Copyright 1991 by The Cerontological Society of America The Cerontologist Vol.31, No. 6, 770-777
Family conflict is an overlooked yet potentially critical component of the caregiving experience. In a study of 100 adult child caregivers, 40% were experiencing relatively serious conflict with another family member, usually a sibling. Most conflict arose because the relative failed to provide sufficient help. Path analysis revealed that caregivers experiencing family conflict had significantly higher perceived burden and poorer mental health than did caregivers without conflict, even when quality of the caregiver's relationship with the parent, extent of caregiver tasks, income, gender, and age were taken into account. Key Words: Burden, Family relationships, Informal care
Impact of Family Conflict on Adult Child Caregivers1
outcome variables. Barusch and Spaid (1989) reported a positive association between "adverse social contacts" (negative aspects of emotional support) and perceived burden for spouse caregivers, but their results were not significant. Brody and colleagues (1989) examined intersibling hassles using a one-item measure and reported that such hassles were positively related to caregiver perceived burden and negatively related to relationship quality with the parent. On a four-point scale of such hassles (none/a little/fair amount/a great deal), the mean score was only slightly above "a little." All of the previous studies involved adult child caregivers. Analyzing burden scores from a mixed group of spouse and adult child caregivers, Keane-Hagerty and Farran (1990) reported that 42% of them said they felt at least some resentment toward other family members who were not helping. In a study of adult spouse caregivers, Pagel, Erdly, and Becker (1987) demonstrated that degree of upset with others in the social support network was correlated with caregiver depression, while positive aspects of support were not. While not presenting the data, one study of caregiving coping strategies stated that caregivers engaging in escape-avoidance coping reported more conflict in their personal relationships than did those using other coping strategies (Stephens et al., 1988). Using the Moos Family Environment Scale to cluster families with a chronically ill spouse, Stuifbergen (1990) reported that those families she characterized as involving "structured conflict" perceived a greater impact of illness than did those characterized as "cohesive." Pearlin and his colleagues consider family conflict to be a secondary stressor, which means it arises as a result of the primary demands of caregiving (Pearlin et al., 1990). Based upon their conceptualization of conflict, they developed three scales that tap the caregiver's assessment of the overall amount of dis-
Conflict between and within groups has been recognized in sociology as an important aspect of social relationships for some time (Collins, 1975; Coser, 1956; Cerhardt, 1989). Social psychology (particularly in exchange theory) explicitly recognizes that social relationships involve costs as well as rewards (Homans, 1974; Emerson, 1976; Nye, 1973). Close relationships are theorized as involving more conflict than peripheral relationships because of a greater convergence of interests, some of which are likely to be incompatible (Scanzoni, 1979). Interpersonal conflict is thus not uncommon in psychotherapy, where its management is seen as an integral part of human development (Heitler, 1990). In social support research as well, negative aspects of interacting with others have been shown to predict well-being more strongly than positive aspects (Rook, 1984). While recognized by the social sciences and in psychotherapy, conflict has played a minor role in research on family caregiving. Five studies have discussed it in general terms, saying that family conflict is a relatively frequent occurrence in caregiving (Abel, 1989; Archbold, 1980; Frankfather, Smith, & Caro, 1981; Hausman, 1979; Smith, Smith, & Toseland, 1991). Several others have made rough attempts at quantifying the amount of family conflict being experienced by caregivers or the amount of impact it has. Using a broad definition of conflict, Rabins, Mace, and Lucas (1982) found that 56% of the caregivers they studied were experiencing conflict, but they did not look at its associations with any ^ n earlier version of this work was presented at the 1990 Annual Meeting of the Cerontological Society of America in Boston. The research for this paper was funded by a Veterans Administration Health Services Research and Development Training Fellowship for Mr. Strawbridge as part of his doctoral dissertation. 2 Research scientist, Human Population Laboratory, 2151 Berkeley Way, Annex 2, Berkeley, CA 94704. Assistant professor, Department of Physiological Nursing, School of Nursing, University of California, San Francisco, CA.
770
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Manitoba on September 6, 2015
William J. Strawbridge, PhD, MPH,2 and Margaret I. Wallhagen, PhD, RN3
Relationship quality with parent
Caregiver tasks
Caregiver mental health
Figure 1. Model showing proposed paths for variables involved with family conflict. Direct relationships and hypothesized causal order are indicated by arrows between variables. Indirect relationships (such as between caregiver income and mental health) are hypothesized where a third variable (such as caregiver tasks) intervenes.
