The Gerontologist 42:766-771 (2002)
© 2002 The Gerontological Society of America
The Influence of Parental Bonding on Emotional Distress in Caregiving Sons for a Parent With Dementia
Andrew P. Daire, PhDa
a Department of Child, Family, & Community Sciences, University of Central Florida, Orlando
Correspondence: Andrew P. Daire, PhD, University of Central Florida, Department of Child, Family, & Community Sciences, P.O. Box 161250, Orlando, FL 32816-1250. E-mail: adaire{at}mail.ucf.edu.
Decision Editor: Laurence G. Branch, PhD
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Abstract
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Purpose: The purpose of this study was to investigate the influence of childhood parental bonding on emotional distress experienced by primary caregiving sons for a parent with dementia. Design and Methods: Data from the 40 participants were obtained using the Parental Bonding Inventory (PBI), Brief Symptom Inventory (BSI), and Caregiver Survey Questionnaire (CSQ). A multivariate analysis of variance was conducted to investigate any main effects or interaction between the two PBI bonding variables (care and overprotection) and the two distress variables, the BSI's Global Severity Index and the CSQ's distress percentage. Results: Caregiving sons who identified more care in the childhood bond with their parent attributed less distress to their primary caregiver role. Sons reporting less care attributed more distress to the primary caregiver role. Implications: Results suggest that the parental bond developed during childhood may play a role in predicting the extent to which caregiving sons will attribute distress to their caregiving role.
Key Words: Caregiver • Burden • Brief Symptom Inventory
Caregivers play a significant role in the health and adjustment of persons with dementia (S. Cohen and Wills 1985
). Not only do they provide much needed emotional support, they may also provide assistance with activities of daily living (bathing, grooming, eating, and toileting) and financial support. However, the role of caregiver comes with the additional challenge of managing one's own personal care needs and affairs along with those of a loved one. This presents the caregiver with a significant amount of psychological strain and burden. Whether the person with dementia resides independently or in an assisted living facility, the caregiver is at risk for psychological distress and depression (Levesque, Ducharme, and Lachance 1999).
Parental attachment and its relationship to caregiving and caregiver burden have been an important topic in caregiving research (Cicirelli 1981; Harmon and Thiessen 1989; Magai and Cohen 1998; Markiewicz, Reis, and Gold 1997). Early research by Bowlby 1969 suggested that feelings of attachment, which play a key role in the development of bonds between individuals (Klaus, Kennell, and Klaus 1995), increased caregiving behaviors. Research has also suggested that increased attachment feelings and attachment behaviors, such as personal visits and telephone calls, were related to greater caregiving (Cicirelli 1981, Cicirelli 1983). Positive caregivers who were coping well in that role also positively affected patient health (S. Cohen and Wills 1985; Uchino, Cacioppo, and Kiecolt-Glaser 1996). The emotional support provided by family caregivers has positive psychological effects on the adjustment, well-being, and health of the dementia sufferer.
Research has demonstrated that the attachment between caregiver and care receiver has an impact on caregiver emotional response. Markiewicz and colleagues 1997 study explored attachment styles in caregivers for dementia patients. Their study focused on the secure, anxious–ambivalent, and avoidant styles of attachment. Secure attachment styles indicate healthy relationships where individuals desire to be available and reliable. The anxious–ambivalent style reflects a clingy attachment that has a mixture of anger and disappointment. The avoidant style reflects those who avoid or detach from others. Markiewicz and colleagues found that anxious–ambivalent caregivers reported more negative emotional responses in their caregiving role and fewer social supports. Cicirelli 1993 reported that caregivers experienced fewer burdens when patient attachments were stronger. Crispi, Schiaffino, and Berman 1997 found that insecurely attached caregivers reported greater difficulty in the caregiving process. The studies were consistent in the position that positive attachment styles and bonds result in positive caregiver emotional responses and negative or strained bonds result in negative or strained emotional responses.
It has been well documented that women, particularly daughters, make up an overwhelming majority of all family caregivers (Doty, Jackson, and Crown 1998; Meshefedjian, McCusker, Bellavance, and Baumgarten 1998; Pillemer and Suitor 1996; Zarit, Stephens, Townsend, and Greene 1998). However, 10%–12% of primary caregivers are sons who make up 52% of secondary caregivers (Stone, Cafferata, and Sangl 1987; Tennstedt, McKinlay, and Sullivan 1989). In D. Cohen 1990 study, 22% of the caregiving sons lived with the care receiver. These men were also committed to their caregiving responsibilities (Harris 1998; Harris and Bichler 1997; Montgomery and Kamo 1989; Motenko 1988). However, there is a paucity of research directly focusing on men who are primary caregivers and the resulting emotional, physiological, and psychological effects. Harris 1998 reported that this lack of research leads to a "lack of in-depth knowledge regarding sons in their caregiving roles" (p. 343).
