Ratings of Parenting Stress in Pediatric Chronic Kidney Disease

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Duquette, Crista Donewar, Stephen R. Hooper This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6148068/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Sep, 2025 Read the published version in Pediatric Nephrology → Version 1 posted 5 You are reading this latest preprint version Abstract Background Parental stress in pediatric chronic illness may be illness-specific. Parents of children with chronic kidney disease (CKD) may be particularly susceptible due to the dynamic nature of the disease and demands of its treatment. Objective The current study evaluated parenting stress in pediatric CKD relative to caregivers of healthy, typically developing children. We hypothesized that caregivers of children with CKD would experience higher levels of child-related parenting stress when compared to parents of children without CKD. Design/Methods: The study included 61 children, ages 6 to 18 years, and their caregivers (CKD Group = 22, Typical Group = 39). CKD participants had experienced kidney dysfunction (i.e., GFR ≤ 75 mL/min/1.73m 2 or dialysis dependent) for at least 3 months. Parents completed the Parenting Stress Index (PSI) as a measure of their current stress. Results Multivariate analyses showed that parents in the CKD group endorsed significantly higher PSI Child Domain Scores than parents in the control group ( p = 0.02). Further, the parents of the CKD participants reported significantly higher rates of Life Stress (~ 32%, p = .05) and Child Acceptability (~ 36%, p = .03) that were in the clinical range (i.e., ≥ 85th percentile) than the controls. Conclusions Results suggest that parenting stress in this population is focally related to child characteristics as well as a perception by parents that the present circumstances are outside their control. These results should guide future studies exploring parent/family factors and potential interventions for reducing parenting stress and related burdens in the clinical care of children with CKD. parent stress pediatric CKD family factors family stress Introduction Parenting stress is well-documented in families of children with chronic medical conditions. Unique stressors include emotional caregiving, financial strain, and uncertainty about the child’s health. Additional factors that increase parent stress include managing treatments, frequent appointments, and disease-related complications. 1 , 2 In this regard, parents of children with chronic kidney disease (CKD) may experience increased stress due to the nature and treatment demands of this condition. CKD involves decreasing kidney function that interferes with the body’s ability to eliminate toxins and waste products. This progression includes increasing severity of kidney dysfunction (CKD stages 1–5) and eventual end stage renal disease (ESRD). Additionally, various other factors may contribute to higher parenting stress in CKD, such as neuropsychological complications involving memory, attention, and executive functioning, 3 , 4 school underachievement, absenteeism, and learning difficulties. 5 – 8 Similarly, social and emotional difficulties have also been reported, 9 – 11 including specific concerns for separation anxiety, school maladjustment, and depression. 12 – 16 Few studies have examined parenting stress as part of the clinical care environment. For example, daily management of CKD can be stressful for parents of children with CKD due to issues with disease progression unpredictability, frequent outpatient visits and hospitalizations, and dietary and fluid restrictions. Several qualitative studies have explored these burdens and stressors for parents of children with CKD, via focus groups and in-depth parent interviews, and concluded that there is significant parent stress in families with a child with CKD. 17 – 19 In addition, only one quantitative study has examined parenting stress in families with a child with CKD. Here, De Bruyne et al. 20 used an abbreviated version of the Parenting Stress Index and showed higher levels of parenting stress in the pediatric CKD population when compared to a control group of healthy, typically developing children. Consequently, the examination of parenting stress in families with a child with CKD remains a relatively unexplored area—an area that could be malleable in the clinical care of children with CKD. The current study aims to address this gap in the literature by comparing parenting stress in pediatric CKD relative to rates in caregivers of healthy, typically developing children. We hypothesized that caregivers of children with CKD would experience higher levels of parenting stress on child-related factors, along with a higher proportion reporting clinically significant levels of parenting stress. Methods Participants The patient sample consisted of children and adolescents with CKD recruited from a pediatric nephrology clinic. Participants ranged from 6 to 18 years of age and had experienced kidney dysfunction for at least 3 months (defined as glomerular filtration rate ≤ 75 mL/min/1.73m 2 calculated by Schwartz formula, or dialysis-dependency for at least 3 months). Patients with a prior kidney transplant or severe CNS anomalies were excluded. The CKD group had 22 participants with mild (n = 10) and moderate (n = 12) kidney disease. The control group had 39 participants who were recruited by fliers, newspaper advertisements, and electronic postings (e.g., e-mail, website) in the catchment area of the pediatric nephrology clinic. They had no chronic health conditions, developmental disorders, head trauma, neurological illness, or medication usage other than a multivitamin. Descriptive variables for the groups are in Table 1 . Table 1 Demographic data for the CKD (n = 22) and control (n = 39) groups. CKD Controls Chronological Age (years) 13.18 (3.78) 11.60 (3.40) % Caucasian 54.55% 76.92% % Female 45.45% 43.59% IQ score 94.73 (16.95) 114.15 (11.88) Maternal Education 3.00 (0.98) 4.23 (0.84) Age of CKD onset 4.19 (5.22) --- Duration of CKD 5.37 (4.54) --- Notes. Continuous variables presented as Mean (Standard Deviation). Procedures Participants were tested as part of a study examining the neurocognitive effects of CKD and concurrent treatment modalities. The protocol was approved by the Institutional Review Board at a major southern university, and all participants and their parent or primary caregiver provided assent and consent prior to testing. Demographic data, including race and maternal education, were collected by parent questionnaire. Socioeconomic status (SES) was defined by maternal education, which was nominally coded (1 = some high school, 2 = high school graduate or GED recipient, 3 = progress towards bachelor’s degree or completed associate’s degree, 4 = completed bachelor’s degree, 5 = completed graduate or professional degree). All testing and scoring were conducted by trained examiners from a psychology doctoral program under the supervision of a clinical neuropsychologist. Measurements Parenting stress level was assessed using the Parenting Stress Index (PSI) 21 and children’s intellectual functioning was assessed using the Wechsler Abbreviated Scale of Intelligence (WASI). Parenting Stress Index (PSI). The PSI is a systematic measure of child- and parent-based characteristics that contribute to parenting stress. It is a 120-item rating scale normed for use with parents of children ages 1 month to 12 years of age. The PSI converts raw scores to percentile scores, which are derived from the frequency distribution of a score relative to the normative sample. The professional manual for the PSI 21 indicates that scores from the 15th to 80th percentile fall within the normal range, and high scores are defined as ≥ 85th percentile. Scores are provided for Total Stress and Life Stress, as well as composites based on child- and parent-based characteristics (e.g., Child Domain, Parent Domain). Individual subscales within the PSI Child Domain include Distractibility/Hyperactivity, Adaptability, Reinforces Parent, Demandingness, Mood, and Acceptability. Individual subscales within the PSI Parent Domain include Competence, Isolation, Attachment, Health, Role Restriction, Depression, and Spouse. The scores of parents of the 13–18 year olds in this sample were used out of the normative age range. Comparisons of these scores to scores of parents whose children fell within the age range did not differ significantly. Wechsler Abbreviated Scale of Intelligence (WASI). Designed for ages 6 years through adulthood, the WASI employs a fluid-crystallized model of intelligence. 