Vol. 31, No. 6,1991
Sample One hundred adult child caregivers caring for frail parents or in-laws were recruited from eight organizational sites in northwestern Washington and the San Francisco Bay area. These sites included adult day health centers, home health agencies, and information and referral agencies. Eligibility criteria included providing at least 4 hours of care a week to a parent or parent-in-law who was at least 55 years old and not institutionalized. Site staff identified potential subjects and sent them a letter describing the study as one examining the benefits and problems of providing care in a home setting. Those interested were asked to return a card and were then contacted and screened for eligibility. Of those returning cards, 83% were determined to be eligible and 95% of them were interviewed. Interviews were conducted in subjects' homes or places of employment and took about an hour. Table 1 indicates that the caregivers averaged 50 years of age, with relatively high education (78% had at least some college) and income (70% earned $24,000 or more). They were predominantly white (88%), female (83%), employed (69%), and married (67%). Most (81%) had living children. These caregivers had been providing care for an average of 5.2 years and averaged 22 hours of care per week. Seventy-three percent considered themselves to be the primary caregiver for their parent or in-law, with most of the rest feeling that they shared caregiving equally with someone else, usually a sibling. Seventy-one percent of the care receivers were mothers of the caregivers, 18% were fathers, and 11% were mothers-in-law or fathers-in-law. Mean age of the care receivers was 80. Fifty-six percent of them lived with their caregivers; 29% lived alone, 7% lived with their spouses, and 8% lived in other arrangements (such as home-sharing). The most frequently reported major health problem was dementia (41%), Table 1. Characteristics of 100 Adult Child Caregivers in Study of Family Conflict
Caregiver perceived burden
Caregiver gender
Caregiver income
Methods
771
Characteristic
Value
Female White Married Employed Age (mean) Have living children Primary caregiver Share home with care receiver
83% 88% 67% 69% 50.5 years 81% 73% 56%
Education High school grad or less Some college College grad or more
22% 43% 35%
Annual income Less than $15,000 $15,000-$24,000 $24,000-$48,000 Over $48,000
11% 19% 42% 28%
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Manitoba on September 6, 2015
agreement present in dealing with relatives. The amount of disagreement found in their study of both child and spouse caregivers was rather modest, but Pearlin and colleagues argue that the impact of family conflict can be great because caregivers have such a strong stake in their family relationships. The aims of our study were to quantify the extent of family conflict among adult child caregivers and to analyze its relative impacts on caregiver perceived burden and mental heath compared with other variables such as the caregiver's relationship with the parent, caregiver tasks, caregiver income, and selected demographic variables. The model proposed for our path analysis viewed family conflict as influenced by the caregiver's gender, age, and relationship with the parent. Family conflict was viewed as directly impacting the two main caregiving dependent variables of perceived burden and mental health. The placement of these variables is consistent with the theoretical framework of Pearlin et al. in which family conflict is viewed as a secondary stressor that is influenced by the caregiver's characteristics and the caregiving history, which includes the relationship between the caregiver and the care receiver (1990). Relationship quality with the parent as a variable preceding caregiving factors is also supported by Archbold and colleagues (1990). The variable of caregiver tasks is viewed as paralleling the relationships between family conflict and the two dependent variables. Caregiver age, gender, and income were hypothesized to have only indirect relationships with the two dependent variables, either through family conflict for age and gender or through caregiver tasks for income. Because of prior research findings, relationship quality with the parent was hypothesized to have both direct relationships with the two dependent variables and indirect relationships through family conflict (Strawbridge, 1991). This proposed model is depicted in Figure 1.
