Cultural and child-related predictors of distress among Latina caregivers of children with intellectual disabilities.

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2015, Vol. 120, No. 2, 145–165

EAAIDD DOI: 10.1352/1944-7558-120.2.145

Cultural and Child-Related Predictors of Distress Among Latina Caregivers of Children With Intellectual Disabilities Kristin A. Long, Barbara Kao, Wendy Plante, Ronald Seifer, and Debra Lobato

Abstract The objective of this article is to examine associations among socioeconomic, cultural, and child factors and maternal distress among families of children with intellectual disabilities (ID). Latino and nonLatino White (NLW) mothers of children with and without ID (N 5 192) reported on familism, language acculturation, maternal distress, child adaptive functioning, and child behavior problems. Among mothers of children with ID, higher levels of child behavior problems mediated the association between Latina ethnicity and elevated maternal distress. Associations between child behavior problems and maternal distress in Latina mothers of children with ID were moderated by single-parent marital status, higher familism, and lower English usage. Thus, child and cultural factors contribute to elevated distress among Latina mothers of children with ID. Key Words: parent; caregiver; intellectual disability; Latino; Hispanic; culture; familism; acculturation

Introduction Childhood intellectual disability (ID) has the potential to alter families’ emotional climate and patterns of functioning. Parents of children with disabilities report poorer mental health than parents of typically developing children (Bourke et al., 2008; Gray et al., 2011). This includes increased rates of psychopathology (Gau, Chiu, Soong, & Lee, 2008); elevated depressive symptomatology (Bailey, Golden, Roberts, & Ford, 2007); and more somatic symptoms such as headaches, backaches, muscle soreness, fatigue, and hot flashes (Smith, Seltzer, & Greenberg, 2012). The majority of research assessing parental distress has focused on mothers, who are often the primary caregivers for the child with ID. Relative to fathers of children with ID, mothers of children with ID have lower general well-being (Olsson & Hwang, 2006, 2008), higher rates of parenting stress (Gerstein, Crnic, Blacher, & Baker, 2009; Herring et al., 2006), and elevated depressive symptoms (Olsson & Hwang, 2001). Maternal mental health is important in its own right and for its association with the K. A. Long et al.

functioning of the child with ID. For example, higher mother-child interaction quality (e.g., maternal technical scaffolding and dyadic pleasure) decreases the likelihood that children with early developmental risk will meet criteria for ID later (Fenning & Baker, 2012). Parental negative affect and higher parenting stress predict subsequent poorer social skills among children with ID (Green & Baker, 2011; Neece & Baker, 2008). In children with Down syndrome, lower maternal sensitivity toward the child is cross-sectionally related to increased aggression in home and school settings (Niccols, Milligan, Chisholm, & Atkinson, 2011). Despite mean differences in maternal distress between samples of mothers with and without a child with ID, there is individual variability in maternal mental health. Therefore, the present research focuses on the identification of contextual risk and protective factors that may increase or decrease mothers’ chances of experiencing elevated distress in the context of having a child with ID. Specifically, we examine associations of maternal distress with cultural (e.g., familism and English language use), child- or disability-related 145


(e.g., maladaptive behaviors and ID severity), and demographic factors (e.g., per capita income and household composition).

Contextual Risk and Protective Factors Psychosocial risk among mothers of children with ID is associated with numerous contextual factors. For example, lower levels of perceived social support and quality of marital and co-parenting relationships are associated with poorer concurrent and prospective parent well-being (HauserCram et al., 2001; Norlin & Broberg, 2013) and lower family quality of life (Cohen, Holloway, Domıńguez-Pareto, & Kuppermann, 2014). Other risk factors for lower maternal well-being include an external locus of control (Hassall, Rose, & McDonald, 2005; Lloyd & Hastings, 2009), decreased psychological acceptance of life circumstances and increased use of avoidant coping strategies (Lloyd & Hastings, 2008), as well as poorer self-rated health (Olsson & Hwang, 2008). With regard to demographic risk factors, distress may be higher in mothers of older (ages 12+ years) than younger children with ID (Gray et al., 2011). Unmarried mothers of children with ID have a higher risk for depression (Olsson & Hwang, 2001), while higher education and income are protective for maternal well-being, quality of life, and depressive symptoms (Olsson & Hwang, 2008; Tekinarslan, 2013; Yildirim & Basbakkal, 2010). When considered together, the protective roles of employment and marriage on maternal mental health have been shown to be mediated by socioeconomic status (SES; Eisenhower & Blacher, 2006). Higher SES is associated with lower risk for psychiatric disorders (Emerson et al., 2010) and fewer symptoms of depression, anxiety, and despair among parents of children with ID (Khamis, 2007). However, findings regarding SES are less robust in culturally diverse samples. For example, SES was not found to be protective for Latina mothers’ perceptions of family quality of life (Cohen et al., 2014), nor was SES a significant moderator of the association between child behavior problems and maternal mental health among South Asian mothers residing in the United Kingdom (Hatton & Emerson, 2009). Other work suggests that the specific components of SES might have different effects across cultural groups; income may be more important for Latina mothers’ well-being, while education may be more important for 146

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nonLatino White (NLW) mothers’ well-being (Eisenhower & Blacher, 2006).

Associations Between Child Behavior Problems and Maternal Mental Health Reduced emotion regulation capabilities among children with ID contribute to increased internalizing and externalizing behavior problems relative to typically developing peers (Baker et al., 2003). A robust finding in the literature examining families of children with ID is the importance of child behavior problems or difficult temperament in predicting elevated maternal distress (Baker et al., 2003; Baker, Blacher, & Olsson, 2005; Gray et al., 2011; Hauser-Cram et al., 2001; Herring et al., 2006; McConkey, Truesdale-Kennedy, Chang, Jarrah, & Shukri 2008; Most, Fidler, BoothLaForce, & Kelly, 2006), parenting stress (Hassall et al., 2005; Neece & Baker, 2008), and less positive impact from the child (Blacher & Baker, 2007; Bostrom, Broberg, & Bodin, 2011). This pattern of findings is consistent regardless of the child’s specific ID-related syndrome (Blacher & McIntyre, 2006). Although most of the existing literature has employed composite measures of behavioral problems in the child with ID, a small subset of research has examined internalizing and externalizing behaviors separately. These studies have documented cross-sectional associations of both internalizing and externalizing behavior problems with poorer maternal mental health (Gray et al., 2011; Hastings, Daley, Burns, & Beck, 2006). Longitudinal research demonstrates that associations between child behavior problems (as assessed using total problems and internalizing scales) and maternal mental health are bidirectional over time (Baker et al., 2003; Hastings et al., 2006). Associations between child internalizing problems and maternal distress persist into adulthood (Orsmond, Seltzer, Krauss, & Hong, 2003), and behavior problems predict families’ likelihood of seeking out-of-home placements for young adults with ID (McIntyre, Blacher, & Baker, 2002). These bidirectional, persistent associations between child behavior problems and maternal well-being highlight the need for early intervention to alter these patterns of family influence. Although child behavior problems have been examined frequently as a predictor of maternal mental health, few studies have examined the Elevated Distress in Latina Caregivers


