a group of gender referees specialising in the field of education at several Jordanianuniversities. In addition, the instrument was piloted in a school for CP in Amman chosen from thestudy population but not included in the original study sample. The questionnaire, which hadalready been validated and tested for its reliability, was then distributed to a group of 10 parentsin this school. The aim was to obtain a preliminary judgement of the questionnaire items and toclarify meanings, so that it would be possible to carry out the necessary changes in order to makeeach item more effective. The participants were asked to respond to the questionnaire and toexpress their views, opinions, and reactions. Changes recommended by the validation panel andthose identified during the pilot testing were deemed essential and were used to modify the instru-ment by omitting, adding, or rephrasing items. The number of items was reduced from 23 to 20, andenabled the measurement of parents’ attitudes towards their child concerning disability competenceand their ability to act independently.

In order to estimate the reliability of the questionnaire, internal consistency measures were com-puted using Cronbach’s alpha. The reliability coefficient obtained was 0.815, which is consideredacceptable for the purpose of the study.

Ethical considerations

Participants were informed before the study commenced about the aims of the research, and wereassured that their responses would be treated with confidentiality and anonymity. The study protocolwas reviewed and approved by the Institutional Review Board at Hashemite University.

Data collection

A list of all children with CP and the public schools within inclusion settings and separate centresthey attended in Amman was provided to the researchers by the MoE and used to identify poten-tial study participants. The researchers distributed the questionnaire among parents of childrenwith CP through the centres and schools at which their children were enrolled at the end ofthe first semester of the 2015–2016 academic year. Before the administration of the question-naire, the researchers explained the purpose of the study to the participants. The study partici-pants were encouraged to read the items presented in both questionnaires before selectingthe appropriate choices.

EARLY CHILD DEVELOPMENT AND CARE 7

Data analysis

The survey questionnaire was quantitatively analysed by utilising the SPSS. The collected data wereanalysed and expressed using means and standard deviations (SDs) for the first question. Pearsoncorrelation coefficient analysis was performed to examine the relationship between the independentand non-independent study variables. Finally, multiple-regression analysis was used to answer thethird study question to determine the predictor independent variables effect on parents’ attitudestowards their children with CP. Parents were oriented about the purpose and confidentiality of thestudy before administering the questionnaire and their consent was obtained.

Findings

The data collected from the sample were coded, entered into SPSS, and analysed using the SPSS soft-ware package (edition 22). Descriptive statistics for all the variables identified in this study were exam-ined using SPSS frequencies. Missing subjects were not detected. The results of the study areaddressed in response to each research question.

Parents’ attitudes towards their children with CP

Research question 1 examined the parents’ attitudes towards their children with CP. Descriptive stat-istics, including mean, and STD were used to analyse the data. As shown in Table 2, the overall meanscore for parents’ attitudes towards their children with CP was 3.064 ± 0.78 STD, indicating thatparents had moderate attitudes towards their child with CP. As shown in Table 2, about 33.3% ofthe respondents held negative attitudes towards their children with CP.

Regarding the scale items, Table 2 shows that item 3, 11, 14, and 2 had the highest mean values(3.98, 3.88, 3.83, and 3.73, respectively), which represent that parents had a positive attitude that theirchild had the ability to live a happy life, and they were not ashamed of their child. They also had posi-tive attitudes related to their child’s ability to learn, and that their child with CP accepted themselves.It is worth noting that between 16% and 22.9% of the respondents held negative attitudes towardstheir children with CP for these same items (3, 11, 14, and 2). However, items 12, 15, 4, 9, 13, 8, 6, 5, 7

Table 2. The distribution of parents’ responses about their attitudes towards children with CP in each item of the study scale,attitudes scale and negative attitudes percentage.

RankItemno. Items M SD

Negative attitude(%)

1 3 My child has the ability to live happy and live normal. 3.98 1.301 162 11 My child’s disability shames me. 3.875 1.552 20.83 14 My child couldn’t learn 3.833 1.373 22.94 2 My child need help to accept himself. 3.7 3 1.270 19.25 12 My child needs an intensive care always. 3.580 1.295 286 15 My child couldn’t make personal decision. 3.549 1.237 23.57 4 My child is highly independent and equal with others. 3.53 1.248 19.18 9 My child couldn’t contribute anything to his community. 3.520 1.313 249 13 My child lives his life in pain, depression, and fear. 3.387 1.440 30.610 8 My child is sick and incapable person 3.333 1.227 33.311 5 My child can learn with his peers without disability. 3.00 1.678 4612 7 My child is different from his peers and siblings a lot more than look

alike.3.00 1.237 39.6

13 6 My child constitutes with his peers from the same need a homogenousgroup.

2.8 1.439 47.8

14 10 Being handicapped is the main reason my child faces difficulties on adaily basis in his life.

