1. Introduction
Parents of children with disabilities are known to experience more depression than parents of typically developing children in the process of accepting new and valuable information about their children’s disabilities [
1]. Children with developmental disabilities, such as autism spectrum disorder, intellectual disabilities, and cerebral palsy (CP), display varying degrees of dysfunction in the acquisition of motor, cognitive, language, or social skills. CP is the most common marked motor developmental disorder. One study reported a range of depression incidence rates of 10% to 59% in mothers of children with autism spectrum, 10% to 79% in mothers of children with fragile X syndrome, and 30% to 38% in mothers of children with Down syndrome [
2]. In children with cerebral palsy (CP), the long-term effects of the disability and accompanying problems are more pronounced [
3]. CP refers to a group of disorders that are caused by non-progressive lesions or damage to the immature brain, leading to abnormal muscle tone and movement disorders. These disorders can be accompanied by sensory, cognitive, communication, and intellectual disabilities [
4].
Health conditions in children with CP are complex, long-term, and often severe [
5]. They negatively affect the daily life of children and their parents [
6]. According to studies on mothers of children with CP, their degree of depression, anxiety, and stress is generally higher than that of mothers of typically developing children [
7]. Ones et al. [
8] reported that mothers of children with CP have a high incidence of depressive symptoms and a low quality of life. Manuel et al. [
7] reported that 30% of mothers of children with CP have depressive symptoms. Depression requires special attention and support as it hinders the mother’s mental health and affects her parenting and treatment of children.
Not all parents experience the same difficulties in caring for a child with CP [
9]. Parental sense of control is an essential part of proper parental role performance. Parental sense of control refers to the expectation of a parent that he/she can raise children well and solve related problems [
10]. In other words, parents with a high sense of control can cope with parenting stress by maximizing resources and maintaining this behavior [
11]. Mothers with a high sense of control can appropriately use personal and social resources to establish a sensitive and harmonious relationship with infants with difficult temperaments. It was reported that no further efforts were made to interact with it [
12].
Child-related variables, particularly the severity of the CP condition, have been considered as variables that affect stress. CP is the most common motor developmental disorder [
13], and the atypical and abnormal movement patterns associated with the disorder make it difficult for parents to care for children with CP daily [
14]. When children are at lower functional levels, their mothers report greater strain and lower quality of life [
12,
13,
14,
15,
16]. Stress levels in mothers of children with CP were different according to the severity of motor dysfunction [
15]. Caring for a child with limited self-mobility requires a high physical and psychological load, which leads to parenting challenges [
16,
17]. Although correlations have been found between children’s level of disability, parental depression, and parenting stress [
18,
19], their causal relationships remain unclear. The impact of the disability’s severity, perceived stress, and perceived social support on parental well-being has been examined, but the severity of disability is not a significant predictor of parental well-being [
20].
Stress caused by children with disabilities harms the growth and development of their families, resulting in a decline in family function [
4]. Therefore, there is a need to alleviate the depression of parents responsible for raising children with disabilities and enhance parental self-control for proper growth and healthy family life. Self-control is one of the health-related variables that can be impaired in mothers of children with CP. Previous research reported that self-control is an important personal resource to support the quality of life for parents of children with CP [
6,
21]. When caring for a family, self-control is the ability to care for oneself, respond to disruptive behavior and other care-related issues, and control negative thoughts and emotions arising from care [
22]. To do so requires the individual to believe that they can cope with the situation and take breaks, delegate tasks, or ask for help when needed. This benefits both their well-being and how they care for others.
In this study, self-control was selected as an independent variable in the same context as self-efficacy in a mother’s role. Mastery is defined as a person’s belief that they can now control important situations that affect their lives [
23]. Self-control is a measure of satisfaction and quality of life, and the sense of self-control perceived by an individual is a functional factor in maintaining a sense of well-being and efficacy under stressful or changing situations [
24]. People with a high sense of self-control are less affected by stress as they successfully face challenges [
25]. This study aims to determine the relationship among gross motor function, parenting stress, self-control, and depression in mothers of children with cerebral palsy.
4. Discussion
The purpose of this study was to investigate the relationship between the gross motor function of children with CP and the self-control, parenting stress, and depression in their mothers through path analysis. For this purpose, data were gathered to measure the gross motor function of children with CP and the self-control, parenting stress, and depression of their mothers; the data were then analyzed. Depression and parenting stress in the mothers of children with CP was reported to be high, and a high sense of self-control was required to lower it. The relationship between the child’s gross motor function and the parenting stress, self-control, and depression of the mother can provide basic data for developing psychological and educational programs for mothers of children with CP by notifying the influence direction and moderating influence between variables. The implications of this study based on major findings are as follows.
