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SUPPLEMENT ARTICLE

Children’s Mental Health and Family Functioning in

Rhode Island

Hyun (Hanna) K. Kim, PhDa, Samara I. Viner-Brown, MSa, Jorge Garcia, MPHb

aRhode Island Department of Health, Family Health, Providence, Rhode Island;bRhode Island Department of Children, Youth and Families, Providence, Rhode Island

The authors have indicated they have no financial interests relevant to this article to disclose.

ABSTRACT

OBJECTIVES.Our objectives were to (a) estimate the prevalence of children’s mental

health problems, (b) assess family functioning, and (c) investigate the relationship between children’s mental health and family functioning in Rhode Island.

METHODS.From the 2003 National Survey of Children’s Health, Rhode Island data

for children 6 to 17 years of age were used for the analyses (N ⫽ 1326). Two aspects of family functioning measures, parental stress and parental involvement, were constructed and were examined by children’s mental health problems, as well as other child and family characteristics (child’s age, gender, race/ethnicity, special needs, parent’s education, income, employment, family structure, number of children, and mother’s general and mental health). Bivariate analyses and multivariate logistic regression were used to investigate the relationship.

RESULTS.Among Rhode Island children, nearly 1 (19.0%) in 5 had mental health

problems, 1 (15.6%) in 6 lived with a highly stressed parent, and one third (32.7%) had parents with low involvement. Bivariate analyses showed that high parental stress and low parental involvement were higher among parents of children with mental health problems than parents of children without those problems (33.2% vs 11.0% and 41.0% vs 30.3%, respectively). In multivariate logistic regression, parents of children with mental health problems had nearly 4 times the odds of high stress compared with parents of children without those problems. When children’s mental health problems were severe, the odds of high parental stress were elevated. However, children’s mental health was not associ-ated with parental involvement.

CONCLUSIONS.Children’s mental health was strongly associated with parental stress,

but it was not associated with parental involvement. The findings indicate that when examining the mental health issues of children, parental mental health and stress must be considered.

www.pediatrics.org/cgi/doi/10.1542/ peds.2006-2089E

doi:10.1542/peds.2006-2089E

Key Words

children’s mental health, family functioning, parental stress, parental involvement, National Survey of Children’s Health, Rhode Island

Abbreviations

NSCH—National Survey of Children’s Health

APS—Aggravation in Parenting Scale CI— confidence interval

aOR—adjusted odds ratio

Address correspondence to Hyun (Hanna) K. Kim, PhD, Division of Family Health, Rhode Island Department of Health, 3 Capitol Hill, Room 302, Providence, RI 02908-5097. E-mail: hanna.kim@health.ri.gov

Accepted for publication Sep 15, 2006

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A

T LEAST 1in 5 children in the United States has a mental health disorder, and 1 in 10 has a serious emotional disturbance.1These problems are a source of

stress for the child, as well as the family, school, com-munity, and larger society.1–3

It is important to understand the burden of children’s mental health problems and their impact on family func-tioning to assess the needs and gaps in mental health services for children and their parents.4,5 Previous

re-search has shown that parents of children with mental or behavioral health problems experience higher levels of stress in their parenting roles.6–9Parents of these

chil-dren have higher rates of mental health problems, as well as higher marital, employment, and financial prob-lems.10–15 In addition, parents of these children are less

likely to be involved or have a close relationship with their children because of stressful life circumstances.15

In Rhode Island, studies have indicated that there are inadequate resources (eg, child psychiatrists) and frag-mented systems of care in mental health services for children and their families.16,17 However, there have

been no population-based studies in the state that esti-mate the burden of children’s mental health problems and its relationship with family functioning.

Our objectives were to (a) estimate the prevalence of children’s mental health problems, (b) assess the level of family functioning, and (c) investigate the relationship between children’s mental health and family function-ing in Rhode Island. We hypothesized that parents of children with mental health problems would be more likely to have high stress levels and less likely to be involved with their children.