nature of this association in depth. A small body of work has found that the association between maternal depressive symptoms and child behavior problems is stronger when the mother displays high criticism and low warmth (Lancaster, Balling, Hastings, & Lloyd, 2014) or reports less optimism (Baker et al., 2005). The literature would benefit from more nuanced examinations of potential moderators of this association to determine if the strength or nature of the association between child behavior problems and maternal mental health varies according to other psychosocial, demographic, or cultural factors. By obtaining a more complete understanding of how these variables interrelate, future research will be able to examine the underlying causal processes for different subgroups of parents. In turn, this may inform intervention targets (e.g., improving the quality of the mother-child relationship or targeting child behavior problems) and will provide insight regarding which families are more likely to benefit from intervention (e.g., parents who display high levels of criticism or low warmth).

Latina Mothers of Children With ID A major weakness of the literature examining parental adjustment to childhood disability is the limited consideration of cultural factors. Since the meaning and processes underlying parental adjustment to childhood ID may be influenced by cultural values and beliefs, the generalizability of the extant literature examining caregivers of children with ID is questionable. Here, we focus on Latina mothers. ‘‘Latina/o’’ refers to the ethnicity of individuals who self-identify as being from a heritage, nationality group, lineage, or country of birth (themselves or their ancestors) of a Spanish-speaking country, including Cuba, Mexico, and Puerto Rico, and South or Central America, regardless of race (United States Office of Management and Budgets, 1997). Latina mothers of children with intellectual and development disabilities report elevated depressive symptoms, physical health problems, and lower morale than both NLW caregivers (Blacher & McIntyre, 2006; Blacher, Shapiro, Lopez, Diaz, & Fusco, 1997) and Latina noncaregivers (Blacher, Lopez, et al., 1997). Given findings that Latino children with ID are four times more likely than their NLW peers to remain in the home into adulthood (Blacher & McIntyre, 2006), caretaking responsibilities often continue K. A. Long et al.

EAAIDD DOI: 10.1352/1944-7558-120.2.145

over the mother’s lifespan. Disparities in caregivers’ mental health persist, as well. Latina mothers of adults with ID report elevated depressive symptomatology (Maganã, 1999; Maganã, Seltzer, & Krauss, 2004; Maganã, Seltzer, Krauss, Rubert, & Szapocznik, 2002), which is exacerbated in the presence of family problems (Maganã, 1999; Maganã et al., 2004; Maganã, Seltzer, Krauss, Rubert, et al., 2002; Maganã, Schwartz, Rubert, Szapocznik, & Floyd, 2006). Compared to matched Latina noncaregivers, midlife Latina caregivers have twice the risk for depression, and older Latina caregivers have 5 and 3.8 times greater risk for heart problems (coronary heart disease, myocardial infarction, angina, or other heart condition) and arthritis-related functional impairments, respectively (Maganã & Smith, 2006). Older Latina mothers who co-reside with adult children with developmental disabilities also smoke more and see a doctor less regularly than noncaregivers (Maganã & Smith, 2008). These findings suggest that Latina caregivers are at risk for longer-term mental and physical health problems, which may adversely affect the likelihood of engaging in supportive parenting practices over their lifespan. Caregiver mental health may be particularly important among Latino families. Latino adults rely more on family support than formal mental health services and are more likely to reside with their families as compared to NLWs (Snowden, 2007). Home-based caretaking is also consistent with previous research with Latino families of individuals with disabilities, which has emphasized the central role of familism (Maganã, 1999). Familism is characterized by interdependence and prioritizing the needs of the family over those of the individual (Marıń & Marıń, 1991), and persists across levels of acculturation among Latino families (Sabogal, Marıń, Otero-Sabogal, Marıń, & Perez-Stable, 1987). Thus, this family orientation may contribute to the increased salience and longevity of caretaking responsibilities in Latino families in general, and in Latina mothers in particular. Familism may also contribute to patterns of home-based caretaking documented in Latino families. Family factors appear to be particularly influential for Latina mothers’ mental health. For example, family problems are a stronger predictor of depressive symptoms in Latina than NLW mothers of adult children with ID (Maganã et al., 2004). This aligns with family-oriented 147

EAAIDD DOI: 10.1352/1944-7558-120.2.145


cultural values in which the healthy functioning of the family is of utmost importance to caregivers and, therefore, Latina mothers may be more tuned into family functioning as a determinant of their own well-being. However, the literature is mixed with regard to whether this strong family orientation is a risk factor, a protective factor, or both. For example, higher levels of familism have been shown to be protective for family quality of life when there is a child with ID (Cohen et al., 2014). These findings suggest that more research is needed to understand how cultural beliefs interact with life stressors and maternal mental health. In addition to familistic values, traditional gender ideals often place mothers in primary caretaking roles and may intensify the extent to which they attend to the needs of the family (Pinquart & Sorenson, 2005). This is consistent with marianismo, in which the Latina ideal of femininity has been traditionally characterized by modesty, virtue, and selfless caretaking for the family (Stevens, 1973). Thus, Latina culture celebrates females’ role as ‘‘nurturer’’ for their children. Children with higher caretaking needs (e.g., children with ID) may intensify Latina mothers’ identification with their caretaking role. In this regard, a small body of work has demonstrated that Latina mothers report higher positive impact of parenting a child with a disability than NLW mothers of children with disabilities (Blacher & Baker, 2007; Blacher, Begum, Marcoulides, & Baker, 2013) and Latina mothers of typically developing children (Blacher et al., 2013). Together, this small body of work suggests a complex picture of maternal adjustment to having a child with ID. The degree to which Latina mothers are integrated into mainstream American culture is also related to their mental and physical health, though the literature has documented both positive and negative effects of acculturation (Lara, Gamboa, Kahramanian, Morales, & Bautista, 2005). Acculturation is a multidimensional construct that includes birth place, language use, ethnic identity, traditionalism, familism, and cultural knowledge and behaviors (Escobar & Vega, 2000). Despite this broad conceptualization of acculturation, previous research indicates that multidimensional measures of acculturation provide limited value above and beyond narrower measures of acculturation, such as language use (Escobar & Vega, 2000). In this regard, mothers who speak English may be more likely to interface 148