First, the relationship between the functional level of children with CP and parenting stress was consistent with that in previous studies. The severity of CP is a major factor influencing parenting stress [
12,
13,
14,
15,
16]. Among the child-related variables, the severity of CP has been considered a variable that affects stress. Mothers of children with CP at lower functional levels report greater stress and lower quality of life than those at higher functional levels [
12,
13,
14,
15,
16]. Parenting challenges arise when providing care for children with CP. In this study, the relationship between the gross motor function level of children with CP and parenting stress was investigated through path analysis. As a result, when the gross motor function level of children with CP increased by 1 standard deviation, the mothers’ parenting stress decreased by 0.202. This is consistent with the results of previous studies. The gross motor function of children with CP affects self-control. When the gross motor function level of children with CP increased by 1 standard deviation, the mothers’ self-control increased by 0.185.
Second, parenting stress was associated with parents’ depression. Parenting stress has been reported as a major factor influencing the development of children in the context of families [
39]. The parents of children with CP have been reported to have higher parenting stress than parents of typically developing children [
40]. Parents of children with CP often perceive themselves to be their children’s advocates who must ensure that they receive optimal services [
41], and more than 60% of them are vulnerable to parenting stress [
18]. Information on the factors affecting stress may be meaningful to help provide appropriate services. This information may be helpful to professionals who can then provide adjusted services based on the needs of the family [
42]. The results of this study showed that alleviating parenting stress in mothers of children with CP was associated with reducing depression.
Third, self-control has a direct relationship with the mother’s depression and can moderate the relationship of variables on depression. Self-control is related to well-being, psychological and physical health, task performance, and emotions. Those with high self-control had fewer psychological difficulties such as depression, anxiety, and stress [
43,
44]. Self-control also has a positive relationship with interpersonal relationships, and people with higher self-control have better interpersonal skills and higher satisfaction with interpersonal relationships than those with low levels [
45,
46]. Self-controlled behavior builds strength, confidence, comfort, and independence in terms of the ability to direct one’s life. Studies have shown a correlation between self-control and behavioral problems in a wide range of problem areas, such as cancer, anxiety, nightmares, medical procedures, exam anxiety, depression, sleep problems, enuresis, encopresis, and stuttering [
47]. Based on the results of this study, when the self-control level increased by 1 standard deviation, the mothers’ depression decreased by 0.314. When parenting stress level increased by 1 standard deviation, the mothers’ depression increased by 0.363. The results of this study showed that the gross motor function of children with CP has a significant direct and indirect effect on self-control. The relationship of gross motor function of children with CP on self-control was mediated by parenting stress, and the relationship of the gross motor function of children with CP on depression was mediated by self-control.
Self-control is defined as the ability to regulate and control inner impulses, wishes, emotions, and behaviors [
48]. It is a set of skills that allows individuals to form behaviors using their free will while replacing one type of behavior with another that is more desirable [
49,
50]. Through self-control, it is possible to understand and control inner needs and emotions and to achieve positive results by adjusting to the environment [
51]. Self-control is derived from the assumption that human behavior is goal-oriented and is always undergoing a process of change and development. It is especially important when a person needs to learn new patterns of behavior or make decisions or when previous behaviors are no longer effective [
49]. It is therefore a flexible, self-regulating ability that changes undesirable thoughts, emotions, and behaviors to adapt to the environment more effectively and predicts success through long-term goal achievement [
52]. The results of this study showed that self-control could mediate the relationship between gross motor function and parenting stress on depression. This result is like that of Stewart et al. [
53], which indicated that a sense of control acts as a modulating variable in the relationship between downward social comparison and subjective well-being in the elderly. The results further suggested that therapeutic interventions to increase the functional level of children with CP, as well as support programs to reduce mothers’ parenting stress and increase the level of self-control of mothers, are needed to reduce the depression level of mothers of children with CP.
The results also confirmed the relationship among the gross motor function of children with CP, parenting stress, self-control, and depression of their mother. More specifically, self-control mediated the relationship of gross motor function and parenting stress on depression. Mothers of children with CP with high self-control were found to have low levels of parenting stress and depression. This lends credence to the belief that self-control can act as a protective variable against subjective well-being and depression, even if an individual is placed in difficult situations. Recent systematic review and meta-analysis reported that interventions to improve psychological well-being in the parents of children with CP was effective [
54].
The limitations of this study were as follows. First, although children diagnosed with CP have some common characteristics, differences according to the type of CP do exist. This study could not identify the differences according to the type of CP. Although the sample size is adequate, the number of children with the dykentic type of CP was much smaller, and there are likely to be other confounders that contribute to these results. Considering that the main participants of this study were the spastic type, it is highly likely that the characteristics of children with spastic CP were reflected. Therefore, in future studies, investigating the relationship between the variables according to the type of CP will be necessary. Second, this study is a cross-sectional correlation study, and there are limitations in revealing the long-term relationship between variables. Therefore, in future studies, it is necessary to investigate the long-term relationship between variables through intervention and to enable a comprehensive interpretation through longitudinal studies.