22 The WASI was administered to gain a brief four-subtest Full Scale IQ score (FSIQ) and will serve as a potential covariate in the study. Data Analyses Preliminary data analyses included Spearman correlations to identify significant correlations between IQ, maternal education, and child age, and the PSI variables (i.e., Parent Stress Domain, the Child Stress Domain, and the Total Score). Chi-square tests were used to evaluate between-group differences on categorical variables of race/ethnicity and sex. Preliminary analyses were also run to ensure that using the PSI out of age range of the adolescents in the sample did not systematically affect results. To address the primary research questions, a multivariate analysis of variance (MANOVA) was used to compare PSI Child Domain and PSI Parent Domain scores between groups. Individual ANOVAs were conducted for the PSI Life Stress and PSI Total scores given the overlap of items with the Child and Parent domains. Estimates of effect sizes (ES) were calculated using partial eta squared (η p 2 ) and interpretive guidelines suggested by Cohen 23 were applied (weak = .01, moderate = .06, strong = .15). All analyses were conducted using Predictive Analysis Software (PASW) 18.0 computer program. Results Participant Description The sample was comprised of 22 individuals with mild to moderate CKD and 39 typically developing controls without CKD. As can be seen in Table 1 , the participants in the CKD Group were 13.18 years of age, about 55% Caucasian, and about 45% female. IQ for the CKD Group was within the average range and maternal education reflected progress towards bachelor’s degree or completed associate’s degree. With respect to disease variables, the age of onset for CKD was approximately age 4, with disease duration being 5.37 years. For the control group, the chronological age was 11.60 years, with the sample being largely Caucasian and male. IQ for the control group fell within the average range and maternal education was reported to be equivalent to a completed bachelor’s degree. Preliminary Analyses The CKD and comparison group did not differ by sex, χ 2 (1) = 0.020, p = 0.89, or race/ethnicity, χ 2 (1) = 3.284, p = 0.70. Further, no significant correlations were found between PSI summary scales and IQ, maternal education, and child age, and all these correlations were small in magnitude (r = .07 to .21). Consequently, none of these variables were covaried in subsequent analyses. When examining the possible use of the PSI out of the normative age range, 23 out of the 61 participants were not in the normative age range (i.e., ages 13 to 18 years). Comparing the raw scores of the out of age range and within age range groups on the PSI summary scores showed similar scores with no ceiling effects, and the MANOVA was non-significant (Wilks’ Λ = 0.996, F (2, 58) = 0.121, p = 0.89); consequently, these cases were included in our analyses. Similarly, a MANOVA comparing the age groups on the subscales was non-significant, as were separate ANOVAs run on the Life Stress and Total Stress Domain scores. Group Comparisons on Parenting Stress Means and standard deviations for each of the PSI Index scores can be seen in Table 2 . The MANOVA comparing the CKD and Control groups on the PSI Child Domain and PSI Parent Domain scores was significant, Wilks’ Λ = 0.887, F (2, 58) = 3.708, p = 0.031, with a moderate effect size being present (η p 2 = 0.11). Follow up ANOVAs indicated that parents in the CKD group endorsed significantly higher (i.e., worse) PSI Child Domain Scores than the Control group, F (1, 59) = 6.281, p = 0.015, with a moderate effect size (η p 2 = 0.09). There was no statistically significant difference between the CKD and control groups on PSI Parent Domain, F(1, 59) = 0.569, p = 0.453. Table 2 Means, standard deviations, and percent at or above the 85th percentile for Parenting Stress Index Scores for Child Domain, Parent Domain, Life Stress, and Total Stress for the CKD (n = 22) and control groups (n = 39). CKD Control M SD ≥ 85th %ile M SD ≥ 85th %ile F-Tests ES (η p 2 ) PSI Child Domain* 56.23 31.78 27.27% 34.74 32.35 12.82% 6.281 0.096 PSI Parent Domain 33.05 26.47 4.55% 27.54 27.86 5.13% 0.569 0.010 PSI Life Stress Score* 54.68 36.53 31.82% 35.18 35.40 15.38% 4.173 0.066 PSI Total Score 42.82 31.62 18.18% 29.13 28.43 5.13% 3.01 0.088 Notes. *p < .05 Group differences on Total Stress and Life Stress were also evaluated. Due to the overlap of items on these factors and the Child and Parent Domain factors, two separate ANOVAs were run. For the Life Stress Score of the PSI, the groups differed significantly, F (1, 59) = 4.173, p = 0.05, with a small to moderate effect size being present (η p 2 = 0.06). There was no statistically significant difference between the CKD and control groups on PSI Total Stress Score, F (1, 59) = 3.008, p = 0.09, although scores were trending in the expected direction (i.e., more stress being reported in the CKD group) and the effect size was in the moderate range ( p η 2 = 0.08). Means and standard deviations for the subscale scores on the PSI can be seen in Table 3 . When examined for between-group differences, the overall MANOVA was not significant, Wilks’ Λ = 0.753, F (13, 47) = 1.186, p = 0.32, therefore follow-up ANOVA testing was not conducted. Table 3 Means, standard deviations, and percent at ≥ 85th percentile for the Parenting Stress subscale scores for the CKD (n = 22) and control (n = 39) groups. CKD Group Control Group M SD ≥ 85th %ile M SD ≥ 85th %ile Distractibility/ Hyperactivity 49.55 30.32 18.18% 28.49 29.01 10.26% Adaptability 48.91 29.14 18.18% 34.21 31.25 12.82% Reinforces Parent 65.32 29.70 36.36% 52.62 32.75 33.33% Demandingness 60.18 32.42 36.36% 38.87 34.42 17.95% Mood 62.14 28.96 36.36% 50.03 28.10 15.38% Acceptability* 60.59 30.32 36.36% 38.97 30.00 12.82% Competence 34.95 26.67 9.09% 24.64 27.26 5.13% Isolation 45.73 26.25 9.09% 41.74 29.14 7.69% Attachment 41.86 31.09 4.55% 37.95 31.92 15.38% Health 49.09 30.42 13.64% 44.44 26.13 5.13% Role Restriction 32.27 30.69 9.09% 26.03 25.97 7.69% Depression 30.00 24.57 4.55% 27.49 28.48 5.13% Spouse 49.32 29.35 18.18% 45.49 28.80 10.26% Notes. *p < .05 Proportions Endorsing Clinically Significant Ratings The CKD and control groups were also compared using Chi-Square analyses on the proportion of ratings falling at or above the 85th percentile for PSI Child, Parent, Life Stress, and