productively with the healthcare system and with English-speaking mothers of children with ID (Santisteban & Mitrani, 2002), which may reduce feelings of isolation or self-blame for their child’s symptoms. More acculturated mothers also may espouse American ideals emphasizing multiple female ‘‘roles’’ (i.e., employee, spouse, community member) in addition to that of ‘‘mother,’’ which may provide multiple sources from which to bolster their self-worth. Indeed, the number of roles reported by mothers is linearly related to maternal well-being among highly acculturated Latina mothers, but this is not associated with well-being in less-acculturated mothers (Eisenhower & Blacher, 2006). This pattern of findings may be related to the tendency for females’ identity as ‘‘caretaker’’ to be valued more than other roles in traditional Latino culture (see previous discussion of marianismo). Finally, among Latina mothers of adults with ID, lower levels of acculturation are related to higher caregiver distress (Maganã, Schwartz, Rubert, Szapocznik, & Floyd, 2006). Taken together, the existing, small body of research suggests that culture is related to caretaking attitudes and maternal emotional adjustment, though findings may vary according to Latina mothers’ degree of acculturation.

Aims and Hypotheses Associations between maternal mental health and child behavior problems are well documented in the extant literature. Maternal distress also appears to be higher among Latina mothers of individuals with ID compared to NLW mothers of individuals with ID and Latina noncaregivers. However, little is known about the risk factors for elevated distress among Latina mothers of children with ID and the relation to child characteristics (e.g., internalizing and externalizing problems) and cultural factors. The present study addresses these gaps by (1) assessing whether child behavior problems predict maternal distress and/or mediate the association between Latina ethnicity and elevated maternal distress and (2) examining potential moderators of the association between maternal mental health and child behavior problems, including socioeconomic, cultural, and child-related factors. We hypothesized that Latina mothers of children with ID would report greater distress (global distress, depressive symptoms, and somatElevated Distress in Latina Caregivers


ic symptoms) than NLW mothers of children with ID and NLW and Latina comparison mothers. Among mothers of children with ID, we expected that Latina mothers’ distress would be heightened in the presence of elevated child behavior problems. This association was expected to be moderated by familistic values and language acculturation. Here, we expected that mothers’ familistic values would increase the salience of their children’s maladaptive symptoms and, therefore, the strength of the association between child behavior problems and maternal mental health would be stronger in the presence of high familism. With regard to language acculturation, we expected that associations between child behavior problems and maternal distress would be stronger among mothers with lower levels of English language acculturation. The question of whether or not child behavior problems mediate the association between ethnicity and maternal distress was considered exploratory; therefore, no a priori hypotheses were offered.

Method Participants Families (N 5 200) were recruited into a communitywide study focused primarily on siblings of children with ID (Kao et al., 2011; Lobato et al., 2011; Long et al., 2013). This is the first publication from this study that focuses on maternal mental health. Recruitment was based on ethnicity and disability status such that half of the sample consisted of families of a child with an ID (n 5 50 Latino, n 5 50 NLW) and the other half were matched comparisons (n 5 50 Latino, n 5 50 NLW). For this study, ‘‘Latino’’ was defined as one or both parents self-identifying as first or second generation Latino. All NLW families self-identified as ‘‘Caucasian’’ using ethnic origin categories from the National Latino and Asian American Study and the U.S. Census (Alegria et al., 2004). The inclusion criteria for all families included the following: (1) a child age 3 to 18 years old (the index child) and (2) at least one unaffected child age 8 to 15 years old (referred to as the sibling). In the families of children with ID, the index child had an ID diagnosis made at least 6 months prior to the family’s participation in the study; the diagnosis was confirmed by research staff. Families of children with ID were excluded if the target sibling had an ID diagnosis or serious medical K. A. Long et al.

EAAIDD DOI: 10.1352/1944-7558-120.2.145

illness; comparison families were excluded if any child had an ID diagnosis or serious medical illness. One parent (96% biological mothers) and one sibling from each family participated in the study. This yielded a final sample of 192 families in which the mother was the parent participant (n 5 97 Latino, n 5 95 NLW). Due to the nature of the research questions, the analyses in the present article focused on the subset of mothers who had a child with ID (n 5 48 Latino and n 5 50 NLW mothers of children with ID). Descriptive comparisons with non-ID families are included as preliminary results in order to contextualize primary findings. ID and comparison families were recruited over 2.5 years via hospital-based general and specialty pediatric programs, community agencies, pediatricians’ offices, public and private schools, and word of mouth. Medical practices and community organizations in southeastern New England were identified, and recruitment procedures were implemented in all practices and organizations that agreed to participate. All recruitment materials had both English and Spanish versions. We attempted to match comparison families to ID families based on gender of the sibling and index child, the sibling’s birth order relative to the index child, the sibling’s age, and the family’s socioeconomic status. Due to the multiple inclusion criteria, 57% of families who were screened were eligible for the study; 87% of eligible families enrolled (see Kao et al., 2011; Lobato et al., 2011, for additional details). There were no significant differences in enrollment rates among the four groups. With parental consent, research staff obtained educational or medical records documenting the index child’s ID diagnosis and most recent developmental assessment results. The median length of time between diagnosis and study enrollment was 6.5 years. All children with ID had significant cognitive impairment (48% mild, 30% moderate, 15% severe, and 7% profound levels). Research staff administered the VinelandII Adaptive Behavior Scales (VABS-II) Daily Living Skills: Personal Subdomain (Sparrow, Cicchetti, & Balla, 2005) with parents to further confirm ID diagnoses and determine the child’s level of adaptive and behavioral functioning; scores ranged from 1 to 11 (M 5 6.28, SD 5 2.69). Some (but not all) children with ID had additional diagnoses, as follows: chromosome disorders such as Down syndrome (Latino ID 5 149

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30%, NLW ID 5 50%), autism spectrum disorders (Latino ID 5 16%, NLW ID 5 24%), neuromuscular disorders such as cerebral palsy (Latino ID 5 8%, NLW ID 5 2%), or neurological disorders such as seizure disorder (NLW ID 5 8%). Additional demographic characteristics of the four groups are presented in Table 1.