METHODS

Data

The 2003 National Survey of Children’s Health’s (NSCH) Rhode Island data were used for the analyses. The NSCH is a random-digit-dial telephone survey of a sample of parents with children⬍18 years of age from each of the 50 states and the District of Columbia, using a state-specific sampling frame. In Rhode Island, a total of 2019 interviews were completed, with the weighted overall response rate of 57.1%. Among them, children 6 to 17 years of age (N ⫽ 1326) were used for this study, be-cause the measures of mental health status and family functioning for children⬍6 years of age were less reli-able. Human subjects review was not required for this study. The survey design is described briefly in the article by Kogan and Newacheck in this issue18; more in-depth

information can be found elsewhere.19

Dependent Variables

Two aspects of family functioning were assessed: paren-tal stress and parenparen-tal involvement with their child.

Parental stress was measured by using the

Aggrava-tion in Parenting Scale (APS), which was derived from the Parenting Stress Index.20 The APS is an index of

stress in the parenting role measured by administering a 4-item sequence of questions that have been used in many other studies.21–23 In accordance with previous

studies, we used those 4 questions to measure the level of parental stress. The 4 questions were: “During the past month, how often have you felt [sample child] is much harder to care for than most children [his/her] age?”; “During the past month, how often have you felt [he/ she] does things that really bother you a lot?”; “During the past month, how often have you felt you are giving up more of your life to meet [sample child]’s needs than you ever expected?”; and “During the past month, how often have you felt angry with [him/her]?” Respondents were asked to choose 1 answer among 4 categories: never, sometimes, usually, or always. Following previ-ous research, we summed respondents’ answers to cre-ate scores ranging from 4 to 16: a score of ⱕ11 was defined as high parental stress.21–23

Parental involvement was measured by using 2 ques-tions: “Is your relationship with [sample child] very close, somewhat close, not very close, not close at all?”; and “How well can you and [sample child] share ideas or talk about things that really matter? Would you say very well, somewhat well, not very well, or not well at all?” Parents who reported “very close” and “very well” to both questions were defined as having high parental involvement.

The measures of parental stress and parental involve-ment were coded as a dichotomous variable (high versus low) for the analyses.

Independent Variables

Four questions were used to identify whether a child had a mental health problem: “Does [sample child] have any kind of emotional, developmental, or behavioral problem for which [he/she] needs treatment or counsel-ing?”; “Has a doctor or health professional ever told you that [sample child] has: Attention Deficit Disorder (ADD) or Attention Deficit Hyperactive Disorder (ADHD)?; depression or anxiety problems?; behavioral or conduct problems?” A child is classified as having a mental health problem when a parent answered “yes” to any of these 4 questions. Therefore, when we refer to “child’s mental health problem” in this article, it refers to a broader array of children’s mental, emotional, devel-opmental, and behavioral problems. The degree of the child’s mental health problem was further classified by using the number of questions that were answered “yes” by parents, with categories of no problem, 1 problem, and 2 or more problems. We considered 2 or more problems as a severe problem in this article.

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income, family structure, employment status, number of children in the household, and mother’s general health and mental health). These variables were considered as confounding factors when examining the association of children’s mental health with the dependent variables in the logistic regression analyses.

Statistical Analysis

Analyses were conducted by using the Survey Data Analysis (SUDAAN 9.0) statistical software to account for the weights and the complex survey design.24

Uni-variate descriptive statistics were used to describe the prevalence of our independent and dependent variables: children’s mental health problems, high level of parental stress, and low level of parental involvement. Bivariate analyses were employed, by using the␹2tests, to

exam-ine the estimated prevalence in relation to selected child/family/parent characteristics. Multivariate logistic regression was used to determine the association of chil-dren’s mental health status with parental stress and pa-rental involvement. A logistic regression model was con-structed with variables that were significantly associated with at least 1 of our dependent variables in the bivariate analysis. Because mother’s general health was highly correlated with mother’s mental heath (correlation co-efficient␳⫽0.42), we excluded mother’s general health from the final model. Separate logistic regression models were constructed for parental stress and parental in-volvement. Responses of “don’t know” and “refuse to answer” were excluded from the analyses. The results presented here are weighted data to reflect the 165 778 Rhode Island children 6 to 17 years of age, except for sample sizes (N) that were unweighted.