Total scores, as well as for the individual subscales. As shown in Table 2 , no significant differences between the two groups were found on the PSI summary scores, although when looking at the rates for the CKD group, higher rates of concerns were found for the PSI Child Domain (~ 27%) and the PSI Life Stress Domain (~ 31.8%) than would be expected from a normal curve expectation (~ 15%). Among PSI subscale scores (see Table 3 ), Child Acceptability was the only subscale in which there was a significant difference between the CKD (36.36%) and control (12.82%) groups in terms of the proportion with scores above the 85th percentile (χ 2 = 4.649, p = .03). In addition, similarly higher rates of concern were reported by parents of the CKD participants on the PSI subscales of Reinforces Parent (~ 36%) Demandingness (~ 36%), and Mood (~ 36%), although these were not significantly different from rates reported by parents of control participants. Discussion This study compared parenting stress levels among parents of children with and without CKD. While scores across domains for both groups were generally in the average range, the CKD group had significantly higher scores on the PSI Child Domain, indicating elevated stress due to their child’s illness. Elevated scores on the PSI Child Domain suggest that parents identify certain qualities in their child as the primary source of parental stress. No between-group differences were found on the PSI Parent Domain, Total Stress Score, or other subscale scores. Additionally, results revealed that a significantly higher proportion of parents in the CKD group reported parenting stress ratings at or above the 85th percentile on the Life Stress Scale versus those of the control group (i.e., 31.8% versus 15.3%). Further, parents also reported clinical levels of stress on the Child Domain subscale of Acceptability. This subscale captures parental perceptions that their child exhibits certain characteristics that do not meet their expectations or wishes. 21 Prior research has shown that elevated scores on the PSI Acceptability subscale have been found in mothers of children with failure to thrive 24 , as well as in mothers of children with intellectual/developmental disorders regardless of etiology (e.g., Williams syndrome, Down syndrome, non-syndromic Intellectual/Developmental Disabilities). 25 , 26 Similarly higher rates of concern were registered by parents of the CKD participants on the PSI subscales of Reinforces Parent (~ 36%) Demandingness (~ 36%), and Mood (~ 36%), although these were not significantly different from rates reported by parents of control participants. Given the high rates when compared to normal curve expectations, however, follow-up studies should address these potential areas of parenting stress as well. In previous research on other pediatric chronic conditions, there have been multiple elevated PSI subscales within the Child Domain. For example, in early studies of children with cystic fibrosis, asthma, sleep apnea, and diabetes, Demandingness and less Adaptability to an illness were among the most prevalent and significant subscales indicative of increased levels of parenting stress. 27 – 30 More recently, research into children with epilepsy showed higher parenting stress levels on the PSI Child Domain subscales capturing Acceptability, Adaptability, Demandingness, and Distractibility/ Hyperactivity, especially for those with drug-resistant forms of epilepsy. 31 This study aligns with a recent study published by De Bruyne et al. 20 who, using an abbreviated version of the PSI, documented higher levels of parenting stress in the pediatric CKD population when compared to a control group of healthy, typically developing children. Their findings, along with the current results, highlight the potential emotional and psychological burden for caregivers of children with CKD, particularly around the management of their child’s health, medical appointments, and treatment regimens. Further, our study utilized the full version of the PSI and, as such, allowed a more thorough understanding of underlying sources of parenting stress. The single elevation in the Acceptability subscale within the PSI Child Domain in our study underscores the potential importance of this factor in the CKD population. Additionally, our related finding documenting elevations in the Life Stress Domain highlights that parents of children with CKD perceive their present, stressful circumstances to be outside the parent-child dyad and outside their control. This study adds to the nascent empirical work addressing the critical, potentially malleable factor of parenting stress in pediatric CKD. As expected, and consistent with parenting stress in other pediatric conditions, parents of children with CKD appear to experience an elevated level of parenting stress derived from child characteristics that they regard as independent from their own parenting abilities and their own personal characteristics. Concurrently, they also experience heightened levels of parenting stress stemming from factors viewed as outside the parent-child relationship and outside the parent’s control. These two indicators, suggesting a manifestation of parenting stress that is perceived as being externally driven and beyond personal control, are potential malleable factors that could support interventions for parents to reduce their level of stress. While this study addresses a much-needed area in pediatric CKD, expands on the relative dearth of scientific literature in parenting stress in CKD, and utilized a comparison group to facilitate group comparisons on parental stress, several limitations are noted. First, this study comprised a relatively small sample size and included CKD participants undergoing different phases of treatment, which were not differentiated in the scope of this study. These features limit the generalization of findings and lessened the power of our study to detect group difference, thus requiring replication. Relatedly, while the sample largely reflected mild to moderate CKD, future studies examining differing levels of disease severity might yield a different pattern of parenting stress. Second, this is a cross-sectional study that does not allow causative interpretations, and future studies should examine parenting stress in a longitudinal fashion to track the changes in parenting stress over time. A longitudinal design also would permit examination of changes in parenting stress as CKD disease progression evolves. Third, although we did use a typically developing control group, comparing parenting stress in pediatric CKD to parent stress manifested in other chronic illness populations would also be helpful to explore so as to determine the specificity versus general aspects of parenting stress associated with a chronic childhood condition. Fourth, while we did use a well-validated measure of parenting stress, we did employ the measure out of age range for participants who were above the test’s age range. We demonstrated that this did not seem to be a factor influencing the current findings, but future studies should ascertain a larger age-appropriate sample. In summary, the current study addresses a major gap in the pediatric CKD literature and is one of the first to examine specific factors underlying parenting stress in pediatric CKD in a comprehensive fashion. Consistent with the parenting stress literature, 32 findings point to acceptability of child characteristics and perception of external locus of control for caregivers—potential malleable factors in parents of children with mild to moderate CKD. These results should guide future efforts in examining parenting stress in CKD and provide the foundation to explore characteristics that can be the focus of interventions to reduce the impact on caregiver burden and associated stress. Declarations Acknowledgements: These data represent a secondary data analysis from earlier project funded from the Renal Research Institute; consequently, there is no current funding source for this work. The authors have no relevant financial or non-financial interests to disclose Correspondence should be directed to Dr. Stephen R. 