2.647 1.397 58.8

15 1 My child couldn’t work independently. 2.28 1.379 66.7Total 3.064 .7894 33.1

M: Mean; SD: Standard Deviation

8 K. A. Al-DABABNEH AND E. K. AL-ZBOON

had moderate parental attitudes (mean values 3.73, 3.58, 3.55, 3.53, 3.52, 3.39, 3.33, 3.20, 3.3, respect-ively), relating to parental attitudes regarding whether their child would always need intensive care,could make personal decisions, and that their child was highly independent and equal to others.Parents also had moderate attitudes concerning their child’s ability to contribute effectively totheir community, if their child was living their life in pain, depression, and fear, and that their childwas sick and an incapable person. Moreover, they held moderate attitudes towards their child’sability to cooperate with children within the same special needs group, to learn with their peers,they considered that their child was completely different from his/her peers and siblings, andbeing handicapped was the main reason why their child faces difficulties on a daily basis. Regardingthese items for which parents held moderate attitudes towards their children with CP, between 19.6%and 58.8% held negative attitudes, as shown in Table 2. It is noticeable that only item 1 had an overallnegative parental attitude with a mean value of 2.28 (66.7%); this item is concerned with parents’ atti-tudes about their child’s ability to work without help.

Correlations between the variables of the study

Research question 2 examined to what extent parents’ attitudes towards their child with CP were cor-related with their children’s behavioural problems and other variables. The Pearson productionmoment correlation coefficient® was utilised to answer this question. As shown in Table 3, theresults revealed statistically significant correlations between parents’ attitudes, internalising behav-ioural problems and child order, which showed moderate negative correlations of 0.30 and 0.44,respectively, at the 0.05 level. Moreover, as shown in Table 3, there were statistically significant cor-relations between parents’ attitudes and level of education and type of school, although theseshowed moderate positive correlations of 0.35 and 0.41, respectively, at the 0.05 level. In contrast,aggressive behaviour, level of disability, child gender, child age, and family income were not signifi-cantly associated with parents’ attitudes according to the parents’ ratings.

Associated factors of parental attitudes

Research question 3 examined the degree to which independent variables contributed to parents’attitudes towards their child with CP. Multiple-regression analyses (Enter) were used to computethe overall strength of the relationship R2 between the dependent variable (parents’ attitudes)

Table 3. Results of correlations analysis between parents’ attitudes and study variables.

Aggressivebehaviour

Childgender

Childage

Childorder

Level ofdisability

Educationlevel Income

Type ofschool

Parentalattitudes

Internalisingproblems

.463*.000

.070

.575−.031.814

.018

.891.118.351

.036

.775.016.900

−.431*.001

−.300*.012

Aggressive .221.072

.140

.278.201.124

−.341*.005

−.057.651

−.052.689

−.467*.000

−.232.053

Child gender −.015.910

.105

.431−.218.083

−.031.805

.140.285

−.235.079

−.107.451

Child age −.072.599

−.157.227

−.099.447

.408*.002

−.025.851

.100.504

Child order −.098.458

−.230.077

.233.087

−.063.656

−.442*.003

Level ofdisability

.157

.213.166.202

−.006.964

.116.426

Education level −.078.549

.069.604

.358*.003

Income −.084.580

Type of school .418*.005

*Correlation is significant at the 0.05 level.

EARLY CHILD DEVELOPMENT AND CARE 9

and each of the combined independent variables, by entering all the independent variables in a multilinear regression equation. Table 4 shows the result of this analysis.

It is clear from Table 4 that the three correlation coefficient values of the multi-correlation coeffi-cient (R) reached 0.852, while the coefficient of variation R2 was 0.725, and the adjusted coefficient ofvariation R2 was 0.626. This indicates that the interpretative independent variables were able to inter-pret (0.725) changes in the level of parental attitudes required and the remainder (0.225) was attribu-table to other factors.

To identify the interpretative power of the model as a whole through a statistic ( f ), an analysis ofthe variance was performed, as shown in Table 5. This shows that all the of the predictors (indepen-dent variables) contributed to statistically significant values (P = 7.33, α < 0.05) when analysing thelevels of parental attitudes, which confirms the explanatory function of the multiple linear regressionmodel from a statistical perspective.

To clarify the overall strength of the relationship between parental attitudes and the independentvariables, the Entry approach was used to determine the impact of the relationship of each indepen-dent variable to the degree of parental attitudes, and those variables that did not contribute signifi-cantly to an increase in the predictive model were not included. Table 6 shows the results of thisanalysis.

Table 6 shows that internalising behaviour problems, aggression, child order, level of disability,parental income, and type of school contributed significantly (at the level P≤ 0.05) to the predictionof the variation of parental attitudes towards their children with CP. Moreover, the value of the stan-dard variable coefficient (Beta) showed that the amount of change in these variables wasaccompanied by changes (−0.844, 1.131, −0.652, 0.882, 2.016, 1.207, respectively) to parental atti-tudes. As the value signal (Beta) is negative, this indicates a negative correlation between the variableand the level of parental attitudes.