A focus of previous research has been on the present-day attachment relationships between caregiver and care receiver. What about the early childhood bonds that influence present-day bonding relationships? Will positive attachment and bonds be a salient factor in positive caregiver emotional response, as previous research has suggested? The purpose of this study was to contribute to the understanding of emotional distress experienced by caregiving sons of a parent with dementia by investigating the influence childhood parental bonding has on emotional distress experienced in the caregiving role. The research question was to identify what relationship exists between the parental bonding factors of care and overprotection with respect to emotional distress in sons who are the primary caregiver of a parent with dementia. It is hoped that the knowledge gained from this study can lead to services and interventions to better assist primary caregiving sons.
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Parental Bonding Inventory
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The Parental Bonding Inventory (PBI; Parker, Tupling, and Brown 1979) is a 25-item self-report measure that evaluates the attachment to one's parent from the adult child's point of view. It is composed of two factorially derived scales, Care and Overprotection, and assesses adults' perceptions of their parent's child-rearing behavior and the nature of the parent–child relationship. Parker and associates 1979 reported test–retest reliability scores of .76 for the Care scale and .63 for Overprotection scale, interrater reliabilities of .85 on the care dimension and .69 on the overprotection dimension, and concurrent validity scores of .77 and .78 for the care dimension and .48 and .50 for the overprotection dimension. More recent test–retest reliabilities with a nonclinical U.S. population ranged from .79 to .81, and long-term stability scores ranged between .65 and .77 (Wilhelm and Parker 1990). Reliability analysis of participants' scores on the PBI resulted in participant alpha scores estimating internal consistency of .84 for the Care scale and .84 for the Overprotection scale.
The Care and Overprotection factor scores yield five different bonding types: average, optimal bonding (high care–low overprotection), absent or weak bonding (low care–low overprotection), affectionate constraint (high care–high overprotection), and affectionless control (low care–high overprotection). In this study, both of the factorially derived scales of care and overprotection were used.
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Brief Symptom Inventory
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The Brief Symptom Inventory (BSI; Derogatis 1993) is a 53-item inventory that measures psychological distress. Items are answered on a 5-point scale (0 = not at all, 1 = a little, 2 = moderately, 3 = quite a bit, 4 = extremely). In addition to the nine subscales (Somatization, Obsessive–Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychotism), the BSI has three global indices of distress: the Positive Symptom Total, the Positive Symptom Distress Index, and the Global Severity Index (GSI). The GSI, which reflects the mean intensity ratings for all items on the BSI and indicates current level of distress, was the index of interest to measure emotional distress. Significant GSI scores were gauged by a t score greater than 63 on the GSI or on two or more of the nine subscales (Derogatis and Spencer 1982).
The test–retest reliability for GSI is .90 (Derogatis 1993). To estimate the internal consistency of the GSI with these participants, an alpha coefficient was derived. The participant alpha coefficient was calculated at .96. The GSI was the first dependent variable in this study and provided a measure of each participant's distress.
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Caregiver Survey Questionnaire
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The Caregiver Survey Questionnaire had three sections and a total of 26 questions. The first section, About You, contained 8 demographic questions about the participant. The next section, About Your Parent With Dementia, contained 11 questions addressing the parent's demographic status and functioning in different areas such as ambulating, memory, and general behaviors. The third section, General Questions, included 7 questions related to the participant's role as the primary caregiver. In this section, the participants were asked to self-report the percentage of emotional stress in their lives attributed to their role as primary caregiver of their parent with dementia (1%–100%). This percentage, known as the distress percentage, was used as the second dependent variable.
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Methods
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Data were obtained during Fall 2000 and Spring 2001 from primary caregiving sons of a parent with dementia. Participants were sons of a parent with dementia who resided in a licensed assisted living facility. Recognize that those who care for parents in their home or the parent's home provide more intensive care and are more involved. However, research has indicated that those who care for institutionalized elders are also at psychological risk (Levesque et al. 1999). One hundred thirty-six assisted living facility administrators in the southeastern United States (Florida = 84, Georgia = 16, Alabama = 16, Tennessee = 11, and South Carolina = 9) were contacted about participating in the study. Of these, 39 agreed to participate. They were given packets containing stamped envelopes with an informed consent form, invitation letters, and postcard to forward to potential participants.
Potential participants were asked to mail back their signed informed consent form along with the completed postcard of demographic information. Survey packets, which included an instruction sheet, the Caregiver Survey Questionnaire, PBI, BSI, and a self-addressed stamped manila envelope, were mailed to those who agreed to participate in the study. Packets were assembled with the order of the instruments alternated to control for possible ordering effect. Participants were instructed to mail the instruments back in the self-addressed stamped envelope provided. To ensure that participation was strictly voluntary, no incentives were offered.