followed by stroke (14%), general frailty (11%), cardiovascular disease (10%), arthritis (6%), mental illness (5%), cancer (4%), and other (9%). As is typical of the samples utilized in most caregiving studies, our subjects were relatively welleducated and predominantly from middle and upper socioeconomic groups. Generalizations to the total caregiving population of the United States should be made with caution. Measures
Caregiver Perceived Burden. — The caregiver perceived burden scale was designed to measure the extent to which caregivers viewed the changes in their lives that had occurred because of caregiving as problems or concerns. Consisting of 22 items, the scale included activity changes (such as no longer having enough time for oneself), emotional factors (such as "I now worry about him/her all the time"), and physical changes ("I now feel tired all the time"). Scale items were adapted from Moss et al. (1987), Poulshock and Deimling (1984), and Wallhagen (1988). To measure the subjective component of perceived burden, caregivers were asked to rate on a five-point scale how much of a problem or concern 772
Caregiver Mental Health. — Mental health was measured with Veit and Ware's Mental Health Inventory (1983). Containing 38 items, the MHI has been used to predict the use of outpatient mental health services (Wells, Manning, & Benjamin, 1986) and general health services (Manning, Newhouse, & Ware, 1982), and to compare the well-being of six different types of chronically ill persons (Cassileth et al., 1984). More recently the MHI was used in a study of coping styles of women with rheumatoid arthritis (Manne & Zautra, 1989). The reliabilities reported for the scale in these studies range from .96 to .97 (Cronbach's alpha). In the current study, the standardized alpha coefficient was also .97. Each item on the scale asks subjects to indicate how much of the time during the past month they felt or behaved in a certain way. Scoring of the scale is done with a six-point response set, ranging from "always" to "never." Higher scores indicate better mental health. Caregiver Tasks. — Extent of caregiver tasks was measured with the Stetz Inventory, Part I (Stetz, 1986), as modified by Wallhagen (1988). This scale includes 15 specific questions about caregiving activities, such as "I help (care receiver) with eating his/ her food" and "I do shopping, appointments, or run errands for (care receiver)." Wallhagen's modifications involve combining several items to shorten the scale and changing the yes/no answers to a six-point frequency range (never, rarely, several times a month, every week, several times a week, and daily). The scale achieved a standardized alpha coefficient of .85. Higher scores indicate more extensive involvement with caregiving activities. Relationship Quality with the Parent. — Relationship quality with the parent was measured by adapting the scale developed by Walker and colleagues for use with caregiving daughters and their mothers so that it could be used on adult children and their parents of either gender (Walker & Thompson, 1983; Walker, Shin, & Bird, 1990). One question was added to the scale to assess similarity of values and four questions were added to specifically address past relationship quality. Sample questions include "We enjoy our relationship," "(care receiver) cares about the way I feel," and "(care receiver) has made some real sacrifices for me in the past." A four-point response set (strongly agree, moderately agree, moderately disagree, strongly disagree) was used. The revised scale has a total of 22 items and achieved a standardized alpha coefficient of .92. Higher scores indicate higher levels of relationship quality with the parent. Care Preferred for Self. — Caregivers were asked what caring for their parent or in-law had taught The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Manitoba on September 6, 2015
Family Conflict. — Family conflict was defined as a clash or strong feeling of resentment toward a relative about caregiving that was perceived as a problem by the caregiver. Resentment was thus included as an aspect of conflict if it was still actively felt, such as expressed dissatisfaction, or was still influencing the caregiver's actions, such as through attempts to renegotiate the situation (Scanzoni, 1979). A two-step process was used to differentiate those caregivers experiencing family conflict from those not experiencing it. The first step involved the Pagel, Erdly, and Becker (1987) social support scale. Based on Rook's (1984) analysis that negative aspects of relationships affect outcomes more than positive ones, this scale is designed to measure negative aspects of social support. All subjects were asked to name any unpaid person who was helping them care for their parent or in-law, anyone they felt should be helping but who was not, and anyone they talked with about caregiving problems or concerns. Caregivers were then asked how helpful and how upsetting each named person was across five dimensions of social relationships. These dimensions were help with caregiver tasks, providing information, sharing activities, providing emotional support, and closeness. A four-point response set was used (not/ slightly/somewhat/very helpful or upsetting). The second step asked a series of questions of those caregivers who indicated that a relative named on the scale was somewhat or very upsetting on any of the five dimensions. Information was collected on who the relative was, the nature of the problem, and what the caregiver had tried to do to resolve the situation. Those caregivers who did not dismiss the problem as a minor concern in this series of questions were scored as having conflict.
each item was for them. Categories used were "not a problem or concern," "sometimes," "usually," "often," and "always." This scale achieved a standardized alpha coefficient of .94. Higher scores indicate higher levels of perceived burden.