Table 4. Strength of the relationship between parents’ attitudes and independence variable.

Model RR2

R squareAdjustedR square Std. error of the estimate

Independence variables .852 .725 .626 .54839

Table 6. The effect of independence variables on parents’ attitudes.

Variable

Unstandardisedcoefficients Standardised coefficients

t PB Std. error Beta

Constant −1.446 1.259 −1.149 .262Internalised problems −.844 .271 −.420 −3.116 .005*Aggression 1.131 .265 .723 4.269 .000*Child gender −.323 .260 −.160 −1.242 .226child age .157 .287 .074 .545 .591Child order −.652 .161 −.523 −4.058 .000*Level of disability .882 .332 .399 2.655 .014*Education level .121 .102 .150 1.192 .244Income 2.016 .615 .380 3.277 .003*Type of school 1.207 .221 .680 5.459 .000*

*significant at (alpha = 0.05).

Table 5. The results of Analyses of Variance (ANOVA) tests to the ability of independent variables together to predict of the parentalattitudes.

Sum of squares df Mean square F Sig.

Regression 19.840 9 2.204 7.33 .000*Residual 7.518 25 .301Total 27.358 34

*significant at (alpha = 0.05).

10 K. A. Al-DABABNEH AND E. K. AL-ZBOON

With reference to Table 7, increasing internalising behavioural problems and child order corre-spond to a decrease in parental attitudes. This table illustrates that with increasing aggression,level of disability, and parental income, there was an increase in parental negative attitudes. Inaddition, children with CP who were enrolled in special education settings hadmore positive parentalattitudes than children with CP who were enrolled in inclusive settings. Child gender, child age, andparental level of education were not found to be significantly associated with parents’ attitudesaccording to the parents’ ratings.

Discussion

This study aimed to identify parents’ attitudes towards children with CP and to explore the inter-relations between parental attitudes and internalising problems, aggression, and other factorsrelated to a child with disability characteristics, their family, and school setting.

Parents’ attitudes towards their children with CP

The results show that parents of children with CP had moderate attitudes from the overall scaletowards their children with CP. A third of respondents had negative attitudes; this could be due toevery parent ‘dreaming’ about their child being ‘perfect’ in all aspects, and then when their childis born with disability, they experience disappointment, which leads to the development of negativeattitudes towards their child. This result could indicate that parents need to increase their knowledgeabout CP to help them to build more positive attitudes towards their children with CP, and to be rea-listic about the abilities of their child with CP. Olawale et al. (2013) agree that parents of children with

Table 7. Mean and standard deviations in terms of rubric scale for the parentalattitudes depending on the study variables.

Variable M SD

Gender of childMale 3.1130 .68040Female 2.9292 1.04008

Child ageLess than 8 3.0111 .961029–13 3.1804 .50649

Child orderFirst born 3.3689 .48065Middle born 3.1619 .48054last born 2.2083 1.47978

Level of disabilityCP 3.0017 .88938CP with other disabilities 3.2444 .30732

Educational levelUndersecondary school 2.9767 .37167Secondary school 2.4333 .44155Undergraduate 3.4200 .41145

Income600 JD and Less 3.0439 .87244More than 600 JD 2.8667 .42613

Type of schoolsInclusion settings 2.7787 .95757Special education settings 3.4963 .44705Internalised problems 2.5031 .46792Anxiety 2.1667 .65954Isolation 2.5056 .64974Depression 2.5785 .62151Shyness 2.7615 .56826Aggressive 2.5218 .52012

M: Mean; SD: Standard Deviation

EARLY CHILD DEVELOPMENT AND CARE 11

CP need adequate knowledge about CP, and this result also agrees with those of many studies whichemphasise that parents who care for children with disabilities (Martins-Ribeiro, Lima-Sousa, Vanden-berghe, & Porto, 2014), including CP (Elad et al., 2013), consider their children to be more vulnerableand dependent. Motor function limitations, delayed cognitive development, and challenges in socialadaptation might cause parents to treat their children as always needing protection and assistance,as emphasised by Jankowska et al. (2015). However, the results of this study are in disagreement withthose reported by Olawale et al. (2013), who noted that parents’ attitudes towards their child with CPwere positive, and Jankowska et al. (2015) showed that parents presented strong tendencies towardsacceptance of their children with CP.