Measures Demographics. Parents provided information about the gender and date of birth for all household members. They also reported the family size; the parents’/primary caregivers’ education level, occupation, marital status, place of birth, and ethnicity; total family income; and their perceptions of income (i.e., doing better/ worse financially than other families). A measure of per capita income was calculated by dividing parent-reported total household income by the number of people living in the home. Child factors. Parents completed the Vineland Adaptive Behavior Scales, 2nd edition (VABS-2; de Bildt, Kraijer, Sytema, & Minderaa,

2005; Sparrow et al., 2005). Adaptive functioning and maladaptive behavior in the child with ID was measured with the Daily Living Skills (Personal Subdomain only) and Maladaptive Behavior Index, respectively. This is a well-validated measure that has published both English and Spanish versions. Better functioning is indicated by higher scores on Daily Living Skills and by lower scores on the Maladaptive Behavior Index. As reported in the VABS-2 manual, the following cutoff scores were used to indicate clinical levels of concern on the Maladaptive Behavior Index: normal range (vscore 1-17), elevated (v-score 18-20), and clinical range (v-score 21-24). Maladaptive behavior was assessed using the internalizing (e.g., dependence on or avoidance of others, eating or sleeping difficulties, sad or anxious mood, avoidant of school or social situations), externalizing (e.g., impulsiveness, aggressiveness, stubbornness), and index scores. In the current sample, Cronbach’s alpha was 0.80 for internalizing (Latina mothers: alpha 5 0.81;

Table 1 Demographic Characteristics Intellectual Disability Latina (n 5 48) Child Age (Years) Child Gender (Female) Parent Age (Years)*** Number of Kids in Home** Mother Employed (Full or part time) Mother Years of School*** Primary Language (Spanish) Immigration (Foreign-Born) Country of Origin

Per Capita Income ($)*** Family Structure (Twoparent)***

8.25 (3.59) 14 (29%) 36.58 (5.61) 3.2 23 (48%)

No Intellectual Disability

NonLatina (n 5 50)

Latina (n 5 49)

9.20 (4.35) 13 (26%) 42.02 (5.18) 2.7 34 (68%)

11.69 (4.22) 15.30 (1.50) 35 (73%) n/a 42 (88%) n/a n/a Dominican Republic (44%) Guatemala (19%) Puerto Rico (19%) Colombia (4%) Mexico (4%) Other (10%) $6,252 (4,544) $15,706 (6,071) 31 (65%) 49 (98%)

NonLatina (n 5 45)

9.94 (4.55) 15 (31%) 38.68 (6.00) 2.7 32 (65%)

8.88 (4.17) 14 (31%) 39.78 (6.52) 2.5 30 (67%)

13.12 (3.24) 42 (86%) 47 (96%) Dominican Republic (51%) Colombia (18%) Guatemala (10%) Puerto Rico (10%) El Salvador (8%) Other (3%) $8,305 (4,751) 36 (74%)

14.42 (1.91) n/a n/a n/a

$10,828 (5,948) 24 (53%)

**p , .01. ***p , .001.

150

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NLW mothers: alpha 5 0.75), 0.85 for externalizing (Latina mothers: alpha 5 0.88; NLW mothers: alpha 5 0.79), and 0.89 for the maladaptive behavior index score (Latina mothers: alpha 5 0.92; NLW mothers: alpha 5 0.83). For the Personal Subdomain scale, published internal consistency split-half reliability coefficients range from .66 to .83 across children ages 3–18. To assess inter-rater reliability, a subset of 23 audiotaped interviews (11 Latino, 12 NLW) was randomly selected for review by the bilingual principal investigator (D. L.), who independently scored the Personal Subdomain items. Intraclass correlation coefficients were 0.99 for both Spanish and English interviews. Maternal distress. Mothers’ psychological symptoms were assessed with the Brief Symptom Inventory (BSI; Derogatis, 1993), a self-report measure of psychological symptoms. Symptoms are rated on a 5-point scale of distress. Based on previous findings regarding mothers of children with ID and the tendency for Latinos to express emotions somatically (Lewis-Fernandez, Das, Alfonso, Weissman, & Olfson, 2005), the global severity index (GSI), somatic symptoms, and depressive symptoms scales were used in the present study. The BSI has demonstrated reliability and validity, and it is published in English and Spanish (Acosta, Nguyen, & Yamamoto, 1994). The test-retest reliability coefficient for the GSI was 0.90 as reported by Derogatis (1993). In the current sample, Cronbach’s alpha was 0.96 for the GSI (Latina mothers: alpha 5 0.96; NLW mothers: alpha 5 0.95), 0.87 for depression symptoms (Latina mothers: alpha 5 0.85; NLW mothers: alpha 5 0.90), and 0.81 for somatic symptoms (Latina mothers: alpha 5 0.78; NLW mothers: alpha 5 0.83). A T-score of 63 on the GSI scale was used to indicate clinically significant symptomatology. Cultural factors. Parents completed the Spanish or English version of The Familism Scale, a 14-item measure of familistic cultural values and attitudes (Sabogal et al., 1987). Items assess obligation (e.g., ‘‘Aging parents should live with their relative’’), support (e.g., ‘‘One can count on help from his/her relatives to solve most problems’’), and families as referents (e.g., ‘‘One should be embarrassed about the bad things done by his/her brothers or sisters’’). Higher scores reflect greater familism. The Total Familism score was used in current analyses. Validity has been demonstrated with Mexican, Central American, K. A. Long et al.

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Cuban, and Puerto Rican families (Sabogal et al., 1987). Reliability was acceptable for the present sample of Latino (alpha 5 0.81) and NLW (alpha 5 0.69) families. Given findings that the strongest indicator of acculturation is language preference (Escobar & Vega, 2000), we measured language use as a parsimonious proxy for acculturation. Mothers completed the language factor of the Short Acculturation Scale (Marıń, Sabogal, Marıń, Otero-Sabogal, & Perez-Stable, 1987). Parents responded to questions regarding language usage on a 5-point Likert scale ranging from 1 (reflecting only Spanish usage) to 5 (reflecting only English usage). Higher scores reflect higher levels of acculturation. This measure was completed by the Latina subsample, in whom the alpha coefficient for the 5-item language factor was 0.92.