them about how they might want to be cared for if they were in a similar situation. Scoring was based upon whether they preferred some form of family care by relatives or an alternative, such as a retirement home or paid care at home. Caregiver Income. — Defined as family income over the past 12 months, caregiver income used the four categories indicated in Table 1 and was scored from low to high Analysis Chi square and t tests were used first to compare the differences between caregivers experiencing conflict and those not experiencing conflict on all of the major study variables. Two-tailed tests were used in conjunction with the t tests. Path analysis using forced entry multiple regression was then used to analyze possible causal paths and compare relative impacts of family conflict, caregiver tasks, relationship quality with the parent, income, caregiver age, and caregiver gender on the two major dependent variables of caregiver perceived burden and mental health. Findings Fifty-eight caregivers reported a family member as somewhat or very upsetting on the social support scale and were thus asked about possible family conflict. Eighteen subjects indicated that the problem was relatively minor, usually because the problem was being worked out (a relative had initially refused to help but was now doing more) or because they had learned how to handle the situation to their satisfaction (waiting for an emotionally sensitive relative to calm down). These 18 were classified, along with the 42 who had not named a relative as somewhat or very upsetting, as not experiencing family conflict. The remaining 40 caregivers who considered the problem with a relative to be more than minor were classified as experiencing family conflict. Thus 40% of the adult child caregivers in the study were experiencing family conflict of sufficient intensity to be considered a problem. The type of relative involved was clear: by far the most frequently named person was a sister (35%) or brother (30%), followed by a spouse (20%), child (5%), other parent (5%), or sibling-in-law (5%). Siblings or siblings-in-law thus constituted 70% of the relatives with whom the caregivers were experiencing conflict. One answer predominated when the cause of the conflict from the caregiver's perspective was analyzed: the relative would not provide sufficient help in caring for the care receiver (60%). The next most frequently mentioned problem was a relative criticizing what the caregiver was doing (12.5%), for instance, constantly calling with unwanted advice, being generally obnoxious, or accusing the caregiver of providing poor care. Relatives who insisted that the care receiver be institutionalized (10%) constituted the third most frequent conflict. Part of the difficulty for the caregiver in this last category was the implicaVol. 31, No. 6,1991
Bivariate Relationships with Family Conflict Table 2 summarizes differences on the major study variables between those experiencing conflict and those not experiencing conflict without regard to which is cause and which is effect. Those experiencing family conflict scored significantly higher on caregiver perceived burden and significantly lower on relationship quality with the parent and caregiver mental health than did those caregivers not experiencing such conflict. Those with conflict were also significantly less likely to prefer family care for themselves should they become frail or disabled. As one put it: "There is no way I want my children to go through what I've been through, just put me in a retirement home with a gate that shuts at night so I'll be safe." Significant differences also occurred for gender and age. Caregivers experiencing conflict were more 773
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tion that these relatives would not provide further help unless the caregiver complied. Three other types of conflict (relative is taking advantage of care receiver, relative thinks caregiver does too much, and relative doesn't visit care receiver) were each mentioned by two caregivers (5% for each type). Finally, one caregiver (2.5%) reported that her husband always got into arguments with his mother (the care receiver), forcing the caregiver to intercede between them. "Whenever she says yes, he says no," she said. Many of these reported conflicts and resentments were quite strong. Two cases resulted in legal action. One woman described her siblings-in-law as "vultures" for only being interested in her father-in-law's money and never helping; another said that her family "had never been farther apart," and a third remarked, "Don't ever try to care for a parent, because it can ruin your family relations." In 20% of the cases, the caregiver indicated that the offending relative had caused some problems in the past, so the current conflict was partly anticipated although obviously not accepted. But in 80% of the cases the conflict or resentment was recent. For example, one caregiver said that her sister had initially offered to care for her mother in exchange for being given the family house but had then tried to simply take the house and institutionalize the mother when she became frail. "I just do not understand my sister anymore," the caregiver said. "We used to be so close and now we don't speak to each other. It greatly upsets me." This type of recent conflict reflects the idea of Pagel, Erdly, and Becker that social support upset impacts mental health because it is the result of something expected but not received (1987). Recalcitrant siblings seemed to cause particular problems because caregivers felt they had grown up together, knew each other well, and should have been able to work things out. As one caregiver said about her brother, who had told her he would not help her care for their mother, "It's his warped sense of values. But we had a good relationship in the past until this happened."