Correlations and associated factors of parental attitudes

The regression analysis results showed that, with increasing internalising behavioural problems, par-ental attitudes towards their child with CP became more negative. This result could be due to theinternalising behavioural problems such children might have, including shyness, anxiety, depression,and isolation, exerting constant pressure on parents. This in turn affects parents’ psychological well-being, including parental adaptation and increasing stress and anxiety, and thus affects parents’ atti-tudes towards raising their child with CP. This explanation is emphasised by many studies; forexample, mothers of children with CP scored high for neuroticism and low for openness (Jankowskaet al., 2015). Parental stress (Hastings & Taunt, 2002) has been found to be the best predictor variablefor children internalising and externalising their problems (Hastings & Taunt, 2002; Yurdusen et al.,2013), whilst mothers’ attitudes have been found to be closely associated with emotional and behav-ioural problems in their children (Yurdusen et al., 2013). This could be due to a child’s behaviour andthe parents’ ability to manage it, by taking into consideration the antecedent triggers that are orig-inally related to parents’ attitudes to their child’s behaviour. Parental attitudes are also connected pri-marily with their skills in managing their child’s behaviour, because if they think that their child’schallenging behaviour is out of their control, then they may develop negative attitudes towardstheir child. Gupta and Singhal (2004) agree with this explanation and find that the way in which afamily functions is influenced by the parent’s perception of their child’s difficulties.

Interestingly, aggression emerged as a predictor of higher parental attitudes, and this result is anew finding. The positive effect of aggression on parental attitudes is especially importantbecause it could help in the highly relevant objective measure of actual parental attitudes. Thisresult could be due to the aggressive behaviour in the parents’ eyes being partly explained aseffect behaviour by their child concerning the environment in which they live, as such behaviourcan be considered as showing a vulnerable sense of self that is expressed as a tendency tobehave aggressively. This result agrees with that of a previous study (Schuengel et al., 2006) whichshowed a positive association between aggression and perceived motor competence, physicalappearance, and self-worth for children with CP.

Generally, studies have found similar associations between parental attitudes and all forms ofbehaviour problems in children with CP (Yurdusen et al., 2013). These results confirm the need formore attention to be paid to internalising problems and aggression behaviour that children withCP might have, and to provide them with appropriate intervention which in turn will lead to alteringparental attitudes towards these children and their abilities, which may ultimately reflect positivelyon the level of services provided to these children. Finally, this finding is considered new, as previousstudies have not examined behaviour problems (internalising and externalising problems) in relationto parents’ attitudes towards their children with CP (McDermott et al., 1996; Schuengel et al., 2006).However, this result should be replicated in other studies before drawing conclusions.

The results also show that with increasing child birth order, there was a decrease in parental atti-tudes. First-born children with CP enjoyed a more favourable parental attitude in comparison to thoseborn later. This difference in attitudes may be due to the expectations and the excitement of parentswith regard to the birth of their first child, which is probably not repeated. Kumar and Rao (2008)

12 K. A. Al-DABABNEH AND E. K. AL-ZBOON

reported a similar result which showed that first children elicit more positive parental attitudes com-pared to those who are born later.

The results also showed that parents’ attitudes were more positive towards their child with CP andanother disability than towards a child with only CP. This result could be attributed to increased par-ental expectations of children with only CP compared to those who have CP and other disabilities. Inaddition, the psychological situation that children with CP experience is more difficult than for thosewith multi-disabilities, as children with CP face difficulties relating to the degree of adjustment, whilechildren with CP and other disabilities adapt to their disability, which makes it easier for them toaccept their disability and also for those around them to accept it. This result disagrees with a pre-vious study by Al-Qaryouti (2008), which showed no significant differences in mothers’ acceptanceof their children with disabilities due to the degree of CP.

Parents with a low income hadmore positive attitudes towards their children with CP than parentswith higher incomes. This result could be due to children with CP having additional needs requiringextra financial input from parents. Parents who fail to provide such services, as a result of their limitedincome, may feel guilty compared to parents with a higher income who have the ability to providetheir child with CP with the additional services that they need. This result is in disagreement with thatof Krstic, Batic, Mihic, and Milankov (2016), where parents with high income exhibited more favour-able attitudes towards their children with CP than parents with low income.

The results also show that children with CP who are enrolled in separate centres have more posi-tive parental attitudes than those whose children are enrolled in inclusive settings. This could bedue to services in centres focusing more on education and more rehabilitation services being avail-able, compared to the situation in inclusion schools. This explanation has been emphasised bymany studies, such as that by Dababneh and Hussan (2009) which showed that centres presentmore effective and higher quality service compared with inclusion schools for children withdisabilities.

Child gender, child age, and parental level of education were not significantly associated with par-ental attitudes, according to the parents’ ratings. This indicates that parents, regardless of their edu-cational level, the gender and age of their child with CP, share the same attitudes. This could beattributed to the fact that the effect of the nature of the disability and its level on parental attitudesis higher regardless of child gender or age. A similar result was reported by Al-Qaryouti (2008) inrelation to child gender, but the degree of mothers’ acceptance was better for children aged 6–12years compared to children less than 6 years and above 18 years old.