Procedure Families provided consent and assent prior to completion of research tasks and chose whether data collection would occur at the family’s home (74%), the research office (24%), or another location (2%). Questionnaires were read aloud to all participants. The majority of Latina parents were interviewed in Spanish (72% of the ID subgroup, 84% of the comparisons). All NLW families were interviewed in English. The interview-based method of data collection ensured that we had complete data for each participating family regardless of their literacy level. Families were compensated for participation. All procedures were approved by the Institutional Review Board at Rhode Island Hospital.

Data Analysis The purpose of enrolling matched comparison groups was to determine if the findings are unique to Latino families or to families of children with ID, or if findings reflect a phenomenon that is more broadly applicable across child development. Preliminary analyses compared the four groups on demographic, cultural, and maternal distress variables. The subsequent primary analyses focused on the subsample of Latina and NLW mothers of children with ID. Preliminary analyses employed chi square or one-way ANOVA to compare Latino and NLW index and comparison families on demographic variables (child with ID and sibling age, gender, and birth order; maternal age, education, and 151


employment status; family per capita and perceived income; number of children and adults in the home; and marital status), cultural variables (language acculturation, familism), and maternal distress. Demographic variables found to be significantly different among the four groups were entered as covariates in subsequent analyses. Associations between maternal distress and IDrelated factors (child adaptive functioning and maladaptive behavior) were assessed using Pearson correlations. The first research question was assessed using multiple regression in order to evaluate associations among demographic variables, child maladaptive behavior, and maternal distress among families of children with ID. Ethnicity was entered into the first step, demographic variables (one- vs. two-parent households, parent age, number of children in the home, and per capita income) were entered into the second step, and child maladaptive behavior was entered into the third step of separate regressions predicting maternal global distress and depressive and somatic symptoms. These regressions were repeated using the child internalizing and externalizing maladaptive behavior scores in place of the index maladaptive behavior score in step 3. Next, mediation analyses were conducted to assess whether child maladaptive behavior mediates the relationship between ethnicity and maternal distress in families of children with ID. This involved testing (1) the total effect (path c) of the independent variable (ethnicity) on the dependent variable (maternal distress), which includes both the direct and indirect effects; (2) the direct effect (path c’ ) of the independent variable (ethnicity) on the dependent variable (maternal distress); and (3) the indirect effect (path

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a 3 b) of the independent variable (ethnicity) on the dependent variable (maternal distress) via the proposed mediator (child maladaptive behavior). Path a is the effect of the independent variable (ethnicity) on the mediator (child maladaptive behavior), while path b is the effect of the mediator (child maladaptive behavior) on the dependent variable (maternal distress), after partialling out the effect of the independent variable (ethnicity). See Figure 1 for a graphical representation of the mediation model. According to the recommendations by Preacher and Hayes (2008), we used a bootstrapping sampling procedure to assess indirect effects. Bootstrapping is a nonparametric resampling procedure in which a large number of samples (1,000 in the current study) are drawn with replacement from the full dataset. Using these resamples, approximations of the bias corrected point estimate and confidence intervals were calculated for the indirect effect. A point estimate for an indirect effect was considered significant if zero was not included in the 95% confidence interval. Finally, the nature of the association between child maladaptive behavior and maternal distress in Latina families was examined using moderation analyses. Based on the existing literature, the following variables were examined as possible moderators of this association: demographic (oneversus two-parent households, maternal education, and per capita income), ID-related (adaptive functioning: personal skills), and cultural (familism and language acculturation) factors. Maladaptive behavior and the possible moderator were entered into the first step, and the interaction between maladaptive behavior and the possible moderator was entered into the second

Figure 1. The current study tested whether child maladaptive behaviors mediate the association between Latina ethnicity and self-reported distress (global distress, somatic symptoms, and depressive symptoms) among mothers of children with intellectual disability (ID). 152



step of regression models predicting global maternal distress.

Results Preliminary Analyses Demographic variables. Demographic characteristics of Latina and NLW families with and without a child with ID were examined (Table 1). Chi square analyses revealed significant group differences in the distribution of oneversus twoparent households among the four groups, such that almost all NLW mothers had two-parent households. One-way ANOVAs revealed group differences in number of children in the home, parent years of school, parent age, and per capita income. Fisher’s least significant difference (LSD) post-hoc tests showed that Latino families of children with ID had significantly more children in the home, and Latina mothers of children with ID had fewer years of school than mothers in the other three groups. Latina mothers of children with ID were significantly younger and had significantly lower per capita income than NLW mothers of children with and without ID, and they were marginally younger and had marginally lower per capita income than Latina comparison mothers. The four groups did not differ on birth order, age, or gender of the index child or sibling. Despite differences in per capita income, groups did not differ according to perceived income (i.e., doing better/worse than other families) or on maternal employment status. Based on these preliminary findings, the following variables were entered as covariates into subsequent regression analyses: oneversus two-parent household, number of kids in the home, parent age, and per capita income. ID-related variables. Across the entire sample, child internalizing and externalizing scores were significantly correlated (r 5 .38). One-way ANOVAs revealed group differences across measures of child maladaptive behaviors (index: F[3,188] 5 28.68, p , .001; externalizing: F[3,188] 5 4.92, p 5 .003; internalizing: F[3,188] 5 27.39, p , .001). LSD post-hoc tests indicated that Latina children with ID had significantly higher index scores and internalizing symptoms compared to the other three groups; Latino children with ID had significantly more externalizing symptoms than Latino comparison children and marginally more externalizing sympK. A. Long et al.