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J Abnorm Child Psychol 46(3):449–461. 10.1007/s10802-017-0313-6 Supplementary Files GraphicalAbstract.pptx Cite Share Download PDF Status: Published Journal Publication published 02 Sep, 2025 Read the published version in Pediatric Nephrology → Version 1 posted Editorial decision: Major Revisions Needed 29 Mar, 2025 Reviewers agreed at journal 06 Mar, 2025 Reviewers invited by journal 05 Mar, 2025 Editor assigned by journal 04 Mar, 2025 First submitted to journal 03 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Duquette","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYPACZhjDhrGBB0SzEVQNJhgbDjCkka7lMGEt5uz9Bx9XMFgn9t1IPv74Q8V52Q1nDh9g+FB2GKcWy57DzIZnGNITZ95IS2w4cOa28YazbQmMM87h1mJwI5lNsoHhcOKGGzmGDQfbbiduOM9jwMzbhkfL/cfsPyFa8j82HPx3DqiF/wPzX3xabjCzMUJtYWw42HAgccPZHgZmRjxaLHuSjSUbDNKNZ555ZjjjzLFkIOOYwcGec+k4tZizH3z4saHCWrbvePKDDxU1drJ9Z5IfPvhRZo3bYXDyAJLoASwq0bQQVDYKRsEoGAUjGgAAv3JlGb1UPKwAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-0750-926X","institution":"Duke University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Peter","middleName":"J.","lastName":"Duquette","suffix":""},{"id":424603769,"identity":"cc99d0ba-97d2-4039-95c6-8cd50aa0d25a","order_by":1,"name":"Crista Donewar","email":"","orcid":"","institution":"UNC-Chapel Hill: The University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"Crista","middleName":"","lastName":"Donewar","suffix":""},{"id":424603770,"identity":"ada8e64e-8cd5-44b0-94e3-2b42010e9c43","order_by":2,"name":"Stephen R. Hooper","email":"","orcid":"https://orcid.org/0000-0002-6761-4504","institution":"UNC-Chapel Hill: The University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"Stephen","middleName":"R.","lastName":"Hooper","suffix":""}],"badges":[],"createdAt":"2025-03-03 16:46:52","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6148068/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6148068/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00467-025-06936-6","type":"published","date":"2025-09-02T15:57:21+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90828106,"identity":"80daddd3-bcfa-47b0-abdc-99528a8cf105","added_by":"auto","created_at":"2025-09-08 16:05:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":555307,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6148068/v1/4375ba50-64fa-4880-bb52-788d8b416460.pdf"},{"id":78123108,"identity":"cf7fa6c1-35e2-4c52-88fb-60066dd8cfb0","added_by":"auto","created_at":"2025-03-10 07:30:36","extension":"pptx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":76430,"visible":true,"origin":"","legend":"","description":"","filename":"GraphicalAbstract.pptx","url":"https://assets-eu.researchsquare.com/files/rs-6148068/v1/492cb24de3a589463e1b94eb.pptx"}],"financialInterests":"","formattedTitle":"Ratings of Parenting Stress in Pediatric Chronic Kidney Disease","fulltext":[{"header":"Introduction","content":"\u003cp\u003eParenting stress is well-documented in families of children with chronic medical conditions. Unique stressors include emotional caregiving, financial strain, and uncertainty about the child\u0026rsquo;s health. Additional factors that increase parent stress include managing treatments, frequent appointments, and disease-related complications.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e In this regard, parents of children with chronic kidney disease (CKD) may experience increased stress due to the nature and treatment demands of this condition. CKD involves decreasing kidney function that interferes with the body\u0026rsquo;s ability to eliminate toxins and waste products. This progression includes increasing severity of kidney dysfunction (CKD stages 1\u0026ndash;5) and eventual end stage renal disease (ESRD). Additionally, various other factors may contribute to higher parenting stress in CKD, such as neuropsychological complications involving memory, attention, and executive functioning,\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e school underachievement, absenteeism, and learning difficulties.\u003csup\u003e\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Similarly, social and emotional difficulties have also been reported,\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e including specific concerns for separation anxiety, school maladjustment, and depression.\u003csup\u003e\u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFew studies have examined parenting stress as part of the clinical care environment. For example, daily management of CKD can be stressful for parents of children with CKD due to issues with disease progression unpredictability, frequent outpatient visits and hospitalizations, and dietary and fluid restrictions. Several qualitative studies have explored these burdens and stressors for parents of children with CKD, via focus groups and in-depth parent interviews, and concluded that there is significant parent stress in families with a child with CKD.\u003csup\u003e\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e In addition, only one quantitative study has examined parenting stress in families with a child with CKD. Here, De Bruyne et al.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e used an abbreviated version of the Parenting Stress Index and showed higher levels of parenting stress in the pediatric CKD population when compared to a control group of healthy, typically developing children. Consequently, the examination of parenting stress in families with a child with CKD remains a relatively unexplored area\u0026mdash;an area that could be malleable in the clinical care of children with CKD.\u003c/p\u003e \u003cp\u003eThe current study aims to address this gap in the literature by comparing parenting stress in pediatric CKD relative to rates in caregivers of healthy, typically developing children. We hypothesized that caregivers of children with CKD would experience higher levels of parenting stress on child-related factors, along with a higher proportion reporting clinically significant levels of parenting stress.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe patient sample consisted of children and adolescents with CKD recruited from a pediatric nephrology clinic. Participants ranged from 6 to 18 years of age and had experienced kidney dysfunction for at least 3 months (defined as glomerular filtration rate\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;75 mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e calculated by Schwartz formula, or dialysis-dependency for at least 3 months). Patients with a prior kidney transplant or severe CNS anomalies were excluded. The CKD group had 22 participants with mild (n\u0026thinsp;=\u0026thinsp;10) and moderate (n\u0026thinsp;=\u0026thinsp;12) kidney disease.