A multivariate analysis of variance (MANOVA) was conducted to investigate any main or interaction effects between the two PBI variables, high or low care and high or low overprotection, and the two distress variables, GSI and distress percentage.
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Results
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A total of 40 sons who were primary caregivers for a parent with dementia contributed data to the analysis conducted in this study. All participants in the sample were White men with a mean age of 55.2. Eighty-five percent were married, 12.5% were single and 2.5% were divorced or widowed. One (2.5%) was between the ages of 30 and 39, 7 (17.5%) were between 40 and 49, 23 (57.5%) were between 50 and 59, 8 (20%) were between 60 and 69, and 1 (2.5%) was between 70 and 79. Four (10%) of the participants had completed high school, 16 (40%) had a college degree, and 20 (50%) had a graduate or professional degree. Twenty-six (65%) of the caregivers had siblings, 9 (22.5%) had no children, 20 (50%) had one or two children, and 11 (27.5%) had three or more children. Descriptive information on caregiving sons is presented in Table 1 .
All care recipients were White (100%), 31 (77.5%) were female, and 9 (22.5%) were male. Their ages ranged from 75 to 96 with a mean age of 85. Twenty-six (65%) had completed high school, 10 (25%) had a college degree, and 4 (10%) had a graduate or professional degree. Thirty-six parents (90%) were divorced or widowed, and 4 (10%) were married. Descriptive information on the care-receiving parents with dementia is presented in Table 2 .
The correlation matrix among the variables of interest is presented in Table 3 , and the means and standard deviations are presented in Table 4 . Sample means and standard deviations for the two distress variables are GSI, M = 0.45, SD = 0.43, and distress percentage, M = 28.15, SD = 20.02. For the PBI variables, the means and standard deviations are Care, M = 1.50, SD = 0.51, and Overprotection, M = 1.53, SD = 0.51.
A 2 x 2 MANOVA was conducted to compare the variables related to parental bond (care and overprotection) for the distress percentage and GSI. I wanted to examine for main effects and any interaction effects, particularly with the high-care, low-overprotection group that characterizes the optimal bonding group (Parker et al. 1979). The multivariate main effect for care was significant at the .05 level (Wilks's 
= .80), F(2,35) = 4.37, p = .02. However, the main effect for overprotection (see Table 5 ) was not significant at the .05 level (Wilks's = .99), F(2,35) = 0.22, p = .80, nor was the main effect of interaction (Wilks's = .97, F(2,35) = 0.49, p = .62.
Post hoc univariate analysis of variance (ANOVA) tests were then conducted, comparing the means of the distress percentage and the GSI across the parental bonding variables, care and overprotection. With the distress percentage dependent variable, the univariate main effect for care was significant at the .05 level, F(1,36) = 4.48, p = .04. However, there were no significant main effects for overprotection, F(1,36) = 0.37, p = .55, or the interaction, F(1,36) = 0.99, p = .33. Means, standard deviations, and analysis results for univariate effects with the distress percentage dependent variable are presented in Table 6 .
With the GSI dependent variable, there were no main effects for care, F(1,36) = 0.42, p = .52; overprotection, F(1,36) = 0.33, p = .57; or in the interaction, F(1,36) = 0.39, p = .54 (see Table 7 ). Therefore, the conclusion for the additional analyses was that there was a significant main effect for care (p = .04) with respect to the distress percentage, but not for overprotection and the interaction between care and overprotection.
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Discussion
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The MANOVA analysis aimed to investigate any main or interaction effects between the two parental bonding variables, high/low care and high/low overprotection, and the two distress variables, GSI and the distress percentage. There was a significant main effect for care (p = .02) with respect to the distress percentage, but no significant effect of overprotection (p = .803) or for the interaction between care and overprotection (p = .617). The follow-up univariate ANOVA comparing the means of the distress variables (GSI and distress percentage) and the parental bonding variables (high–low care and high–low overprotection) yielded a significant main effect for the care means (p = .04) with respect to the distress percentage, but not for any other main effects or interaction effects. A graphical representation of the relationship between high–low care and high–low overprotection with respect to the distress percentage is provided in Fig. 1.
Individuals who reported less care (emotional warmth, empathy, and closeness) in the bonding relationship with their parent (during their first 16 years) attributed more distress to the primary caregiving role for their parent with dementia. However, if high levels of care were reported, less distress was attributed to the primary caregiving role. Fig. 1 also displays that there was no significant interaction between the care and overprotection variables.