RESULTS

Study Population

Table 1 describes the distribution of the study population by selected child/family/parent characteristics used in the analyses. The characteristics of the children included: more than half (59%) of the children were aged 6 to 12 years; 51% were male; the majority were white (86%), non-Hispanic (87%), and did not need special services or care (86%). The characteristics of the household or par-ents included: the majority had more than a high school education (anyone in the household who had the high-est level of education) (66%); one third (33%) of the children lived in households with⬍200% of the federal poverty level; 61% of the children were living with 2 parents (biological/adopted); 89% were living in house-holds with anyone who was employedⱖ50 weeks in the past year; 62% of the household had 1 or 2 children. The majority of the mothers of these children had “good, very good or excellent” mental health (91%) and “good, very good or excellent” general health (90%).

Univariate and Bivariate Analyses

Table 2 shows the prevalence of children with a mental health problem, high parental stress, and low parental involvement, and their relation to selected characteris-tics.

Mental Health Problem

Nearly 1 in 5 (19.0%; 95% confidence interval [CI]: 16.5–21.9) children 6 to 17 years of age in Rhode Island had mental health problems by our definition. The pro-portion of children in Rhode Island that had a severe mental health problem was 9.8% (95% CI: 8.0 –12.1;

TABLE 1 Distribution of Study Population: Rhode Island Children 6 to 17 Years of Age

N⫽1326a % (95% CI)b

Child characteristics Age, y

6–12 752 59.1 (55.9–62.3)

13–17 574 40.9 (37.7–44.1)

Gender

Male 684 50.9 (47.6–54.1)

Female 642 49.1 (45.9–52.4)

Race

White only 1047 86.1 (83.3–88.4)

Black only 71 6.7 (5.1–8.8)

Multiple race 56 4.6 (3.3–6.3)

Other 31 2.6 (1.6–4.1)

Ethnicity

Hispanic 217 13.3 (11.3–15.6)

Non-Hispanic 1096 86.7 (84.4–88.7)

Needed special services/care

No 1029 86.0 (83.4–88.2)

Yes 175 14.0 (11.8–16.6)

Family/parent characteristics Education

Less than high school 72 7.7 (5.9–10.0) High school graduate 229 26.4 (23.3–29.7) More than high school 1024 65.9 (62.5–69.2) Poverty level, % FPL

⬍200 336 33.4 (30.1–37.0)

200% to⬍400 424 37.4 (34.1–40.8)

ⱖ400 439 29.2 (26.4–32.1)

Family structure

2 parents, biological/adopt 774 60.7 (57.3–64.0) 2 parents, stepfamily 114 9.6 (7.7–11.9) Single mother, no father present 355 29.7 (26.7–33.0) Anyone employedⱖ50 wks

No 119 10.9 (8.8–13.4)

Yes 1195 89.1 (86.6–91.2)

No. of children in household

1–2 1058 61.6 (58.1–65.0)

ⱖ3 268 38.4 (35.0–41.9)

Mother’s mental health

Good/very good/excellent 1155 90.9 (88.5–92.9)

Poor/fair 91 9.1 (7.1–11.5)

Mother’s general health

Good/very good/excellent 1116 89.5 (87.3–91.4)

Poor/fair 130 10.5 (8.6–12.7)

FPL indicates federal poverty level.

aThe sample sizes (N) are unweighted numbers.

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data not shown). The prevalence of children’s mental health problems varied by child and parent social/ health/demographic characteristics. Compared with their counterparts, the rate of mental health problems was significantly higher among teens (22.8%); males (22.7%); children with special health care needs (56.6%); those living below 200% of the poverty level (25.3%); those living with single mothers (25.7%) or in

stepfamilies (26.6%); those living in the families with no adults who worked full-time (30.2%); and children whose mothers had “poor or fair” mental health (47.0%) or “poor or fair” general health (36.0%).