likely to be female and were 3.6 years younger on the average than those not experiencing conflict. No significant differences were found for caregiver tasks, care receiver having dementia, or income. The fact that care-receiver dementia played no part in family conflict is surprising, since drastic personality changes on the part of the care receiver would seem a likely reason for other relatives to pull away, criticize what the caregiver is doing, or recommend institutionalization. Path Analysis
Table 2. Impact of Family Conflict on Selected Variables in Study of 100 Adult Child Caregivers
Mean scores for groups With Without conflict conflict (n = 40) (n = 60) Significance
Measure Caregiver perceived burden Caregiver mental health Relationship quality with parent Caregiver age (mean years) Caregiver tasks (mean score) Caregiver income (mean score) Caregiver gender (female) Prefer family care for self Care-receiver dementia
56.0 144.2 61.2 48.4 51.8 3.0 92% 18% 40%
44.3 167.1 71.5 52.0 48.7 2.8 77% 55% 42%
p p p p
< .001= < .01= < .001= < .05" NS NS
p
Family conflict is an overlooked yet potentially critical component of the caregiving experience. In a study of 100 adult child caregivers, 40% were experiencing relatively serious conflict with another family member, usually a sibling. Most conflict arose because the relative failed to provide sufficient help. Path analysis revealed that caregivers experiencing family conflict had significantly higher perceived burden and poorer mental health than did caregivers without conflict, even when quality of the caregiver's relationship with the parent, extent of caregiver tasks, income, gender, and age were taken into account. Key Words: Burden, Family relationships, Informal care
Impact of Family Conflict on Adult Child Caregivers1
outcome variables. Barusch and Spaid (1989) reported a positive association between "adverse social contacts" (negative aspects of emotional support) and perceived burden for spouse caregivers, but their results were not significant. Brody and colleagues (1989) examined intersibling hassles using a one-item measure and reported that such hassles were positively related to caregiver perceived burden and negatively related to relationship quality with the parent. On a four-point scale of such hassles (none/a little/fair amount/a great deal), the mean score was only slightly above "a little." All of the previous studies involved adult child caregivers. Analyzing burden scores from a mixed group of spouse and adult child caregivers, Keane-Hagerty and Farran (1990) reported that 42% of them said they felt at least some resentment toward other family members who were not helping. In a study of adult spouse caregivers, Pagel, Erdly, and Becker (1987) demonstrated that degree of upset with others in the social support network was correlated with caregiver depression, while positive aspects of support were not. While not presenting the data, one study of caregiving coping strategies stated that caregivers engaging in escape-avoidance coping reported more conflict in their personal relationships than did those using other coping strategies (Stephens et al., 1988). Using the Moos Family Environment Scale to cluster families with a chronically ill spouse, Stuifbergen (1990) reported that those families she characterized as involving "structured conflict" perceived a greater impact of illness than did those characterized as "cohesive." Pearlin and his colleagues consider family conflict to be a secondary stressor, which means it arises as a result of the primary demands of caregiving (Pearlin et al., 1990). Based upon their conceptualization of conflict, they developed three scales that tap the caregiver's assessment of the overall amount of dis-
Conflict between and within groups has been recognized in sociology as an important aspect of social relationships for some time (Collins, 1975; Coser, 1956; Cerhardt, 1989). Social psychology (particularly in exchange theory) explicitly recognizes that social relationships involve costs as well as rewards (Homans, 1974; Emerson, 1976; Nye, 1973). Close relationships are theorized as involving more conflict than peripheral relationships because of a greater convergence of interests, some of which are likely to be incompatible (Scanzoni, 1979). Interpersonal conflict is thus not uncommon in psychotherapy, where its management is seen as an integral part of human development (Heitler, 1990). In social support research as well, negative aspects of interacting with others have been shown to predict well-being more strongly than positive aspects (Rook, 1984). While recognized by the social sciences and in psychotherapy, conflict has played a minor role in research on family caregiving. Five studies have discussed it in general terms, saying that family conflict is a relatively frequent occurrence in caregiving (Abel, 1989; Archbold, 1980; Frankfather, Smith, & Caro, 1981; Hausman, 1979; Smith, Smith, & Toseland, 1991). Several others have made rough attempts at quantifying the amount of family conflict being experienced by caregivers or the amount of impact it has. Using a broad definition of conflict, Rabins, Mace, and Lucas (1982) found that 56% of the caregivers they studied were experiencing conflict, but they did not look at its associations with any ^ n earlier version of this work was presented at the 1990 Annual Meeting of the Cerontological Society of America in Boston. The research for this paper was funded by a Veterans Administration Health Services Research and Development Training Fellowship for Mr. Strawbridge as part of his doctoral dissertation. 2 Research scientist, Human Population Laboratory, 2151 Berkeley Way, Annex 2, Berkeley, CA 94704. Assistant professor, Department of Physiological Nursing, School of Nursing, University of California, San Francisco, CA.
770
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Manitoba on September 6, 2015
William J. Strawbridge, PhD, MPH,2 and Margaret I. Wallhagen, PhD, RN3
Relationship quality with parent
Caregiver tasks
Caregiver mental health
Figure 1. Model showing proposed paths for variables involved with family conflict. Direct relationships and hypothesized causal order are indicated by arrows between variables. Indirect relationships (such as between caregiver income and mental health) are hypothesized where a third variable (such as caregiver tasks) intervenes.