The finding related to the effect of educational level could be due to the respondents’ partners’educational level, and their acceptance of their child with CP could have more effect on the respon-dents’ attitudes than their educational level. Consequently, the educational level of the respondents’partners as a variable needs to be considered in future studies. This result is in disagreement with thatof Omoniyi (2014), where parents exhibited more favourable attitudes towards their sons with disabil-ities than towards their daughters and with Krstic et al. (2016) result which showed that as educationlevels improve, parental attitudes also become more favourable.

Implications and conclusions

There are two main implications of these results that emphasise the need to provide parent-centredinterventions in addition to providing children with CP with appropriate emotional and social ser-vices. Parents caring for children with disabilities tend to perceive these children as particularlyweak and dependent (Martins-Ribeiro et al., 2014). However, internalising behaviour problems andaggression behaviour might have a significant effect on parental attitudes towards their childrenwith CP.

In addition, due to the nature of CP, children with these disabilities do not simply require intensiverehabilitation and care; they also need opportunities to discover and explore their skills, and tobehave as independently (physically and psychologically) as possible. Thus, it is necessary to

EARLY CHILD DEVELOPMENT AND CARE 13

provide parents with appropriate knowledge and to promote their sensitivity towards enhancing thepsychological and social development of their children.

Intervention programmes should provide parents with social support and increase their aware-ness of the nature of CP and its effect on their child’s emotional and social development, andprovide appropriate interventions for parents. These interventions should focus on strengtheningtheir skills and abilities to deal with and reduce the behaviour problems of their child with CP,increase their strengths, and maintain appropriate behaviour. They should also be assisted in recog-nising the effect of this on their attitudes towards their children and how this affects their child’sability to reach developmental milestones and even affects the results of rehabilitation. Parentshave to be able to deal effectively with their child with CP and develop positive attitudes towardsthe child and their competence.

This study contributes to the literature on behavioural problems associated with CP and the abilityto predict parents’ attitudes concerning the competence of their child with CP. More research isneeded to replicate these findings in other samples and to establish valid scale cut-off scores thatdiscriminate between children and adolescents needing professional health care and those whodo not. Finally, there is a need to encourage parental involvement in every aspect of the policiesand strategies relevant to the teaching of their children in a safe learning environment, in order toenhance shared understanding of their child with CP.

In summary, parental attitudes are not single or static but are multifactorial and are determinedand formed over time. Mental health professionals should be aware of the effect of parental attitudesand factors, in order to consider these when creating counselling or mental health programmeswhich can empower parents to adapt favourable attitudes towards their children with CP. Since par-ental attitudes play such an important role in the education and rehabilitation of any child with a dis-ability, it may be desirable to measure parents’ attitudes in centres and schools for children with CP.This may aid in understanding parental attitudes and feelings about their children’s disability, andsuggest guidelines for counselling parents to bring about attitudinal changes relating to discrimi-nation among children with CP and their education. Finally, future studies could involve a comparisonof parental attitudes towards a child with CP and a typically developing sibling, or a child withanother form of disability.

Implication for medical research and practice

This study results are necessary for healthcare policy-makers and mental health professionals for theirplanning and improving mental health services that emphasise the need to provide parents of chil-dren with CP with their healthcare needs along with rehabilitation services for a child with CP.

It should be noted that CP can effect the family life in various ways, so mental health professionalsshould be aware and sensitive for the diversity of attitudes among those who provide care. If mentalhealth professional understanding the parents’ attitudes about CP and the impact of having a childwith CP on their lives, they will be more effective in adapting behaviour that may allow early treat-ment and adaptive coping. Mental health professionals usually focus on the problems of the childwith CP and ignore the parents’ role as source of child support which consider main contributorto the child progress and adjustment. Parents who have a child with CP who have variety ofneeds and requirements, especially who did not receive support from their life partner, are morelikely to have distress and pressures. Medical intervention should take these factors into consider-ation and present support to parents while caring for children with CP.

Limitations of the study

This study has some limitations which indicate that caution should be taken in the generalisationof the findings. The number of children with CP was relatively low since CP is a rare event; there-fore, the relatively small sample size limits the statistical power to detect (sub) group differences.

14 K. A. Al-DABABNEH AND E. K. AL-ZBOON

Thus, the lack of statistically significant differences should be interpreted with caution. The studysample included parents of children with CP from only one city in Jordan, Amman. The studymainly used a questionnaire as the research instrument, whereas other instruments, such asinterviews and observation reports, were not used. Finally, data were collected using a surveymodel.

Notes on contributors

Kholoud A. Al-Dababneh is an associate professor of special education in the Department of Special Education at QueenRania Faculty for Childhood at Hashemite University, Jordan. Previously she worked as vice dean of Queen Rania Facultyfor Childhood, and head of the Childhood Education Department. Her research interests in special education includechildren with disabilities, early intervention, inclusive schools, learning disability, parental involvement, and gifted andcreative students.