Parental Stress

Approximately 1 (15.6%) in 6 (95% CI: 13.3–18.1) Rhode Island children lived with a parent who felt

TABLE 2 Prevalence of Mental Health Problems, High Parental Stress, and Low Parental Involvement by Selected Characteristics

Independent Variable: Have Mental Health Problem

Dependent Variable: High Parental Stress

Dependent Variable: Low Parental Involvement

%a Pb %a Pb %a Pb

All persons, % (95% CI) 19.0 (16.5–21.9) 15.6 (13.3–18.1) 32.7 (29.6–35.9)

Child characteristics

Mental health problem NA ⬍.001 .019

Have problem 100 33.2 41.0

No problem 0 11.0 30.3

Age, y .027 .037 ⬍.001

6–12 16.5 13.4 24.3

13–17 22.8 18.6 44.7

Gender .007 .811 .569

Male 22.7 15.3 31.8

Female 15.3 15.9 33.6

Race .132 .148 .711

White only 18.7 12.7 33.8

Black onlyc 13.3 23.4 33.5

Multiple racec 37.7 22.2 32.7

Otherc 25.6 28.6 22.0

Ethnicity .412 ⬍.001 .212

Hispanic 16.5 32.9 28.1

Non-Hispanic 19.6 13.0 33.6

Needed special services/care ⬍.001 .003 .064

No 13.1 12.8 30.8

Yes 56.6 26.5 40.7

Family/parent characteristics

Education .631 ⬍.001 .138

Less than high school 24.1 26.0 23.1

High school graduate 19.5 22.2 37.1

More than high school 18.3 11.7 32.0

Poverty level, % FPL .015 .005 .015

⬍200 25.3 21.8 32.1

200% to⬍400 17.6 12.0 38.6

ⱖ400 14.8 11.5 27.4

Family structure ⬍.001 .001 .004

2 parents, biological/adopt 13.3 11.8 28.1

2 parents, stepfamily 26.6 16.8 45.4

Single mother, no father present 25.7 23.0 37.2

Anyone employedⱖ50 wk .031 .028 .158

No 30.2 26.4 40.5

Yes 17.8 14.3 31.9

No. of children in household .942 .412 .040

1–2 19.0 14.7 29.8

ⱖ3 19.2 17.0 37.4

Mother’s mental health ⬍.001 .003 ⬍.001

Good/very good/excellent 15.5 13.7 30.2

Poor/fair 47.0 34.5 55.5

Mother’s general health .001 .059 .044

Good/very good/excellent 16.2 14.7 31.2

Poor/fair 36.0 23.9 43.0

NA indicates not applicable; FPL, federal poverty level.

aThe percentages are weighted to the Rhode Island children population. bPvalues are based on the␹2tests.

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highly stressed. Parents who had children with mental health problems were 3 times more likely to be stressed than parents of children without mental health prob-lems (33.2% vs 11.0%). The prevalence of high parental stress was higher among parents of teens (18.6%), His-panics (32.9%), and children who needed special care (26.5%). Parental stress was higher among parents with less than a high school education (26.0%), household incomes ⬍200% of federal poverty (21.8%), single mothers (23.0%), and those not working full-time (26.4%). Mothers with “poor or fair” mental health were more likely to be stressed (34.5%).

Parental Involvement

Nearly one third (32.7%; 95% CI: 29.6 –35.9) of parents had a low level of involvement with their child. Parents who had children with mental health problems were more likely to have low involvement with their child than parents who had children without mental health problems (41.0% vs 30.3%). Low parental involvement was more prevalent among parents of teens (44.7%), parents with 3 or more children (37.4%), and among mothers who have “poor or fair” mental health (55.5%) and “poor or fair” general health (43.0%). Parents with incomes of 200% to 400% of poverty level (38.6%), single mothers (37.2%), or stepparents (45.4%) were more likely to have low involvement compared with their counterparts.

Multivariate Analyses

Our final model of multivariate logistic regression, based on our bivariate analysis, included child’s mental health status, child’s age, race/ethnicity, whether or not the child needed special care, parent’s education, poverty level, family structure, employment status, number of children in the household, and mother’s mental health (Table 3).