Vol. 31, No. 6,1991
Sample One hundred adult child caregivers caring for frail parents or in-laws were recruited from eight organizational sites in northwestern Washington and the San Francisco Bay area. These sites included adult day health centers, home health agencies, and information and referral agencies. Eligibility criteria included providing at least 4 hours of care a week to a parent or parent-in-law who was at least 55 years old and not institutionalized. Site staff identified potential subjects and sent them a letter describing the study as one examining the benefits and problems of providing care in a home setting. Those interested were asked to return a card and were then contacted and screened for eligibility. Of those returning cards, 83% were determined to be eligible and 95% of them were interviewed. Interviews were conducted in subjects' homes or places of employment and took about an hour. Table 1 indicates that the caregivers averaged 50 years of age, with relatively high education (78% had at least some college) and income (70% earned $24,000 or more). They were predominantly white (88%), female (83%), employed (69%), and married (67%). Most (81%) had living children. These caregivers had been providing care for an average of 5.2 years and averaged 22 hours of care per week. Seventy-three percent considered themselves to be the primary caregiver for their parent or in-law, with most of the rest feeling that they shared caregiving equally with someone else, usually a sibling. Seventy-one percent of the care receivers were mothers of the caregivers, 18% were fathers, and 11% were mothers-in-law or fathers-in-law. Mean age of the care receivers was 80. Fifty-six percent of them lived with their caregivers; 29% lived alone, 7% lived with their spouses, and 8% lived in other arrangements (such as home-sharing). The most frequently reported major health problem was dementia (41%), Table 1. Characteristics of 100 Adult Child Caregivers in Study of Family Conflict
Caregiver perceived burden
Caregiver gender
Caregiver income
Methods
771
Characteristic
Value
Female White Married Employed Age (mean) Have living children Primary caregiver Share home with care receiver
83% 88% 67% 69% 50.5 years 81% 73% 56%
Education High school grad or less Some college College grad or more
22% 43% 35%
Annual income Less than $15,000 $15,000-$24,000 $24,000-$48,000 Over $48,000
11% 19% 42% 28%
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Manitoba on September 6, 2015
agreement present in dealing with relatives. The amount of disagreement found in their study of both child and spouse caregivers was rather modest, but Pearlin and colleagues argue that the impact of family conflict can be great because caregivers have such a strong stake in their family relationships. The aims of our study were to quantify the extent of family conflict among adult child caregivers and to analyze its relative impacts on caregiver perceived burden and mental heath compared with other variables such as the caregiver's relationship with the parent, caregiver tasks, caregiver income, and selected demographic variables. The model proposed for our path analysis viewed family conflict as influenced by the caregiver's gender, age, and relationship with the parent. Family conflict was viewed as directly impacting the two main caregiving dependent variables of perceived burden and mental health. The placement of these variables is consistent with the theoretical framework of Pearlin et al. in which family conflict is viewed as a secondary stressor that is influenced by the caregiver's characteristics and the caregiving history, which includes the relationship between the caregiver and the care receiver (1990). Relationship quality with the parent as a variable preceding caregiving factors is also supported by Archbold and colleagues (1990). The variable of caregiver tasks is viewed as paralleling the relationships between family conflict and the two dependent variables. Caregiver age, gender, and income were hypothesized to have only indirect relationships with the two dependent variables, either through family conflict for age and gender or through caregiver tasks for income. Because of prior research findings, relationship quality with the parent was hypothesized to have both direct relationships with the two dependent variables and indirect relationships through family conflict (Strawbridge, 1991). This proposed model is depicted in Figure 1.