Eman Al-Zboon is an assistant professor at Queen Rania Faculty for Childhood. She received her PhD in Special Educationfrom the University of Jordan in 2012. Her research interests focus on children with disabilities, curriculum, and currenttrends in special education.

References

Abasiubong, F., Ansa, V., Udoh, B., Edemeking, I., & Akpan, M. (2010). Stress, attitude and marital relationships of mothersof children with chronic neurological disorders in Southern Nigeria. TAF Preventive Medicine Bulletin, 9(5), 413–420.

Abu-Hamour, B., & Al-Hmouz, H. (2013). Special education in Jordan. European Journal of Special Needs Education, 29(1),105–115.

Al-Dababneh, K., Fayez, M., & Bataineh, O. (2012). Needs of parents caring for children with physical disabilities: A casestudy in Jordan. International Journal of Special Education, 27(3), 1–14.

Al-Jabery, M. & Zumberg, M. (2008). General and special education systems in Jordan: present and future perspectives.International Journal of Special Education, 23(1), 1–9.

Al-Khateeb, A. (2011). A proposed model for developing educational programs and services provided to intellectually disabledand autistic children in special education centers and institutions in Jordan according to international standards(Unpublished MA thesis). Amman Arab University, Amman, Jordan.

Almasri, N., O’Neil, M., & Palisano, R. (2014). Predictors of needs for families of children with cerebral palsy. Disability andRehabilitation, 36(3), 210–219.

Al-Qaryouti, I. (2008). Jordanian mothers’ acceptance of their handicapped children. Jordan Journal of Science inEducation, 4(3), 167–177.

Barnett, D., Clements, M., Kaplan-Estrin, M., & Fialka, J. (2003). Building new dreams. Supporting parents’ adaptation totheir child with special needs. Infants and Young Children, 16, 184–200.

Bigge, J., Best, S., & Heller, K. (2001). Teaching individuals with physical, health, or multiple disabilities (4th ed.). Upper SaddleRiver, NJ: Merrill/Prentice-Hall.

Brossard-Racine, M., Hall, N., Majnemer, A., & Rosenbaum, P. (2012). Behavioural problems in school age children withcerebral palsy. European Journal of Paediatric Neurology, 16(1), 35–41.

Chavira, V., Lopez, S., Blacher, J., & Shapiro, J. (2000). Latina mothers’ attributions, emotions, and reactions to the problembehaviors of their children with developmental disabilities. Journal of Child Psychology and Psychiatry, 41(2), 245–252.

Chong, J., Mackey, A., Broadbent, E., & Stott, S. (2011). Children’s perceptions of their cerebral palsy and their impact onlife satisfaction. Disability and Rehabilitation, 34(24), 2053–2060.

Cohen, E., Biran, G., Aran, A., & Gross-Tsur, V. (2008). Locus of control, perceived parenting style, and anxiety in childrenwith cerebral palsy. Journal of Developmental and Physical Disabilities, 20, 415–423.

Colver, A. (2006). Study protocol: SPARCLE – a multi-centre European study of the relationship of environment to partici-pation and quality of life in children with cerebral palsy. BMC Public Health, 6, 5. doi:10.1186/1471-2485-6-105

Colver, A., Dickinson, H., Parkinson, K., Arnaud, C., Beckung, E., Fauconnier, J.,… Thyen, U. (2011). Access of children withcerebral palsy to the physical, social and attitudinal environment they need: A cross-sectional European study.Disability and Rehabilitation, 33(1), 28–35.

Dababneh, K. (2012). The socio-emotional behavioural problems of children with cerebral palsy according to theirparents’ perspectives. International Journal of Adolescence and Youth, doi:10.1080/02673843.2012.655443

Dababneh, K., & Hussan, S. (2009). Mainstreaming Students with Hearing Impairment in Regular Schools according toteachers’ point of view. Journal of Educational Sciences, 5(1), 1–14.

Dalal, A., & Pandey, N. (1999). Cultural beliefs and family care of the children with disability. Psychology and DevelopingSocieties, 11, 55–75.

EARLY CHILD DEVELOPMENT AND CARE 15

DeMarle, D., & Roux le, P. (2001). The life cycle and disability: Experiences of discontinuity in child and family develop-ment. Journal of Loss and Trauma, 6, 29–43.

Dolk, H., Parkes, J., & Hill, N. (2006). Trends in the prevalence of cerebral palsy in Northern Ireland, 1981–1997.Developmental Medicine and Child Neurology, 48, 406–412.

Elad, D., Barak, S., Eisenstein, E., Bar, O., Givon, U., & Brezner, A. (2013). Discrepancies between mothers and clinicians inassessing functional capabilities and performance of children with cerebral palsy. Research in DevelopmentalDisabilities, 34, 3746–3753.