Parental Stress

The results of logistic regression revealed that children’s mental health was strongly associated with parental stress. After controlling for all variables in the model, parents of children with mental health problems had nearly 4 times the odds of high stress (adjusted odds ratio [aOR]: 3.9; 95% CI: 2.3– 6.6), compared with parents of children without mental health problems. When a child’s mental health problems were severe, the odds of high parental stress were elevated (aOR: 5.7; 95% CI: 2.8 –11.6; data not shown). In addition to children’s mental health status, factors significantly associated with high parental stress were race/ethnicity, parental educa-tion, mother’s mental health status, and whether or not the child needed special care. Blacks (aOR: 2.9; 95% CI: 1.1–7.8), Hispanics (aOR: 3.6; 95% CI: 1.5– 8.4), parents of children who needed special care (aOR: 2.0; 95% CI: 1.1–3.7), parents with a high school education (aOR:

2.2; 95% CI: 1.1– 4.3), and mothers with poor mental health (aOR: 2.3; 95% CI: 1.1– 4.8) had significantly increased odds of high parental stress compared with their reference groups.

Parental Involvement

After controlling for child and parent characteristics in the logistic regression model, children’s mental health was not associated with parental involvement (aOR: 1.2; 95% CI: 0.7–1.9). In this model, child’s age, parental employment status, and mother’s mental health were significantly associated with the level of parental in-volvement. Low parental involvement was significantly higher among mothers of teens (aOR: 2.6; 95% CI: 1.8 –3.7), families with no one employed full-time (aOR: 2.3; 95% CI: 1.2– 4.6), and mothers with poor mental health (aOR: 2.7; 95% CI: 1.4 –5.3) compared with their reference groups.

DISCUSSION

This is the first population-based study conducted in Rhode Island that allows us to estimate the prevalence of children’s mental health problems and to investigate the relationship between children’s mental health and fam-ily functioning. According to our study, nearly 1 (19.0%) in 5 Rhode Island children 6 to 17 years of age, or an estimated 31 500 children, had a mental health problem. Approximately 1 (9.8%) in 10, an estimated 16 200 children, had a severe problem. Using the same definition and data source, the prevalence of children with mental health problems for the United States was 15.5% (95% CI: 15.0 –15.9) and those with a severe problem was 7.7% (95% CI: 7.3– 8.1). This result is consistent with the national report that ⬃20% of chil-dren and adolescents have a mental health disorder, and 10% have a serious emotional disturbance.1 Among

those children who had mental health problems, Ap-proximately one half (48.7%) of Rhode Island children reported that they received mental health care or coun-seling 12 months before the survey, compared with 42.2% of the US children.

Rhode Island family functioning level, measured by parental stress and parental involvement, was lower than the United States as a whole. Our study revealed that 15.6% of Rhode Island parents felt high stress, and 32.7% of parents did not have strong involvement with their children. The figures for the United States were 13.5% (95% CI: 13.1–14.0) and 29.6% (95% CI: 29.0 – 30.3), respectively.

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strongly associated with high parental stress, although these factors were not associated with parental involve-ment. In other words, a child’s poor physical or mental health may be a stressor for the parents, but these factors do not affect parental involvement with their child. In addition, minority parents (black and Hispanic) were found to have significantly higher stress levels, whereas minority status was not associated with parental in-volvement. Parental involvement was significantly lower among those parents who had teenagers and par-ents who were not fully employed; however, these fac-tors were not associated with parental stress. Mother’s mental health status was found to be the only factor that was significantly associated with both parental stress

and parental involvement. If a mother had poor mental health, the family functioning level was significantly lower.

Several limitations of this study should be noted. First, our study found that children’s mental health was strongly associated with parental stress. Because this is a cross-sectional study, we could not determine the direc-tion of the associadirec-tion. Children’s mental health cer-tainly can impact parental stress, but high parental stress can also be a risk factor of children’s mental health problems.13,14Second, there is no standard definition of

children’s mental health problems in the survey ques-tions, making it difficult to compare with other sources of data. By asking a parent whether a doctor diagnosed

TABLE 3 aORs and 95% CIs for Child/Family/Parental Characteristics Associated With High Parental Stress and Low Parental Involvement