This finding is reasonably consistent with previous research that suggested that strong attachments are associated with less caregiver emotional distress and caregiver burden (Magai and Cohen 1998). In Magai and Cohen's study, which looked at present-day attachment and caregiver emotional regulation, caregivers of securely attached individuals reported less anxiety, depression, and overall burden. However, this study examined the relationship between the participants' perception of the parental bonding factors of care and overprotection as they developed during their first 16 years and the current level of emotional distress, along with the percentage of distress attributed to the primary caregiving role. The results suggested an interesting relationship, with childhood bonds influencing the distress attributed to the primary caregiver role. Male caregivers attributed less distress to their caregiver role when they perceived the bonding relationship with their parent as one of affection, emotional warmth, empathy, and closeness (care). Conversely, more distress was attributed when there was less care (affection, emotional warmth, empathy, and closeness in the childhood bond). This may reflect the strong sense of duty that caregiving sons report in the primary caregiving role (Harris 1998), which might contribute to their not viewing their distress as stemming from their caregiver role.
Another explanation comes from Bowlby 1988 cognitive–affective schema, called an internal working model of attachment. Related to caregiving, the working model consists of beliefs, rules, and strategies that direct attention to, process attachment-related cues, and are involved in affect regulation (Pistole 1999). The working model of these caregiving sons (high care during childhood bond) could involve a strong sense of duty where distress is not attributed to their primary caregiving role but to other sources. In addition, individuals who reported higher care in the parental bond developed during the first 16 years may have more familiarity and comfort with that relationship dynamic. The authors of the PBI (Parker et al. 1979) defined the care factor by "emotional warmth, empathy, and closeness" (p. 8). Some of these behaviors that define the care factor may be needed with the cognitive and independent living limitations of individuals with dementia. On the other hand, individuals with parental bonds with low care are less familiar with these behaviors and possibly more uncomfortable in that role. More research is needed in this area to better understand the working models of caregiving sons.
Several practice implications became evident as a result of this study's findings. This study suggests that the parental bonds developed during the first 16 years are related to how much distress is attributed to the caregiver role. For sons in the primary caregiving role, counselors may want to explore parental bonds' impact on the amount of care provided or the quality of the caregiving interactions. Also, does the distress attributed have a psychosocial impact on the client? For sons considering the primary caregiver role, the counselor can examine how the early parental bonds influence the role acquisition decision-making process. Also, how does examination of early parental bonds affect role acquisition decisions? Although these are possible practice implications, they are also areas for future research. The more we understand, the better we can assist.
Although I believe that this study contributes to the body of knowledge in the caregiving literature, some limitations do exist. The first limitation is the sample size. Caregiving sons comprise a relatively small percentage (approximately 12%) of primary caregivers for a parent with dementia (Stone et al. 1987; Tennstedt et al. 1989). Challenges in identifying these individuals were very apparent in this study. Replication of this study with a larger sample size may yield additional findings not evidenced here due to the power limitation present with a sample size of 40.
Future research could involve replication of this study with a larger population of caregiving sons with the inclusion of caregiving daughters for the purpose of examining gender differences. Also, replication with a larger sample would allow for a robust investigation of the influence that various demographic variables have on emotional distress, distress attribution, and variables of caregiver involvement. In addition, research to identify how family members decide who should be the primary caregiver and the effectiveness of this decision would be beneficial to the caregiving community. For example, what are the predictive factors for caregiver distress in primary caregiving sons and how can this information be used in role acquisition decisions? And what role does early or present-day bonding play? These are some of the questions that future research needs to address.
In addition to sample size, a more economically and culturally diverse group of participants would improve the generalizability of this study to more economically and culturally diverse individuals. Generalizations to caregivers of noninstitutionalized elders are also limited. Research has indicated that caregivers of institutionalized elders are also at psychological risk (Levesque et al. 1999). However, I fully recognize that those who care for parents in their home or the parent's home provide more intensive care and are more involved.
As the incidence of dementia increases, more knowledge will be needed to better assist caregivers, with hopes of decreasing their distress and increasing their involvement. With the knowledge gained from the clinical and research community on factors involved in greater distress attribution such as early parental bonds, it is hoped that the information can be applied directly to services and interventions for primary caregiving sons. A final and important note is that continued clinical and research attention to this area further opens professional dialogue on the impact primary caregiving sons can have on the lives of their parents with dementia and how they are affected on an emotional level.
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Acknowledgments
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I thank Dr. Gary Peterson from Florida State University for his assistance in this research project, as well as Dr. Mark Young and Dr. Chuck Dziuban from the University of Central Florida for their assistance in the review of the manuscript. Most of all, thanks to the caregiving sons who participated in this valuable project.
Received for publication January 16, 2002.
Accepted for publication April 15, 2002.
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Abstract
Parental Bonding Inventory