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toms than NLW comparison children. Within the ID subgroup, Latina and NLW children with ID did not differ on adaptive functioning (Daily Living Skills: Personal Subdomain). Maternal distress. One-way ANOVAs revealed significant group differences in global distress (F[3,188] 5 3.30, p 5 .02), depressive symptoms (F[3,188] 5 4.92, p , .003), and somatic symptoms (F[3,188] 5 3.98, p 5 .009). LSD post-hoc tests showed that Latina mothers of children with ID reported significantly more depressive symptoms and somatic symptoms and marginally higher levels of global distress than NLW mothers of children with ID and both Latina and NLW mothers of matched comparison children (Figure 2). Cultural variables. Cultural variables were compared among Latina and NLW families with and without a child with ID. One-way ANOVAs revealed group differences in familism (F[3,188] 5 20.18, p , .001), and LSD post-hoc tests indicated that Latina mothers of children with ID reported significantly higher levels of familism compared to the other three groups. Given the absence of Spanish-speaking NLW mothers, language acculturation was compared only between the two groups of Latina mothers using independent samples t-tests. Latina mothers of children with ID had marginally higher levels of acculturation (i.e., spoke English more frequently) than Latina comparison mothers (t[95] 5 1.91, p 5 .06). Associations of child disability factors with maternal distress. In the ID subgroups, maladaptive behavior was associated with all three measures of maternal distress (GSI: r 5 .37, p , .001; depressive symptoms: r 5 .32, p , .01; somatic symptoms: r 5 .32, p , .01). Adaptive functioning (VABS Personal Subdomain) was not significantly associated with maternal distress.

Disability and Sociodemographic Predictors of Maternal Distress Multiple regression was used to assess the influence of demographic and ID-related variables on maternal distress among families of children with ID. Ethnicity was entered into the first step, other demographic variables were entered into the second step, and maladaptive behavior was entered into the third step of separate regressions predicting global distress and depressive and somatic symptoms among mothers of children with ID (see Table 2). These regressions were repeated using the child internalizing and externalizing maladaptive 153

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Figure 2. Latina mothers of children with intellectual disability (ID) report significantly higher levels of global distress, somatic symptoms, and depressive symptoms compared to all three other groups, as measured by T-scores on the Brief Symptom Inventory. NLW 5 NonLatino White. behavior scores in place of the index maladaptive behavior score in step 3. In the model predicting maternal global distress, there was an initial trend for Latina

ethnicity to predict maternal global distress. Ethnicity was no longer significant once other demographic factors were taken into account. In the final model, higher maternal global distress

Table 2 Multiple Regression Analyses Examining Demographic Factors and Maladaptive Behavior as Predictors of Distress Among Mothers of Children With ID Global Distress Beta .17

+

Step 2 Ethnicity # Kids in home Mother age One- vs. two-parent Per capita income

+

.26*

.00 .01 2.13 .18 2.05

Depressive Symptoms Beta .28**

.18 .01 .03 .00 2.13

.07* .10 .05 2.10 .19 2.06 .11**

.09** .13 2.02 .05 2.04 2.13 .28**

Adj R2 .07**

.02

.12** 2.06 2.03 2.10 .13 2.04 .35**

Adj R

2

.06*

.02

Step 3 Ethnicity # Kids in home Mother age One- vs. two-parent Per capita income Maladaptive behavior

Beta

.02+

Step 1 Ethnicity

Adj R

Somatic Symptoms 2

.06 .02 2.08 .15 2.06 .23*

p , .10. *p , .05. **p , .01.

154



was significantly associated with higher scores on the maladaptive behavior index, independently of demographic variables (Table 2). The same pattern of results was obtained when externalizing (b 50.18, p 5 .10) and internalizing (b 5 0.23, p 5 .05) were entered together in place of the index maladaptive behavior score. In the model predicting maternal somatic symptoms, Latina ethnicity initially predicted somatization among mothers of children with ID but was no longer significant once other demographic factors were taken into account. In the final model, maternal somatic symptoms were significantly associated with higher scores on the maladaptive behavior index, independently of demographic variables (Table 2). When child externalizing and internalizing scores were entered in place of the index maladaptive behavior score, neither one independently, significantly predicted somatic symptoms among mothers of children with ID (bs # .17, ps $ .16). In the model predicting maternal depressive symptoms, Latina ethnicity initially predicted depression among mothers of children with ID but was no longer significant once other demographic factors were taken into account. In the final model, maternal depression symptoms were significantly associated with higher scores on the maladaptive behavior index, independently of demographic variables (Table 2). When externalizing and internalizing scores were entered in place of the index maladaptive behavior score, neither one independently, significantly predicted depressive symptoms among mothers of children with ID (b # .17, ps $ .15).

Child Behavior Problems as a Mediator of the Association Between Ethnicity and Maternal Distress Due to the high correlation between the ID (ethnicity) and the demographic covariates (i.e., per capita income, parent age, single parent status, and number of children in the home), the mediation analyses were carried out without covariates. Mediation results are presented in Table 3. Latina ethnicity significantly predicted child maladaptive behavior (the a path), and maladaptive behavior significantly predicted all three measures of maternal distress (the b path for maternal global distress, somatic symptoms, and depressive symptoms). For all three measures of maternal distress, the indirect effect of ethnicity K. A. Long et al.

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on maternal distress (a 3 b path) did not include zero in the confidence interval (global distress: CI 5 0.72–4.90; somatic symptoms: CI 5 0.35–4.40; depressive symptoms: CI 5 0.36–3.75); this implies that maladaptive behavior mediates the association between Latina ethnicity and increased maternal distress among mothers of children with ID.

Moderators of the Association Between Child Maladaptive Behavior and Latina Maternal Distress The final set of analyses further examined the association between child maladaptive behavior and maternal global distress. Given demographic differences between Latina and NLW mothers of children with ID, we conducted these analyses only with the Latina ID subsample. The following variables were examined as possible moderators of this association: sociodemographic (oneversus two-parent households, maternal education, per capita income), child ID-related (adaptive functioning: personal skills), and cultural (familism and language acculturation) factors. Findings showed that the association between child maladaptive behavior index scores and maternal distress was stronger for single-parent Latino families (interaction term DR2 5 .12, p 5 .01), those that reported higher levels of familism (interaction term DR2 5 .09, p 5 .03), and those who reported lower language acculturation (interaction term DR2 5 .10, p 5 .02; Figures 3 and 4). All other moderation analyses were nonsignificant. The same pattern of results was obtained when child internalizing scores were used in place of maladaptive behavior index scores as a focal predictor of maternal distress; findings were less consistent when child externalizing scores were used.

Discussion Preliminary analyses suggested that Latina mothers of children with ID report more distress than NLW mothers of children with ID and both Latina and NLW matched comparison mothers. When focusing just on the subsample of mothers of children with ID, ethnicity was no longer a significant predictor of maternal distress once other demographic variables (single parent household, per capita income, maternal age, and number of children in the household) were entered into the model. None of the individual 155

156

Mal Behavior Mal Behavior Mal Behavior

Ethnicity Ethnicity Ethnicity

Global Distress Somatic Symptoms Depressive Symptoms

Dependent Variable (DV)

Note. Mal Behavior 5 Maladaptative Behavior. *p , .05. +p , .10.