High Parental Stress Low Parental Involvement

aOR 95% CI aOR 95% CI

Child characteristics Mental health problem

No problem — — — —

Have problem 3.89a 2.29–6.60 1.20 0.74–1.94

Age, y

6–12 — — — —

13–17 1.48 0.93–2.34 2.62a 1.83–3.74

Race

White, only — — — —

Black, only 2.90a 1.08–7.80 1.25 0.56–2.77

Multiple race 1.19 0.51–2.77 0.90 0.42–1.92

Other 1.24 0.17–9.16 0.63 0.17–2.30

Ethnicity

Hispanic 3.58a 1.52–8.41 0.87 0.41–1.84

Non-Hispanic — — — —

Needed special services/care

No — — — —

Yes 2.03a 1.11–3.73 1.26 0.73–2.19

Family/parent characteristics Education

Less than high school 1.98 0.49–7.90 0.26 0.05–1.27

High school graduate 2.20a 1.13–4.29 1.19 0.73–1.93

More than high school — — — —

Poverty level, % FPL

⬍200 0.43 0.18–1.00 0.84 0.47–1.50

200 to⬍400 0.61 0.35–1.06 1.29 0.87–1.92

ⱖ400 — — — —

Family structure

2 parents, biological/adopted — — — —

2 parents, stepfamily 1.32 0.56–3.11 1.56 0.82–2.97

Single mother, no father present 1.49 0.77–2.88 1.44 0.93–2.22 Anyone employedⱖ50 wk

No 1.44 0.63–3.32 2.34a 1.19–4.59

Yes — — — —

No. of children in household

1–2 — — — —

ⱖ3 1.08 0.59–1.97 1.46 0.96–2.22

Mother’s mental health

Good/very good/excellent — — — —

Poor/fair 2.25a 1.05–4.82 2.67a 1.35–5.31

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their child with certain symptoms of mental health prob-lems, we may exclude those children who experienced the symptoms but were not diagnosed by a doctor. Therefore, the prevalence of children with mental health problems may be underestimated. Third, previous re-search revealed that the measure of parental stress using 4 questions has limited cultural validity among Spanish-speaking Hispanic parents.23The cultural validity of this

measure was not verified in this study. Lastly, by using state-specific data, some groups have small sample sizes that make it difficult to produce meaningful results (eg, blacks, multiple and other races, those with less than a high school education, etc).

CONCLUSIONS

When examining the mental health issues and needs of children, parental mental health and stress must also be considered. Identification of families with high stress levels and providing appropriate support services to ad-dress the needs of both parents and children is critical. Health care providers, schools, public and private insur-ers, and social service programs can play a key role in early identification and counseling. It is important that these services and programs be accessible, family-cen-tered, continuous, comprehensive, compassionate, cul-turally effective, and coordinated via the medical home concept.

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DOI: 10.1542/peds.2006-2089E

2007;119;S22

Pediatrics

Hyun (Hanna) K. Kim, Samara I. Viner-Brown and Jorge Garcia

Children's Mental Health and Family Functioning in Rhode Island

Services

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http://pediatrics.aappublications.org/content/119/Supplement_1/S22 including high resolution figures, can be found at:

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http://www.aappublications.org/cgi/collection/psychosocial_issues_s Psychosocial Issues

al_issues_sub

http://www.aappublications.org/cgi/collection/development:behavior Developmental/Behavioral Pediatrics

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This article, along with others on similar topics, appears in the

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DOI: 10.1542/peds.2006-2089E

2007;119;S22

Pediatrics

Hyun (Hanna) K. Kim, Samara I. Viner-Brown and Jorge Garcia

Children's Mental Health and Family Functioning in Rhode Island

http://pediatrics.aappublications.org/content/119/Supplement_1/S22

located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Figure

TABLE 1Distribution of Study Population: Rhode Island Children 6to 17 Years of Age
TABLE 2Prevalence of Mental Health Problems, High Parental Stress, and Low Parental Involvement by Selected Characteristics
TABLE 3aORs and 95% CIs for Child/Family/Parental Characteristics Associated With High ParentalStress and Low Parental Involvement

References

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