followed by stroke (14%), general frailty (11%), cardiovascular disease (10%), arthritis (6%), mental illness (5%), cancer (4%), and other (9%). As is typical of the samples utilized in most caregiving studies, our subjects were relatively welleducated and predominantly from middle and upper socioeconomic groups. Generalizations to the total caregiving population of the United States should be made with caution. Measures
Caregiver Perceived Burden. — The caregiver perceived burden scale was designed to measure the extent to which caregivers viewed the changes in their lives that had occurred because of caregiving as problems or concerns. Consisting of 22 items, the scale included activity changes (such as no longer having enough time for oneself), emotional factors (such as "I now worry about him/her all the time"), and physical changes ("I now feel tired all the time"). Scale items were adapted from Moss et al. (1987), Poulshock and Deimling (1984), and Wallhagen (1988). To measure the subjective component of perceived burden, caregivers were asked to rate on a five-point scale how much of a problem or concern 772
Caregiver Mental Health. — Mental health was measured with Veit and Ware's Mental Health Inventory (1983). Containing 38 items, the MHI has been used to predict the use of outpatient mental health services (Wells, Manning, & Benjamin, 1986) and general health services (Manning, Newhouse, & Ware, 1982), and to compare the well-being of six different types of chronically ill persons (Cassileth et al., 1984). More recently the MHI was used in a study of coping styles of women with rheumatoid arthritis (Manne & Zautra, 1989). The reliabilities reported for the scale in these studies range from .96 to .97 (Cronbach's alpha). In the current study, the standardized alpha coefficient was also .97. Each item on the scale asks subjects to indicate how much of the time during the past month they felt or behaved in a certain way. Scoring of the scale is done with a six-point response set, ranging from "always" to "never." Higher scores indicate better mental health. Caregiver Tasks. — Extent of caregiver tasks was measured with the Stetz Inventory, Part I (Stetz, 1986), as modified by Wallhagen (1988). This scale includes 15 specific questions about caregiving activities, such as "I help (care receiver) with eating his/ her food" and "I do shopping, appointments, or run errands for (care receiver)." Wallhagen's modifications involve combining several items to shorten the scale and changing the yes/no answers to a six-point frequency range (never, rarely, several times a month, every week, several times a week, and daily). The scale achieved a standardized alpha coefficient of .85. Higher scores indicate more extensive involvement with caregiving activities. Relationship Quality with the Parent. — Relationship quality with the parent was measured by adapting the scale developed by Walker and colleagues for use with caregiving daughters and their mothers so that it could be used on adult children and their parents of either gender (Walker & Thompson, 1983; Walker, Shin, & Bird, 1990). One question was added to the scale to assess similarity of values and four questions were added to specifically address past relationship quality. Sample questions include "We enjoy our relationship," "(care receiver) cares about the way I feel," and "(care receiver) has made some real sacrifices for me in the past." A four-point response set (strongly agree, moderately agree, moderately disagree, strongly disagree) was used. The revised scale has a total of 22 items and achieved a standardized alpha coefficient of .92. Higher scores indicate higher levels of relationship quality with the parent. Care Preferred for Self. — Caregivers were asked what caring for their parent or in-law had taught The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Manitoba on September 6, 2015
Family Conflict. — Family conflict was defined as a clash or strong feeling of resentment toward a relative about caregiving that was perceived as a problem by the caregiver. Resentment was thus included as an aspect of conflict if it was still actively felt, such as expressed dissatisfaction, or was still influencing the caregiver's actions, such as through attempts to renegotiate the situation (Scanzoni, 1979). A two-step process was used to differentiate those caregivers experiencing family conflict from those not experiencing it. The first step involved the Pagel, Erdly, and Becker (1987) social support scale. Based on Rook's (1984) analysis that negative aspects of relationships affect outcomes more than positive ones, this scale is designed to measure negative aspects of social support. All subjects were asked to name any unpaid person who was helping them care for their parent or in-law, anyone they felt should be helping but who was not, and anyone they talked with about caregiving problems or concerns. Caregivers were then asked how helpful and how upsetting each named person was across five dimensions of social relationships. These dimensions were help with caregiver tasks, providing information, sharing activities, providing emotional support, and closeness. A four-point response set was used (not/ slightly/somewhat/very helpful or upsetting). The second step asked a series of questions of those caregivers who indicated that a relative named on the scale was somewhat or very upsetting on any of the five dimensions. Information was collected on who the relative was, the nature of the problem, and what the caregiver had tried to do to resolve the situation. Those caregivers who did not dismiss the problem as a minor concern in this series of questions were scored as having conflict.
each item was for them. Categories used were "not a problem or concern," "sometimes," "usually," "often," and "always." This scale achieved a standardized alpha coefficient of .94. Higher scores indicate higher levels of perceived burden.