Mediator (M)

Independent Variable (IV)

Table 3 Results of Mediation Analysis

1.24* 1.24* 1.24*

Effect of IV on M (a path) 1.97* 1.48* 1.34*

Effect of M on DV (b path)

1.66 3.28 4.22*

Direct Effect (c9 path)

2.44* 1.83* 1.65*

Indirect Effect (a 3 b path)

Coefficients (Unstandardized)

4.10+ 5.11* 5.88*

Total Effect (c path)


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Figure 3. Among Latina mothers of children with intellectual disability (ID), the association between child maladaptive behavior and maternal distress is stronger in families that report higher familism. This association is significant at medium (p5.007) and high (p5.003) but not low levels of familism.

Figure 4. Among Latina mothers of children with intellectual disability (ID), the association between child maladaptive behavior and maternal distress is stronger in families that report lower levels of language acculturation. This association is significant at medium (p5.002) and low (p5.002) but not high levels of language acculturation. K. A. Long et al.

157


demographic predictors were significant predictors of maternal distress when they were all entered together, which suggests substantial overlap among these demographic variables. Thus, the current findings suggest that the constellation of demographic risk factors, versus Latina ethnicity per se, contributes to increased distress in Latina mothers of children with ID. The current findings suggest that child maladaptive behavior mediates the association between Latina ethnicity and maternal distress (global distress, somatic symptoms, and depressive symptoms) among mothers of children with ID. The current analyses also identified several risk factors for elevated distress among Latina mothers of children with ID. Specifically, the association between maternal distress and child behavior problems among Latina mothers of children with ID was stronger for single-parent households and for mothers who reported more familistic values and lower acculturation (i.e., less English usage). Child adaptive functioning did not moderate associations between child and maternal functioning. Associations between child behavior problems and maternal distress have been demonstrated previously (Baker et al., 2003; Baker et al., 2005; Blacher & McIntyre, 2006; Gray et al., 2011; Hassall et al., 2005; Hauser-Cram et al., 2001; Herring et al., 2006; McConkey et al., 2008; Most et al., 2006; Neece & Baker, 2008). The current work builds on this previous research by contextualizing maternal distress in relation to a comparison group of Latino and NLW mothers of children without ID and by investigating effects of both child internalizing (e.g., sad/anxious mood, social isolation) and externalizing (e.g., impulsiveness, aggressiveness) behavior problems on maternal distress. This contrasts most previous research that employed composite scores of child maladaptive behavior (e.g., Hauser-Cram et al., 2001; Herring et al., 2006; McConkey et al., 2008; Most et al., 2006). Current findings are consistent with previous work in families of children with ID that documented cross-sectional effects of internalizing and externalizing symptoms on maternal mental health (Gray et al., 2011; Hastings et al., 2006). In addition, current findings that child adaptive functioning (personal skills) are not significantly associated with maternal mental health suggest that mothers more easily accept their child’s caretaking needs than challenging 158

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behaviors. Rather, challenging behaviors may serve as a risk factor for maternal distress in the context of childhood ID. Mechanisms underlying the links between maternal distress and child behavior problems were not assessed in the present research. It is possible that this pattern reflects the social/emotional caretaking context or genetic similarity between mother and child. Common genetic underpinnings may account for elevations in both maternal and child distress. Due to the enrollment of Latina and NLW comparison mothers, we were able to put the current sample and findings into context. Both internalizing and externalizing problems were highest in the Latino ID subgroup. This is consistent with previous research documenting significantly more maladaptive behaviors in Puerto Rican than NLW adults with ID (Maganã, Seltzer, & Krauss, 2002). This has not been examined previously in child/adolescent samples with ID diagnoses. However, previous work with children and young adults with autism spectrum disorders has reported no differences in maladaptive behavior between Latino and NLW subgroups (Maganã & Smith, 2006) or lower levels of maladaptive behavior among the Latino children with autism spectrum disorders (Maganã, Lopez, Aguinaga, & Morton, 2013). Thus, it is possible that the severity of child behavior problems in Latino children may vary by specific diagnosis, but this requires further investigation. The present study did not assess reasons underlying elevated maladaptive behaviors in the current sample of Latino children with ID. This finding may be related to the service delivery system (e.g., fewer services, difficulty communicating with the healthcare system due to limited English proficiency, less knowledge of available services, or perceptions that existing services are unnecessary or irrelevant for their family’s needs), the childrearing context (e.g., different responses to the child’s challenging behaviors), or perceptions of the child’s behavior (e.g., tendency to report more problems on standardized measures). Similarly, it is possible that Latino children with ID who have more behavior problems are receiving more therapeutic services and, therefore, are more likely to be recruited into research studies. Findings related to higher levels of problematic behaviors should be confirmed with future research using multiple informants and/or observational methods. Elevated Distress in Latina Caregivers


The current study replicated findings that Latina mothers of children with ID report more distress than NLW mothers of children with ID and Latina mothers of typically developing children (Blacher, Lopez, Shapiro, & Fusco, 1997; Blacher & McIntyre, 2006). It extends previous research by highlighting the other demographic and child-related factors that may contribute to the elevated distress reported by Latina mothers of children with ID. Regardless of the mechanisms underlying Latina mothers’ distress, elevated distress among Latina mothers of children with ID is important for two key reasons. First, elevated distress and physical health problems suggest that these mothers are a highrisk group worthy of clinical attention themselves. Second, the extant literature has documented the importance of maternal mental health for their children’s psychosocial outcomes (Green & Baker, 2011; Neece & Baker, 2008). It is important to note that the effect of ethnicity on maternal distress was no longer significant once other demographic variables were entered into the model. Although each factor (single parent household, per capita income, maternal age, and number of children in the home) was associated with maternal distress in bivariate analyses, none retained its significance once all of these demographic factors were considered together. This is consistent with high levels of overlap among these variables; in other words, the addition of other demographic variables did not increase the amount of variance in maternal distress explained above and beyond that of ethnicity alone. One particularly interesting aspect of these findings is that per capita income did not have a significant, independent effect on maternal distress once other variables were taken into account. This contrasts previous work with NLW mothers that showed higher SES to be protective against maternal psychopathology and distress (Emerson et al., 2010; Khamis, 2007). However, the current results are consistent with previous findings that SES is not protective for Latina mothers’ perceptions of family quality of life (Cohen et al., 2014). This lends further support to the idea that the protective role of higher SES may differ according to ethnicity and should be further examined in future work. The question of whether or not SES is important for maternal and/or family functioning may be particularly relevant for families of children with ID in light of previous findings K. A. Long et al.