Fox, M. (2002). The self-esteem of children with physical disabilities: A review of the research. Journal of Research in SpecialEducational Needs, 2, 1–9.

Goodman, R. (2002). Brain disorders. In M. Rutter & E. Taylor (Eds.), Child and adolescent psychiatry (4th ed., ch. 14, pp. 241–260). Malden, MA: Blackwell.

Gray, P., Q’callaghan, M., & Poulsen, L. (2008). Behaviour and quality of life at school age of children who had broncho-pulmonary dysplasia. Early Human Development, 84, 1–8.

Gupta, A., & Singhal, N. (2004). Positive perceptions in parents of children with disabilities. Asia Pacific DisabilityRehabilitation Journal, 15(1), 22–35.

Hastings, R., & Taunt, H. (2002). Positive perceptions in families of children with developmental disabilities. AmericanJournal on Mental Retardation, 107, 116–127.

Heller, K., Alberto, P., & Meagher, T. (1996). The impact of physical impairments on academic performance. Journal ofDevelopmental and Physical Disabilities, 8, 233–245.

Heward, W. (2006). Exceptional children: An introduction to special education (8th ed.). Columbus, OH: Merrill, Prentice Hall.Hinton, V., Nereo, N., Fee, R., & Cyrulnik, S. E. (2006). Social behavior problems in boys with duchenne muscular dystrophy.

Developmental and Behavioral Pediatrics, 27(5), 1–7.Hutton, J., & Pharoah, P. (2006). Life expectancy in severe cerebral palsy. Archives of Disease in Childhood, 91, 254–258.Jankowska, A., Włodarczyk, A., Campbell, C., & Shaw, S. (2015). Parental attitudes and personality traits, self-efficacy, stress,

and coping strategies among mothers of children with cerebral palsy. Health Psychology Report, 3(3), 246–259.Jones, M., Morgan, E., Shelton, J., & Thorogood, C. (2007). Cerebral palsy: Introduction and diagnosis (part I). Journal of

Pediatric Health Care, 21, 146–152.Kendziora, K., & O’Leary, S. (1993). Dysfunctional parenting as a focus for prevention and treatment of child behavior pro-

blems. Advances in Clinical Child Psychology, 15, 175–206.Ketelaar, M., Volman, M., Gorter, J., & Vermeer, A. (2008). Stress in parents of children with cerebral palsy: What sources of

stress are we talking about? Child: Care, Health & Development, 34(6), 825–829.Khayatzadeh, M., Rostami, H., Amirsalari, S., & Karimloo, M. (2012). Investigation of quality of life in mothers of children

with cerebral palsy in Iran: Association with socio-economic status, marital satisfaction and fatigue. Disability andRehabilitation, 35(10), 803–808.

Krstic, T., Batic, S., Mihic, L., & Milankov, V. (2016). Mothers’ reactions to the diagnosis of cerebral palsy: Associations withtheir educational level. International Journal of Disability, Development and Education, 63(4), 467–483.

Kumar, S., & Rao, G. (2008). Parental attitudes toward children with hearing impairment. Asia Pacific DisabilityRehabilitation, 19(2), 45–53.

Lin, S. (2000). Coping and adaptation in families of children with cerebral palsy. Exceptional Children, 66, 201–218.Maloni, P., Despres, E., Habbous, J., Primmer, A., Slatten, J., Gibson, B., & Landry, M. (2011). Perceptions of disability among

mothers of children with disability in Bangladesh: Implications for rehabilitation service delivery. Disability andRehabilitation, 32(10), 845–854.

Martins-Ribeiro, M., Lima-Sousa, A., Vandenberghe, L., & Porto, C. (2014). Parental stress in mothers of children and ado-lescents with cerebral palsy. Revista Latino-Americana de Enfermagem, 22, 440–447.

McDermott, S., Coker, L., Mani, S., Krishnaswami, S., Nagle, R., Barnett-Queen, L., & Wuori, F. (1996). A population-basedanalysis of behavior problems in children with cerebral palsy. Journal of Pediatric Psychology, 21(3), 447–63.

McLeod, B., Weisz, J., & Wood, J. (2007a). Examining the association between parenting and childhood depression: Ameta-analysis. Clinical Psychology Review, 27, 986–1003.

McLeod, B., Wood, J., & Weisz, J. (2007b). Examining the association between parenting and childhood anxiety: A meta-analysis. Clinical Psychology Review, 27, 155–172.

Ministry of Education (MOE). (2016). Ministry of education’s projects in Jordan. Unpublished Documents. Amman, Jordan.Olawale, O., Deih, A., & Yaadar, R. (2013). Psychological impact of cerebral palsy on families: The African perspective.