\u003c/p\u003e \u003cp\u003eThe control group had 39 participants who were recruited by fliers, newspaper advertisements, and electronic postings (e.g., e-mail, website) in the catchment area of the pediatric nephrology clinic. They had no chronic health conditions, developmental disorders, head trauma, neurological illness, or medication usage other than a multivitamin. Descriptive variables for the groups are in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data for the CKD (n\u0026thinsp;=\u0026thinsp;22) and control (n\u0026thinsp;=\u0026thinsp;39) groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCKD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControls\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronological Age (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.18 (3.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.60 (3.40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Caucasian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54.55%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.92%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45.45%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.59%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIQ score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94.73 (16.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114.15 (11.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.00 (0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.23 (0.84)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge of CKD onset\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.19 (5.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.37 (4.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNotes. Continuous variables presented as Mean (Standard Deviation).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProcedures\u003c/h3\u003e\n\u003cp\u003eParticipants were tested as part of a study examining the neurocognitive effects of CKD and concurrent treatment modalities. The protocol was approved by the Institutional Review Board at a major southern university, and all participants and their parent or primary caregiver provided assent and consent prior to testing. Demographic data, including race and maternal education, were collected by parent questionnaire. Socioeconomic status (SES) was defined by maternal education, which was nominally coded (1\u0026thinsp;=\u0026thinsp;some high school, 2\u0026thinsp;=\u0026thinsp;high school graduate or GED recipient, 3\u0026thinsp;=\u0026thinsp;progress towards bachelor\u0026rsquo;s degree or completed associate\u0026rsquo;s degree, 4\u0026thinsp;=\u0026thinsp;completed bachelor\u0026rsquo;s degree, 5\u0026thinsp;=\u0026thinsp;completed graduate or professional degree). All testing and scoring were conducted by trained examiners from a psychology doctoral program under the supervision of a clinical neuropsychologist.\u003c/p\u003e\n\u003ch3\u003eMeasurements\u003c/h3\u003e\n\u003cp\u003eParenting stress level was assessed using the Parenting Stress Index (PSI)\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e and children\u0026rsquo;s intellectual functioning was assessed using the Wechsler Abbreviated Scale of Intelligence (WASI).\u003c/p\u003e \u003cp\u003e \u003cem\u003eParenting Stress Index (PSI).\u003c/em\u003e The PSI is a systematic measure of child- and parent-based characteristics that contribute to parenting stress. It is a 120-item rating scale normed for use with parents of children ages 1 month to 12 years of age. The PSI converts raw scores to percentile scores, which are derived from the frequency distribution of a score relative to the normative sample. The professional manual for the PSI\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e indicates that scores from the 15th to 80th percentile fall within the normal range, and high scores are defined as \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;85th percentile. Scores are provided for Total Stress and Life Stress, as well as composites based on child- and parent-based characteristics (e.g., Child Domain, Parent Domain). Individual subscales within the PSI Child Domain include Distractibility/Hyperactivity, Adaptability, Reinforces Parent, Demandingness, Mood, and Acceptability. Individual subscales within the PSI Parent Domain include Competence, Isolation, Attachment, Health, Role Restriction, Depression, and Spouse. The scores of parents of the 13\u0026ndash;18 year olds in this sample were used out of the normative age range. Comparisons of these scores to scores of parents whose children fell within the age range did not differ significantly.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWechsler Abbreviated Scale of Intelligence (WASI).\u003c/em\u003e Designed for ages 6 years through adulthood, the WASI employs a fluid-crystallized model of intelligence.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e The WASI was administered to gain a brief four-subtest Full Scale IQ score (FSIQ) and will serve as a potential covariate in the study.\u003c/p\u003e\n\u003ch3\u003eData Analyses\u003c/h3\u003e\n\u003cp\u003ePreliminary data analyses included Spearman correlations to identify significant correlations between IQ, maternal education, and child age, and the PSI variables (i.e., Parent Stress Domain, the Child Stress Domain, and the Total Score). Chi-square tests were used to evaluate between-group differences on categorical variables of race/ethnicity and sex. Preliminary analyses were also run to ensure that using the PSI out of age range of the adolescents in the sample did not systematically affect results. To address the primary research questions, a multivariate analysis of variance (MANOVA) was used to compare PSI Child Domain and PSI Parent Domain scores between groups. Individual ANOVAs were conducted for the PSI Life Stress and PSI Total scores given the overlap of items with the Child and Parent domains. Estimates of effect sizes (ES) were calculated using partial eta squared (η\u003csub\u003ep\u003c/sub\u003e\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e) and interpretive guidelines suggested by Cohen\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e were applied (weak\u0026thinsp;=\u0026thinsp;.01, moderate\u0026thinsp;=\u0026thinsp;.06, strong\u0026thinsp;=\u0026thinsp;.15). All analyses were conducted using Predictive Analysis Software (PASW) 18.0 computer program.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Description\u003c/h2\u003e \u003cp\u003eThe sample was comprised of 22 individuals with mild to moderate CKD and 39 typically developing controls without CKD. As can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the participants in the CKD Group were 13.18 years of age, about 55% Caucasian, and about 45% female. IQ for the CKD Group was within the average range and maternal education reflected progress towards bachelor\u0026rsquo;s degree or completed associate\u0026rsquo;s degree. With respect to disease variables, the age of onset for CKD was approximately age 4, with disease duration being 5.37 years. For the control group, the chronological age was 11.60 years, with the sample being largely Caucasian and male. IQ for the control group fell within the average range and maternal education was reported to be equivalent to a completed bachelor\u0026rsquo;s degree.