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that these families report significantly lower income and higher dependence on means-tested income support (e.g., social security) than families who are not supporting a child with ID (Emerson, 2003; Fujiura, 1998; Fujiura & Yamaki, 1997). Poorer financial status might be one additional stressor for these families. Further, income is not equal across racial/ethnic groups. Income is significantly lower for Black and Latino families with ID compared to their NLW counterparts (Fujiura, 1998). Thus, Latina mothers of children with ID have fewer economic resources, but this does not account for elevated distress reported by these mothers. The current research also examined moderators of the association between child maladaptive behaviors and maternal distress among Latina mothers of children with ID. Findings indicated that this association was stronger for Latina mothers who resided in single parent households, reported more familistic values, and had lower levels of English language acculturation. With regard to single parent status, it is likely that the task of managing challenging behaviors in the child with ID is taxing and enduring, and single mothers may perceive limited support in dealing with these child-related stressors on a daily basis. This may contribute to higher levels of perceived stress and distress, though the mechanisms underlying this finding were not evaluated in the current study. Familistic cultural values are likely to influence how Latina mothers conceptualize their maternal role. When mothers’ identities are closely aligned with caretaking, they may internalize their child’s behavior problems and interpret them as a reflection of their own parenting shortcomings, which in turn may influence mothers’ self-concept and mood. Maternal attributions have been shown to be important among Latina mothers of children with ID; Latina mothers who believe that the child is not responsible for his or her behavior problems are less likely to respond aggressively toward the child (Chavira, Lopez, Blacher, & Shapiro 2000). Familism also may influence families’ decisions to provide more care within the family versus utilizing community services. This may contribute to Latina mothers’ perception that their caretaking role for the child with ID is enduring. Overall, the role of maternal attributions and decision making about their child’s behavior problems should be examined further. 159


From a clinical perspective, attribution-based explanations of maternal distress are consistent with the goals of cognitive restructuring interventions. Conceptualizations of motherhood may be revised to incorporate aspects of the child’s disability (i.e., behavior problems), and mothers may be encouraged to develop more realistic expectations about their child’s behavior and their role in managing the child’s multiple developmental and behavioral needs. Mothers also may be encouraged to increase the degree to which they identify with additional roles (e.g., spouse, employee, community member) in addition to that of caretaker. Mothers may benefit from supportive, group-based interventions with other Latina mothers of children with similar clinical presentations for support in handling their reactions to having temperamentally difficult children. Finally, problem-solving skills may help mothers handle objective stressors associated with raising a child with ID in the presence of other challenges, such as single parenthood, low income, and multiple other children in the home. Associations between child behavior problems and maternal distress are stronger among Latina mothers with lower levels of English usage. Given findings that language preference is the strongest indicator of acculturation (Escobar & Vega, 2000), the present study administered the language subscale of the acculturation measure. Thus, it is unclear whether findings reflect acculturation, broadly defined, or the narrower index of language preference. Less acculturated Latina mothers speak primarily or solely Spanish, which may limit opportunities for formal support services and lead to perceptions that she is left alone to handle the child’s behavioral difficulties. Indeed, limited English proficiency is associated with higher expressed needs for family, social, and community support among Latino families of children with developmental disabilities, and lack of Spanish materials and Spanish-speaking personnel contribute to parents’ dissatisfaction with service providers (Bailey et al., 1999). It is important to note that positive and negative parent/family impact appear to be independent of each other and can co-exist within the same families. Many parents cope well with ID-related stressors and acknowledge the positive aspects of parenting children with intellectual and behavioral difficulties (Blacher & McIntyre, 2006). The co-occurrence of positive and negative impact underscores the complexity of Latina 160

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caregivers’ adjustment to having a child with ID and highlights the need for future research to disentangle these findings, identify culturally pertinent risk and protective factors, and inform future, family-focused interventions. Findings related to Latino samples may not be comparable across all nationalities. The present study enrolled a sample comprised primarily of mothers from Central America and the Caribbean islands (e.g., Puerto Rico and the Dominican Republic). Although the scope of the current study is insufficient to examine Latina mothers’ distress according to country of origin, previous work has found higher rates of depression in the general population of Latino Americans from Puerto Rican (6.9%) versus Cuban (2.5%) or Mexican descent (2.8%; Oquendo et al., 2001). Thus, Puerto Rican mothers residing in the United States may have even higher risk for ongoing distress or development of depression in the face of their child’s ID. Overall, the current findings extend previous research examining maternal psychosocial functioning in the context of a child’s ID by considering (1) the mediating role of child behavioral problems and (2) cultural moderators of the well-established associations between child behavior problems and maternal distress. Although findings are limited by some methodological factors (e.g., cross-sectional design and potential respondent bias arising from the fact that mothers reported on both their own mental health and the child’s behavior), the current findings underscore the importance of considering sociocultural and demographic variables when examining families’ responses to childhood ID. Future work should further assess mechanisms underlying increased behavioral problems and maternal distress among Latino families of children with ID and should continue to examine the interplay among cultural, socioeconomic, familial, and disability-related factors.

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K. A. Long et al.

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Yildirim, S. H. & Basbakkal, Z. (2010). Depression among mothers of children and adults with an intellectual disability in Turkey. International Journal of Nursing Practice, 16(3), 248– 253. http://dx.doi.org/10.1111/j.1440-172X. 2010.01837.x Received 10/28/2013, accepted 7/12/2014. This work was supported by grant number 1R01HD050557 awarded by the National Institute of Child Health and Human Development to Debra Lobato, PhD (principal investigator). Authors: Kristin A. Long, Bradley Hasbro Children’s Research Center and the Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University; Barbara Kao, Department of Pediatrics of Rhode Island Hospital, Alpert Medical School of Brown University; Wendy Plante, Ronald Seifer, and Debra Lobato, Bradley Hasbro Children’s Research Center and the Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University. Correspondence concerning this article should be addressed to Kristin A. Long, Department of Psychological and Brain Sciences, Boston University, 648 Beacon Street, Room 510, Boston, MA 02215, USA (e-mail: [email protected]).

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