Journal of Neurosciences in Rural Practice, 4(3), 159–163.Omoniyi, M. (2014). Parental attitude towards disability and gender in the Nigerian context: Implications for Counselling.

Mediterranean Journal of Social Science, 5(20), 2255–2260.Ong, L., Afifah, I., Sofiah, A., & Lye, M. (2016). Parenting stress among mothers of Malaysian children with cerebral palsy:

Predictors of child- and parent-related stress. Annals of Tropical Pediatrics, 18(40), 301–307.Osofsky, J., & Thompson, M. (2000). Adaptive and maladaptive parenting: Perspectives on risk and protective factors. In J.

P. Shonkoff & S. J. Meisels (Eds.), Handbook of early childhood intervention (pp. 54–75). Cambridge: CambridgeUniversity Press.

16 K. A. Al-DABABNEH AND E. K. AL-ZBOON

Parkes, J., Carvale, B., Marcelli, M., Franco, F., & Colver, A. (2011). Parenting stress and children with cerebral palsy: AEuropean cross-sectional survey. Developmental Medicine & Child Neurology, 53(9), 815–821.

Parkes, J., & Hill, N. (2010). The needs of children and young people with cerebral palsy. Paediatric Nursing, 22(4), 14–9.Piggot, J., Paterson, J., & Hocking, C. (2002). Participation in home therapy programs for children with cerebral palsy: A

compelling challenge. Qualitative Health Research, 12, 1112–1129.Plant, K., & Sanders, M. (2007). Predictors of care-giver stress in families of preschool-aged children with developmental

disabilities. Journal of Intellectual Disability Research, 51, 109–124.Saleh, M., & Almasri, N. (2015). Cerebral palsy in Jordan: Demographics, medical characteristics and access to services.

Children’s Health Care, 1–17. http://dx.doi.org/10.1080/02739615.2015.1124770Schuengel, C., Voorman, J., Stolk, J., Dallmeijer, A., Vermeer, A., & Becher, J. (2006). Self-worth, perceived competence, and

behaviour problems in children with cerebral palsy. Disability & Rehabilitation, 28(20), 1251–8.Seligman, M., & Darling, R. (2007). Ordinary families, special children: A systems approach to childhood disability (3rd ed.).

New York, NY: The Guilford Press.Sigurdardottir, S., Indredavik, M., Eiriksdottir, A., Einarsdottir, K., Gudmundsson, H., & Vik, T. (2010). Behavioural and

emotional symptoms of preschool children with cerebral palsy: A population-based study. Developmental Medicineand Child Neurology, 52(11), 1056–1061.

Sipal, R., Schuengel, C., Voorman, J., Van Eck, M., & Becher, J. (2010). Course of behaviour problems of children with cer-ebral palsy: The role of parental stress and support. Child: Care, Health and Development, 36, 74–84.

Sloper, P., & Turner, S. (1993). Risk and resistance factors in the adaptation of parents of children with severe physicaldisability. Journal of Child Psychology and Psychiatry, 34, 167–188.

Thomas, M. (2002). An overview of disabilities issues in South Asia. Asia Pacific Disability Rehabilitation Journal, 13, 62–84.Thousand, J., Nevin, A., & Villa, R. (2007). Collaborative teaching: Critique of the scientific evidence. In L. Florian (Ed.),

Handbook of special education research (pp. 417–428). London: Sage.Trope, Y., & Pomerantz, E. (1998). Resolving conflicts among self-evaluative motives: Positive experiences as a resource for

overcoming defensiveness. Motivation and Emotion, 22, 53–72.Vermaes, I., Janssens, J., Mullaart, R., Vinck, A., & Gerris, J. (2008). Parents’ personality and parenting stress in families of

children with spina bifida. Child: Care, Health and Development, 34(5), 665–674.Whittingham, K., Wee, D., Sanders, M., & Boyd, R. (2011). Responding to the challenges of parenting a child with cerebral

palsy: A focus group. Disability and Rehabilitation, 33(17–18), 1557–1567.Wiegerink, D., Roebroeck, M., Donkervoort, M., Stam, H., & Cohen-Kettenis, P. (2006). Social and sexual relationships of

adolescents and young adults with cerebral palsy: A review. Clinical Rehabilitation, 20(12), 1023–1031.Wong, P. (2015). A cultural–historical model to understand and facilitate children’s development. European Early

Childhood Education Research Journal, 23(5), 645–661.Yamaguchi, R., Perry, K., & Hines, M. (2014). Pain, pain anxiety and emotional and behavioural problems in children with

cerebral palsy. Disability and Rehabilitation, 36(2), 125–30.Yurdusen, S., Erol, N., & Gencoz, T. (2013). The effects of parental attitudes and mothers’ psychological well-being on the

emotional and behavioral problems of their preschool children. Maternal and Child Health Journal, 17, 68–75.

EARLY CHILD DEVELOPMENT AND CARE 17