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePreliminary Analyses\u003c/h3\u003e\n\u003cp\u003eThe CKD and comparison group did not differ by sex, χ\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (1)\u0026thinsp;=\u0026thinsp;0.020, p\u0026thinsp;=\u0026thinsp;0.89, or race/ethnicity, χ\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (1)\u0026thinsp;=\u0026thinsp;3.284, p\u0026thinsp;=\u0026thinsp;0.70. Further, no significant correlations were found between PSI summary scales and IQ, maternal education, and child age, and all these correlations were small in magnitude (r\u0026thinsp;=\u0026thinsp;.07 to .21). Consequently, none of these variables were covaried in subsequent analyses.\u003c/p\u003e \u003cp\u003eWhen examining the possible use of the PSI out of the normative age range, 23 out of the 61 participants were not in the normative age range (i.e., ages 13 to 18 years). Comparing the raw scores of the out of age range and within age range groups on the PSI summary scores showed similar scores with no ceiling effects, and the MANOVA was non-significant (Wilks\u0026rsquo; Λ\u0026thinsp;=\u0026thinsp;0.996, \u003cem\u003eF\u003c/em\u003e(2, 58)\u0026thinsp;=\u0026thinsp;0.121, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.89); consequently, these cases were included in our analyses. Similarly, a MANOVA comparing the age groups on the subscales was non-significant, as were separate ANOVAs run on the Life Stress and Total Stress Domain scores.\u003c/p\u003e\n\u003ch3\u003eGroup Comparisons on Parenting Stress\u003c/h3\u003e\n\u003cp\u003eMeans and standard deviations for each of the PSI Index scores can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The MANOVA comparing the CKD and Control groups on the PSI Child Domain and PSI Parent Domain scores was significant, Wilks\u0026rsquo; Λ\u0026thinsp;=\u0026thinsp;0.887, \u003cem\u003eF\u003c/em\u003e(2, 58)\u0026thinsp;=\u0026thinsp;3.708, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031, with a moderate effect size being present (η\u003csub\u003ep\u003c/sub\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.11). Follow up ANOVAs indicated that parents in the CKD group endorsed significantly higher (i.e., worse) PSI Child Domain Scores than the Control group, \u003cem\u003eF\u003c/em\u003e(1, 59)\u0026thinsp;=\u0026thinsp;6.281, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.015, with a moderate effect size (η\u003csub\u003ep\u003c/sub\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.09). There was no statistically significant difference between the CKD and control groups on PSI Parent Domain, F(1, 59)\u0026thinsp;=\u0026thinsp;0.569, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.453.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMeans, standard deviations, and percent at or above the 85th percentile for Parenting Stress Index Scores for Child Domain, Parent Domain, Life Stress, and Total Stress for the CKD (n\u0026thinsp;=\u0026thinsp;22) and control groups (n\u0026thinsp;=\u0026thinsp;39).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eCKD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;85th %ile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;85th %ile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eF-Tests\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eES (η\u003csub\u003ep\u003c/sub\u003e\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePSI Child Domain*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.27%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12.82%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6.281\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.096\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePSI Parent Domain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.55%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.569\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePSI Life Stress Score*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.82%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e35.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15.38%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePSI Total Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eNotes. *p\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eGroup differences on Total Stress and Life Stress were also evaluated. Due to the overlap of items on these factors and the Child and Parent Domain factors, two separate ANOVAs were run. For the Life Stress Score of the PSI, the groups differed significantly, \u003cem\u003eF\u003c/em\u003e(1, 59)\u0026thinsp;=\u0026thinsp;4.173, p\u0026thinsp;=\u0026thinsp;0.05, with a small to moderate effect size being present (η\u003csub\u003ep\u003c/sub\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.06). There was no statistically significant difference between the CKD and control groups on PSI Total Stress Score, \u003cem\u003eF\u003c/em\u003e(1, 59)\u0026thinsp;=\u0026thinsp;3.008, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.09, although scores were trending in the expected direction (i.e., more stress being reported in the CKD group) and the effect size was in the moderate range (\u003csub\u003ep\u003c/sub\u003eη\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.08).\u003c/p\u003e \u003cp\u003eMeans and standard deviations for the subscale scores on the PSI can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. When examined for between-group differences, the overall MANOVA was not significant, Wilks\u0026rsquo; Λ\u0026thinsp;=\u0026thinsp;0.753, \u003cem\u003eF\u003c/em\u003e(13, 47)\u0026thinsp;=\u0026thinsp;1.186, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.32, therefore follow-up ANOVA testing was not conducted.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMeans, standard deviations, and percent at \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;85th percentile for the Parenting Stress subscale scores for the CKD (n\u0026thinsp;=\u0026thinsp;22) and control (n\u0026thinsp;=\u0026thinsp;39) groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eCKD Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;85th %ile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;85th %ile\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistractibility/ Hyperactivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.26%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdaptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12.82%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReinforces Parent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.36%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33.33%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemandingness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.36%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17.95%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.36%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15.38%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptability*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.36%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12.82%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.09%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIsolation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.09%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.69%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttachment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.55%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15.38%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.64%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRole Restriction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.09%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.69%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.55%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.26%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNotes. *p\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eProportions Endorsing Clinically Significant Ratings\u003c/h2\u003e \u003cp\u003eThe CKD and control groups were also compared using Chi-Square analyses on the proportion of ratings falling at or above the 85th percentile for PSI Child, Parent, Life Stress, and Total scores, as well as for the individual subscales. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, no significant differences between the two groups were found on the PSI summary scores, although when looking at the rates for the CKD group, higher rates of concerns were found for the PSI Child Domain (~\u0026thinsp;27%) and the PSI Life Stress Domain (~\u0026thinsp;31.8%) than would be expected from a normal curve expectation (~\u0026thinsp;15%). Among PSI subscale scores (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), Child Acceptability was the only subscale in which there was a significant difference between the CKD (36.36%) and control (12.82%) groups in terms of the proportion with scores above the 85th percentile (χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;4.649, p\u0026thinsp;=\u0026thinsp;.03). In addition, similarly higher rates of concern were reported by parents of the CKD participants on the PSI subscales of Reinforces Parent (~\u0026thinsp;36%) Demandingness (~\u0026thinsp;36%), and Mood (~\u0026thinsp;36%), although these were not significantly different from rates reported by parents of control participants.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study compared parenting stress levels among parents of children with and without CKD. While scores across domains for both groups were generally in the average range, the CKD group had significantly higher scores on the PSI Child Domain, indicating elevated stress due to their child\u0026rsquo;s illness. Elevated scores on the PSI Child Domain suggest that parents identify certain qualities in their child as the primary source of parental stress. No between-group differences were found on the PSI Parent Domain, Total Stress Score, or other subscale scores.\u003c/p\u003e \u003cp\u003eAdditionally, results revealed that a significantly higher proportion of parents in the CKD group reported parenting stress ratings at or above the 85th percentile on the Life Stress Scale versus those of the control group (i.e., 31.8% versus 15.3%). Further, parents also reported clinical levels of stress on the Child Domain subscale of Acceptability. This subscale captures parental perceptions that their child exhibits certain characteristics that do not meet their expectations or wishes.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Prior research has shown that elevated scores on the PSI Acceptability subscale have been found in mothers of children with failure to thrive\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, as well as in mothers of children with intellectual/developmental disorders regardless of etiology (e.g., Williams syndrome, Down syndrome, non-syndromic Intellectual/Developmental Disabilities).\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Similarly higher rates of concern were registered by parents of the CKD participants on the PSI subscales of Reinforces Parent (~\u0026thinsp;36%) Demandingness (~\u0026thinsp;36%), and Mood (~\u0026thinsp;36%), although these were not significantly different from rates reported by parents of control participants. Given the high rates when compared to normal curve expectations, however, follow-up studies should address these potential areas of parenting stress as well.\u003c/p\u003e \u003cp\u003eIn previous research on other pediatric chronic conditions, there have been multiple elevated PSI subscales within the Child Domain. For example, in early studies of children with cystic fibrosis, asthma, sleep apnea, and diabetes, Demandingness and less Adaptability to an illness were among the most prevalent and significant subscales indicative of increased levels of parenting stress.\u003csup\u003e\u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e More recently, research into children with epilepsy showed higher parenting stress levels on the PSI Child Domain subscales capturing Acceptability, Adaptability, Demandingness, and Distractibility/ Hyperactivity, especially for those with drug-resistant forms of epilepsy.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis study aligns with a recent study published by De Bruyne et al.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e who, using an abbreviated version of the PSI, documented higher levels of parenting stress in the pediatric CKD population when compared to a control group of healthy, typically developing children. Their findings, along with the current results, highlight the potential emotional and psychological burden for caregivers of children with CKD, particularly around the management of their child\u0026rsquo;s health, medical appointments, and treatment regimens. Further, our study utilized the full version of the PSI and, as such, allowed a more thorough understanding of underlying sources of parenting stress. The single elevation in the Acceptability subscale within the PSI Child Domain in our study underscores the potential importance of this factor in the CKD population. Additionally, our related finding documenting elevations in the Life Stress Domain highlights that parents of children with CKD perceive their present, stressful circumstances to be outside the parent-child dyad and outside their control.\u003c/p\u003e \u003cp\u003eThis study adds to the nascent empirical work addressing the critical, potentially malleable factor of parenting stress in pediatric CKD. As expected, and consistent with parenting stress in other pediatric conditions, parents of children with CKD appear to experience an elevated level of parenting stress derived from child characteristics that they regard as independent from their own parenting abilities and their own personal characteristics. Concurrently, they also experience heightened levels of parenting stress stemming from factors viewed as outside the parent-child relationship and outside the parent\u0026rsquo;s control. These two indicators, suggesting a manifestation of parenting stress that is perceived as being externally driven and beyond personal control, are potential malleable factors that could support interventions for parents to reduce their level of stress.\u003c/p\u003e \u003cp\u003eWhile this study addresses a much-needed area in pediatric CKD, expands on the relative dearth of scientific literature in parenting stress in CKD, and utilized a comparison group to facilitate group comparisons on parental stress, several limitations are noted. First, this study comprised a relatively small sample size and included CKD participants undergoing different phases of treatment, which were not differentiated in the scope of this study. These features limit the generalization of findings and lessened the power of our study to detect group difference, thus requiring replication. Relatedly, while the sample largely reflected mild to moderate CKD, future studies examining differing levels of disease severity might yield a different pattern of parenting stress. Second, this is a cross-sectional study that does not allow causative interpretations, and future studies should examine parenting stress in a longitudinal fashion to track the changes in parenting stress over time. A longitudinal design also would permit examination of changes in parenting stress as CKD disease progression evolves. Third, although we did use a typically developing control group, comparing parenting stress in pediatric CKD to parent stress manifested in other chronic illness populations would also be helpful to explore so as to determine the specificity versus general aspects of parenting stress associated with a chronic childhood condition. Fourth, while we did use a well-validated measure of parenting stress, we did employ the measure out of age range for participants who were above the test\u0026rsquo;s age range. We demonstrated that this did not seem to be a factor influencing the current findings, but future studies should ascertain a larger age-appropriate sample.