them about how they might want to be cared for if they were in a similar situation. Scoring was based upon whether they preferred some form of family care by relatives or an alternative, such as a retirement home or paid care at home. Caregiver Income. — Defined as family income over the past 12 months, caregiver income used the four categories indicated in Table 1 and was scored from low to high Analysis Chi square and t tests were used first to compare the differences between caregivers experiencing conflict and those not experiencing conflict on all of the major study variables. Two-tailed tests were used in conjunction with the t tests. Path analysis using forced entry multiple regression was then used to analyze possible causal paths and compare relative impacts of family conflict, caregiver tasks, relationship quality with the parent, income, caregiver age, and caregiver gender on the two major dependent variables of caregiver perceived burden and mental health. Findings Fifty-eight caregivers reported a family member as somewhat or very upsetting on the social support scale and were thus asked about possible family conflict. Eighteen subjects indicated that the problem was relatively minor, usually because the problem was being worked out (a relative had initially refused to help but was now doing more) or because they had learned how to handle the situation to their satisfaction (waiting for an emotionally sensitive relative to calm down). These 18 were classified, along with the 42 who had not named a relative as somewhat or very upsetting, as not experiencing family conflict. The remaining 40 caregivers who considered the problem with a relative to be more than minor were classified as experiencing family conflict. Thus 40% of the adult child caregivers in the study were experiencing family conflict of sufficient intensity to be considered a problem. The type of relative involved was clear: by far the most frequently named person was a sister (35%) or brother (30%), followed by a spouse (20%), child (5%), other parent (5%), or sibling-in-law (5%). Siblings or siblings-in-law thus constituted 70% of the relatives with whom the caregivers were experiencing conflict. One answer predominated when the cause of the conflict from the caregiver's perspective was analyzed: the relative would not provide sufficient help in caring for the care receiver (60%). The next most frequently mentioned problem was a relative criticizing what the caregiver was doing (12.5%), for instance, constantly calling with unwanted advice, being generally obnoxious, or accusing the caregiver of providing poor care. Relatives who insisted that the care receiver be institutionalized (10%) constituted the third most frequent conflict. Part of the difficulty for the caregiver in this last category was the implicaVol. 31, No. 6,1991
Bivariate Relationships with Family Conflict Table 2 summarizes differences on the major study variables between those experiencing conflict and those not experiencing conflict without regard to which is cause and which is effect. Those experiencing family conflict scored significantly higher on caregiver perceived burden and significantly lower on relationship quality with the parent and caregiver mental health than did those caregivers not experiencing such conflict. Those with conflict were also significantly less likely to prefer family care for themselves should they become frail or disabled. As one put it: "There is no way I want my children to go through what I've been through, just put me in a retirement home with a gate that shuts at night so I'll be safe." Significant differences also occurred for gender and age. Caregivers experiencing conflict were more 773
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tion that these relatives would not provide further help unless the caregiver complied. Three other types of conflict (relative is taking advantage of care receiver, relative thinks caregiver does too much, and relative doesn't visit care receiver) were each mentioned by two caregivers (5% for each type). Finally, one caregiver (2.5%) reported that her husband always got into arguments with his mother (the care receiver), forcing the caregiver to intercede between them. "Whenever she says yes, he says no," she said. Many of these reported conflicts and resentments were quite strong. Two cases resulted in legal action. One woman described her siblings-in-law as "vultures" for only being interested in her father-in-law's money and never helping; another said that her family "had never been farther apart," and a third remarked, "Don't ever try to care for a parent, because it can ruin your family relations." In 20% of the cases, the caregiver indicated that the offending relative had caused some problems in the past, so the current conflict was partly anticipated although obviously not accepted. But in 80% of the cases the conflict or resentment was recent. For example, one caregiver said that her sister had initially offered to care for her mother in exchange for being given the family house but had then tried to simply take the house and institutionalize the mother when she became frail. "I just do not understand my sister anymore," the caregiver said. "We used to be so close and now we don't speak to each other. It greatly upsets me." This type of recent conflict reflects the idea of Pagel, Erdly, and Becker that social support upset impacts mental health because it is the result of something expected but not received (1987). Recalcitrant siblings seemed to cause particular problems because caregivers felt they had grown up together, knew each other well, and should have been able to work things out. As one caregiver said about her brother, who had told her he would not help her care for their mother, "It's his warped sense of values. But we had a good relationship in the past until this happened."
likely to be female and were 3.6 years younger on the average than those not experiencing conflict. No significant differences were found for caregiver tasks, care receiver having dementia, or income. The fact that care-receiver dementia played no part in family conflict is surprising, since drastic personality changes on the part of the care receiver would seem a likely reason for other relatives to pull away, criticize what the caregiver is doing, or recommend institutionalization. Path Analysis
Table 2. Impact of Family Conflict on Selected Variables in Study of 100 Adult Child Caregivers
Mean scores for groups With Without conflict conflict (n = 40) (n = 60) Significance
Measure Caregiver perceived burden Caregiver mental health Relationship quality with parent Caregiver age (mean years) Caregiver tasks (mean score) Caregiver income (mean score) Caregiver gender (female) Prefer family care for self Care-receiver dementia
56.0 144.2 61.2 48.4 51.8 3.0 92% 18% 40%
44.3 167.1 71.5 52.0 48.7 2.8 77% 55% 42%
p p p p
< .001= < .01= < .001= < .05" NS NS
p