\u003c/p\u003e \u003cp\u003eIn summary, the current study addresses a major gap in the pediatric CKD literature and is one of the first to examine specific factors underlying parenting stress in pediatric CKD in a comprehensive fashion. Consistent with the parenting stress literature,\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e findings point to acceptability of child characteristics and perception of external locus of control for caregivers\u0026mdash;potential malleable factors in parents of children with mild to moderate CKD. These results should guide future efforts in examining parenting stress in CKD and provide the foundation to explore characteristics that can be the focus of interventions to reduce the impact on caregiver burden and associated stress.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements: These data represent a secondary data analysis from earlier project funded from the Renal Research Institute; consequently, there is no current funding source for this work. The authors have no relevant financial or non-financial interests to disclose\u003c/p\u003e\n\u003cp\u003eCorrespondence should be directed to Dr. Stephen R. Hooper, Department of Health Sciences, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC. 27599; email: [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCousino MK, Hazen RA (2013) Parenting stress among caregivers of children with chronic illness: a systematic review. J Pediatr Psychol 38(8):809\u0026ndash;828. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/jpepsy/jst049\u003c/span\u003e\u003cspan address=\"10.1093/jpepsy/jst049\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHung JW, Wu YH, Yeh CH (2004) Comparing stress levels of parents of children with cancer and parents of children with physical disabilities. 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Front Pediatr 10:948286. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fped.2022.948286\u003c/span\u003e\u003cspan address=\"10.3389/fped.2022.948286\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarroso NE, Mendez L, Graziano PA, Bagner DM (2018) Parenting Stress through the Lens of Different Clinical Groups: a Systematic Review \u0026amp; Meta-Analysis. J Abnorm Child Psychol 46(3):449\u0026ndash;461. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10802-017-0313-6\u003c/span\u003e\u003cspan address=\"10.1007/s10802-017-0313-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pnep","sideBox":"Learn more about [Pediatric Nephrology](http://link.springer.com/journal/467)","snPcode":"467","submissionUrl":"https://www.editorialmanager.com/pnep/default2.aspx","title":"Pediatric Nephrology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"parent stress, pediatric CKD, family factors, family stress","lastPublishedDoi":"10.21203/rs.3.rs-6148068/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6148068/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eParental stress in pediatric chronic illness may be illness-specific. Parents of children with chronic kidney disease (CKD) may be particularly susceptible due to the dynamic nature of the disease and demands of its treatment.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThe current study evaluated parenting stress in pediatric CKD relative to caregivers of healthy, typically developing children. We hypothesized that caregivers of children with CKD would experience higher levels of child-related parenting stress when compared to parents of children without CKD.\u003c/p\u003e\u003ch2\u003eDesign/Methods:\u003c/h2\u003e \u003cp\u003eThe study included 61 children, ages 6 to 18 years, and their caregivers (CKD Group\u0026thinsp;=\u0026thinsp;22, Typical Group\u0026thinsp;=\u0026thinsp;39). CKD participants had experienced kidney dysfunction (i.e., GFR\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;75 mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e or dialysis dependent) for at least 3 months. Parents completed the Parenting Stress Index (PSI) as a measure of their current stress.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMultivariate analyses showed that parents in the CKD group endorsed significantly higher PSI Child Domain Scores than parents in the control group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02). Further, the parents of the CKD participants reported significantly higher rates of Life Stress (~\u0026thinsp;32%, p\u0026thinsp;=\u0026thinsp;.05) and Child Acceptability (~\u0026thinsp;36%, p\u0026thinsp;=\u0026thinsp;.03) that were in the clinical range (i.e., \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;85th percentile) than the controls.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eResults suggest that parenting stress in this population is focally related to child characteristics as well as a perception by parents that the present circumstances are outside their control. These results should guide future studies exploring parent/family factors and potential interventions for reducing parenting stress and related burdens in the clinical care of children with CKD.\u003c/p\u003e","manuscriptTitle":"Ratings of Parenting Stress in Pediatric Chronic Kidney Disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-10 07:30:31","doi":"10.21203/rs.3.rs-6148068/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major Revisions Needed","date":"2025-03-29T17:05:41+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-03-06T21:12:06+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-05T15:27:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-04T09:45:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Nephrology","date":"2025-03-03T11:44:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pnep","sideBox":"Learn more about [Pediatric Nephrology](http://link.springer.com/journal/467)","snPcode":"467","submissionUrl":"https://www.editorialmanager.com/pnep/default2.aspx","title":"Pediatric Nephrology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0df13d2d-c7bd-4dd2-87df-efc3e4cbf3f3","owner":[],"postedDate":"March 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T16:04:51+00:00","versionOfRecord":{"articleIdentity":"rs-6148068","link":"https://doi.org/10.1007/s00467-025-06936-6","journal":{"identity":"pediatric-nephrology","isVorOnly":false,"title":"Pediatric Nephrology"},"publishedOn":"2025-09-02 15:57:21","publishedOnDateReadable":"September 2nd, 2025"},"versionCreatedAt":"2025-03-10 07:30:31","video":"","vorDoi":"10.1007/s00467-025-06936-6","vorDoiUrl":"https://doi.org/10.1007/s00467-025-06936-6","workflowStages":[]},"version":"v1","identity":"rs-6148068","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6148068","identity":"rs-6148068","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}